Definition:
A renal transplant is a surgical procedure to transplant a functioning kidney from a donor to a patient with end-stage renal failure (ESRF). The transplant can either be from a live or cadaveric donor.
Signs:
Can be divided into:
Signs of current renal replacement:
- Right Iliac fossa scar
- Mass underneath – size, tender, percussion quality (dull) and consistency
- Sometimes LIF scar with mass underneath – may be due to failure of old transplant
Signs of previous renal replacement:
- AV fistula – palpate and auscultate for thrill to assess function and look for any recent venepuncture marks
- Peritoneal catheter or scars from previous catheter sites
- Scars on chest from previous tunnelled haemodialysis venous lines or central lines – these scars can be very subtle
Complications of ESRF:
- Pallor suggesting anaemia
- Parathyroidectomy scar from secondary or tertiary hyperparathyroidism
Side effects and complications of immunosuppressants:
- Gum hypertrophy – ciclosporin
- Hirsutism – ciclosporin
- Hypertension – ciclosporin
- Cushingoid features – steroids
- Purpura – steroids
- Evidence of skin malignancy – much more common with immunosuppressants
Clues as to aetiology:
- Unilateral/bilateral palpable native kidneys – Polycystic kidney disease (PKD)
- Nephrectomy scar or debulking scars ?kidney removal due to PKD
- Hypertension
- Fingerprick marks from CBG testing
Adequacy of renal replacement:
- Fluid status
- Signs of uraemia
Symptoms:
The patient should have no symptoms if the transplant is functioning and they are tolerating immunosuppressants.
Symptoms that may indicate a failing transplant include tenderness over the transplant, fever, increased fluid retention, abdominal pain, and reduced urine output
Causes:
Hypertension
Diabetes
Glomerulonephritis
Autosomal dominant polycystic kidney disease
Investigations prior to transplant:
Renal screen to assess for cause should have already been performed
Blood tests – routine bloods such as FBC/U+E/LFT/Coag screen/inflammatory markers
Viral serologies – Hepatitis/HIV/CMV
Group and save and cross match
ECG
Echo
Pulmonary function tests
CXR
In females – up to date cervical smear
Up to date dental check up
Management:
Patients reviewed routinely at specialist centre
Regular blood tests checking U+E/FBC/LFT
BP and cardiovascular risk monitored
Assessment of transplant function is performed
Assessment for side effects and complications of immunosuppressants
Women need regular cervical smear
Patients should wear a medic alert bracelet/necklace
Advice to contact doctor if they develop fever or prolonged illness
Annual influenza vaccination
Advice regarding smoking cessation and weight loss
Top tips:
To complete the renal transplant station say that you would want to dip urine and ask for BP. Always check the gums of a transplant patient in case they are on ciclosporin (an immunosuppressant which can cause gum hypertrophy). This looks very slick in the exam!
Written by Jo Corrado
Resources used to write this document are listed in the references section of this webpage