Phys · renal
Kidney Transplantation
Also known as renal transplantation · kidney transplant · renal allograft · deceased donor transplant · living donor transplant · pre-emptive transplant · delayed graft function · acute rejection · antibody-mediated rejection · chronic allograft nephropathy · interstitial fibrosis and tubular atrophy · post-transplant lymphoproliferative disorder · new-onset diabetes after transplant · panel reactive antibody
Consultant-physician-depth guide to kidney transplantation — the indications (ESKD from any cause, refer for workup once the eGFR is below 20), the donor types (deceased donor DBD versus DCD, living donor, pre-emptive), the contraindications and workup, the immunosuppression regimen (induction with basiliximab or anti-thymocyte globulin; maintenance tacrolimus plus mycophenolate plus steroid), the surgical and medical complications (rejection classified by mechanism, the infection timeline, malignancy including PTLD and skin cancer, CNI nephrotoxicity, recurrent disease, NODAT, cardiovascular disease), and pregnancy after transplant. Structured for FRACP DWE and DCE preparation.
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Red flags
- A tender graft in a transplant recipient is acute rejection, pyelonephritis, renal vein thrombosis or a perinephric collection until proven otherwise — urgent bloods, urine culture, Doppler ultrasound and usually biopsy
- A positive crossmatch is an absolute contraindication to transplant — it causes hyperacute rejection within minutes of reperfusion
- A rising creatinine with BK viraemia is BK nephropathy until biopsy proves otherwise — reduce immunosuppression, do not add cidofovir or leflunomide
- New hyperglycaemia on tacrolimus plus steroids is new-onset diabetes after transplant — screen with fasting glucose and HbA1c, and modify the regimen if severe
- Fever, falling urine output and a graft bruit early post-op suggests renal artery or vein thrombosis — a surgical emergency, graft loss within hours without exploration
- Mycophenolate is teratogenic — switch to azathioprine with a 6-week washout before any planned pregnancy
- Macrolides, azole antifungals, diltiazem and grapefruit raise tacrolimus levels precipitously; rifampicin and St John wort lower them — check every new drug for CYP3A4 interaction
Kidney Transplantation
The answer first
Kidney transplantation is the treatment of choice for end-stage kidney disease (ESKD) from any cause: it improves survival, quality of life and cost-effectiveness compared with dialysis, and it does so for almost every recipient who has no absolute contraindication [1]. The single rule that prevents the most missed opportunities in clinical practice: refer every patient with chronic kidney disease to a transplant unit for workup once the eGFR falls below 20 mL/min/1.73 m2. A pre-emptive transplant — performed before the patient starts dialysis — gives the best graft and patient survival of all, because the recipient has not yet accumulated the vascular, infective and nutritional burden of time on dialysis [2].
The organising principle for the whole topic, the one sentence a candidate can repeat under viva pressure: transplantation trades the disease of kidney failure for the controlled disease of immunosuppression. Every management decision — induction, maintenance, biopsy, infection prophylaxis, malignancy surveillance, pregnancy, drug interaction — is a re-balancing of that single trade-off: enough immunosuppression to prevent rejection, little enough to avoid infection, malignancy and toxicity. [1]
DWE high-yield: The triad of tacrolimus plus mycophenolate plus prednisolone is the global standard maintenance regimen. The SYMPHONY study established tacrolimus-based low-dose regimens as the best balance of efficacy and nephrotoxicity [5]. Know the regimen, levels, toxicities and the interactions cold — they generate more MCQs than any other part of the topic.
References9ShowHide
- [1]Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant N Engl J Med, 1999.PMID 10580071
- [2]Hariharan S, Johnson CP, Bresnahan BA, Taranto SE, McIntosh MJ, Stablein D Improved graft survival after renal transplantation in the United States, 1988 to 1996 N Engl J Med, 2000.PMID 10699159
- [3]Chadban SJ, Ahn C, Axelrod DA, et al. KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation Transplantation, 2020.PMID 32301874
- [4]Nashan B, Moore R, Amlot P, Schmidt AG, Abeywickrama K, Soulillou JP Randomised trial of basiliximab versus placebo for control of acute cellular rejection in renal allograft recipients. CHIB 201 International Study Group Lancet, 1997.PMID 9652559
- [5]Ekberg H, Tedesco-Silva H, Demirbas A, et al. Reduced exposure to calcineurin inhibitors in renal transplantation N Engl J Med, 2007.PMID 18094377
- [6]Solez K, Colvin RB, Racusen LC, et al. Banff '05 Meeting Report: differential diagnosis of chronic allograft injury and elimination of chronic allograft nephropathy ('CAN') Am J Transplant, 2007.PMID 17352710
- [7]Kotton CN, Kumar D, Caliendo AM, et al. The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation Transplantation, 2018.PMID 29596116
- [8]Kotton CN, Kamar N, Wojciechowski D, et al. The Second International Consensus Guidelines on the Management of BK Polyomavirus in Kidney Transplantation Transplantation, 2024.PMID 38605438
- [9]Taylor AL, Marcus R, Bradley JA Post-transplant lymphoproliferative disorders (PTLD) after solid organ transplantation Crit Rev Oncol Hematol, 2005.PMID 15979320