337 Transplantation in Renal Failure

Question 1

Treatment of choice for advanced chronic renal failure

Answer 1

Transplantation

Question 2

Expanded Criteria Donor (ECD)

Answer 2

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

Question 3

Donation after Cardiac Death (DCD) I

Answer 3

Brought in dead

Question 4

Donation after Cardiac Death (DCD) II

Answer 4

Unsuccessful resucitation

Question 5

Donation after Cardiac Death (DCD) III

Answer 5

Awaiting cardiac arrest

Question 6

Donation after Cardiac Death (DCD) IV

Answer 6

Cardiac arrest after brainstem death

Question 7

Donation after Cardiac Death (DCD) V

Answer 7

Cardiac arrest in a hospital patient

Question 8

Deceased-donor grafts have _ % 1 year survival and living donor grafts have _ % 1year survival

Answer 8

92%, 96%

Question 9

Current life expectancy of living-donor graft is _years, deceased donor graft is _ years

Answer 9

20 years, 14 years

Question 10

Candidates for renal transplant should have life expectancy of _ years

Answer 10

5 years

Question 11

Routine screening for transplant patients include:

Answer 11

HIV, Hep B C, TB, HIV, Neoplasm

Question 12

ABsolute “immunologic” contraindications for transplantation

Answer 12

Presence of antibodies against donor kidneys: ABO, HLA

Question 13

True or False.

Rh system is expressed in graft tissue.

Answer 13

False.

Question 14

Direct pathway

Answer 14

Class II MHC recognized by CD4 helper cells, CD8 cells recognized -> cytotoxic cells

Question 15

Indirect pathway

Answer 15

MHC molecules are transformed into peptides, self APCs, Th cells activated -> secrete cytokines, proliferation of cells, activation of macrophage

Normal physiologic process

Question 16

Induction therapy

Answer 16

antibodies that could be monoclonal or polyclonal; and depletional or nondepletional

Question 17

Maintenance therapy

Answer 17

Prednisone, calcineurin inhibitor, antimetabolite; or mTor (can replace the last 2 agents)

Question 18

Belatacept

Answer 18

Prevent long term calcineurin inhibitor toxicity, binds to ligands on APCs interrupting binding to CD28 on T cells leading to Tcell anergy and apoptosis

Question 19

Azathioprine

Answer 19

analogue of mercaptopurine, inhibit DNA RNA synthesis

Question 20

Mycophenolate mofetil or mycophenolate sodium

Answer 20

similar to azathioprine, less side effects

Question 21

Prednisone given as

Answer 21

200-300 mg immediately before or at the time of transplant, then reduced to 30mg within a week

Question 22

Methylprednisone for acute rejection given as

Answer 22

0.5g to 1g IV immediately on diagnosis then continued once daily for 3 days

Prevents IL 1 and IL 6

Question 23

Cyclosporine

Answer 23

Calcineurin inhibitor , inhibits Tcell proliferation

Toxic effects: Nephrotoxicity*, hepatotoxicity, hirsutism, tremor, gingival hyperplasia

Question 24

Tacrolimus / FK506

Answer 24

Same as cyclosporine, no hirsutism or gingival hyperplasia

Adverse effect: de novo diabetes mellitus

Question 25

mTOR inhibitors

Answer 25

Sirolimus, inhibits Tcell growth factor, preventing IL2 and other cytokines

Question 26

mTOR inbitor

Answer 26

Everolimus - better bioavailability

Question 27

Most common clinical evidence of rejection.

Answer 27

Increase in serum creatinine with or without reduction in urine volume RARE : fever, swelling, tenderness on allograft

Question 28

Prophylaxis for CMV and PCP are given when

Answer 28

6-12 months after transplantation

Question 29

Peritransplant infections (<1 month)

Answer 29

WOund infections Herpesvirus Oral candidiasis UTI

Question 30

Early infections (1-6 months)

Answer 30

``` PCP CMV Legionella Listeria Hepatitis B, C ```

Question 31

Late infections (>6 months)

Answer 31

``` Aspergillus Nocardia BK virus Herpes zoster Hep B, C ```

Question 32

Case: Renal transplant patient unresponsive to all medications, what is the diagnostic of choice?

Answer 32

Renal biopsy

Question 33

Renal biopsy shows acute rejection, management?

Answer 33

Anti-CD3 monoclonal antibody (OKT3 5g/d x 7-10days)

Question 34

Incidence of tumors in patients on immunosuppressive therapy

Answer 34

5-6%

Question 35

Common cancers in immunosuppressed patient

Answer 35

skin, cervix, lips, Lymphomas | Surveillance is necessary

Question 36

Target BP for renal transplant patients

Answer 36

120-130 /70-80 mmHg Meds: CCBs more used initially