Approach
- As for abdominal examination
- Signs of anaemia (pale palmar creases, pale conjunctivae)
- Scar over wrist (site of Bresica-Cimino AV fistula)
- Signs of steroid use - bruising, thin skin
- Swelling in RIF or LIF if combined kidney-pancreas transplant
- Specific scar over RIF (curved inguinal incision used to perform transplant - Rutherford-Morrison)
- Presence of previous nephrectomy scars and points of access of old dialysis catheters
- Perma-cath / porta-cath / tunnelled-lines
- Collar incision (for parathyroidectomy; hyperparathyroidism is a common complication of chronic kidney disease, vitamin D deficiency from failure of 1-OH-lation)
- Mass in iliac fossa - superficial, well defined as transplanted kidney placed outside peritoneum (covered only by external and internal oblique and transversus abdominis muscles
- Should only be palpated very lightly
Renal transplantation
Indication = End stage renal failure
- DM
- Hypertensive renal disease
- Glomerulonephritis
- Polycystic kidney disease
- Congenitally small kidneys
Matching of kidneys
- ABO compatability
- HLA compatability - HLA DR has greatest importance, hen HLA-B
Anastamoses performed in renal transplantation
- Renal artery (with Carrel patch from aorta) anastamosed to either internal or external iliac artery
- Renal vein to external iliac vein
- Ureter attached to bladder
Post-operative problems
- Potential malignancies associated with immunosuppression (1) post-transplant lymphoproliferative disease (2) Skin cancer
- Infections - CMV
Transplant rejection
- Hyperacute: within hours of surgeyr: due to pre-formed antibodies in a sensitized patient
- Accelerated acute: 1-4 days postoperatively due to a "secondary immune reposne" as a consequence of activation of T-memory cells
- Acute: 5 days - 2 weeks: cell-mediated
- Chronic: Humoural mechanisms more important
Features of transplant rejection
- Tenderness over graft
- Reduction in urine output
- Rising Creatinine
