Renal Transplantation

Question 1

indications for kidney tranplants

Answer 1

*chronic renal failure
*dialysis is an alternative
*priority based upon renal function, time on dialysis, age, sensitization, match

Question 2

indications for liver transplants

Answer 2

*acute and chronic liver failure
*no viable treatment alternative
*priority based on MELD (adult), PELD (pediatric)

Question 3

indications for pancreas transplants

Answer 3

*insulin dependent type 1 or type 2 diabetes mellitus
*exogenous insulin is an alternative

Question 4

indications for intestine transplants

Answer 4

*short gut syndrome
*hyperalimentation

Question 5

renal transplant vs. dialysis

Answer 5

*transplant:
-requires initial operation
-requires an organ
-immunosuppression unless identical sibling
-intensive early follow up
-provides substantial renal function
-restores normal physiology
-doubles life expectancy compared to dialysis
-improves quality of life

*dialysis:
-requires initial operation
-lifelong ongoing treatments
-renal failure despite treatments
-7-10% risk of death/year
-initial procedure less invasive
-can be done in patients with exclusions to transplant
-can be done short-term (a safety net)

Question 6

contraindications for renal transplantation

Answer 6

*comorbidities that preclude recovery from surgery: CVD, pulmonary insufficiency, frailty
*comorbidities that increase risk of immunosuppression: frailty, cancer, chronic infection
*poor social support: lack of transportation, education, or family support sufficient to meet post-transplant care needs
*poor financial support: ongoing costs of medications and follow-up care

Question 7

process for getting a kidney transplant

Answer 7

*referral to a transplant center
*patient and family education
*assessments: medical, social, financial
*committee decision based upon center-established guidelines with oversight by UNOS and CMS

Question 8

different types of kidney donors

Answer 8

*living:
-related
-unrelated but “emotionally related”
-unrelated but not “emotionally related”; Good Samaritan

*deceased:
-brain dead
-cardiac death
-expanded criteria donors
-high KDPI (age, height, weight, race, HTN, diabetes, COD, creatinine, HCV, DCD)

Question 9

donor features that make some kidneys “better” than others

Answer 9

*living donor > deceased donor
*brain dead > cardiac death (cardiac death increases ischemia)
*younger > older (less “wear and tear”)
*bigger > small (larger nephron mass)

Question 10

in general, is it more important to have a better functioning kidney donation or a matched kidney donation?

Answer 10

*better function trumps matching
*a zero match living kidney functions immediately 97% of the time
*a zero mismatched (best matched) brain dead (young) donor kidney functions immediately about 75% of the time

Question 11

when does “matching” matter for kidney transplantation

Answer 11

*sensitized recipient (person who already had a transplant but rejected it)
*HLA-identical sibling (living donor)
*identical twin (living donor) - no transplant medications

Question 12

the wait list for a kidney transplant

Answer 12

*median wait time for 5 years
*half of those on the Wait List become sick or die before they receive a transplant
*allocation rules developed by UNOS determine rank and type of offers

Question 13

complications of renal transplant operation

Answer 13

*bleeding
*graft thrombosis
*re-operation
*primary non-function
*delayed graft function

*operation requires overnight ICU stay, ultrasound to check vascular patency, monitor Hb and renal function, 3-4 day hospital stay, then regular clinic follow up

Question 14

surgical complications AFTER renal transplant

Answer 14

*TRAS
*ureteral obstruction/stenosis
*lymphocoele
*wound infection

Question 15

immunosuppression complications after renal transplantation

Answer 15

*overimmunosuppression → BK virus, lymphoma, CMV
*underimmunosuppression → acute rejection
*intolerability (diabetes, nephrotoxicity)