renal transplantation

Question 1

what are the contraindications of kidney transplants?

Answer 1

• active infection/malignancy
• severe heart disease not suitable for correction
• severe lung disease
• reversible renal disease
• uncontrolled substance abuse, psychiatric illness
• on going treatment non adherence
• short life expectancy

Question 2

what is the best RRT in terms of patient survival and QoL?

Answer 2

kidney transplantation

Question 3

what is a living related donor transplation?

Answer 3

donor is a living relative

best possible transplant as patients have elective procedure with a selected donor that might have good compatibility

Question 4

what are the types of living unrelated donor transplantations?

Answer 4

4 forms
1) live donor paired exchanged

2) live donor/deceased donor exchanged
3) live donor chain
4) altruistic donation

Question 5

what is deceased donor transplantation?

Answer 5

• most transplants
• patients receive a kidney or two from the same donor with little time for prep, so transplant protocols are important to keep updated regularly
• time to transplantation happen in years
• lower survival rate of kidney allograft and patient than with a live donor

Question 6

what is a induction treatment?

Answer 6

at transplantation, immunosuppressives are used to create tolerance of the graft and avoid rejection

include use of methylprednisolone in combination with any of the following: basiliximab and thymoglobulin. Less commonly used are alentuzumab and rituximab.

Question 7

what maintenance treatment is used post transplantation?

Answer 7

Steroids : Prednisolone (or prednisone)

Calcineurin inhibitors (CNI): tacrolimus, cyclosporine, voclosporin

Antimetabolite medications: mycophenolate azathioprine

Rapamycin inhibitors: Sirolimus and everolimus

T cell regulation: Belatacept and Belimumab

Question 8

what long term care is used for transplant patients?

Answer 8

• follow up several times a month for the first 6 months, then less often
• monitor GFR, CNI levels, proteinuria, Ca, phosphate, PTH, lipids and glucose
• screen for infections
• vaccination
• monitor and control CV disease, bone and mineral metabolism disease
• screen for malignancies (annual skin cancer checks)
• contraception needed in the first year, counsel about pregnancy 1 year after
• mortality is related to cv disease, infections and malignancies

Question 9

what are the complications of transplantation?

Answer 9

1) acute complications within first month are related to surgery or infections

<4 weeks - nosocomial infection or related to donor

1-12 months - activation of latent infections, relapsed, residual or opportunistic infections , community

consider CMB, hep B, HSV, varicella zoster, EBV, BK, aspergillus, Myobacterium tuberculosis.

2) within first year, patients can develop new onset diabetes after transplant (NODAT)
3) increased risk of malignancy requires regular screening.

Question 10

what is a simultaneous kidney transplant?

Answer 10

can do 2 transplants at the same time e.g

1) liver kidney for patients with liver failure or cirrhosis and ESRF
2) pancreas kidney in patients
3) patients with kidney transplant who progress into ESRF can be retransplanted