Kidney transplantation

Question 1

Where does a kidney transplant go?

Answer 1

Goes into the right or left iliac fossa where it is plumbed into the iliac vessels

Question 2

What do patients dislike about dialysis?

Answer 2

• Always exhausted
• Fluid restriction
• Restricted diet - K+, PO4-
• Women are infertile \
• Reduced life expectancy - feel like they are going to die soon

Question 3

Who is unsuitable for a kidney transplant?

Answer 3

• Potential contra-indications to transplant
• Reduced life expectancy- those older or unlikely to service 5 years
• Hyper/hypotension
• those with diseases that will recur in the transplant: atypical haemolytic uremic syndrome or FSGS
• Surgical contra-indications: congenital bladder problems, calcified blood vessels

Question 4

What are the classical diseases seen in the dialysis clinic?

Answer 4

• Renovascular disease
• T2 diabetic nephropathy
• Vasculitis
• Obstructive uropathy

Question 5

What are the classical diseases seen in the transplant clinic?

Answer 5

• APKD
• Glomerulonephritis
• Reflux nephropathy
• T1 diabetes nephropathy

Question 6

Explain transplants from deceased donors

Answer 6

• Brain stem death - heart beating/non-heart beating
• No malignancy or unidentified/untreated infection
• Good kidney function
• Kidneys donated in any part of the UK are allocated to the most appropriate in UK via NHS blood

Question 7

What is the average waiting time for a kidney from a deceased donor?

Answer 7

2-3 years

Question 8

What are the advantages of living vs deceased kidney donation?

Answer 8

• can have pre-emptive transplantation
• Better kidneys
• Better outcomes- longer kidney survival

Question 9

What leads to rejection?

Answer 9

• Blood group incompatibility
• HLA incompatibility
• T cell mediated and antibody mediated rejection

Question 10

What are the immunosuppressive drugs given after transplant?

Answer 10

• Basiliximab: chimeric mouse-human monoclonal antibody directed against IL-2 receptor
• Tacrolimus- calcineurin inhibitor
• Mycophenolate mofetil - inhibitor of inosine 5’-monophosphate dehydrogenase+/- steroids

Question 11

What are the types of rejection

Answer 11

• cell mediated rejection

* Antibody mediated rejection

Question 12

Explain cell mediated rejection

Answer 12

• Interstitial inflammation and tubulitis
• Often easily treated with steroids if caught early
• Wouldn’t expect to see proteinuria and would require a biopsy to confirm

Question 13

Explain antibody mediated rejection

Answer 13

• Endothelial swelling, glomerulitis and peri-tubular capillarities
• Donor specific antibodies
• Often difficult to treat especially if chronic
• May have proteinuria

Question 14

Describe infection in transplantation

Answer 14

• Immunosuppressed
• Common organisms in common sites, reactivation of infections or uncommon
• Reduced immunosuppression and treat with antibiotics or anti-virals

Question 15

Explain malignancy in transplant

Answer 15

• Increased risk due to immunosuppression
• Kaposi sarcoma is most common, then skin
• Reduce immunosuppression +/- rituximab or chemotherapy