Transplanted Kidney

Relevant physical signs

• Transplanted kidney
  • J shaped scar, usually in right iliac fossa
  • May have midline laparotomy scar in simultaneous pancreas and kidney transplant
  • Mass in the right iliac fossa, dull to percussion
• Whether or not the graft is working
  • Scars
    • Old, non-functioning AVFs
    • Non-tunneled central venous catheter scars
    • Tunneled central venous catheter scars
    • Peritoneal dialysis catheter scars
  • Arteriovenous fistulae
    • Presence of a thrill
    • If no thrill, presence of a bruit
    • Needling marks over the AVF
  • Tunneled central dialysis catheters
    • Signs of surrounding infection
  • Peritoneal dialysis catheters
• Adequacy of renal replacement therapy
  • Asterixis (uraemic encephalopathy)
  • Volume status
  • Excoriations (pruritus from uraemia)
  • Tachypnoea (respiratory compensation for metabolic acidosis)
  • Pericardial rub (uraemic pericarditis)
• Complications of end-stage renal failure
  • Parathyroidectomy scar (tertiary hyperparathyroidism) ± auto-implantation scar in deltoid
  • Pseudo-clubbing (short terminal phalanges from tertiary hyperparathyroidism)
  • Anaemia due to erythropoietin deficiency (conjunctival pallor)
  • Volume overload
• Complications of immunosuppression
  • Steroids
    • Cushingoid appearance
    • Thin skin
    • Abdominal striae
    • Easy bruising
    • Proximal myopathy
    • Cataracts
  • Cyclosporine (calcineurin inhibitor)
    • Tremor
    • Gingival hyperplasia
    • Hypertrichosis
    • Nephrotoxicity
  • Mycophenolate (inhibitor of lymphocyte proliferation)
    • Rash
    • Peripheral oedema
    • Tremor
  • Tacrolimus (calcineurin inhibitor)
    • Diabetes mellitus
    • Rash
    • Tremor
  • Sirolimus (mTOR inhibitor)
    • Peripheral oedema
    • Acne vulgaris
    • Arthralgia
  • Chronic immunosuppression in general
    • Opportunistic infections
    • Post-transplant lymphoproliferative disease (hepatosplenomegaly, lymphadenopathy)
    • Skin malignancies (basal cell carcinoma, squamous cell carcinoma, melanoma)
    • Viral warts
  • Aetiology of renal disease
    • Bilateral ballotable kidneys (APKD)
    • Nephrectomy scars (APKD)
    • Finger prick marks for blood sugar monitoring
    • Diabetic dermopathy
    • Hearing aids (Alport’s syndrome)
    • Symmetrical deforming polyarthropathy (rheumatoid arthritis)
    • Non-scarring alopecia (SLE)
    • Oral ulcers (SLE)
    • Vasculitic or malar rash (SLE)

Causes of end-stage renal failure

• Diabetes mellitus (most common cause in Singapore)
• Hypertension
• Chronic glomerulonephritis
• Autosomal dominant polycystic kidney disease
• Drug-induced nephropathy (cyclosporine, NSAIDs, aminoglycosides)
• Autoimmune disease (SLE, RA, Wegner’s granulomatosis, Goodpasture’s disease)
• Obstructive uropathy
• Vesico-ureteric reflux / recurrent urinary tract infection
• Alport’s syndrome
• Hepatorenal / cardiorenal syndrome

Further investigation

• Confirm diagnosis and assess graft: ultrasound Doppler of the transplanted kidney
• Check that the graft is working
  • Full blood count: anaemia due to erythropoietin deficiency
  • Renal function
  • Calcium and phosphate (renal osteodystrophy)
  • Assessment of volume status
    • Chest radiography to look for pulmonary oedema
  • Consider arterial blood gas if graft function is declining (metabolic acidosis)
• Look for complications of immunosuppression
  • Full septic work-up in patients presenting with fever
  • Thorough examination of lymphatic system
  • Thorough examination of the skin for skin malignancies
  • Full blood count (myelosuppression)
  • Renal function (cyclosporine and tacrolimus are nephrotoxic)
  • Liver function tests (hepatotoxicity)
  • Fasting plasma glucose and HbA1c measurement (tacrolimus-induced diabetes)
  • Fasting lipids (tacrolimus)
• Look for an underlying cause
  • Measure blood pressure
  • Fasting plasma glucose and HbA1c
    • Retinal screen as diabetic retinopathy and nephropathy often co-exist
  • Ultrasound of the native kidneys and urinary tract
  • Consider renal biopsy
  • Autoantibody screening

Management

• Multidisciplinary team approach
• Patient education on control of risk factors for renal disease, importance of compliance to medication, need to present to hospital if fever develops
• Monitoring for toxicity of immunosuppressants
  • FBC, RP, LFT
  • Screening for opportunistic infections in the context of fever
  • Monitoring of graft function
  • Referral to Dermatology for surveillance for skin malignancies
• Treat acute presentations with sepsis
  • Broad-spectrum antibiotics
  • Full septic work-up; spectrum of disease may be
    • Common, community-acquired pathogens
    • Opportunistic infections
      • Pneumocystis jirovecii
      • Cytomegalovirus
      • Epstein-Barr virus (especially in the context of post-transplant LPD)
      • Invasive aspergillosis
      • BK virus
      • JC virus
• Initiation of renal replacement therapy if graft function declines despite appropriate immunosuppression
  • Symptomatic uraemia
    • Uraemic encephalopathy
    • Uraemic pericarditis
    • Nausea, vomiting, anorexia
  • Resistant fluid overload
  • Decompensated metabolic acidosis

Summary

Sir, this patient has a kidney transplant located in the right iliac fossa. On examination of the abdomen, there is a J-shaped scar over the right iliac fossa, which is associated with a firm, non-tender underlying mass. The mass is dull to percussion, and does not move with respiration.

With regards to previous modes of renal replacement therapy, there is an arteriovenous fistula in the left arm, which has no thrill, bruit or needle marks. There are scars on the neck and anterior chest wall to suggest previous central venous catheter placement for haemodialysis. There are also scars on the abdomen suggestive of previous peritoneal dialysis.

As for complications of chronic kidney disease, I note that the patient has a scar over the anterior neck, which may be suggestive of previous parathyroidectomy. This is associated with a scar over the right deltoid, suggesting auto-implantation of parathyroid tissue. There is no evidence of uraemia or volume overload.

There is a coarse tremor suggestive of immunosuppressant use. There is no gingival hyperplasia, which is sometimes associated with cyclosporine use. There were no obvious skin lesions to suggest a mitotic lesion, which may complicate long-term immunosuppression, although I would have liked to examine the skin thoroughly. There is no palpable lymphadenopathy, which in this context may suggest a post-transplant lymphoproliferative disease.

Regarding the aetiology of the chronic kidney disease, there were no nephrectomy scars to suggest removal of the native kidneys. I was unable to ballot any masses, and there are no finger prick marks or dermopathic changes in the legs to suggest underlying diabetes. Common causes of end-stage renal failure include diabetes, hypertension and chronic glomerulonephritis.

In summary, this patient has a renal transplant, which currently appears to be functioning.