Hi there. We've now learned about the surgical aspects and challenged patients. But once a transplantation has been successful, it doesn't mean that everything is stable. What are actually the graft survival data and which challenges do we face in the first months and how can we tackle these problems? Take a minute to look at the lectures of this module, 3D movies about early surgical challenges and about the targets for immune suppression, will help you to understand the concepts. In addition, we invite you to give your opinion in the patient cases, so if you have questions, discuss it on the forum. Moreover, there are exercises to practice and there's also a game. Can you solve the challenges? Also, take a look at the optional assignments. Can you think of a scenario for the game and can you help us building it? Let's now first focus on an overview of the survival data and the early challenges. In this graph, you find the graft survival data from 1966 until now from deceased donors in our center in Leiden. We will focus on the early period after transplantation. Similar graphs you can find in other centers. On the y-axis, you find the percentage of graft survival proportion, and on the x-axis, the follow-up in years. The different cohorts are shown in different line colors. For example, in red, you see the patients who were transplanted between 1966 and 1984, and in black, after 2004. As you can see, graft survival rates have remarkably improved in the last decades. This decline is mainly due to improvements in the early periods due to better immune suppression, better surgical techniques and better overall medical care. In the early period, we can also still make progression. In addition, factors which might compromise renal function in the early period might influence long term survival. Of importance, we do transplant nowadays patients with more risk factors as you also heard in module two and this increases risk for complications. Which factors might compromise renal function in the early period? In the first place, surgical issues. These include thrombosis, bleeding, urinary leakage and stenosis of the ureter, wound complications and lymphoceles, which is a collection of lymphatic fluid within the body. These surgical challenges will be shown in a visualization and explained in one of the next lectures. For most of these surgical issues, diagnosis can be made by imaging tests, in addition to the anamnestic and physical examination. As an example, a Doppler ultrasound is used for measurement of blood flow, which is disturbed when there is thrombosis. An ultrasound can also diagnose lymphoceles and hydronephrosis, as also explained in module one. The ischemia reprofusion injury, which you've heard in module two, is associated with DGF. DGF is linked to a decreased long term graft function and survival. Risk factors for DGF are a deceased donor source, especially donation after brain dead, increased donor age, prolonged ischemia time and a compromised renal function of the donor. DGF is suggestive when there are risk factors present and can be diagnosed by a renal biopsy. The third factor that could compromise renal function is acute rejection. Although acute rejection rates have declined, it remains a strong risk factor for the development of fibrosis. There are different risk factors for acute rejection. They are of importance to consider when you estimate the risk of the patient for acute rejection. Take a look at these risk factors and take them in mind when you try to solve the patient case. For the diagnosis of acute rejection, a renal biopsy is necessary. Other factors which might compromise renal function include recurrent disease of the kidney, which means that the original disease of the patient recurs. A low blood pressure, which gives renal dysfunction due to a low blood flow to the kidney. Calcineurin inhibitor toxicity, which might give constriction of the vessels and can thereby compromise the renal function. Herefore, levels should be checked. In addition, infections including urinary tract and viral infections for which cultures and measurement of viral load are needed. Some of these causes are also of importance beyond three months and will be discussed in module four. These are lot of causes and I can imagine this is a lot of information. Here we show you a table to help you with all the causes and the diagnostic procedures. So what have we learned? In the first place, we have seen that graft survival has markedly improved, but that we can still make improvements, also early after transplantation. Secondly, we have seen that different factors might compromise renal function. These include surgical complications, delayed graft function, acute rejection and other factors. These can pose a challenge in transplantation and will be discussed in more detail in this module.