Our notes are now found under OSCE Learning! Click here
image

Renal transplant

Renal transplant examination

  • Perform renal exam (see 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 and 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)

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

Post-operative immunosuppression (lifelong)

  • Triple immunosuppression is usually required:
    • Prednisolone
    • Calcineurin inhibitor (e.g. ciclosporin, tacrolimus)
    • Antimetabolite (e.g. azathioprine, mycophenolate mofetil)

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

Prognosis

  • Graft usually lasts 12-15 years 

Affected by: ‘cold time’ (time out of donor/recipient body); type of donor (live/cadaveric); donor age

image