Renal transplantation

Successful renal transplantation offers the potential for almost complete rehabilitation in ESRF. It allows freedom from dietary and fluid restriction and anaemia and infertility are corrected.

Factors affecting success:

• Matching donor and recipient for HLA type
• Adequate immunosuppressive therapy
• Preoperative blood transfusion
• The ‘centre effect’ (graft survival is higher in those centres with extensive experience of management of transplant recipients)

The donor kidney:

• Cadaveric donation:
• Organ is removed from a brainstem-dead individual whilst their heart is still beating
• Living relative donation:

Immunosuppression for transplantation:

• Risk of rejection is highest in the first 3 months (as some degree of immunological tolerance to the graft does develop)

Corticosteroids:

• High-dose methylprednisolone is used as the primary treatment for acute rejection

Azathioprine:

• Prevents cell-mediated rejection by interfering with nucleic acid synthesis and preventing the replication of lymphocytes

Cyclosporin:

• A fungal metabolite
• Prevents the activation of T-lymphocytes in response to new antigens
• Highly effective in preventing rejection, whilst leaving the rest of the immune system largely intact

Tacrolimus:

• A macrolide (antibiotic)
• Blocks T cell activation by a mechanism very similar to that of cyclosporin but with fewer rejection episodes

Mycophenolate mofetil:

• Metabolised to mycophenolic acid
• May supplement azathioprine as an immunosuppressant
• Still in trial stages

Complications:

• Technical failure:
• Occlusion/stenosis of the arterial and/or venous anastomoses
• Leaks (owing to damage to the lower ureter)
• Immunosuppression:
• Corticosteroid complications (e.g. moon face, easy bruising, etc)
• Cyclosporin can produce a rash, nephrotoxicity, tremor, diabetes
• Tacrolimus can cause nephrotoxicity and neurotoxicity
• Azathioprine can lead to bone marrow suppression

Factors rendering a patient less suitable for transplantation:

• Previous malignancy
• Severe non-renal disease that is likely to limit survival post-transplantation
• Vascular disease (especially DM)