Leyland Chuang Elective posting to Dept of Renal Medicine

Renal Transplant

ESRD
50% are due to diabetes patients are usually not suitable for transplant due to
comorbidities
other 50% due to other causes suitable for transplant patients usually do better, have
lower mortality and is cheaper to treat

ESRD

Low dependency High dependency

(ie relatively healthy)
Eg malignancy, HPT, DM ,
Suitable for transplant IHD, ADL dependent
Aim for living related donor Unsuitable for transplant
If no living related donor Perform dialysis (HD or PD)
available, listed on cadaveric
donor waiting list

Criteria for transplant

Recipient Living related donor Cadaveric donor
< 60 YO Siblings <65 YO
ADL independent Offsprings no hepatitis B or C
No malignancies Parents no HIV
No PVD Spouse no systemic infections
No IHD 1st or 2nd degree relatives
No CVA no DM
No active liver disease no HPT
No HepBsAg or HepBeAg no Hepatitis
No HIV no disease
No mental retardation
Medical Priority cases:
vascular access problems
Anaemia <7g%

Poor Px indicators for post-transplant survival

Previous rejection
Host Ab vs donor
Delayed graft function usually presents with oliguria
Hep B & C need to treat Hep C with interferone for a year first and check that it is
successfully treated before transplant is carried out. Treatment not available for Hep B
Paid donor transplant (eg China, India) due to high rates of Hep B, Hep C and HIV
infections and a tendency for over immunosuppression with drugs given by overseas
doctors.

DGIM Last updated March 2005

Management pathway for transplant recipient

Check Graft function

Possible Delayed graft function Immediate graft function

(urine output <50ml/hr) (urine output >50ml/hr)
Exclude inadequate renal perfusion as
cause of delayed graft function Determine level of
Check CVP immunosuppression required based
Check perfusion scan on PRA (?antigen levels)

If CVP > 10 cm H2O

Give IV Lasix 80-120mg stat
PRA 25 PRA < 25
FK506 Cyclosporine A
+ Azathioprine + Azathioprine
Impaired Normal + prednisolone
+ prednisolone
perfusion perfusion + Zenapax

Surgery Lasix Lasix

responsive unresponsive

+ Delayed Mx of Delayed Graft Function

graft function Daclizumab < 6 hrs post
anastomosis
Cyclosporine A: monitor levels to
Determine level of avoid toxicity
immunosuppression required based
on PRA
Day 5-7

PRA 25 PRA < 25

Cyclosporine A Cyclosporine A PT still dialysis PT recovering
+ MMF + Azathioprine dependent
+ prednisolone + prednisolone
+ Zenapax + Zenapax Renal biopsy of
allograft kidney:
Check for rejection

DGIM Last updated March 2005