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Results of Renal Transplantation

Introduction The use of outcome data for renal transplantation in the United States (US) represents one of the best available examples of medical care supported by local and national databases to allow evidence-based decisions in the field. According to requirements directed by the United Network for Organ Sharing (UNOS), a federal government-authorized body, all transplant centers must submit transplant data to the Scientific Registry of Transplant…

Kidney Transplantation in Developing Countries

Introduction: The Role of Organ Transplantation in the Developing World Africa is the most underdeveloped continent when it comes to transplantation options for patients with end-stage organ disease. Renal failure is a common condition, and for this reason exploring options for renal transplantation on the continent makes sense. However, starting a transplant program is a daunting task and despite previous meetings driven by the World Health…

Kidney Transplantation in Children

Introduction Kidney transplantation is the preferred treatment for end-stage renal disease (ESRD) in children and confers improved survival, skeletal growth, health-related quality of life, and neuropsychological development compared with dialysis. The medical and surgical care of ESRD and kidney transplantation in children poses unique challenges. Growth and neurocognitive development are impaired during chronic kidney disease (CKD) and are a unique focus of pediatric nephrology care. The…

Pancreas and Kidney Transplantation for Diabetic Nephropathy

The prevalence of diabetes mellitus (DM) in the US in 2015 according to the American Diabetes Association is estimated to be 30.3 million Americans, 9.4% of the population. Diabetes remains the seventh leading cause of death in the US in 2015, with 79,535 death certificates listing it as the underlying cause of death and a total of 252,806 death certificates listing diabetes as an underlying or…

Cancer in Dialysis and Transplant Patients

Dialysis patients and kidney transplant recipients have considerably greater cancer risk than the general population. This chapter discusses cancer in dialysis patients and kidney transplant recipients, with the exception of skin malignancies, which are considered separately in Chapter 34 . Cancer in Dialysis Patients Soon after the first reports of cancer arising de novo in kidney transplant recipients, it was suggested that dialysis patients were also…

Cutaneous Disease in Kidney Transplantation Patients

Introduction Organ transplant recipients (OTRs), which include renal transplant patients, are significantly affected by cutaneous disease as a result of a prolonged immunosuppressed state. Renal transplant recipients have a 5-year survival rate of 85%. Therefore with promising odds for survival, the chronic nature of skin disease may become challenging to manage for these patients. Because the skin is visible, cutaneous disease may significantly affect patient quality…

Neurologic Complications after Kidney Transplantation

Neurologic complications occur frequently in the setting of kidney disease and transplantation, with an incidence reported at 10% to 21% in the posttransplant setting. Neurologic complications may arise immediately after transplantation or can occur months to years after transplant. Renal disease can also lead to neurologic conditions, some of which can be improved or resolved by kidney transplantation. In this chapter, we will first discuss the…

Liver Disease Among Renal Transplant Recipients

Overview of Incidence and Clinicopathologic Associations Theoretically, the spectrum of liver disease in renal transplant recipients should mimic the spectrum of disease seen in society. It is axiomatic that renal transplant recipients are at risk for all the acute and chronic liver disorders seen in the nontransplant population. Surveys of the prevalence of chronic liver injury in otherwise healthy subjects suggest that the burden of unrecognized…

Infection in Kidney Transplant Recipients

Overview Successful management of infections in kidney transplant recipients is a function of the immune status of the host and the epidemiology of infectious exposures. Transplant recipients are susceptible to a broad spectrum of infectious pathogens while manifesting diminished signs and symptoms of invasive infection. Thus the diagnosis of infection is more difficult in transplant recipients than in immunologically normal individuals. The interactions between infection, immunosuppression,…

Cardiovascular Disease in Renal Transplantation

Introduction A successful renal transplant is the most effective way of reducing the incidence of cardiovascular disease (CVD) and cardiovascular (CV) mortality in patients with end-stage renal disease (ESRD). Although the risk of CVD in renal transplant recipients (RTR) is approximately three times that of the general population, this is much less than the 10- to 20-fold increase in CV risk in patients receiving maintenance hemodialysis.…

Urologic Complications After Kidney Transplantation

Urologic complications are inevitable in renal transplantation. Their incidence and effect on graft survival can, however, be minimized. This chapter reviews the types of urologic complications that may occur, maneuvers to prevent them, when to suspect and how to diagnose them, and treatments to maximize long-term outcome. Retrospective series quote an incidence of urologic complications of 1% to 15%, which has remained relatively stable. The first…

Vascular and Lymphatic Complications After Kidney Transplantation

Introduction The enduring techniques of vascular anastomoses described by Alexis Carrel more than a century ago have not changed significantly (see Chapter 1 ). His simple test of satisfactory vascular anastomosis was observation of a viable kidney transplant producing urine within minutes of completion. No matter how many times it has been witnessed before, this observation will always put a smile on the face of everyone…

Chronic Allograft Failure

Acknowledgments I am grateful for the excellent photomicrographs provided by Dr. Rajathurai Murugasa and Professor Ranjit S. Nanra of John Hunter Hospital, Newcastle, NSW, Australia. Introduction Epidemiology Despite the success of modern kidney transplantation where early acute rejection rates are less than 15% and 1-year graft survivals exceed 90%, yearly graft-loss rates have not greatly changed at 4%. Short-term improvements have incompletely translated into better long-term…

Biomarkers of Kidney Injury and Rejection

Acknowledgments Original work by the authors was funded by the NIH (grant 1U01AI070107) and National Health and Medical Research Council of Australia. Karen Keung is a recipient of the Jacquot Research Entry Scholarship from the Royal Australasian College of Physicians and the Australian and New Zealand Society of Nephrology. Philip O’Connell is a recipient of an NHMRC Practitioner Fellowship. As is the case for other complex…

Pathology of Kidney Transplantation

Abbreviations AMR antibody-mediated rejection ATN acute tubular necrosis CAN chronic allograft nephropathy CMV cytomegalovirus CNI calcineurin inhibitor CNIT calcineurin inhibitor toxicity DGF delayed graft function DSA donor-specific antibody EM electron microscopy FSGS focal segmental glomerulosclerosis GBM glomerular basement membrane HLA human leukocyte antigen IFTA interstitial fibrosis and tubular atrophy MGN membranous glomerulonephritis MPGN membranoproliferative glomerulonephritis PAS periodic acid-Schiff PTC peritubular capillary PTLD posttransplant lymphoproliferative disease PTN…

Kidney Allocation

It is a favorite assertion of the authors that clinical transplantation is an excellent example of “medical ethics in practice.” Perhaps this is best demonstrated by the processes of organ allocation where a balance must be struck between allocation that makes best use of a scarce resource and the principle of equitable access to all on the waiting list. Two-Step Process It is important to acknowledge…

Paired Exchange Programs for Living Donors

Introduction There are far more eligible kidney transplant candidates worldwide than there are organs available. Kidney exchange, also referred to as paired kidney donation, has become strongly established over the past decade as a modality for facilitating living kidney donation by donors who are not compatible with their intended recipients. Instead of donating directly to the intended recipient, candidate-donor pairs are matched together to participate in…

Transplantation in the Sensitized Recipient and Across ABO Blood Groups

Naturally occurring antibodies against blood group antigens and acquired alloantibodies against donor human leukocyte antigens (HLAs; secondary to a prior kidney transplant, blood transfusions, or pregnancy) may pose major barriers to a successful renal transplantation. Because approximately 20% of renal allograft candidates may be blood group incompatible with their living donor and more than one-third will demonstrate some level of anti-HLA antibody pretransplant, understanding the unique…

Approaches to the Induction of Tolerance

Acknowledgments The work from the authors’ own laboratories described in this review was supported by grants from The Wellcome Trust, Medical Research Council, British Heart Foundation, The Deutsche Forschungsgemeinschaft, and The European Union ONE Study, Optistem, TRIAD, AFACTT (European Union COST action – BM1305), and BioDRIM networks. Introduction Historical Perspective In 1951 Billingham and Medawar published a landmark article entitled “The Technique of Free Skin Grafting…

Other Forms of Immunosuppression

Small Molecules Leflunomide and Malononitrilamides Leflunomide, initially developed as an agriculture herbicide, was explored as an immunosuppressant because of its ability to inhibit the enzyme dihydroorotate dehydrogenase. The potential of leflunomide as an immunosuppressant in the field of transplantation was extensively demonstrated in various experimental studies, but its long half-life (several days) poses the problem of potential overimmunosuppression in transplant patients. Analogs of the active metabolite…