Renal Transplantation

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Overview

• Kidney transplantation is generally the optimal form of renal replacement therapy (RRT) in terms of patient survival, quality of life and cost-effectiveness.

• Immunosuppressive treatment is necessary for the life of the kidney transplant—hence compliance is a major issue in the graft survival.

• (Blood group) ABO compatibility is desirable between the donor and recipient. The risk of transplant rejection is less where there is good human leukocyte antigen (HLA) antigen ‘match’. Blood transfusions can sensitize the recipient to potential donor HLA antigens, and so should be avoided if possible when there is a likelihood of transplantation.

• A live, unrelated transplant with complete HLA mismatching has a better long-term outcome than a cadaveric organ with no mismatch at all.

• Living donors now account for > 25% of all kidneys transplanted in the United Kingdom, and this is increasing.

• Post-operatively, most kidneys function immediately. Acute tubular necrosis (ATN) is the single most likely cause of delayed graft function, and is usually reversible.

• The main complications of kidney transplantation are:

  • Rejection: 10–30% of transplanted kidneys are acutely rejected; this presents as a decline in renal function usually within the first three months. Hyperacute rejection, which occurs within hours, is very rare.

  • Tubulo-interstital fibrosis, scarring, sclerosis and vasculopathy: this is the main cause of graft failure; progressive and irreversible increases in creatinine, associated with proteinuria, usually occur over years.

  • Infection: the main concern is susceptibility to opportunistic infections, notably Cytomegalovirus and Pneumocystis carinii.

  • Malignancy: increased risk of post-transplantation lymphoproliferative disorders associated with Epstein–Barr virus …