HC24: Introduction MOOC

Lectures

Mandatory MOOC lectures:

• The kidney in health and disease
• Options if kidneys fail
• Immunogenetics
• Histocompatibility
• The diabetic patient
• SPK and islet cell transplantation
• Introduction and overview of early challenges (from 1,15 to the end)
• Cellular rejection
• Antibody mediated rejection
• Cases from daily practice A: patient cases with early challenges
• Cases from daily practice B: patient cases with early challenges
• Introduction and overview of late challenges (from 0,56 to the end)
• Infections: overview and CMV infection
• Infections: BK and EBV infection
• Cases from daily practice A: patient cases with late challenges
• Cases from daily practice B: patient cases with late challenges
• MOOC module 1: Etivity, which treatment do you advise?
• MOOC module 2: Etivity, which donor do you advise?

Functions

The kidney has several functions:

• Clearance of toxins
  • Ureum
  • Creatinine
  • Potassium
  • Acid
• Regulation
  • Water
  • Salt
  • Blood pressure
• Production
  • Erythropoietin
  • Vitamin D

Renal failure

Renal failure can have multiple causes:

• Prerenal
  • For example a very low blood pressure
• Renal
  • Lie within the kidney
• Postrenal
  • For example a tumor which presses on the urinary tract

There are many types of chronic renal failure:

• Diabetic
• Non-diabetic
  • Vascular: nephrosclerosis
  • Glomerular
    • Primary: IgA nephropathy
    • Secondary
  • Interstitial: reflux nephropathy
  • Cystic kidneys
• Chronic transplant dysfunction

Renal replacement therapy

There are several options if the kidneys do not work:

• Dialysis
  • Hemodialysis (1960)
  • Peritoneal dialysis (1970)
• Transplantation (1966)
  • Deceased donor
  • Living donor

Diabetes

Diabetes leads to severe vascular complications:

• Microvascular
  • Adenopathy
  • Nephropathy
  • Neuropathy
• Macrovascular
  • Cerebral artery disease
  • Cardiac disease
  • Peripheral artery disease

Simultaneous pancreas kidney transplantation:

In case of diabetes type 1, a simultaneous pancreas and kidney transplantation can be made. This way, the patient can make new insulin.

Problems after transplantation

A kidney transplantation isn't always succesful:

• Week 1 post-transplantation
  • Acute tubular necrosis
  • Hyperacute rejection
  • Urologic
    • Obstruction
    • Urine leak
  • Vascular thrombosis
    • Renal artery
    • Renal vein
• <12 weeks post-transplantation
  • Acute rejection
  • Calcineurin inhibitor toxicity
  • Volume contraction
  • Urologic
    • Obstruction
  • Infection
    • Pyelonephritis
    • Viral infections
  • Interstitial nephritis
  • Recurrent disease
• >12 weeks post-transplantation
  • Acute rejection
  • Volume contraction
  • Calcineuron inhibitor toxicity
  • Urologic
    • Obstruction
  • Infection
    • Pyelonephritis
    • Viral infections
  • Chronic allograft nephropathy
    • Decline in renal function
  • Recurrent disease
  • Renal artery stenosis
  • Post-transplantation lymphoproliferative disorder

Infections following renal transplantation:

• 1st month after transplantation: mostly due to the operation
• Long term: opportunistic infections
  • Important factor for later renal failure

Rejection

Diagnosis:

In case of rejection, donor antigen presenting cells present an antigen, which triggers reactions of T-cells.

Clinical signs of rejection are:

• Malaise
• Fever
• Oliguria
• Hypertension
• Graft tenderness

Diagnosis hinges on serial creatinine measurements. Elevation of 20% over the baseline creatinine triggers further evaluation. Non-immunologic causes need to be ruled out:

• Ultrasonography
• Renal scanning
• Percutanous biopsy

Graft rejection:

Graft rejection is an allogenic response. It is the result of the recipient immune system recognizing "alloantigens" in the graft as foreign and mounting an immune response. Alloantigens are endogenous (self)antigens whose structure can vary between individuals in the population.

Acute rejection:

There are 2 types of acute rejection:

• Type I acute cellular rejection: manifested by interstitial mononuclear cell infiltration with invasion of the tubules
• Type II acute cellular rejection: manifested by endothelialitis with mononuclear cell infiltration beneath the arterial endothelium
  • Also called acute vascular rejection
  • More severe

Survival rates

The 1 year survival rates of renal transplantation are 90-95%. The 5 year survival rates are 55-70%. This can have 2 reasons:

• Death with function (50%) → death isn't caused by the kidneys
  • Cardiovascular disease
    • Diabetes
    • Hypertension
    • Dyslipidemia
    • Renal function
  • Malignancy
  • Infection
  • Miscellaneous
• Kidney graft loss (40%)
  • Organ quality and IR-injury
  • Acute rejection episodes
  • Drug-related nephrotoxicity
  • Recurrent kidney disease
  • Vascular disease
    • Hypertension
    • Hyperlipidemia
    • Nicotine abuse