Kidney Transplantation

Indications & Workup - Kidney SOS Call

• Primary Indication: End-Stage Renal Disease (ESRD)
  • GFR < 15 mL/min/1.73m² or on dialysis.
• Common Causes leading to ESRD:
  • Diabetic Nephropathy (most frequent)
  • Chronic Glomerulonephritis
  • Hypertensive Nephrosclerosis
  • Autosomal Dominant Polycystic Kidney Disease (ADPKD)
• 📌 SOS Criteria:
  • Stage 5 CKD (ESRD: GFR < 15 or dialysis)
  • Optimal medical therapy failed
  • Suitable candidate (post-workup)

⭐ Diabetic nephropathy is the leading cause of ESRD requiring kidney transplantation in India.

Donor Selection & Surgery - New Kidney on Block

• Donor Types:
  • Living: Related (HLA-identical best), unrelated (altruistic, paired kidney exchange).
  • Deceased (Cadaveric): DBD (Donation after Brain Death), DCD (Donation after Circulatory Death).
• Key Donor Criteria:
  • ABO compatibility.
  • Negative T-cell crossmatch.
  • Age 18-65 years (flexible).
  • Normal renal function (GFR > 80 mL/min).
  • No transmissible diseases (HIV, active Hepatitis B/C, active malignancy).
• Recipient Surgery:
  • Gibson incision (extraperitoneal).
  • Kidney placed in iliac fossa (usually right).
  • Vascular Anastomosis:
    • Renal artery to external/internal iliac artery.
    • Renal vein to external iliac vein.
  • Ureteroneocystostomy (e.g., Lich-Gregoir technique).

⭐ Most common site for renal artery anastomosis is the external iliac artery.

Immunosuppression Protocols - Peace Treaty Drugs

• Core Principle: Balance preventing graft rejection & minimizing drug toxicity.
• Phases & Typical Regimens:
  • Induction (at transplant):
    • Antibody therapy (Basiliximab, ATG) + high-dose steroids.
  • Maintenance (long-term):
    • Triple Therapy: Calcineurin Inhibitor (CNI: Tacrolimus/Cyclosporine) + Antiproliferative (Mycophenolate Mofetil [MMF]/Azathioprine) + Steroid (Prednisolone).
    • CNI-sparing options: mTOR inhibitors (Sirolimus/Everolimus).
  • Rejection Treatment:
    • Acute Cellular Rejection (ACR): Pulse steroids; ATG for steroid-resistant cases.
    • Antibody-Mediated Rejection (AMR): Plasmapheresis, IVIG, Rituximab.
• Monitoring: Essential for CNIs (drug levels), renal function, infections, malignancies.

⭐ Mycophenolate Mofetil (MMF) generally offers better efficacy in preventing acute rejection than Azathioprine but is a known teratogen, contraindicated in pregnancy.

Rejection & Complications - Transplant Tremors

• Rejection Types:
  • Hyperacute: Pre-formed Ab (ABO/HLA). Mins-hrs. Irreversible.
  • Acute Cellular (ACR): T-cell. Days-months. Biopsy: Tubulitis. Rx: Steroids, ATG.
  • Acute Humoral (AMR): DSA. Biopsy: C4d+. Rx: Plasmapheresis, IVIG, Rituximab.
  • Chronic Allograft Dysfunction (CAD): Months-yrs. Fibrosis, atrophy. Multifactorial.
• Key Complications:
  • Infections: CMV, BK virus nephropathy. Prophylaxis vital.
  • Malignancy: PTLD (EBV), skin cancers.
  • Cardiovascular disease: Major long-term risk.
• Transplant Tremors (CNI-induced):
  • Cause: Calcineurin Inhibitors (Tacrolimus > Cyclosporine) neurotoxicity.
  • Features: Fine, postural, action tremor. Dose-dependent.
  • Mgmt: Optimize CNI levels, ↓dose or switch CNI, Propranolol.

  ⭐ Tacrolimus shows higher neurotoxicity (tremors, PRES) vs. Cyclosporine.

High‑Yield Points - ⚡ Biggest Takeaways

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