Kidney Transplantation
Core concepts
Understand rejection types: hyperacute (preformed antibodies, minutes-graft removal), acute cellular (days–weeks, T-cell mediated), acute antibody-mediated (donor-specific antibodies, C4d staining), and chronic (interstitial fibrosis, transplant glomerulopathy). Immunosuppression: induction (basiliximab or antithymocyte globulin), maintenance (tacrolimus, mycophenolate, steroids), and treatment of rejection (pulse steroids, thymoglobulin, plasmapheresis/IVIG for antibody-mediated).
Complications: delayed graft function, calcineurin inhibitor nephrotoxicity, BK virus nephropathy, CMV, post-transplant lymphoproliferative disorder, and recurrent primary disease (FSGS, IgA, MPGN). Donor types: living related/unrelated, deceased standard vs extended criteria.
Traps
Tacrolimus levels and nephrotoxicity-do not miss drug toxicity vs rejection; biopsy is key. BK viremia requires reducing immunosuppression. CMV prophylaxis vs preemptive therapy depends on serostatus. Hyperacute rejection is a surgical emergency. Recurrent FSGS can cause heavy proteinuria early.
Rule of thumb
Rising creatinine after transplant = biopsy; check drug levels, BK PCR, and donor-specific antibodies before adjusting immunosuppression.
Worked example
A transplant recipient at 6 months has creatinine rise, BK PCR 10,000 copies/mL, and biopsy showing viral cytopathic changes. Management: reduce immunosuppression, monitor BK PCR, and avoid empiric steroid pulses for presumed rejection.