Renal Transplantation and Assessing a Patient with Renal Disease

Question 1

What are types of organ donor?

Answer 1

• Deceased donor
  
  • ​Brain death (DBD)
  • Circulatory death (DCD)
• Living donor
  
  • ​Directed
  • Non-directed
  • Paired / pooled

Question 2

What are the ideal treatment principles for a patient with end-stage renal disease (ESRD)?

Answer 2

• Long-term survival
• Quality of life
• Cost-effective

Question 3

What are the benefits of renal transplantation for the patient?

Answer 3

• Free of dietary restrictions
• Time
• Fertility
• Employment

Question 4

What are the problems with renal transplant?

Answer 4

• Not all patients will benefit:
  
  • Multimorbidity
  • Cancer / other active disease
  • Cardiovascular disease
  • Recurrent disease
• Average waiting time 2.5-3 years for a deceased donor kidney to become available.
• Pre-emptive - 6 months before dialysis.

Question 5

What are the immunological considerations in renal transplantation?

Answer 5

• ABO system
  
  • Most transplants are between a donor-recipient pair of the same blood group.
  • ABO-incompatible transplantation is an option in some circumstances.
  • Recipient has to undergo desensitisation.
    
    • Reduction of the B lymphocyte pool using anti-CD20 antibody.
    • Plasmapheresis.
• MHC antigens / Human leukocyte antigen
  
  • Have a crucial role in identifying foreign pathogens.
  • These are proteins found in cell membranes.
  • In transplantation, the donated organ is recognised as foreign mainly because of differences between donor / recipient major human leukicyte antigens (HLAs).
  • These differences lead to cellular (T cell) and antibody-mediated responses.
  • HLA matching is done by comparing HLA antigens of potential donor and recipient.
  • The main antigens compared are HLA-A, HLA-B and HLA-DR.
  • Usually expressed as HLA mismatch.
  • Compatibility at these loci leads to the best long-term outcomes.

Question 6

What would cause a HLA incompatible transplantation.

Answer 6

• Potential recipient has pre-formed antibodies against the donor.
• ‘Sensitisation’ events are usually previous blood transfusions, pregnancy and previous organ transplantation.
• Desensitisation process can allow a transplant to take place, though there is an increased risk of rejection and a need for potent immunosuppression.

Question 7

What are the complications of renal transplant in hours-days following transplant?

Answer 7

• Arterial / venous thrombosis
• Ureteric leak
• Delayed graft function (DGF)
• Hyperacute rejection

Question 8

What are the complications of renal transplant in weeks following transplant?

Answer 8

Acute rejection

Question 9

What are the complications of renal transplant in months following transplant?

Answer 9

• BK virus nephropathy
• Renal artery stenosis

Question 10

What are the complications of renal transplant in years following transplant?

Answer 10

Chronic allograft nephropathy

Question 11

What are the complications of renal transplant anytime following transplant?

Answer 11

• CNI toxicity
• Infection
• Disease recurrence

Question 12

What is the most common opportunistic infection in kidney transplant recipients?

Answer 12

Cytomegalovirus.

The risk is higher if the donor is seropositive and recipient is seronegative.

Question 13

What might a patient present with post-transplant?

Answer 13

• Infection - most common is CMV.
• Fever / malaise.
• Pneumonitis / hepatitis / retinitis / GI disease.
• Leukopaenia, thrombocytopaenia.

Prevention = prophylaxis with antivirals for at least 3/12.

Question 14

What is P. jiroveci?

Answer 14

• (P. carinii)
• Yeast-like fungus
• Severe respiratory illness in immunocompromised patients.
• Fever / cough / SOB / hypoxia disproportional to clinical findings / radiology.
• Prophylaxis for a minimum of 6-12 months after transplantation.

Question 15

What is the correlation between renal transplant and subsequent cancer?

Answer 15

• Cancer is a common cause of mortality and morbidity in kidney transplant recipients.
• Multifactorial:
  
  • Immunosuppression
  • Oncogenic viruses
  • Altered T cell immunity
• Skin tumours (BCC and SCC)
  
  • Relative risk for SCC ~100-fold higher than that in the immunocompetent population.
• PTLD
• Cervical

Question 16

What is the most frequent cause of death in transplant recipients?

Answer 16

• Cardiovascular disease - 35-50% of all-cause mortality.
• Atherosclerotic vascular disease is a feature of CKD (especially on dialysis).
• Traditional risk factors in play and risk factors unique to transplant recipients e.g. immunosuppressive therapy and the chronic inflammatory state.