Renal Transplantation and Transplant Surgery
What this domain tests
This domain tests recipient and donor evaluation, immunologic compatibility, immunosuppression, surgical technique, and early and late complications after kidney transplantation.
Core rules and concepts
- ABO compatibility and HLA matching reduce rejection; a positive crossmatch contraindicates transplantation because of preformed antibodies. Living donor evaluation assesses renal function, hypertension, diabetes, and malignancy risk.
- Induction therapy and maintenance immunosuppression usually include a calcineurin inhibitor, an antimetabolite, and steroids. Drug levels, infection, and malignancy require monitoring.
- Hyperacute rejection occurs minutes to hours after reperfusion from preformed antibodies. Acute cellular rejection is treated with steroids or antithymocyte globulin; antibody-mediated rejection requires plasma exchange and IVIG in selected cases.
- Surgical complications include vascular thrombosis, ureteral leak, ureteral stenosis, lymphocele, and wound problems. Delayed graft function is common after deceased-donor transplantation.
- CMV and BK virus are important opportunistic infections; BK nephropathy can mimic rejection.
Worked example
A transplant recipient develops rising creatinine and reduced urine output at 6 days. Reasoning: evaluate for obstruction, leak, thrombosis, and rejection. Ultrasound and Doppler come first; a fluid collection may need drainage. Do not adjust immunosuppression blindly before excluding mechanical causes.
Traps
Do not transplant across a positive crossmatch. Do not attribute all dysfunction to rejection; obstruction and vascular problems are reversible. Do not miss BK virus when creatinine rises.