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APPENDIX IV – AIMS, OBJECTIVES, COMPETENCIES & OUTCOMES Aims During the Transplant rotation, the trainee should acquire the knowledge, skills and attitudes needed to independently care for both stable and ill renal transplant patients. This is to include; patient and donor evaluation for transplantation, acute pre and post operative care, care of patients in the initial months after transplantation, stable patients well-removed from transplantation, and patients with a failing allograft. Objectives At the end of the rotation, the trainee will be able to demonstrate knowledge in the following areas: Basic Sciences i) Transplant Immunology: A) Describe the HLA system and its’ relevance to transplantation. B) Describe mechanisms of rejection including mechanisms of allorecognition and the processes involved in the effector arms of the immune system. ii) The role of the Transplant Immunology Laboratory: A) Describe techniques for HLA typing and their significance. B) Describe techniques for anti HLA antibody screening (PRA testing and cross matching) and their significance. C) Demonstrate the ability to interpret the results of tissue typing, antibody screening and cross match procedures. iii) Transplant Pathology: A) Develop a working knowledge of the Banff schema of allograft pathology. B) Describe the histologic findings in rejection as well as causes of allograft dysfunction other than rejection (i.e. drug toxicity, recurrent disease, and infection). C) Interpret renal allograft biopsy findings in a clinical setting. iv) Immunosuppressive Therapy: Develop a broad understanding of immunosuppressive therapy including; drug mechanisms of action, side effects and toxicities, drug interactions, indications and clinical practice of induction and maintenance immunosuppression, practice therapeutic drug monitoring and management, and relevant intra-class differences of the following: A) Calcineurin inhibitors (Cyclosporine and Tacrolimus). B) Anti-metabolites (Mycophenolate and Azathioprine). C) Corticosteroids. D) Rapamycin. E) Anti-IL2 receptor monoclonal antibodies (Basiliximab and Daclizumab). F) OKT3 and polyclonal depleting antibodies (Thymoglobulin and ATG). Donor & Recipient Evaluation & Organ Allocation i) Recipient Evaluation: A) Describe the recipient risks, benefits and contraindications of transplantation. B) Perform a complete recipient evaluation. - PAGE 2 – C) D) E) Demonstrate knowledge of how prior malignancies, co-morbid cardiovascular disease, and other specific conditions or patient variables affect eligibility and outcomes in transplantation. Demonstrate the ability to counsel a potential kidney transplant recipient. Describe the indications and contraindications, advantages and disadvantages of kidney-pancreas transplantation. ii) Live Donor Evaluation: A) Describe what comprises a transplant donor evaluation; appreciating absolute and relative contraindications. B) Describe the operative procedure as well as short and long term risks and outcomes of transplant donor nephrectomy. C) Demonstrate the ability to counsel a potential live kidney donor. iii) Cadaveric Donor Evaluation: A) Explain who may be considered an eligible cadaveric donor including the diagnosis of brain death and non-heart beating donors. B) Describe the absolute and relative contraindication to cadaveric donation. C) Describe the ICU care of the brain dead donor. iv) Organ Allocation: A) Describe the issues regarding transplant waiting lists and donor supply. B) Describe relative advantages and disadvantages of live donor vs. cadaveric donor transplantation. C) Describe the issues of allosensitization, including how allosensitization occurs, it’s impact on patient and transplant outcomes, and how it affects recipient access to transplantation integrating knowledge of tissue typing and histocompatibility testing in potential recipients. D) Describe the relevance of donor and recipient matching. E) Demonstrate the ability to rationally allocate a cadaveric organ. Clinical Care of the Transplant Patient The transplant operation and immediate post-operative care: i) Describe the operative technique of kidney transplantation. ii) Demonstrate the ability to care for the stable acute transplant patient. iii) Demonstrate an approach to delayed graft function, understand it’s potential causes and significance, and demonstrate the ability to manage patients with delayed graft function. iv) Be able to diagnose and manage other complications in the immediate posttransplantation period. Early Post-Transplant Management i) Demonstrate the ability to monitor and mange the transplant patient in the initial outpatient period including: A) The prescription of immunosuppression including the ability to adjust drug doses to maximize effectiveness, recognize and respond appropriately to drug toxicities and side effects, and describe the role of individualizing protocols for a particular patient’s needs. B) Demonstrate a differential diagnosis and approach to early allograft dysfunction. - PAGE 3 – C) D) ii) Demonstrate the ability to diagnose and manage acute rejection, integrating clinical science, immunobiology and pathology. Describe the pathogenesis and clinical impact of rejection. Describe the impact of CMV infection in transplant recipients including: A) The clinical impact of CMV infection. B) Strategies for monitoring and prophylaxis. C) Treatment of CMV disease. Long-Term Post-Transplant Care i) Demonstrate an understanding of transplant outcomes including average patient and graft survivals in different patient subsets and appreciate the determinants of each (JJ). ii) Describe the issues involved in prescribing maintenance immunosuppression, including, but not limited to: A) Risks of inadequate or excessive immunosuppression. B) Long term toxicities of individual immunosuppressive agents. C) Strategies and clinical considerations for minimization of long term immunosuppression. iii) Develop an understanding of the pathogenesis, importance, and clinical management of long-term post-transplant complications including: A) Cardiovascular disease/HTN/dyslipidemia. B) Malignancies: PTLD, skin Ca, other. C) Recurrent disease. D) Fertility and pregnancy in transplant recipients. E) Transplant RAS. F) Post-transplant erythrocytosis. G) Bone and mineral metabolism – osteoporosis and parathyroid disorders. H) Polyoma virus infection. I) Gout. The Failing Allograft i) Describe the determinants of declining allograft function due to chronic allograft nephropathy. ii) Demonstrate an approach to management of the patient with a failing allograft including strategies aimed at optimizing graft survival and managing complications of CRF. iii) Describe the impact of the failed allograft and outline the management of the patient returning to dialysis including strategies for the withdrawal of immunosuppression.