119. renal transplant

Question 1

outcome of renal transplant cases according to Schmeidt et al vet Surgery 2008

Answer 1

78% survive to dischargeMST 600 days6 mo survival 65%3 yr survival 40%

Question 2

indications for renal transplant

Answer 2

end stage chronic renal failurechronic interstitial nephritisrenal dysplasiaethylene glycol toxicity (transplant after dialysis)glomerulonephropathypolycystic kidney diseaseamyloidosis*pyelonephritis**unsure if appropriate candidates

Question 3

screening of a potential renal transplant candidate

Answer 3

–MDB –Blood type—major and minor cross match to donor–thyroid hormone–UA ,culture–UPC–Ab rads and US–thoracic rads—BP–echocardiography–FeLV/FIV–toxoplasma titers (IgG, IgM)must rule out infection, neoplasia and/or obstruction!

Question 4

age as a risk factor of mortality following discharge from hospital

Answer 4

–cats older >10 yr had great mortality (esp in first 6 mo post op)–MST decreased with increasing age

Question 5

azotemia as a risk factor

Answer 5

azotemia with Cr> 10 were more likely to die before dischargein another study, severity of azotemia was NOT related to mortality but increased the risk of neurologic complications in the peri-operative period

Question 6

protocol if patient suffers from recurrent UTIs

Answer 6

can only transplant with negative culture.at time of negative culture, start 2 week cyclosporine test and recheck urineif it grows negative at that time, transplant can be donepositive culture eliminates the candidate for transplant

Question 7

findings that preclude renal transplant

Answer 7

–neoplasia–CHF–FeLV +–active FIV infection–recurrent/existing UTI (fails cyclosporin challenge)–uncontrolled hyperthyroidism–fractious temperamentmany grey areas (IBD, cardiomyopathy, diabetes)

Question 8

are seropositive toxoplasma cats denied transplant?

Answer 8

nobut require lifelong clindamycin or TMS therapy(started pre-op)sensitivity of the test may not be the most accurate

Question 9

evaluation of renal donors

Answer 9

1-3 YOexcellent healthscreening excellent (labs, urine, radiography, cardiovasclular, and infectious)CT angiogram to eval vasculature and parenchymal abnormalities (exclude donors that have infarcts, multiple vessel anomalies)donor gets adopted

Question 10

how is routine compatibility of donor and recipient addressed

Answer 10

blood typingmajor and minor cross matching

Question 11

study evaluating the outcome of unilateral nephrectomy in donor cats

Answer 11

15/16 cats were normal for follow up 24-67 mo (one cat was diagnosed with chronic renal insufficiency 52 months post)all dogs remained healthy within 2.5 yr followuplife long screening is recommended expected to have a normal life expectancy

Question 12

preoperative preparation of recipient

Answer 12

–preoperative hemodialysis if severe azotemia–IVF–Ca channel blocker therapy (amlodipine) if hypertensive–EPO therapy if transplant is delayed (can make Ab against)–correct pre existing anemia if indicated (whole blood, pRBC)–immunosuppression 4-5 days before surgery (cyclosporine–Neoral and prednisolone in cats ; azathioprine, cyclosporine in dogs +/- ketoconazole)–test cyclosporine concentrations pre-op–at induction, whole blood from donor given to recipient –consider feeding tube

Question 13

MOA of cyclosporine

Answer 13

Blocks calcineurindecrease activation of transcription factors necessary to make cytokines (TNF alpha, IL 2 IFN gamma, granulocyte-macrophage colony stimulating factor) which play a role in graft rejection

Question 14

purpose of mannitol given IV to donor cat

Answer 14

mannitol given to donor cat at time of abdominal incision and right before nephrectomy (+/- to recipient after anastomosis)to promote perfusion to kidney

Question 15

renal artery length recommendation from donor

Answer 15

0.5 cm length (minimum)single renal artery

Question 16

which kidney is preferred from the donor and why

Answer 16

LEFT kidneylonger vein

Question 17

2 methods of vascular anastomoses for renal vasculature

Answer 17

—donor renal vessels to recipient ext iliac vessels (end to end)—–12% cats pelvic limb probs—donor renal vessels end to side with Aorta (proximal to cd mesenteric br) and Cd Cava 2 simple continuous patterns 8-0 nylon aorta 7-0 silk cava

Question 18

what is graft flushed with after harvested

Answer 18

phosphate buffered sucrose preservation solution

Question 19

T/Fvenous clamp is removed prior to arterial clamp after anastomosis is done

Answer 19

TRUE

Question 20

treat vascular spasms

Answer 20

topical lidocaine or acepromazine

Question 21

when simultaneous donor and recipient surgeries can not happen, what preserves the harvested graft kidney

Answer 21

hypothermic storage while sitting in phosphate buffered sucrose preservation solution

Question 22

three techniques for ureteroneocystostomy (ureteral reimplantation)

Answer 22

1. extravehicular2. intravesicular mucosal apposition (ventral cystotomy)3. extravesicular technique with harvested ureter and ureteral papilla

Question 23

what needs to be done to minimize renal torsion

Answer 23

NEPHROPEXY the allograft

Question 24

two commonly reported complications following renal transplant in dogs

Answer 24

intussusception (consider enteroplication)immunosuppression (leaking to sepsis)

Question 25

CNS dysfunction and seizures in post op feline transplant patients was related to what parameter

Answer 25

post op hypertensionadministration of antihypertensive therapy (amlodipine PO or hydrazaline SQ) significantly decreased risk seizure and MM associated with neuro complications

Question 26

at what point does azotemia start to improve following renal transplant

Answer 26

24-72 hr post opif no improvement seen—ab US is warranted

Question 27

patient follow up recommendations

Answer 27

once a week for the first 6-8 weeksthen monthly for 6 monthsthen every 2-3 month visitsTPR, BP, CBC/Chem/UA, PCV/TP, body weight, cyclosporine concentrations

Question 28

rare but lethal side effect of cyclosporin therapy

Answer 28

hemolytic uremic syndromehemolytic anemia, thrombocytopenia, rapid deterioration in renal fx

Question 29

list post op complications with renal transplant in cats

Answer 29

Acute rejectionchronic rejectionhemolytic uremic syndrome (cyclosporin tx)Ca oxalate uroliths retroperitoneal fibrosisureteral obstruction————-ALL THE ABOVE LEAD TO RENAL DYSFUNCTIONseizures (esp if hypertensive post op)

Question 30

list 3 complications associated with aggressive immunosuppression

Answer 30

Infection (sepsis or reactivate Toxoplasma)diabetes mellitus (5.5 x more likely in renal transplant patient)cancer (transplant and cyclosporin tx risk 6x for development of cancer)