Transplant surgery

Question 1

When is kidney transplantation indicated

Answer 1

ESKD (CKD stage 5 = GFR < 15 and symptomatic)

On RRT (dialysis) while waiting

Question 2

Explain how kidneys are transplanted

Answer 2

Explanted human kidney (from living or deceased donor) is anastamosed to iliac vessels of recipient and donor ureter is placed in recipients bladder

Question 3

Survival post-renal transplant

Answer 3

13-16 years

Question 4

Considerations in renal transplantation

Answer 4

ABO compatibility
Minimising HLA mismatches
Donor virus status
Immunosuppression

Question 5

How do pre-formed HLA antibodies occur

Answer 5

Previous transplant, blood transfusion, pregnancy

Question 6

Early complications of renal transplants

Answer 6

Early technical failure:
- occlusion/stenosis of arterial or venous anastamosis
- urinary leaks 2˚ damage to ureter or defects in anastamosis bw bladder and ureter

Acute tubular necrosis
- delayed graft Fx from ATN in deceased donor graft 2˚ hypotension or loss of CO and prolonged cold ischaemia time

Hyperacute rejection (< 48hrs) 2˚ preformed ABO or HLA antibodies against donor molecules

Acute rejection (<3mo) 2˚ to host T cells recognising donor kidney as foreign and generating a cell mediated and antibody mediated response
- presents with pain and swelling in graft region, fever, increased BP and reduced UO

Infection
- Bacterial (< 1mo post-op): UTI, wound, chest
- CMV (weeks - months)
- Opportunistic: PJP

Question 7

Late complications of renal transplantation

Answer 7

Immunosuppressive drugs
- Post-transplant lymphoproliferative disorders
- Skin cancer risk including SCC, BCC
- Renal, vaginal, cervical malignancies
- Osteoporosis (steroids)
- Drug toxicity
CVD
Recurrent renal disease

Question 8

Liver transplantation indications

Answer 8

Acute hepatic failure of any cause

Chronic liver disease usually for complications of cirrhosis that are no longer responsive to therapy
- End stage cirrhosis (Child’s grade C) w/ debilitating Sx

PBC when bilirubin is > 100umol/L or intractable pruritus

Chronic HBV if HBV negative or levels are falling with Tx

Chronic HCV

Autoimmune hep if failing to respond to medical Tx

Alcoholic liver disease if well motivated and stoped drinking

Wilsons, haemochromatosis, a1at-def

NASH

Question 9

Complications in liver transplant

Answer 9

Sepsis
Haemorrhage

Acute or cellular rejection (5-10 days; fever)
- immunosuppression

Chronic ductopaenic rejection (6weeks - 9mo) - arteriopathy with narrowing and occlusion of arteries and disappearing bile ducts
- re-transplantion

GVHD (rare)