Renal Transplantation and Vascular Access
Core concepts
Transplant questions focus on recipient and donor evaluation, immunosuppression, and complications. Understand donor types (living vs deceased), HLA matching, crossmatching, and the importance of avoiding preformed antibodies. Immunosuppression typically combines a calcineurin inhibitor, an antimetabolite, and steroids; recognize drug-specific toxicities (tacrolimus: nephrotoxicity and neurotoxicity; cyclosporine: hypertension and gingival hyperplasia; mycophenolate: gastrointestinal and marrow effects). Surgical complications include vascular thrombosis, ureteral leak or stricture, lymphocele, and wound issues. Graft dysfunction requires distinguishing rejection, drug toxicity, obstruction, and infection; biopsy is often needed. Vascular access for dialysis: arteriovenous fistula is preferred, with the rule of distal-first and vein preservation before dialysis. Recognize steal syndrome and access infection.
Traps
Questions test the difference between surgical and immunologic causes of graft dysfunction, and the timing of complications. Do not place a fistula on the dominant arm if a suitable distal site exists without reason. Preserve veins in patients approaching dialysis.
Worked example / rule of thumb
A transplant recipient with rising creatinine and a fluid collection near the graft: consider ureteral obstruction or lymphocele; image before assuming rejection. Rule of thumb: preserve veins, place the fistula distally first, and investigate before escalating immunosuppression.