Renal Transplant

Question 1

List some factors associated with higher post-op morbidity/mortality

Answer 1

• Cats older than 10yo
• Creatinine over 10mg/dl and high BUN more likely to die before discharge
• Pre-op blood pressure and weight
• In dogs, every 1yr increase in age increases odds of death by 6m by 42%

Question 2

What test is performed is a recipient cat has recently had a UTI or has a history of recurrent UTI?

Answer 2

A cyclosporine challenge test for 2 weeks
- If they have a positive culture result at end of test, they are eliminated as candidates

Question 3

Can patients with positive toxoplasma titres be candidates for renal transplant?

Answer 3

Yes but they will need to be on clindamycin for life

Question 4

List findings that eliminate a cat as a candidate for renal transplantation

Answer 4

Question 5

What imaging is performed on potential kideny donors?

Answer 5

CT angiography

Question 6

What pre-operative medications can reduce the chances of requiring blood products?

Answer 6

Erythropoietin or darbepoietin

Question 7

What are is the main immunosuppresive combon used in cats?

Answer 7

• Prednisolone
• Cyclosporine

Question 8

How does cyclosporine work?

Answer 8

Inhibits calcineurin, thus preventing activation of transcription factors regulating genes for cytokines including TNFa, IL-2, IL-4, IFN-gamma and granulocyte-macrophage colony-stimulating factor

Question 9

What can be added to the immunosuppressive protocol to be able to reduce the dose of cyclosporine?

Answer 9

Ketoconazole
- Itraconazole and clarithromycin may also be effective and have less adverse side effects

Question 10

What kind of donor improves graft survival in dogs?
What is the most common immunosuppresive protocol?

Answer 10

• A major-histocompatibility complex-identical littermate
• Cyclosporine, prednisolone and azathioprine

Question 11

What complications can be seen with ketoconazole in dogs?

Answer 11

• Hepatotoxicity
• Cataract formation

Question 12

Addition of what substance to immunosuppresive protocol after transplantation from a nonrelated dog improves survival?

Answer 12

Rabbit antidog antithymocyte serum

Question 13

Why is mannitol administerd during renal transplantation?

Answer 13

• Minimise renal artery spasm
• Improve renal blood flow
• Protect against injury which may occur during the warm ischaemic period

Question 14

What intra-op factors are assoc with overall decreased survival?

Answer 14

• Hypotension
• Prolonged anaesthesia over 6hr
• Cats older than 12yo
• Intraop hypoxaemia

Question 15

What medication can be used to treat periop hypertension?

Answer 15

Hydralazine

Question 16

Which kidney is preferred for transplantation?

Answer 16

Left kidney - longer vein

Question 17

List the 2 methods of vascular anastomosis?

Answer 17

• anastomosed to recipient iliac vessels (12% HL complication rate)
• Renal artery anastomosed end-to-side to aorta uwing 8-0 nylon and renal vein anastomosed end-to-side to caudal vena cava using 7-0 silk

Question 18

After graft harvest, what solution is used for flushing?

Answer 18

Ice-cold phosphate buffered sucrose organ preserving solution

Question 19

List the technique options for ureteroneocystostomy

Answer 19

Intravesicular
Extravesicular
- Ureter to bladder
- or can save a 2mm cuff of donor bladder around the donor ureter to use for anastomosis

Question 20

What additional procedures may be performed at the time of surgery?

Answer 20

• Pexy kidney to abdominal wall
• Biopsy of one of the native kidneys
• Enteroplications in dogs (intussusception in up to 25% of dogs after renal transplantation)

Question 21

What factors are assoc with increased risk of post-op seizures/neuro abnormalities

Answer 21

• An increase of 1mg/dL serum creatinine or 10mg/dL BUN increases liklihood of post-op CNS disease by 1.8x and 1.6x respectively

Question 22

If transplant is successful, how quickly should azotaemia resolve?

Answer 22

24-72hr

Question 23

What is haemolytic uraemic syndrome?

Answer 23

A rare but fatal complication reported in cats
- Haemolytic anaemia
- Thrombocytopaenia
- Rapid deterioration of renal function secondary to glomerular and renal arteriolar platelet and fibrin thrombi

Question 24

What is the prognosis following renal transplant in cats and dogs?

Answer 24

Cats:
- 70-92% discharged from hospital
- MST 360-613 days

Dogs:
MST 24 days in 26 dogs (range 0.5 - 4014)

Question 25

List the most common post-op complications after renal transplant in cats

Answer 25

• Acute rejection 13-26%
• Chronic rejection
• Haemolytic uraemic syndrome
• Calcium ocalate urolithiasis
• Retroperitoneal fibrosis
• Ureteral obstruction
• Infection
• Diabetes mellitus 13.9% (5.45x more likely)
• Neoplasia 9.5 - 24%, lymphoma more common. 6.1-6.6x more likely to develop neoplasia

Question 26

List some factors associated with higher post-op morbidity/mortality

Answer 26

• Cats older than 10yo
• Creatinine over 10mg/dl and high BUN more likely to die before discharge
• Pre-op blood pressure and weight
• In dogs, every 1yr increase in age increases odds of death by 6m by 42%