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