Renal transplant

Renal transplant examination

• Perform renal exam (see renal examination notes)
• Look for:
  • Aetiology: fingertip capillary glucose monitoring marks (diabetes), flank masses (PKD), butterfly rash (SLE), hearing aid (Alport syndrome), collapsed nasal bridge (granulomatosis with polyangiitis), sternotomy (renovascular disease)
  • Previous renal replacement therapy: AV fistula, central line scars, peritoneal dialysis scars
  • Graft functionality: active marks in AV fistula, fluid retention, anaemia, uraemia
  • Immunosuppression side effects: tremor (calcineurin inhibitor), cushingoid/bruising (steroids), skin lesions/excisions (immunosuppression)

Renal transplant, AV fistula, PD scars

Arteriovenous fistula

Indications

• End stage chronic kidney disease (GFR <15ml/minute)
• Commonest causes
  • Diabetes mellitus
  • Polycystic kidney disease
  • Hypertension
  • Autoimmune glomerulonephritis

Contraindications

• Cardiac/pulmonary insufficiency
• Hepatic disease
• Cancer
• Active infection

Procedure

• Pre-operative donor and recipient screening: HLA, cross-match, infection screen (HIV, hepatitis B/C, CMV/EBV, human T-lymphotropic virus, Varicella zoster virus, syphilis, Toxoplasma)
• Additional donor screening: renal ultrasound, blood tests (U&Es, FBC, LFTs, fasting glucose, coagulation screen), urine tests (dipstick, MC&S, protein-creatinine ratio)
• Remove donor kidney (loin scar)
• Anastomose in recipient’s iliac fossa (Rutherford-Morrison scar)
  • Renal vein to external iliac vein
  • Renal artery to external iliac artery

Complications

• Rejection
  • Hyper-acute rejection (immediate): thrombosis and occlusion of graft vessels during surgery
  • Acute rejection (weeks to months): deterioration in renal function ± flu-like symptoms and graft tenderness
  • Chronic rejection (months to years): gradual deterioration in renal function
• Immunosuppression complications
  • Opportunistic infections and sepsis
  • EBV-mediated post-transplant lymphoproliferative disorder
• Other
  • UTIs
  • Renal graft thrombosis

Test your knowledge

How long does a renal graft last?

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What affects this time?

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Which immunosuppressive agents are usually given post-transplant?

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