SU13.1-4 | Transplantation — Assignment

CLINICAL SCENARIO

You are the transplant-team registrar at a tertiary hospital. A 28-year-old man, Mr K, has suffered a non-survivable traumatic brain injury after a road traffic accident and is ventilated in the ICU. The intensive-care team is preparing to assess him for brain-stem death, and he is a potential deceased organ donor. Separately, his cousin has end-stage renal disease, and a relative has asked whether the family could 'just give a kidney directly'. Over the next 24 hours you must reason through the immunology that makes a successful transplant possible, the immunosuppression the eventual recipient will need, the legal framework that governs donation, and the way the family is approached and counselled.

Section 1 — The immunological barrier and matching

Explain why a transplanted organ is at risk of rejection and which antigen systems must be considered before transplantation. Describe what ABO compatibility, HLA matching and the pre-transplant cross-match each contribute, and why a positive cross-match would be a contraindication.

Guidance: Anchor on HLA (MHC) as the principal alloimmune target, ABO compatibility as a prerequisite, and the cross-match as the test that detects pre-formed antibodies which cause hyperacute rejection.

Section 2 — Recognising and timing rejection

Contrast hyperacute, acute and chronic rejection by time-course, dominant mechanism and reversibility. Explain how each would present in the recipient and which is the major cause of late graft loss.

Guidance: Hyperacute = minutes–hours, pre-formed antibodies, prevented by cross-matching; acute = days–weeks, T-cell mediated, often treatable; chronic = months–years, progressive fibrosis, poorly reversible and the main cause of late failure.

Section 3 — Immunosuppression: classes and trade-offs

Set out the standard triple-therapy regimen the recipient would need, naming one drug from each class and its mechanism. Then explain the central trade-off that governs all chronic immunosuppression and how it shapes monitoring.

Guidance: Triple therapy = calcineurin inhibitor (tacrolimus/ciclosporin) + antiproliferative (mycophenolate/azathioprine) + corticosteroid. The trade-off: preventing rejection raises the risk of opportunistic infection and malignancy.

Section 4 — The legal framework for donation

Explain how donation could lawfully proceed for Mr K (deceased donor) and for the cousin's potential living donor. Address brain-death certification, the near-relative provisions, and the safeguards THOTA imposes to prevent commercial dealing in organs.

Guidance: Deceased donation requires formal brain-stem-death certification under THOTA 1994 (amended 2011). Living-related donation between near relatives is permitted; unrelated donation needs authorisation-committee approval; commercial organ trade is prohibited.

Section 5 — Counselling the family

Describe how you would approach Mr K's family about donation. Explain the rule of decoupling, how voluntariness and respect for the family's autonomy are protected, and what compassionate, non-coercive counselling looks like in practice.

Guidance: Apply decoupling — break the news of death first, let it be understood, then raise donation separately and compassionately. Donation must be voluntary and free of coercion; read the room and respond to the family's emotional state.