he patient was a 66-year-old male with ESRD due to chronic glomerulonephritis.

Chronic haemodialysis was initiated in 1970 when the patient was 28 years of age and this modality was still rare in Japan. For the first 26 years, he received nocturnal haemodialysis for 12 h twice a week. After that he had received haemodiafiltration (HDF) for 4.5 h three times a week until transplantation. He had surgery for aseptic necrosis of the right femoral head at the age of 58 and suffered from cerebral infarction but recovered without any neurological defect. He was noted to have atrial fibrillation at the age of 63, and has since then been treated with an anticoagulant. After maintenance haemodialysis for 38 years and 2 months, he received a kidney transplant from a 54-year-old female who had been diagnosed as brain dead due to traumatic subarachnoid haemorrhage. At the time of emergent admission, screening was performed to evaluate the risk of transplantation. There was no critical problem regarding the cardiovascular system except for the anticoagulant treatment. Computed tomography (Figure 1a) showed minimal calcification of his iliac vessels in spite of the long-term haemodialysis.

Long case Renal Transplant (draft)

I think for long case purpose we need to keep discussion concise and list only the key points that we should know. (actually i am too lazy/tired to type ) 65 years old man with renal transplant on chronic immunosuppression complicated with skin cancers now presents with watery diarrhoea and abdominal pain Issues 1. Diarrhea and abdominal pain in transplant patient 2. Immunosuppresion and skin cancer 3. Long term management of renal transplant pt 1. Diarrhea and abdominal pain in transplant patient DDx Gastroenteritis virus (CMV), bacterial, c difficile etc Inflammatory colitis if blood. Drugs immunosuppression (especially MMF- can cause subacute diarrhea) If Graft pain/tenderness need to rule out acute rejection (unlikely if pt compliant with meds) IVx

Stool mcs, ocp, c diff Check urine Bloods- renal function, inflammatory markers Acute rejection - 2 histologic classification 1. acute T cell mediated(cellular) rejection 2. acute antibody mediated rejection (histology, C4D, donor specific antibodies) - Clinical Fever, graft pain, tenderness - Tests raised creatitine, kidney biopsy, rule out BK virus (serum PCR), rule out interstitial nephritis (urine eosinophillia) - Treatment 1. pulse metylprednisolone 5mg/kg 3-5days 2. monoclonal antibodies (rituximab) 3. Rescue therapy add tacrolimus, MMF, for antibody mediated rejection, consider splenectomy, IVIG. 2. Immunosupression and skin cancer. How do you manage if pt has skin cancer on immunosuppresion - Review immunosuppression drugs higher risk with Azathioprine (SCC), calcineurin inhibitor ( Cyclosporin), Tacrolimus - Change to Sirolimus (m-Tor inhibitor), MMF - need to know the pathology, then need regular follow up (6 monthly if multiple skin cancer with dermatologist/surgeon) Superficial/premalignant topical retinoid, cryotherapy, invasive excision with margin examination - risk factor avoidance (UV exposure- protective suncreen, clothing) - reduce immunosuppresion to lowest possible. 3. Long term management of renal transplant pt If you are the renal physician, how would you manage a pt with renal transplant in long-term?. - Monitor risk factors of immunosuppressive agents. Steroid- insulin resistance, PUD, psychiatric, HTN, cholesterol

calcineurin inhibitor insulin resistance, HTN, cholesterol, renal impairment, neurological (tremor, peripheral neuropathy) Azathioprine /MMF marrow suppresion, GI effect/PUD, pancreatitis. - Screen for malignancy. 1. skin cancer (annual ) 2. Renal cell carcinoma ( +++risk in native kidney) USS every 2-3 years, 3. Urinary tract malignancy (cychophosphamide) 4. Colorectal cancer (scope 5 years +/FOBannually) 5. Anal cancer 6. Gynae (pap smear annually) - Primary prevention for cardiovascular disease Review cardiovascular risk factors and treat Hypertension, Diabetes-metformin, Hypercholesterolemia-statin , Obesity- lose weight (diet,exercise, bariatric surgery) Life style risks smoking - Ensure adherence to medication, regular follow up and well-being of graft.