Transplantation
Evaluation and matching
Understand pretransplant evaluation: cardiovascular risk, infection screening, malignancy history, psychosocial readiness, and immunologic compatibility (ABO blood type and human leukocyte antigen matching). Know living versus deceased donation, and the concepts of brain death and donation after circulatory death. Recognize that waiting time and sensitization affect allocation.
Immunosuppression and rejection
Explain induction therapy and maintenance regimens: calcineurin inhibitors (tacrolimus, cyclosporine), antimetabolites (mycophenolate, azathioprine), corticosteroids, and mechanistic target of rapamycin inhibitors. Understand rejection types: hyperacute (preformed antibodies, immediate), acute cellular and antibody-mediated (days to months), and chronic (gradual fibrosis and graft dysfunction). Recognize signs of graft dysfunction: rising creatinine, decreased urine output, fever, graft tenderness, and weight gain.
Complications and traps
Anticipate infection (cytomegalovirus, BK virus, pneumocystis), drug toxicity (calcineurin inhibitor nephrotoxicity, tremor, gingival hyperplasia), posttransplant diabetes, hypertension, and malignancy. Trap: assuming a calcineurin inhibitor level is therapeutic without checking timing relative to dose. Trap: missing drug interactions that raise or lower tacrolimus levels (azoles, macrolides, rifampin, some anticonvulsants). Trap: attributing fever to rejection when infection is more likely early after transplant.
Worked example and rule of thumb
A transplant recipient has creatinine rising from 1.3 to 2.1 mg/dL, low-grade fever, and a subtherapeutic tacrolimus level. Evaluate for rejection and infection in parallel; do not simply increase immunosuppression without excluding infection. Rule of thumb: new graft dysfunction always prompts simultaneous consideration of rejection, infection, drug toxicity, and obstruction.