The renal transplant patient

1
The renal transplant patient

• Tintinallis Chapter 99

2

• Majority of solid organ transplants
• 60 are cadaveric donors (the ones we donate to
  LifeBanc)
• Graft prognosis is directly related to source of
  donor kidney
• Cadaveric kidneys have more episodes of rejection
  and lower graft survival rates
• Major causes of morbidity hypertension,
  hyperlipidemia, cardiovascular dz, DM,
  osteoporosis, malignant neoplasm
• Graft prognosis from live donors is better
• Causes of death CAD, sepsis, neoplasm, stroke

3
Causes of graft failure

• ARF (20 rise in baseline serum creatinine)
• Complications of surgery
• Rejection syndromes
• Anti-rejection meds (immunosuppressive agents)
• Recurrent renal dz
• Renal vascular stenosis thrombosis
• Second post-op month to after 1 yr

4
Causes of graft failure

• Transplant rejection
• Hyperacute (mins to hrs of transplant)
• Acute (days to decades after transplant most
  commonly in the first 3 mos.)
• Hypertension, low urine output, fever, pain over
  graft site, leukocytosis ck creatinine
• Chronic
• Anytime there is a gradual inc. in creatinine
  with low grade proteinuria and progressive
  hypertension

5
Immunosuppressive agents

• Table 99-2
• Corticosteroids
• Cyclosporine
• Tacrolimus
• Sirolimus
• Azathioprine
• Mycophenolate mofetil
• Monoclonal antibodies

6
Infectious complications

• Most common cause of mortality morbidity in the
  1st year
• Most common types
• Mucocutaneous
• UTI
• Respiratory tract (pneumonia accounts for about ½
  of deaths from infection)
• Most common orgs
• Bacteria
• Viral (most common CMV, HSV, VZV)
• Fungal
• Protozoan
• Table 99-4

7
Other complications.

• Cardiovascular dz
• Inc. in post-transplant pts. (3-5-fold)
• Hypertension
• CCBs to tx
• Chronic liver dz
• Viral hepatitis (CMV, Hep C B)
• Side effects of antirejection drugs
• Malignancy
• Colon, larynx, lung bladder prostate testis
• Lip, skin, kidney, endocrine glands
  non-Hodgkins lymphoma cervix vulva-vagina

8

• Immunosuppressed pts need CMV seronegative blood
  for transfusion
• Most common reason presenting to ED fever (may
  be masked secondary to immunosuppressive agents)
• Work up for infxn, hypersensitivity rxn,
  rejection, or malignancy
• Esp. if b/w 1st-6th postoperative months

9

• Physical exam (table 99-6)
• Edema (may be misleading in vol. depleted pt)
• Pain over graft site
• Orthostatics to determine hypovolemia
• Vital signs, pt wt, skin turgor
• Look for common sites of infxn.
• Over graft
• Surgical incision
• Pulmonary tract
• GU tract
• Abdomen
• Head neck
• Rectum

10

• Tests
• Serum creatinine
• U/A
• Cyclosporine/tacrolimus blood levels
• CBC w/ diff
• LFTs
• Urine Legionella Ag
• Bacterial fungal blood urine cxs
• Renal US

11

• Disposition
• GET THEM BACK TO THEIR TRANSPLANT CENTER!!!
• Call transplant coordinator ASAP