Renal Transplantation

Question 1

progression to renal transplant?

Answer 1

CKD (stage 3-4) > end stage renal disease (CKD stage 5) > renal replacement therapy
- haemodialysis/peritoneal dialysis > transplant = last result

Question 2

which is better, transplant or dialysis>

Answer 2

transplant
dialysis has fairly high mortality (esp in older people)
dialysis damages blood vessels increasing cardiovascular risk
transplant = better QoL
transplant = cheaper

Question 3

3 types of kidney transplant?

Answer 3

decreased heart beating donor - DBD (people who are brain stem dead)
non-heart beating donor (DCD)
live donation (altruistic)
- directed and undirected
- paired donation
- financially procured (illegal)

Question 4

criteria for a transplant recipient?

Answer 4

reasonable life expectancy >5 yrs

safe to undergo procedure (anaesthetic, immunosuppression etc)

Question 5

no survival benefit of kidney transplant is seen until how long after transplant?

Answer 5

3 months

first 3 months is actually worse than dialysis

Question 6

how is a potential kidney transplant recipient assessed?

Answer 6

immunology (tissue typing and antibody screening)
virology (exclude active infection)
assess cardiorespiratory risk
assess peripheral vessels
assess bladder function
assess mental state (risk of steroids)
any co-morbidity

Question 7

contraindications to transplant?

Answer 7

malignancy (immunosuppression will cause tumour to grow faster)
active HCV/HIV infection
untreated TB
severe ischaemic heart disease, not amenable to surgery
severe airway disease
active vasculitis
severe peripheral vascular disease
hostile bladder

Question 8

how is a potential donor assessed?

Answer 8

fitness for surgery
good enough renal function for 1 kidney to be enough
anatomically normal kidneys
any co-morbidities
immunologically compatible
psychologically compatible
coming forward to offer kidney without coercion

Question 9

what blood types can donate to each other?

Answer 9

O can donate to all types
A can donate to A and AB
B can donate to B and AB
AB can only donate to AB

Question 10

how is tissue type matched?

Answer 10

blood group

HLA

Question 11

why is HLA matching so important?

Answer 11

can sensitise to foreign material creating antibodies

therefore antibodies will attack any potential subsequent transplants

Question 12

what can cause sensitisation to foreign DNA etc which can impact future transplants?

Answer 12

blood transfusion
pregnancy/miscarriage (exposure to paternal DNA via foetus’s blood)
previous transplant

Question 13

how is a kidney donation allocated?

Answer 13

1st line = paediatric recipient (any match)
2nd = ideal match
3rd = slight mismatch
4th = any other match

Question 14

what is paired donation?

Answer 14

2 couples
in each couple, one wants to give to the other but isn’t a match
however the donor in each couple is a match for the recipient in the other couple
simultaneous transplants are performed on opposite partners

Question 15

what is desensitisation?

Answer 15

used in people who are very sensitive so therefore have a very small pool of potential donors
involves active removal of blood group or donor specific antibody
can be done via
- plasma exchange
- B cell antibody (rituximab)

Question 16

kidney transplant comes with what?

Answer 16

comes with an artery, vessel and ureter

attached onto the iliacs

Question 17

how is a kidney transplant performed?

Answer 17

extra-peritoneal
transplant inserted into iliac fossa and attached to external iliac artery and vein
ureter plumbed into bladder with stent

Question 18

surgical complications of transplant?

Answer 18

bleeding
stenosis of vessels
ureteric stricture/hydronephrosis
infection
lymphocele (space filled with lymph)

Question 19

immediate vs delayed graft function?

Answer 19

immediate 
- good urine output
- falling urea and creatinine
delayed graft function
- post transplant acute tubular necrosis (needs haemodialysis and biopsy to detect at rejection)

Question 20

what is hyperacute rejection?

Answer 20

due to preformed antibodies
unsalvageable
transplant nephrectomy required

Question 21

what is acute rejection?

Answer 21

cellular or antibody mediated

can be treated with increased immunosuppression

Question 22

what is chronic rejection?

Answer 22

antibody mediated slowly progressive decline in renal function
poorly responsive to treatment so usually needs to be removed

Question 23

how does anti-rejection therapy work?

Answer 23

reduces activation of T cells

prevents host vs transplant mediated immune response

Question 24

describe immunosuppressive therapy used in transplant

Answer 24

induction treatment = basiliximab/dacluzimab
IV prednisolone during surgery
prednisolone, tacrolimus, MMF or prednisolone, ciclosporin, azathioprine

Question 25

what infections are common after kidney transplant and how is this risk managed?

Answer 25

bacterial infection (UTI, LRTI)
pneumocystis jirovecci is common
- co-trimoxazole is given as prophylaxis
viral infections (CMV, HSV, BK)
fungal infections

Question 26

what cancers commonly occur following kidney transplant?

Answer 26

non-melanoma skin cancers
lymphoma (EBV mediated PTLD)
solid organs
should be monitored for malignancy (regular derm review etc)

Question 27

anti-rejection treatment?

Answer 27

pulsed IV methylprednisolone
anti-thymocyte globulin
IV immunoglobulin
plasma exchange
rituximab, bortezimab, eculizumab