Approach

• As for abdominal examination

1. Inpsect
   • Signs of anaemia (pale palmar creases, pale conjunctivae)
   • Scar over wrist (site of Bresica-Cimino AV fistula)
   • Signs of steroid use - bruising, thin skin
   • Swelling in RIF
   • Specific scar over RIF (curved inguinal incision used to perform transplant - Rutherford-Morrison)
   • Presence of previous nephrectomy scars and points of access of old dialysis catheters
2. Palpate
   • Mass in iliac fossa - superficial, well defined as transplanted kidney placed outside peritoneum (covered only by external and internal oblique and transversus abdominis muscles
   • Should only be palpated very lightly
3. Percuss
4. Auscultate

Renal transplantation

1. Indication = End stage renal failure
   • DM
   • Hypertensive renal disease
   • Glomerulonephritis
   • Polycystic kidney disease
2. Matching of kidneys
   • ABO compatability
   • HLA compatability - HLA DR has greatest importance, hen HLA-B
3. Anastamoses performed in renal transplantation
   • Renal artery (with Carrel patch from aorta) anastamosed to either internal or external iliac artery
   • Renal vein to external iliac vein
   • Ureter attached to bladder
4. Transplant rejection
   • Types
     1. Hyperacute: within hours of surgeyr: due to pre-formed antibodies in a sensitized patient
     2. Accelerated acute: 1-4 days postoperatively due to a "secondary immune reposne" as a consequence of activation of T-memory cells
     3. Acute: 5 days - 2 weeks: cell-mediated
     4. Chronic: Humoural mechanisms more important
   • Features of transplant rejection
     1. Tenderness over graft
     2. Reduction in urine output
     3. Rising creatinine