Table of Contents
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