Renal Transplant

Physical Examination

General Examination:

• Observe the patient's general appearance and any obvious abnormalities, such as signs of distress or fluid overload

• Assess for signs of peripheral oedema or ascites

• Hands - AV fistula (check if it is functioning - thrill or bruit, and whether being used recently - recent needling marks)

Inspection:

• Inspect the abdomen for any distension, asymmetry, or masses

• Look for any scars related to the transplant, such as a midline laparotomy scar or an oblique scar in the iliac fossa

Palpation:

• Begin with light palpation to assess for tenderness, guarding, and superficial masses

• Move on to deep palpation to assess for organomegaly or deep masses

• Assess for hepatosplenomegaly and any palpable masses in the liver or spleen

• Assess for any palpable masses in the kidneys or bladder

• Assess for any masses underneath the scar

Percussion:

• Assess for any areas of dullness which may indicate the presence of fluid

Auscultation:

• Listen for bowel sound

• Assess for any bruits in the abdominal aorta, renal arteries, or iliac arteries

Additional Examination:

• Check for any signs of chronic immunosuppression, such as increased skin pigmentation, multiple skin warts, and prematurely aged skin

• Look for evidence of skin malignancies, including basal cell carcinoma or squamous cell carcinoma, or previously excised skin malignancies

• Check for any evidence of fine tremor, which may indicate ciclosporin toxicity

• Look for surgical or radiotherapy scars suggestive of treatment of other malignancies, such as lymphoma

• Check for any signs of gingival hypertrophy, which is rare due to meticulous dental care

• Assess for any evidence of hearing aids which could suggest Alport's disease or aminoglycoside-induced nephrotoxicity plus ototoxicity

• Look for any evidence of complications of chronic kidney disease or renal replacement therapy, such as peritoneal dialysis or hemodialysis

• Assess for the functioning status of the renal transplant, including hypertension, fluid overload, and current evidence of dialysis

• Look for any evidence of phosphate binders by the bedside, which may be used to treat complications of chronic kidney disease.

Commonest causes of Renal Transplant

• Diabetes

• Hypertensive Nephropathy

• Polycystic Kidney Disease

• Glomerulonephritis, such as Lupus Nephritis

Complications of renal transplant

Acute complications

• Acute rejection

• Acute vascular injury

Chronic complications

• Chronic rejection

• Recurrence of the original disease

• Side effects of immunosuppressants

  • Steroids: Cushingoid features (moon face, acne, purpura, striae, hirsutism), hypertension, diabetes mellitus, osteoporosis

  • Cyclosporin: gum hypertrophy, tremor, hypertension, hirsutism, nephrotoxicity

  • Tacrolimus: diabetes mellitus, hypertension, nephrotoxicity

  • Azathioprine & Mycophenolate mofetil: bone marrow suppression, hepatotoxicity, increased susceptibility to infection

• Infection

• Malignancy: skin malignancy, post-transplant lymphoproliferative disorders

Differential diagnosis of a mass in Right Iliac Fossa

• Appendicular mass

• Appendicular abscess

• Caecal cancer

• Crohn's disease

• Diverticulitis

• Ileo-caecal TB

• Tuboovarian mass in female patients

• Undescended testes in male patients

Opportunistic infection associated with renal transplant

Viral infections:

• Cytomegalovirus (CMV) - can cause fever, myelosuppression, hepatitis, pneumonitis, and gastrointestinal disease.

• Epstein-Barr virus (EBV) - associated with post-transplant lymphoproliferative disorder (PTLD).

• Herpes simplex virus (HSV) - can cause oral and genital lesions or disseminated disease.

• Varicella-zoster virus (VZV) - can cause shingles or disseminated varicella infection.

• Human herpesvirus-6 (HHV-6) - associated with fever, bone marrow suppression, and encephalitis.

• Polyomavirus BK virus (BKV) - can cause nephropathy and ureteral stenosis.

• Hepatitis B and C viruses - may reactivate or cause de novo infection in transplant recipients.

Fungal infections:

• Candida species - can cause oral and oesophagal candidiasis, urinary tract infections, or disseminated infections.

• Aspergillus species - associated with sinusitis, pulmonary infections, or disseminated disease.

• Cryptococcus neoformans - can cause meningitis or disseminated infections.

• Pneumocystis jirovecii - causes Pneumocystis pneumonia (PCP).

Parasitic infections:

• Toxoplasma gondii - can cause encephalitis or disseminated infections in recipients of an infected donor organ.

• Strongyloides stercoralis - can cause strongyloidiasis with the potential for hyperinfection and dissemination.

• Mycobacterial infections:

  • Mycobacterium tuberculosis - can cause reactivation of latent tuberculosis or de novo infection.

  • Nontuberculous mycobacteria (NTM) - can cause pulmonary or disseminated infections.