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12 Transplant Flashcards

1
Q

what is the hierarchy for permission for organ donation from next of kin?

A

spouse, adult son or daughter, either parent, adult brother or sister, guardian, any other person authorized to dispose of body

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2
Q

what are the fungal causes of opportunistic infections?

A

fungal: aspergillus, candida, cryptococcus

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3
Q

what prophylaxis do you give for opportunistic infection and what does it cover?

A

bactrim for protozoan

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4
Q

what are the protozoan causes of opportunistic infections after lung txp?

A

protozoan: pneumocystic jiroveci pneumonia

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5
Q

what are the viral opportunistic infections after txp?

A

cmv, hsv, vzv

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6
Q

what is the cause of chronic rejection in lung txp patients?

A

bronchiolitis obliterans

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7
Q

what is the mcc of late death and death overall following lung txp?

A

chronic rejection - bronchiolitis obliterans

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8
Q

what are the path findings in lung acute rejection?

A

perivascular lymphocytosis

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9
Q

what is the exclusion criteria for using lungs for donor?

A 
aspiration
moderate to large contusion
infiltrate
purulent sputum
PO2 less than 350 on 100%
FiO2 and PEEP 5
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10
Q

what is the indication for double-lung txp?

A

cystic fibrosis

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11
Q

what is the treatment to reperfusion injury after lung tx?

A

similar to ards

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12
Q

what is the mcc cause of early mortality in lung transplant pts?

A

reperfusion injury

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13
Q

what is life expectancy of pts before lung tx?

A

less than 1 yr

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14
Q

what compatibility tests are needed before lung tx?

A

abo and crossmatch

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15
Q

how long can you store a lung before transplant?

A

6 hrs

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16
Q

what is the mcc of late death and death overall following heart txp?

A

chronic allograft vasculopathy (progressive diffuse coronary atherosclerosis)

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17
Q

what is pathology of heart during acute rejection after transplant?

A

perivascular lyphocytic infiltrate with varying grades of myocyte inflammation and necrosis

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18
Q

what is treatment for persistent pulm htn after heart tx?

A

inhaled NO, ECMO if severe

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19
Q

what is a big complication of postop heart transplantation?

A

pulmonary htn. assoc w early mortality

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20
Q

what is the life expectancy of pts before heart transplant?

A

<1yr

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21
Q

what compatibility tests do you need for heart transplant?

A

compatibility and crossmatch

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22
Q

how long can a heart be stored?

A

6 hours

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23
Q

how do you diagnosis pancreas rejection?

A

hard to diagnose if they don’t also have kidney transplant

can see inc glucose or amylase. fever, leukocytosis

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24
Q

how do you treat venous thrombosis after pancreas transplant?

A

hard to treat

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25
Q

what are the complications of pancreas transplant?

A

venous thrombosis (#1) and rejection

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26
Q

what diabetic signs/sx are improved after pancreas transplant and what can’t be reversed?

A 
stabilization of retinopathy
dec neuropathy
inc nerve conduction velocity
dec autonomy dysfunction (dec gastroparesis)
orthostatic hypotension.
no reversal of vascular dz
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27
Q

how do you drain pancreas enterically after transplant? what do you need from the donor?

A

take second portion of duodenum from donor + ampulla of Vater and pancreas.
perform anastomosis of donor duodenum to recipient bowel

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28
Q

what vessel do you attach the pancreas to?

A

iliac vessels

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29
Q

what donor vessel do you need for venous drainage in pancreas transplant?

A

donor portal vein

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30
Q

what donor vessels do you need for arterial supply in pancreas transplant?

A

donor celiac artery and SMA

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31
Q

what is the 5 year survival rate after live transplant?

A

70%

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32
Q

what is the liver retransplantation rate?

A

20%

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33
Q

what do you find with chronic rejection of the liver? is it common?

A
  • unusual. get disappearing bile ducts
  • gradually obstruction of bile ducts w inc in alk phos
  • portal fibrosis
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34
Q

what is the cause of disappearing bile ducts during chronic rejection after liver transplant?

A

antibody and cellular attack on bile ducts

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35
Q

when does acute rejection of the liver occur?

A

usually in 1st 2 months

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36
Q

what is pathology of liver biopsy after acute rejection post liver transplant?

A

portal triad lymphocytosis, endotheliitis (mixed infiltrate), and bile duct injury

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37
Q

what labs are abnormal in acute rejection after liver transplant?

A

leukocytosis, eosinophilia, inc LFTs, inc total bilirubin, inc PT

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38
Q

what are the clinical signs of acute rejection?

A

fever, jaundice, decreased bile output.

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39
Q

what is the cause of acute rejection after liver transplant?

A

T cell mediated against blood vessels

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40
Q

what kinds of cells do you find around the portal triad if the pt gets cholangitis after liver transplant?

A

PMNs (not a mixed infiltrate)

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41
Q

what is treatment for portal vein thrombosis after liver transplant?

A

if early, re-op thrombectomy and revise anastomosis

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42
Q

what are the manifestations of portal vein thrombosis after liver transplant? is it common?

A

rare. early signs: abdominal pain.

late signs: UGI bleed, ascites, may be asymptomatic.

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43
Q

what is treatment for IVC stenosis / thrombosis?

A

thrombolyticcs, IVC stent

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44
Q

do abscesses appear from early or late hepatic artery thrombosis after liver transplant?

A

late (chronic) hepatic artery thrombosis

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45
Q

what are the signs of IVC stenosis / thrombosis after liver transplant?

A

edema, ascites, renal insufficiency. it is rare.

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46
Q

what happens during early hepatic artery thrombosis after liver transplant?

A

inc LFTs, dec bile output, fulminant hepatic failure

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47
Q

what is the treatment for early hepatic artery thrombosis after liver transplant?

A

will likely need emergent retransplantation for ensuing fulminant hepatic failure (can try to stent or revise anastomosis)

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48
Q

what can late hepatic artery thrombosis after liver transplant result in?

A

biliary strictures and abscesses

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49
Q

can late hepatic artery thrombosis after liver transplant result in fulminant hepatic failure?

A

no

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50
Q

what is the most common early vascular complication of liver transplant?

A

early hepatic artery thrombosis

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51
Q

what is treatment for primary nonfunction after liver transplant?

A

requires retransplantation

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52
Q

what happens during the beginning of primary nonfunction after liver transplant?

A

total bili >10, bile output <20 cc/12 h, elevated PT and PTT

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53
Q

what happens later during primary nonfunction after liver transplant and when does it happen?

A

after 96h. mental status changes, inc LFTs, renal failure, resp failure

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54
Q

when is primary nonfunciton of the liver likely to occur after transplant?

A

first 24 hours

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55
Q

what is the treatment for bile leak after liver transplant?

A

place a drain, then ERCP with stent across leak

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56
Q

what is the most common complication of liver transplant?

A

bile leak

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57
Q

what is the most common arterial anatomy in liver transplant?

A

right hepatic coming off SMA

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58
Q

what does the viability of the biliary system (including ducts) depend on?

A

hepatic artery blood supply

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59
Q

where do you place drains after liver transplant?

A

right subhepatic, right and left subdiaphragmatic drains

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60
Q

how is a liver transplant performed in adults and in kids?

A

adults: duct-to-duct anastomosis
kids: hepaticojejunostomy

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61
Q

how likely will a donor liver suffer primary non function if it has macrosteatosis?

A

if 50% of cross-section is macrosteatatic in potential donor liver, 50% chance of primary non function

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62
Q

what is macrosteatosis?

A

extracellular fat globules in the liver allograft

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63
Q

how likely will an alcoholic start drinking again?

A

20% (recidivism)

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64
Q

is portal vein thrombosis a contraindication to liver transplant?

A

no

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65
Q

can you consider liver transplant if pt has hepatocellular carcinoma?

A

yes if no vascualr invasion or if mets

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66
Q

what is the rate of reinfection of hep C after liver transplant? where does it recur?

A

most likely recurs in new liver allograft. reinfects essentially all grafts.

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67
Q

what is the reinfection rate after HBIG and lamivudine?

A

reduced to 20%

68
Q

how do you treat pts iwth hep B antigenemia?

A

HBIG (hepatitis B immunoglobulin) and lamivudine (protease inhibitor) after liver transplant to prevent reinfection

69
Q

what is the criteria for an urgent liver transplant?

A

fulminant hepatic failure (encephalopathy)

70
Q

at what MELD will a pt benefit from liver transplant?

A

> 15

71
Q

what is included in the MELD score? what does it tell you?

A

creatinine, INR, bilirubin. predicts if pts with cirrhosis will benefit more from liver transplant than from medical therapy

72
Q

what is the most common reason for liver transplant in adults?

A

hepatitis C

73
Q

what are the contraindications to liver transplant?

A

current EtOH abuse, acute ulcerative colitis

74
Q

how long can you store a liver for transplant?

A

24h

75
Q

what happens to the remaining kidney in living kidney donor?

A

hypertrophies

76
Q

what is the most common cause of death in living kidney donor?

A

fatal PE

77
Q

what is the most common complication to living kidney donor and what is the incidence?

A

wound infection (1%)

78
Q

what is 5 year graft survival in kidney transplant? cadaveric? living donor?

A

70% (65% cadaveric, 75% living donor)

79
Q

when does acute rejection occur in kidney transplant?

A

usually occurs in 1st 6 months

80
Q

when does chronic rejection usually happen in kidney transplant?

A

usually do not see until after 1 year.

81
Q

what do you rule out with u/s with duplex if suspect kidney rejection?

A

vascular problems and ureteral obstruction

82
Q

why do you empirically decrease CSA or FK when suspect kidney rejection?

A

they can be nephrotoxic

83
Q

what is the kidney rejection workup?

A

U/S w duplex and biopsy, empiric dec in CSA or FK, empiric pulse steroids

84
Q

when do you do a kidney rejection workup?

A

usually for inc in Cr or poor UOP

85
Q

what do you see on pathology after acute rejection?

A

tubulitis (vasculitis with more severe form)

86
Q

what is the most common viral infection after kidney transplant?

A

CMV and HSV

87
Q

what is the treatment for CMV and HSV after kidney transplant?

A

CMV: ganciclovir. HSV: acyclovir

88
Q

what is the most likely cause of postop diabetes after kidney transplant?

A

side effect of CSA, FK, steroids

89
Q

if the donor has a UTI, can you use the kidney for transplant?

A

yes

90
Q

if there’s an acute increase in creatinine (1.0-3.0) can you use the kidney for transplant?

A

yes

91
Q

To which vessels do you attach the kidney in transplant?

A

iliac vessels

92
Q

what is the treatment for urine leak after kidney transplant?

A

drainage and stenting

93
Q

what is the most common cause of external ureter compression after kidney transplant?

A

lymphocele

94
Q

what is the treatment for lymphocele after kidney transplant?

A

1st try percutaneous drainage. if fails, then need peritoneal window (make hole in peritoneum, lymphatic fluid drains into peritoneum and is absorbed (90% successful))

95
Q

what is the cause of postop oliguria after kidney transplant? what do you see on pathology?

A

usually ATN. hydrophobic changes on pathology.

96
Q

what is the cause of postop diuresis after kidney transplant?

A

usually due to urea and glucose

97
Q

what is the cause of new proteinuria after kidney transplant?

A

renal vein thrombosis

98
Q

how do you diagnose and treat renal artery stenosis after kidney transplant?

A

diagnose w ultrasound. treat with PTA with stent

99
Q

what is the number one complication of kidney transplant?

A

urine leak.

100
Q

what is the most common cause of mortality after kidney transplant?

A

stroke and MI

101
Q

what is the pre kidney transplant workup?

A

ABO type compatibility and cross-match

102
Q

how long can a kidney be stored?

A

48h

103
Q

what is the treatment for chronic rejection?

A

increase immunosuppression. no really effective treatment

104
Q

what is the result of chronic rejection?

A

graft fibrosis

105
Q

what is the cause of chronic rejection?

A

partially a type IV hypersensitivity reaction (sensitized T cells) with antibody formation also.

106
Q

what is the treatment for acute rejection?

A

increase immunosuppression, pulse steroids, possibly antibody therapy

107
Q

what is the cause of acute rejection?

A

caused by T cells (cytotoxic and helper T cells)

108
Q

what is the treatment for accelerated rejection?

A

inc immunosuppression, pulse steroids, possibly antibody therapy

109
Q

what is the cause of accelerated rejection?

A

sensitized T cells to donor antigens

110
Q

what is treatment for hyperacute rejection?

A

emergent re-transplant (or just removal of organ if kidney)

111
Q

what happens during hyperacute rejection?

A

preformed antibodies activates the complement cascade and thrombosis of vessels occurs

112
Q

what is the cause of hyperacute rejection?

A

preformed antibodies that shoul dhave been picked up by the cross-match

113
Q

what are the types of rejection and when do they occur?

A

hyperacute (min to hrs)
accelerated (<1 week)
acute (1 week to 1 mo)
chronic (months to yrs)

114
Q

is zenapax cytolytic?

A

no

115
Q

when is zenapax used?

A

induction and acute rejection.

116
Q

what is zenapax?

A

daclizumab. human monoclonal antibody against IL-2 receptors

117
Q

what is treatment for cytokine release syndrome?

A

steroids and benadryl given before drug to prevent

118
Q

what are sx of cytokine release syndrome and what causes it?

A

fever, chills, pulm edema, shock. caused by ATG.

119
Q

what are side effects of giving ATG?

A

cytokine release syndrome.

120
Q

what should WBCs be when treating with ATG?

A

> 3

121
Q

is ATG cytolytic? what does cytolytic mean?

A

yes. complement dependent

122
Q

what does cytolytic mean?

A

complement dependent

123
Q

when is ATG used?

A

induction and acute rejection episodes

124
Q

what does ATG target?

A

CD2, CD3, CD4

125
Q

what is another name for rabbit ATG?

A

thymoglobulin

126
Q

what is another name for equine ATG?

A

ATGAM

127
Q

how is sirolimus used?

A

maintenance therapy

128
Q

what happens if mTOR is inhibited?

A

inhibits T and B cell response to IL-2

129
Q

how does sirolimus work?

A

binds FK-binding protein like tacrolimus, but inhibits mammalian target of rapamycin (mTOR)

130
Q

what is another name for sirolimus?

A

rapamycin

131
Q

what is trough level for tacrolimus?

A

10 to 15

132
Q

compared to CSA, does tacrolimus cause less or more rejection episodes in kidney transplant?

A

less.

133
Q

what are side effects of tacrolimus?

A

nephrotoxicity, more GI sx and mood changes than CSA. much less entero-hepatic recirculation compared to CSA

134
Q

is CSA or tacrolimus more potent?

A

tacrolimus

135
Q

how does tacrolimus work?

A

binds FK-binding protein. has actions similar to CSA.

136
Q

what are other names for FK-506?

A

prograf, tacrolimus

137
Q

how is CSA metabolized and excreted?

A

hepatically metabolised, biliary excretion (reabsorbed into gut, get entero-hepatic recirculation)

138
Q

what is trough for CSA?

A

200-300

139
Q

what are side effects of CSA?

A

nephrotoxicity, hepatotoxicity, tremors, sz, hemolytic-uremic syndrome

140
Q

when is cyclosporin used?

A

maintenance therapy

141
Q

which cytokines do cyclosporin inhibit the genes for?

A

IL-2, and IL, 4

142
Q

how does cyclosporin work?

A

binds cyclophilin protein and inhibits genes for cytokine synthesis

143
Q

when are steroids used?

A

for induction after transplant, for maintenance, and for acute rejection episodes

144
Q

which cytokines are inhibited by steroids?

A

IL-1, IL-6. their genes are turned off

145
Q

how do steroids work when giving for posttransplant?

A

inhibits inflammatory cells (macrophages) and genes for cytokine synthesis.

146
Q

what does azathioprine do and what is another name?

A

imuran. similar action as MMF

147
Q

can mycophenolate be used as maintenance therapy?

A

yes. prevents rejection

148
Q

what should WBCs be when using mycophenolate?

A

> 3

149
Q

what is the side effect of mycophenolate?

A

myelosuppression

150
Q

what does mycophenolate do?

A

inhibits de novo purine synthesis, which inhibits growth of T cells

151
Q

what is treatment for PTLD?

A

withdrawal of immunosuppression. may need chemo and XRT for aggressive tumor

152
Q

what virus is related to PTLD?

A

EBV

153
Q

what is the second most common malignancy following transplant?

A

PTLD.

154
Q

what is PTLD?

A

post transplant lympho-proliferative disorder.

155
Q

what is the number 1 malignancy following any transplant?

A

skin cancer (sq cell ca #1)

156
Q

what is treatment for severe rejection?

A

steroid and antibody therapy (ATG or daclizumab)

157
Q

what is treatment for mild rejection?

A

pulse steroids

158
Q

what can increase PRA?

A

transfusions, pregnancy, previous transplant, and autoimmune disease

159
Q

what is a high PRA and what does it mean?

A

> 50%, which is percent of cells that the recipient serum reacts with.

160
Q

what is panel reactive antibody?

A

technique identical to crossmatch, detects preformed recipient antibodies using a panel of HLA typing cells.

161
Q

what happens if you transplant an organ in pt with a postiive cross-match?

A

hyperacute rejection

162
Q

how does cross-matching work?

A

mix recipient serum w donor lymphocytes. if antibodies are present, it is a positive crossmatch

163
Q

what does cross-matching detect?

A

preformed recipient antibodies to the donor organ

164
Q

which transplants require ABO blood compatibility?

A

all except liver

165
Q

which HLA is the most important overall?

A

HLA-DR

166
Q

which HLA types are most important in recipient/donor matching?

A

HLA-A, -B, and -DR

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