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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)

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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