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