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INTRODUCTION

With the advent of more potent and well-tolerated immunosuppressive regimens and further improvements in short-term graft survival, renal transplantation remains the treatment of choice for most pts with end-stage renal disease. Results are best with living-related transplantation, in part because of optimized tissue matching and in part because waiting time can be minimized; ideally, these pts are transplanted prior to the onset of symptomatic uremia or indications for dialysis. Many centers now perform living-unrelated donor (e.g., spousal) transplants. Graft survival in these cases is far superior to that observed with cadaveric transplants, although less favorable than with living-related transplants. Factors that influence graft survival are outlined in Table 151-1. Pretransplant blood transfusion should be avoided, so as to reduce the likelihood of sensitization to incompatible HLA antigens; if transfusion is necessary, leukocyte-reduced irradiated blood is preferred. Contraindications to renal transplantation are outlined in Table 151-2. Overall, the current standard of care is that the pt should have>5 years of life expectancy to be eligible for a renal transplant, since the benefits of transplantation are only realized after a perioperative period in which the mortality rate is higher than in comparable pts on dialysis.

TABLE 151-1SOME FACTORS THAT INFLUENCE GRAFT SURVIVAL IN RENAL TRANSPLANTATION
TABLE 151-2CONTRAINDICATIONS TO RENAL TRANSPLANTATION

REJECTION

Immunologic rejection is the major hazard to the short-term success of renal transplantation. Rejection may be (1) hyperacute (immediate graft dysfunction due to presensitization) or (2) acute (sudden change in renal function occurring within weeks to months). Rejection is usually detected by a rise in serum creatinine but may also lead to hypertension, fever, reduced urine output, and occasionally graft tenderness. A percutaneous renal transplant biopsy confirms the diagnosis. Treatment usually consists of a "pulse" of methylprednisolone (500–1000 mg/d ...

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