Where is a kidney transplant placed?
Right iliac fossa and anastomosed to the iliac vessels
What happens to the native kidney?
Usually left in.
- Oversized e.g. polycystic kidney disease
- Infected e.g. Chronic Pyelonephritis
List the medications used for immunosuppression in transplantees?
2) Calcineurin inhibitors (Tacrolimus or Cyclosporin)
3) Anti-proliferative (Azathioprine or Mycophenolate)
4) mTOR inhibitors (Sirolimus)
5) Costimulatory signal blockers (Belatacept)
6) Depleting agenets (Rituximab or basiliximab)
Explain how we go about immunosuppressing patients?
Induction with basiliximab (depleting agent)
Maintenance with Tacrolimus (CNI), mycophenolate (Anti-proliferative) and steroids
Steroid free treatments can be used
CNI-free treatments replace tacrolimus with Belatacept
what are the types of kidney donor?
- DBD (post brain death)
- DCD (post cardiac death)
What are the criteria for brain death?
Coma Apnoea despite CO2 build up Absent cephalic reflexes e.g. pupillary Body temp >34 No drug intoxication
What are the risks to the kidney donator?
Having one kidney puts you at higher risk of renal disease.
But the one compensates by increasing GFR up to 70%
Being older or having a high BMI is associated with ending up with a low GFR
List the complications of transplant?
- Anastomotic bleed
- Perirenal Haematoma
- Arterial/venous thrombosis
- Urine leak
- CV problems
What kind of CV problems can arise post=transplant?
Post transplant Diabetes!
What kind of cancers does a renal transplant predispose to?
Desc. order: 1) Non-melanoma skin cancer 2) Melanoma Leukaemia Cervical 3) Testicular/bladder
What are the major post-transplant infections?
Polyomaviridae (specifically BK or JC virus)
How do you get a CMV infection?
Either reactivation of latent virus or transmission from donor tissue.
It affects 8% of transplants despite prophylaxis
What can CMV infection cause?
CMV viraemia –> Tissue invasive disease
Affects many tissues e.g. hepatitis, nephritis, pneumonitis, colitis etc.
What can BK associated nephropathy cause?
What are the risk factors for a BK associated nephropathy post-transplant?
Patient factors - Old, male, white, DM
Organ factors - HLA mismatch, graft injury or ureteral stent
Viral factors - Changes in viral capsid protein (VP-1)
How do you treat BK infection?
Reduce the immunosuppression
- Cidofovir +/- IVIG
- OR Leflunomide
What is hyperacute rejection?
When theres a pre-existing alloreactivity to the donor
What are the modes of Acute Rejection?
T cell mediated (TCMR) Antibody Mediated (ABMR)
Explain the banff categorisation of TCMR?
Banff 1 - Tubulointerstitial
Banff 2 - Arteritis/Endothelialitis
Banff 3 - Arterial Fibrinoid Necrosis
Explain the Banff Categorisation of ABMR?
Banff 1 - ATN-like
Banff 2 - Capillary and/or glomerular inflammation
Banff 3 - Arteritis