Renal Transplantation

The University of Alberta has an active multi-organ transplant program resulting in the transplantation of approximately 70 kidney, 5-8 simultaneous pancreas-kidney, 45 liver, 40 heart, heart-lung, or lung transplants each year. Renal transplant recipients are admitted to the nephrologists on a Multi-organ Transplant Unit (MOT Unit) at the University Hospital such that the nephrology service is responsible for the post-operative care, including immunosuppressive therapy and the management of medical post-operative complications. There is a close working relationship with the transplant surgeons. All renal transplant recipients in northern Alberta are followed longitudinally by the Northern Alberta Renal program; currently there are approximately 850 active patients in the program. The program is an active participant in clinical trials including those of new immunosuppressive agents such that the resident will be exposed to innovations emerging in the field.

The transplant rotation is a four-week rotation at the University Hospital, during which the subspecialty resident is responsible for the care of all renal transplant recipients admitted to the renal transplant service. This includes all adult patients admitted for kidney transplantation and patients readmitted with transplant-specific complications. The resident also attends a minimum of two half-day transplant clinics each week, during which he/she will have the opportunity to assess transplant recipients at various points in their course. They will participate in the assessment of potential transplant recipients and living kidney donors. The resident is expected to attend Renal Pathology Rounds, during which interesting renal transplant biopsies are reviewed. The resident participates in the weekly multidisciplinary renal transplant meeting where recently transplanted patients, interesting cases, and study protocols are discussed. During the rotation, the trainee meets with several of the transplant nephrologists to review key topics in a one-on-one fashion. A reading list is provided for the rotation.

Formal seminars and journal clubs in renal transplantation have been incorporated into the year-round schedule.

The renal transplant program is involved in both bench and clinical research. Active areas of research include gene expression in the injured or rejecting allograft, endothelial biology, the diagnosis and management of antibody-mediated rejection, determinants of long-term allograft function, and post-transplant viral infections. There are abundant opportunities for trainees to participate in research during their training.

Objectives

  1. The resident should understand aspects of the basic science of transplantation such that he/she will be able to describe in general terms the HLA, the recognition of antigens, describe the events of T cell activation, and the components of the allograft response.
  2. The resident should be able to describe the postulated mechanism of action, efficacy, indications, monitoring and toxicity of the following available immunosuppressive agents: glucocorticoids, azathioprine, cyclosporine, tacrolimus, mycophenolate acid and its analogues, sirolimus and everolimus, polyclonal antilymphocyte preparations, OKT3, and anti-IL2R monoclonal antibodies.
  3. The resident should understand the principles and methods of tissue typing, panel reactive antibody testing, and cross-matching and their impact on recipient selection.
  4. The resident should be able to discuss the relative and absolute contraindications to renal transplantation. The resident should be able to work-up a CRF patient for transplant and demonstrate knowledge of patient and graft survival, and impact and management of co-morbid conditions pre-transplant.
  5. The resident should understand donor selection and contraindications and brain death criteria, the management of organ donors, and renal preservation. The resident will work-up one living kidney donor, and demonstrate knowledge of the evaluation, risks, psychosocial and ethical issues of living kidney donation.
  6. The resident should demonstrate competency in the perioperative management of a renal allograft recipient, including the pre-operative preparation, post-operative management of fluid and electrolytes, and the differential diagnosis and management of the renal transplant recipient with delayed graft function. The resident should be able to discuss the approach to initial immunosuppression in a well-matched living related donor kidney recipient, an unsensitized first cadaveric transplant recipient, and a highly sensitized re-transplant recipient.
  7. The resident should be able to discuss the management of a patient with delayed or deteriorating allograft function early post-transplant, including the management of surgical complications such as urine leak, lymphocele, and ureteric obstruction.
  8. The resident should be able to develop an approach to the evaluation and management of a renal transplant recipient with deteriorating allograft function late post-transplant.
  9. The nephrology resident should master the technique of transplant kidney biopsies, including the management of common complications of renal biopsy.
  10. The resident should be able to describe the mechanism, pathology, and treatment of hyperacute, acute and chronic rejection.
  11. The resident should be familiar with current patient and graft survival data, and be able to describe the major determinants of allograft and patient survival. He/she should be able to discuss the issue of recurrent disease, the indications for a transplant nephrectomy, and the approach to pregnancy in renal allograft recipients.
  12. The resident should be able to discuss the ethical issues in transplantation, including the equitable access to kidney transplantation, the allocation of cadaveric kidneys, and living and cadaveric organ donation.
  13. The resident should be familiar with the common complications of transplantation, including:
    • Bacterial infection, including pneumonia in an immunosuppressed host and UTI
    • CMV infection
    • EBV infection
    • Polyomavirus infection
    • Post-transplant malignancy, including post-transplant lymphoproliferative disorder
    • Post-transplant polycythemia
    • Hypertension
    • Diabetes mellitus
    • Post-transplant bone disease
    • Dyslipidemia and cardiovascular disease