337 Transplantation in Renal Failure Flashcards
Treatment of choice for advanced chronic renal failure
Transplantation
Expanded Criteria Donor (ECD)
Deceased donor >60 years
Deceased donor >50 years, hpn and crea >1.5mg/dl
Deceased donor >50 years, hpn, death by CVA
Deceased donor >50 yrs caused by CVA, crea >1.5mg/dl
Donation after Cardiac Death (DCD) I
Brought in dead
Donation after Cardiac Death (DCD) II
Unsuccessful resucitation
Donation after Cardiac Death (DCD) III
Awaiting cardiac arrest
Donation after Cardiac Death (DCD) IV
Cardiac arrest after brainstem death
Donation after Cardiac Death (DCD) V
Cardiac arrest in a hospital patient
Deceased-donor grafts have _ % 1 year survival and living donor grafts have _ % 1year survival
92%, 96%
Current life expectancy of living-donor graft is _years, deceased donor graft is _ years
20 years, 14 years
Candidates for renal transplant should have life expectancy of _ years
5 years
Routine screening for transplant patients include:
HIV, Hep B C, TB, HIV, Neoplasm
ABsolute “immunologic” contraindications for transplantation
Presence of antibodies against donor kidneys: ABO, HLA
True or False.
Rh system is expressed in graft tissue.
False.
Direct pathway
Class II MHC recognized by CD4 helper cells, CD8 cells recognized -> cytotoxic cells
Indirect pathway
MHC molecules are transformed into peptides, self APCs, Th cells activated -> secrete cytokines, proliferation of cells, activation of macrophage
Normal physiologic process
Induction therapy
antibodies that could be monoclonal or polyclonal; and depletional or nondepletional
Maintenance therapy
Prednisone, calcineurin inhibitor, antimetabolite; or mTor (can replace the last 2 agents)
Belatacept
Prevent long term calcineurin inhibitor toxicity, binds to ligands on APCs interrupting binding to CD28 on T cells leading to Tcell anergy and apoptosis
Azathioprine
analogue of mercaptopurine, inhibit DNA RNA synthesis
Mycophenolate mofetil or mycophenolate sodium
similar to azathioprine, less side effects
Prednisone given as
200-300 mg immediately before or at the time of transplant, then reduced to 30mg within a week
Methylprednisone for acute rejection given as
0.5g to 1g IV immediately on diagnosis then continued once daily for 3 days
Prevents IL 1 and IL 6
Cyclosporine
Calcineurin inhibitor , inhibits Tcell proliferation
Toxic effects: Nephrotoxicity*, hepatotoxicity, hirsutism, tremor, gingival hyperplasia
Tacrolimus / FK506
Same as cyclosporine, no hirsutism or gingival hyperplasia
Adverse effect: de novo diabetes mellitus
mTOR inhibitors
Sirolimus, inhibits Tcell growth factor, preventing IL2 and other cytokines
mTOR inbitor
Everolimus - better bioavailability
Most common clinical evidence of rejection.
Increase in serum creatinine with or without reduction in urine volume
RARE : fever, swelling, tenderness on allograft
Prophylaxis for CMV and PCP are given when
6-12 months after transplantation
Peritransplant infections (<1 month)
WOund infections
Herpesvirus
Oral candidiasis
UTI
Early infections (1-6 months)
PCP CMV Legionella Listeria Hepatitis B, C
Late infections (>6 months)
Aspergillus Nocardia BK virus Herpes zoster Hep B, C
Case: Renal transplant patient unresponsive to all medications, what is the diagnostic of choice?
Renal biopsy
Renal biopsy shows acute rejection, management?
Anti-CD3 monoclonal antibody (OKT3 5g/d x 7-10days)
Incidence of tumors in patients on immunosuppressive therapy
5-6%
Common cancers in immunosuppressed patient
skin, cervix, lips, Lymphomas
Surveillance is necessary
Target BP for renal transplant patients
120-130 /70-80 mmHg
Meds: CCBs more used initially
