Nephrology curriculum standards

Knowledge guide

Knowledge guide 4: Kidney transplantation

Clinical Sciences

Advanced Trainees will describe the principles of the foundational sciences.

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Eligibility and considerations

Advanced Trainees will assess the patient’s current condition and plan the next steps.

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Undertaking Therapy

Advanced Trainees will monitor the progress of patients during the therapy.

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Post Therapy

Advanced Trainees will know how to monitor and manage patients post-therapy.

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Important specific issues

In addition to what is listed above, Advanced Trainees will identify important specific issues and the impact of these on diagnosis and management.

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Transplant immunology

Management of highly sensitised recipients, including blood group incompatibility and paired exchange
The immunological basis for allograft rejection
The pharmacology of immunosuppressives used in transplantation, including their short- and long-term side effects and drug interactions
The process of tissue typing and crossmatching, and how to interpret tissue typing reports
The risk factors for HLA sensitisation, which can include the role of epitope matching for recipients expected to need future transplantation

Recipient eligibility
Blood group, human leukocyte antigen (HLA) testing, and sensitisation and impacts on graft waiting times and outcomes
Cancer (previous cancer and screening)
Cardiac investigations
Cause of kidney disease
Comorbidities
Counselling patients, family and/or carers regarding benefit and risk of transplant and the process of eligibility, activation, donor offers, and acute and chronic transplant management
Inclusion and exclusion criteria:
- absolute and relative
- cardiovascular status and function
- cognitive and carer factors
- metabolic
- socioeconomic factors
Infection in particular viral status and prophylaxis including:
- cytomegalovirus (CMV)
- Epstein–Barr virus (EBV)
- hepatitis B and C
- HIV
Medical and psychological complications of transplant
Urinary tract and bladder function
Vaccinations
Vascular imaging
Kidney donors
- Living donor (e.g. related versus unrelated, directed, paired kidney exchange and chains, altruistic):
  - donor evaluation
  - ethics of donation
  - outcomes and short- and long-term donor risks
  - paired kidney donation and chains
  - post-transplant follow-up of transplant donor
  - potential donor counselling and/or referral to specialist services, e.g. psychiatric, cardiac, and anaesthetic assessment
  - understand organisations including Donate Life as a strategy for improving organ availability
- Deceased donor kidney transplantation:
  - deceased donor wait list process
  - donor risk – high kidney donor profile index (KDPI), increased viral risk, cancer risk
  - how the allocation system works, which strongly informs whether or not to accept a kidney offer
  - kidney transplant outcomes
  - types (e.g. DBD, DCD, SCD, ECD)
Reviewing a kidney donation
- Current data recorded by ANZDATA living kidney donor registry
- Incompatible live donors
- Protocols of the local transplant unit
- Reviewing and accepting a donor organ offered to a patient

Acute transplant, including:
- immunosuppression, particularly risks and benefits of commonly used drugs (calcineurin inhibitors (CNI), glucocorticoids, mammalian target of rapamycin (mTOR) inhibitors, antimetabolites and monoclonal antibodies):
  - effects
  - induction
  - maintenance
- perioperative management
- preparation of a patient
Comorbidities in patients due to conditions including cardiovascular disease, hypertension, and obstruction

Short-term

Bone status evaluation and treatment
Complications and their short- and long-term impacts, including:
- BK virus nephropathy
- diabetes, including worsening of pre-existing diabetes or new onset diabetes after transplant (NODAT)
- diarrhoea
- neutropenia
Evaluation of graft function and dysfunction in the early post-transplant period
Fluid management
Immunosuppression
Kidney transplant biopsy indications and interpretation, including use of Banff classification in the diagnosis of acute rejection
Management of cytomegalovirus (CMV) viraemia and infection
Management of early complications
Management of rejection:
- antibody mediated
- hyperacute
- T-Cell mediated
Management of the failing graft
Radiological investigation, such as ultrasound scan and radioisotope scanning
Prophylactic antibiotics
Transplant glomerulopathy

Long-term

Bone health
Living with a donor kidney:
- counselling regarding healthy lifestyle
- immunosuppression
- prescribe and monitor effects
- regular outpatient review
Prevent, identify, and manage longer-term complications:
- increased risk of cardiovascular disease
- increased risk of malignant disease, including post-transplant lymphoproliferative disease (PTLD) and other cancers
- primary kidney disease recurrence
Strategies that maximise long-term graft function and survival

BK virus diagnosis and management
Combined kidney and pancreatic transplant
Ethical issues in organ transplantation
Interpretation of kidney biopsy histopathology changes, including:
- BK nephropathy » calcineurin inhibitor toxicity
- rejection » thrombotic microangiopathy (TMA)
- transplant glomerulopathy
Male and female fertility in transplantation
Organ sharing and allocation processes
Other organ transplant including liver, lung, and heart
Patients with known comorbid conditions which make transplant difficult, including:
- diabetes
- obesity
- polycystic kidney disease
- vascular disease
Pregnancy in patients with transplanted kidneys:
- evaluating and minimising risks to kidney transplant
- evaluating and minimising risks to mother
- fetal outcomes
Previous transplant patients being retransplanted: » graft removal prior
- immunosuppression issues
- MBD issues
Survival matching
The importance of immunologic compatibility in recipients likely to require repeat transplantation
Timing of dialysis recommencement
Vaccination recommendations, risks, and benefits

PCH

Growth in children post transplantation
Maintain adequate perfusion where there is a mismatch between donor and recipient blood pressure
Patients with substantial native urine output at transplantation
Peri-operative complications specific to small children at transplantation, e.g. abdominal compartment syndrome
The effects of immunosuppression in children
The increased risk of graft thrombosis among small children, and practises to minimise this risk