Kidney transplantation

Question 1

Where is a transplanted kidney placed in the body?

Answer 1

Into the iliac fossa and anastomosed to the iliac vessels.

Question 2

The native kidneys usually remain where they are. However, sometimes a nephrectomy is required. Why might this be the case?

Answer 2

Size of kidney - polycystic kidneys

Infection - chronic pyelonephritis

Question 3

Living donor nephrectomy

Answer 3

Gives those in need of a kidney transplant an alternative to waiting for a deceased-donor organ

Question 4

Complications associated with transplant surgery

Answer 4

Vascular:
Bleeding
Arterial thrombosis
Venous thrombosis
Lymphocele

Ureteric:
Urine leak

Infections

Question 5

Why are immunosuppressive agents given to kidney transplant patients?

Answer 5

To lower the body’s ability to reject a transplanted organ

Question 6

Which immunosuppressive agents are commonly used in renal transplant cases?

Answer 6

Corticosteroids

Calcineurin inhibitors - Cyclosporine

Anti-proliefratives - Mycophenolate mofetil, Azathioprine

mTOR inhibitors - Sirolimus

Costimulatory signal blockers - Belatacept

Depleting agents - Basiliximab ( anti-CD25),

Question 7

Side effects of corticosteroids (5)

Answer 7

Hypertension
Hyperglycaemia
Infection
Bone loss
GI bleeding

Question 8

Which immunosuppressant is used for induction (time of kidney transplant)?

Answer 8

Basiliximab

Question 9

Types of living kidney donors

Answer 9

Live related donor

Live unrelated donor (eg spousal)

Live unrelated donor – altruistic, non-directed

Paired / pooled

ABO incompatible / HLA incompatible

Question 10

Complications after renal transplantation

Answer 10

Rejection - cell mediated, humoral

Cardiovascular - underlying renal disease, chronic renal failure, high BP, hyperlipidaemia

Infective - bacterial, viral, fungal

Malignancy - skin, lymphoma, solid cancers

Question 11

What is Cytomegalovirus?

Answer 11

Most important transplant-related infection

Affects around 8% of transplant recipients, despite prophylaxis therapy

High mortality and morbidity if untreated

Recipient affected via

• Transmission from donor tissue
• Reactivation of latent virus

Question 12

What are examples of cytomegalovirus viraemias - tissue invasive disease? (6)

Answer 12

Pneumonitis
Hepatitis
Retinitis
Gastroenteritis
Colitis
Nephritis

Question 13

BK and JC viruses are part of which family?

Answer 13

Polyomaviridae

Question 14

Clinical manifestations of BK virus in renal transplant patients (3)

Answer 14

Ureteral stenosis
Interstitial nephritis
ESRF - end stage renal failure

Question 15

Clinical manifestations of BK virus in patients with AIDS (3)

Answer 15

Nephritis
ESRF
Retinitis
Meningoencephalitis 
Pneumonitis

Question 16

Risk factors for BK associated nephropathy

Answer 16

Intensity of immunosuppression

Patient determinants - older age, males, white, DM,

Organ determinants - graft injury, HLA mismatches

Viral determinants - changes in epitopes of viral capsi protein VP-1

Question 17

What is HLA matching?

Answer 17

In organ donation an HLA identical or fully HLA matched sibling is considered the optimal and first choice

Important to match human leukocyte antigens to reduce risk of rejection

Question 18

Outcome of BK associated nephropathy

Answer 18

Allograft dysfunction (transplant)

Loss of graft in 45-80%

Question 19

Treatment of BK associated nephropathy

Answer 19

Reduce immunosuppression

Antiviral therapy - cidofovir, leflunomide

Question 20

Risk of malignancy after renal transplant

Answer 20

From highest to lowest

Non-melanoma skin, Kaposi Sarcoma, Non Hodgkins Lymphoma (PTLD)

Renal

Melanoma, leukaemia, cervical

Testicular, bladder

Question 21

What is the best way to treat end stage renal disease?

Answer 21

Kidney transplantation

Question 22

What is paired/pooled donation?

Answer 22

Paired/pooled donation is used if:
The donor and recipient are incompatible (or mismatched), either by blood group or HLA sensitisation, or
The donor and recipient are compatible but are seeking a better age or HLA match

The pair may be matched to another couple in a similar situation so that both people in need of a transplant receive a matched organ or part organ.

Question 23

What are the mechanisms of acute rejection

Answer 23

T cell mediated rejection (TCMR)

Acute antibody mediated rejection (ABMR)