Renal Transplant

Transplanted kidney is the main focus of a short case in 9% of attempts at PACES station 1. It is also a short case for medical students. It is not difficult to diagnose this condition. Just remember, iliac fossa scar with a mass equivalent to transplanted kidney until proven otherwise! However, the story does not end here for MRCPian. As a MRCPian, you need to search for the causes, complications and the functional capacity of the patient (4Cs rule).

1. Causes
* Most of the cases shown are polycystic kidney disease
* Other causes include DM (check for dermopathy and diabetic ulcers), GN and etc

2. Complications
a. Side effects of medications
** Azathioprine - myelosuppression with bruises, pallor, jaundice
** Cyclosporin - hand tremor, hypertrichosis, gum hyperplasia, high BP
** Prednisolone - Cushing's syndrome, pallor secondary to UGIB
b. Hepatitis B/C with CLD signs

3. Functional capacity
* Signs of graft rejection - tender transplanted kidney
* Signs of infections - they have 1001 reasons to get infections
* Uremic/hepatic encephalopathy - unlikely to appear in PACES!

Record:
I would complete my examination on this gentleman by checking his blood pressure, looking at his temperature chart and dipstick the urine to look for evidence of haematuria and proteinuria. I would also like to do a per rectal examination to exclude malaena as a possible cause for his pallor.

This gentleman is lying comfortable on one pillow. He is on supplemental O2 administered via nasal prong running at 2L/min. He has a sallow complexion. There is no peripheral stigmata of chronic liver disease. He has no flapping tremour. He has hirsutism as evidenced by coarse hairs over both of his arms as well as on the face. He looks pale however there is no jaundice. There is gum hypertrophy.

On inspection of the abdomen, there is a transverse surgical scar noted at the right lumbar region extending to the infraumbilical region which is well healed. The umbilicus is centrally located and inverted. Palpation of the abdomen has revealed a mass situated at the right iliac fossa which measures around 5x8cm in size, is firm in consistency, non-tender and it produces a dull note upon percussion. There is no other mass felt in the abdomen. There is no ascites and the bowel sounds are normal. There is no signs of fluid overload.

Therefore, I would like to draw conclusion that this gentleman has a right transplanted kidney complicated by signs suggestive of cyclosporin side effects, currently no signs of fluid overload and not in uraemic encephalopathy. The possible etiologies for his renal failure I would like to offer include diabetic nephropathy, hypertensive nephropathy and other primary glomerulonephritis.