Transplanted Kidney
Presentation
Sir, this patient has a transplanted kidney in the right iliac fossa associated with
bilateral enlarged kidneys with a functioning AVF with features of cyclosporine and
chronic steroid use.
There is presence of a rounded palpable mass in the right iliac fossa with an overlying
scar. It is non-tender. In addition there are bilateral masses in the flanks which are
bimanually palpable and ballotable with a nodular surface. I am able to get above
these masses and they are not tender. They move inferiorly with respiration and
percussion note is resonant over them. There is no associated ascites and no renal
bruit.
The liver and spleen are both not enlarged.
The patient does have features of renal impairment with a sallow appearance and is
thin looking. He does not have any bruises or pruritic scratch marks and no
leukonychia or Terry’s mails were detected. There is also no conjuctival pallor to
suggest anaemia and there are also no features of polycythemia such as a plethoric
facies or conjunctival effusion. He is also not in fluid overload with no pedal edema
and is able to lie flat and is not oxygen dependent. There is no Kussmaul’s breathing
with no uremic fetor or flapping tremor of the hands.
There is presence of an arterio-venous fistula in the right upper limb. It is functioning
with a good thrill. There are no recent needle puncture marks and no aneurysm was
noted.
There is presence of diabetic dermopathy noted on the lower limbs.
There is no evidence of transplant related hepatitis B or C with no jaundice or
stigmata of chronic liver disease.
Patient has hypertrichosis and gum hypertrophy which are complications of
cyclosporine usage. Moreover, he has a Cushingnoid habitus with steroid purpura and
thin skin, suggesting chronic steroid usage.
I would like to complete my examination:
 Temperature chart for fever
 BP for hypertension
 Fundoscopy for hypertensive changes
 Urine analysis for hematuria, proteinura or pyuria
 CVM – MVP or AR
 Neurological – III nerve palsy or PHx of stroke
In summary, this middle age gentleman has a transplanted kidney for underlying
Adult Polycystic kidney disease with previous dialysis. The graft is functioning well
as he is not uremic and is well with features of cyclosporin and steroid use.
Questions
What are the differential diagnoses for a right iliac fossa mass?
 Transplanted kidneys
 Carcinoma of the caecum (hard mass, LNs)
 Abscess – appendicular, ileocecal
 Crohn’s disease (mouth ulcers, PR for fistulas)
 Ovarian tumors (in females)
 Others
o Amoebiasis, TB lymphadenitis, actinomycosis
o Carcinoid
o Ectopic kidney
What are your differential diagnoses for a left iliac fossa mass?
 Transplanted kidney
 Colonic carcinoma (hard mass, hepatomegaly LNs)
 Diverticular abscess
 Fecal mass
 Ovarian tumors
 Others – lymphadenitis
What are the common kidney diseases leading to transplant?
 DM
 Hypertension
 GN
How does renal transplant compare with dialysis?
 Higher patient survival rates
 Better quality of life with lower hospitalisation rates
What are the causes of transplant loss?
 Patient death
 Allograft failure
o Immunological
 Acute rejection
 Single most important event determining graft survival
 Can result in rapid loss of graft or progression to chronic
rejection or chronic allograft nephropathy
 Treated with pulse steroid or anti-lymphocyte antibody therapy
 Chronic rejection
o Non-immunological
 Renovascular thrombosis
 Ischaemia reperfusion injury
 Nephrotoxicity from calcineurin inhibitors
 CMV, polyoma virus
 DM, hypertension, hyperlipdaemia
o Others
 Recurrence of primary disease (GN and DM)
 Chronic allograft nephropathy
What is delayed graft function?
 Defined as requirement of dialysis in the first week post transplant
o Immunological – acute rejection
o Non-immunological – ischaemia reperfusion injury, donor hypertension
What are the strategies one can use to reduce graft loss?
 Immunological
o Live donor better than cadaveric
o HLA matched at A, B and DR loci
o Absence of pre-sensitisation
 Previous transplant
 Pregnancies
 Transfusions
 Idiopathic
o Immunosuppresive therapy to reduce acute rejection
 Traditionally use of steroid and cyclosporin
 Others
 Calcineurin inhibitors eg Cyclosporin and tacrolimus
 Mycophenolate mofetil
 Sirolimus
 Non-immunological
o Pre-transplant
 Donor factors – old age, CVA, hypertension
 Recepient factors – older, male, obese, diabetic, hypertension
o Technical factors
 increase cold ischemia time – LD transplant, renoprotective
preservative solutions
 hyperfiltration from inadequate nephron dose – match size and better if
male to female; use of ACE inhibitors
o Post-transplant
 Calcineurin inhibitors induced nephrotoxicity
 Monitor levels
 Use others such as sirolimus or MMF
 CMV infections and polyoma virus
 Prophylaxis with ganciclovir for CMV
 No Rx for polyoma virus
 Treat BP (<130/80) and hyperlipidaemia and DM
What are the complications of cyclosporine?
 Hirsutism/hypertrichosis
 Hypertrophy of the gums
 Hypertension
 Hyperkalaemia, hyperuricaemia, hypercholesterolaemia, hypomagnesemia
 Hepatotoxicity
 Hemolytic uremic syndrome
 Hiccuping (gastroparesis)
 Hole-in-bones (osteoporosis)
 Nephrotoxicity


Neoplasia (lymphoproliferative)
Neurological (tremors, headaches, seizures and strokes)
What are the complications of chronic steroid use?
 Skin – thin skin, telangiectasia, steroid purpura
 Cushingoid habitus
 Osteoporosis, AVN femoral head
 Peptic ulcer disease
 Hypertension
 Diabetes mellitus
 Cataracts
 Steroid psychosis
How do yo manage?
 Education and counselling, regular follow up, compliant
 Treat underlying cause
 Require preparation prior to transplant
 Post transplant management to reduce graft loss (See above)