Indications for Transplant

• most common diseases resulting in transplant referrals

• diabetes mellitus w/ renal failure (high on waiting list)
• hypertensive renal disease
• glomerulonephritis
• reversible kidney disease should be excluded
• most patients are on dialysis for extended time periods before transplant
• rehabilitation of patients with glomerulonephritis is usually good, but not in patients with focal
glomerulosclerosis (idopathic form)
• in 1989 one-year allograft survival was 79%
• number of patients waiting for transplant is growing and greatly exceeds suply

Evaluation for Transplant

• physician must monitor patient’s health since the patient will be undergoing surgery and
subsequent immunosupression

Transplant
• surgeon places kidney in iliac fossa and anastamoses renal artery (with hypogastric artery), renal
vein (with iliac vein) and connect ureter to bladder
• immediate allograft reject is now uncommon due to crossmatching
• patients should have daily assessment of renal function
• watch for cyclosporin toxicity!
• OKT3 (mouse immunoglobulins to T cell receptor) is used in some regimens or for acute
rejection, but the host develops antibodies to the mouse Ig

Outpatient Follow-Up
• hyperacute rejection ! host has antibodies to donor HLA
• acute or chronic rejection
• often associated with marked infiltration of the allograft with edema
• watch for vascular lesions ! poor prognosis
• if rejection ! increase immunosuppressive doses
• infections in first few weeks can cause fever and impair allograft function, might also be confused
with rejection
• opportunistic infections (viral infections are dominant)

Immune Aspects
• T cell reaction is initiated when recipient’s lymphocytes encounter donor’s HLA antigens
• when mature cytotoxic cells are generated they lyse the graft cells
• CD4 cells induce increased vascular permeability with local accumulation of macrophage
• how does T cell respond: 1) foreign MHC mollecules are shed and present by host APCs or 2)
graft cells present donor peptides on their surface
• hyperacute rejection occurs when preformed antidonor antibodies are present in recipient
• previous kidney transplant patients (who reject)
• women who have been pregnant
• prior blood transfusions
• initial target of anitbody respond is graft vasculature ! rejection vasculitis
• immunosuppressive therapy is a necessity ! even HLA identical sibs may differ in minor
histocompatibility loci
• cyclosporin inhibits activation of cytokines (especially IL-2) ! inhibits T cell mediated immunity

• T cells are necessary for rejection