🩺 Chapter 90: Renal Transplant

ESRD causes · Pre-transplant evaluation · Donor selection · Immunosuppression (induction, maintenance) · Delayed graft function · Rejection types (hyperacute, accelerated, acute, chronic) · Complications (infections, PTLD, hypertension, growth) · Vaccination

🔍 Core Concepts: Renal Transplant

📌 ESRD Aetiologies (Paediatric)
Most common: congenital anomalies (aplasia/hypoplasia/dysplasia), obstructive uropathy (posterior urethral valves), FSGS, reflux nephropathy, polycystic kidney disease.
💊 Immunosuppression
Induction: basiliximab (IL-2 receptor), ATG. Maintenance: tacrolimus/cyclosporine (calcineurin inhibitor) + MMF/azathioprine + steroids. Steroid withdrawal may improve growth.
⚡ Rejection Types
Hyperacute (minutes-hours, preformed antibodies) → irreversible. Accelerated (2-5 days). Acute (1 week-3 months, T-cell mediated). Chronic (months-years).
🦠 Infectious Complications
CMV, EBV (PTLD), BK virus (nephropathy), UTI. Prophylaxis: TMP-SMX (PJP, UTI), valganciclovir (CMV if donor+/recipient-).
⚠️ Post-transplant Complications
Delayed graft function (ATN, thrombosis). Hypertension (calcineurin inhibitors, steroids). Post-transplant lymphoproliferative disorder (PTLD — EBV-related). BK virus nephropathy.
💉 Vaccination
Administer live vaccines (MMR, varicella) BEFORE transplant. Inactivated vaccines after transplant (≥3-6 months). Family/household vaccination important.

🩺 Stepwise Approach: Post-Renal Transplant Care

1
Immediate post-op (PICU)
Monitor urine output (goal >2 mL/kg/h). Maintain euvolemia (CVP 8-10). Replace urine output with 0.45% NS + D5W. Avoid hypotension (graft perfusion). Daily weight, electrolytes, SCr.
2
Immunosuppression protocol
Induction: basiliximab or ATG. Maintenance: tacrolimus (or cyclosporine) + mycophenolate mofetil (MMF) + prednisone. Monitor drug levels (tacrolimus 5-10 ng/mL).
3
Suspect rejection (rising SCr, oliguria, graft tenderness)
Exclude other causes (hypovolaemia, calcineurin toxicity, obstruction). Renal biopsy is gold standard. Acute rejection: pulse methylprednisolone (10-15 mg/kg/day x 3 days). Steroid-resistant: ATG.
4
Infectious prophylaxis & monitoring
TMP-SMX (PJP, UTI) for 6-12 months. Valganciclovir if CMV D+/R-. Monitor EBV PCR for PTLD. BK virus PCR (nephropathy).
5
Manage complications
Hypertension: calcium channel blockers (nifedipine, amlodipine), ACE inhibitors (caution with renal artery stenosis). Delayed graft function: avoid nephrotoxins, consider biopsy. PTLD: reduce immunosuppression, rituximab.
6
Long-term care
Monitor growth (steroid-sparing or alternate-day). Bone health (vitamin D, calcium). Vaccination: no live vaccines post-transplant. Yearly influenza (inactivated).