Renal Transplant Patient

OVERVIEW

  • commonest transplant
  • anastamosed to common iliac artery and vein in the pelvis. the ureter is plumbed into the bladder
  • allows ease of access for palpation and biopsy
  • kidney will be matched for HLA and MHC to minimise rejection but this is never guaranteed
  • immune suppression is induced prior to surgery and maintained long term. The drugs involved are usually different

Renal Transplant Criteria (NZ)

  • age < 65
  • BMI < 35
  • if solid organ cancer > 2 year disease free or longer
  • no hepatitis B or C
  • rigorous IHD assessment and optimization

– > 80% survival @ two years from all causes

HISTORY

  • when
  • indication
  • immunosuppression drugs
  • drugs
  • co-morbidities
  • complications

EXAMINATION

  • fluid status
  • site of donor kidney – tenderness?
  • complications

INVESTIGATIONS

  • U+E: Cr may be normal but renal function isn’t (only 50% of nephrons work)

MANAGEMENT

  • close liaison with renal team about perioperative plan
  • optimise prior to surgery

Intraoperative

  • strict asepsis
  • avoid hypovolaemia and hypotension
  • avoid nephrotoxic agents
  • careful positioning during operation to avoid damage to transplant

Postoperative

  • aggressive monitoring
  • MDT input

COMPLICATIONS

Early

  • post-operative bleeding
  • renal artery thrombosis – high BP, low urine Na ,needs surgical intervention
  • renal vein thrombosis – pain, fever, high BP, proteinuria, needs anticoagulation
  • Infection – up to 20% following surgery
  • ureteric obstruction – get an ultrasound – really important
  • acute rejection – pain, fever, high BP, needs a biopsy to confirm

Late

  • new renal disease
  • chronic rejection – HTN, proteinuria, slow rise in creat, no real treatment
  • infection – common and opportunistic
  • side effects of immunosuppressants
  • skin cancers and lymphoma

PROGNOSIS

  • graft survival 95% for matched, living donor.
  • about 90% for cadaveric donors

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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