Kidney Transplant

Question 1

On examination of a patient with a renal transplant, what are important factors to mention in your presentation?

Answer 1

1. The current mode of replacement therapy- i.e. presence of a transplant
2. Signs previous mode of renal transplant
3. Adequacy of transplant- any signs of uraemia and the patient’s fluid status, bruits on auscultating transplant.
4. Signs of complications of RF e.g. anaemia
5. Complications of immunosuppressive therapy
6. Aetiology of the renal disease

Question 2

What drugs would be used for immunosuppression in renal transplant patients?

Answer 2

Tacrolimus
Steroids
Cyclosporin

Question 3

What side effects of tacrolimus can you look for on examination?

Answer 3

Tremor

DM

Question 4

What side effects of cyclosporin can you look for on examination?

Answer 4

Gum hypertrophy, hirstutism, coarse tremor,

HTN, DM

Question 5

What side effects of all immunosuppressants can you look for on examination?

Answer 5

Signs of infection

Presence of skin lesions (benign and malignant) or biopsy

Question 6

What side effects of steroids can you look for on examination?

Answer 6

Cushingoid features- bruising, striae, centripetal obesity

Question 7

What scar do you get with renal transplantation?

Answer 7

Rutherford-Morrison scar

Hockey stick shaped

IF- usually R

Always palpate if can see!

Question 8

What is the normal size of the mass felt with a kidney transplant?

Answer 8

5x8cm (obviously can vary)

Question 9

Important features to comment on when presenting a transplanted kidney

Answer 9

Size
Tenderness
Consistency
Margins- smooth?
Percussion note- should be dull
Presence of bruits

Question 10

What are absolute CIs to renal transplant?

Answer 10

Active infection

Cancer (consider if “cured” >5 years ago)

Severe comorbiditiy

Failed pre-implantation cross-match

Question 11

What types of renal transplant are there?

Answer 11

Cadaveric- donors after cardiac death and after brainstem death (latter reduced risk delayed graft function)

Living donor- better outcomes. Elective surgery. May be related or unrelated. Need permission form Human Tissue Authority

Question 12

What type of assessment must all potential transplant patients have before they can have a transplant?

Answer 12

Psychological assessment to assess understanding of risks of transplant (sorry for poor q)

Question 13

What factors are considered before trying to match a donor and recipient

Answer 13

Virology
Co-morbidities
Blood group (ABO compatibility)
Anti-HLA antibodies
Haplotype
Cross-match blood

Question 14

What viruses are donors screened for?

Answer 14

HIV
CMV
VZV
Hepatitis

Question 15

What haplotypes are considered between a donor and recipient?

Answer 15

HLA-DR > HLA-B > HLA- A

Reduced mismatches –> increased survival (90% 1 year survival when HLA and ABO matched)

2 alleles for each, therefore potential for 6 mismatches

Question 16

What immunosuppression regimes are most renal transplant patients on?

Answer 16

For maintenance, triple therapy- calcineurin inhibitor (e.g. tacrolimus, ciclosporin), an antimetabolite (e.g. azathioprine) and prednisolone

Question 17

What complications can occur with a renal replacement?

Answer 17

Surgical complications

Delayed graft function: more common in cadaver donors

Rejection: Acute or chronic- treat with high dose IV methylprednisolone

Drug toxicity

Infection

Malignancy (related to immunosuppression)

CV disease

Question 18

How long would you expect a renal transplant to last

Answer 18

Half life for cadaveric: 15 years

Half life HLA-matched live: >20 yrs

Question 19

How might you be aware that transplant is occurring?

Answer 19

Tenderness over graft
Reduction in urine output
Rising creatinine

Question 20

What are the types of transplant rejection?

Answer 20

Hyperacute: within hours of surgery
Accelerated acute: 1-4 days post op
Acute: 5 days- 2 weeks
Chronic

Question 21

What is hyper acute rejection?

Answer 21

Within hours of surgery.

Due to preformed antibodies in a sensitised recipient.

Question 22

What is accelerated acute rejection?

Answer 22

1-4 days post op.

Due to secondary immune response as a consequence of activation of memory T cells.

Question 23

What is acute rejection?

Answer 23

5 days to 2 weeks after surgery.

Cell-mediated immunity. Renal epithelial cells destroyed by lymphocyte interstitial infiltrate

Question 24

What is chronic rejection?

Answer 24

Humoral mechanisms more important, tubular atrophy and interstitial fibrosis are the histological features

Question 25

What drug group do tacrolimus and cyclosporin belong to?

Answer 25

Calcineurin inhibitors- block IL2 production