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Nephrology Board Review Pearls > ASN QBank Pearls - Renal Transplant > Flashcards

ASN QBank Pearls - Renal Transplant Flashcards

1
Q

what are HLA class 1?

A
  • A, B, C

- all nucleated cells

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2
Q

what are HLA class 2?

A
  • DP, PQ, DR

- on Ag presenting cells (APCs)

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3
Q

sensitization of immune system occurs from

A
  • blood transfusions
  • pregnancy
  • prior transplants
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4
Q

panel reactive antibodies (PRA)

A
  • tells how sensitized a patient is to HLAs in general population
  • 0-100%
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5
Q

donor specific antibodies (DSA)

A
  • tests presence of Abs to DONOR’S HLA types only

- semiquantitative

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6
Q

crossmatch

A
  • combines donor cells w/ recipient serum
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7
Q

positive crossmatch predicts what?

A

HYPERacute rejection

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8
Q

blood groups between donor and recipient must be

A

compatible (like blood transfusion)

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9
Q

crossmatch between donor and recipient must be

A

negative

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10
Q

HLA typing of donor and recipient determines

A
  • matching compatibility

- range from 0/6 to 6/6

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11
Q

HLA matching has better outcomes if

A

match is 6/6

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12
Q

can rejection still occur if HLA match is 6/6? and, if yes, why?

A
  • yes!

- non-HLA incompatibilities

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13
Q

contraindications to kidney transplantation

A
  • poor cardiac function
  • morbid obesity
  • psychosocial issues which can affect compliance
  • active infection
  • recent, unresolved cancer
  • ANY serious comorbidity which reduces life expectancy
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14
Q

infections that need to be tested for in a transplant recipient

A
  • HBV
  • HCV
  • EBV
  • CMV
  • syphilis
  • HIV
  • latent TB
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15
Q

what cancer screening needs to done for transplant recipients?

A
  • mammogram
  • PAP smear
  • PSA
  • colonoscopy
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16
Q

waiting time after cancer treatment for most cancers before proceeding w/ transplant?

A

2 years

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17
Q

waiting time after cancer treatment for metastatic breast, colorectal, and melanoma before proceeding w/ transplant?

A

5 years

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18
Q

waiting time after cancer treatment for non-melanoma skin cancer and some in situ malignancies before proceeding w/ transplant?

A

none, considered low risk

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19
Q

contraindications to living donation

A
  • age < 18
  • GFR < 80 ml/min
  • hematuria
  • proteinuria
  • HTN
  • DM
  • obesity
  • h/o cancer
  • infectious disease
  • significant, unresolved medical issues
  • psychosocial factors
  • inability to give informed consent
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20
Q

long term risk of ESRD over 15 years for kidney donor

A

6 fold increase

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21
Q

donor evaluation

A
  • H&P
  • CMP
  • FLP
  • GFR; 24 hour urine
  • UA, C+S
  • serum hCG
  • EKG
  • CXR
  • TTE
  • age-appropriate cancer screening
  • CT a/p
  • SW evaluation
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22
Q

minimum criteria for listing for kidney transplant

A
  • initiation of dialysis (time is backlogged from start time)
  • GFR < 20 ml/min (time starts at time of eval and consent given to list)
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23
Q

what is a nonstand kidney?

A
  • higher kidney donor profile index (KDPI) score (higher = worse)
  • cardiac death donor (longer CIT)
  • “higher-risk” donors
  • HBV and/or HCV donors
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24
Q

thymoglobulin MOA

A

depletes T cells

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25
Q

basiliximab MOA

A

blocks IL-2 receptors in T cells

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26
Q

thymoglobulin adverse effects

A
  • leukopenia
  • thrombocytopenia
  • fever
  • flu-like symptoms
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27
Q

CNI MOA

A

binds FK-binding protein thus inhibiting response to IL-2

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28
Q

CNI adverse effects

A
  • Afferent arteriole vasoconstriction
  • hyperkalemia
  • metabolic acidosis
  • hypomagnesemia
  • hyperglycemia and HLD by blocking beta cells in pancreas
  • renal fibrosis (long-term)
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29
Q

azathioprine and MMF adverse effects

A
  • leukopenia

- MMF can cause diarrhea

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30
Q

do levels of azathioprine and MMF correlate well with toxicity?

A

no

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31
Q

use of azathioprine and allopurinol is

A

contraindicated

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32
Q

sirolimus MOA

A

mTOR inhibitor; blocks FK-binding protein thus inhibiting IL-2 response

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33
Q

adverse effect of sirolimus

A
  • poor wound healing

- proteinuria

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34
Q

belatacept MOA

A

blocks accessory pathway of T cell stimulation

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35
Q

advantage of using belatacept

A

avoid CNI nephrotoxicity

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36
Q

perioperative complications

A
  • wound infection
  • bleeding
  • lymphocele
  • urine leak
  • transplant RAS
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37
Q

delayed graft function (DGF) histology

A

ATN

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38
Q

delayed graft function (DGF) risk factors

A
  • quality of donor kidney
  • kidney from after cardiac death donor
  • prolonged CIT
  • perioperative hypotension
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39
Q

how long to wait before renal transplant biopsy if DGF?

A

4 weeks

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40
Q

opportunistic infections

- first month

A

bacterial, perioperative

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41
Q

opportunistic infections

- 2-6 months

A

viral;

  • CMV
  • BK (polyoma) virus
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42
Q

opportunistic infections

- > 6 months

A

mostly bacterial

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43
Q

infection ppx

- antifungal

A
  • fluconazole or nystatin x 1 month
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44
Q

infection ppx

- PJP

A
  • SMX/TMP or dapsone (if sulfa allergy) x 12 months
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45
Q

infection ppx

- CMV

A

depends on IgG serology

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46
Q

infection ppx

  • CMV positive donor
  • CMV negative recipient
A

valganciclovir x 6 months

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47
Q

infection ppx

  • CMV positive donor
  • CMV positive recipient
A

valganciclovir x 3 months

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48
Q

infection ppx

  • CMV negative donor
  • CMV negative recipient
A

low risk

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49
Q

CMV clinical manifestations

A
  • flu-like symptoms
  • leukopenia
  • diarrhea
  • colitis
  • rare; hepatitis, pneumonitis, ophthalmitis
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50
Q

BK virus normally dormant in

A

urinary tract

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51
Q

subacute or chronic loss of allograft function d/t over IS

A

BK nephropathy

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52
Q

treatment for BK nephropathy

A

taper down IS

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53
Q

uncommon clinical features of BK virus

A
  • hematuria

- ureteral stricture

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54
Q

ddx of AKI in setting of transplant

A
  • same ddx as native kidneys (prerenal, renal, postrenal)
  • acute rejection
  • CNI toxicity
  • surgical complications (if soon after surgery) (urine leak, ureteral stenosis, transplant RAS)
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55
Q

acute cellular rejection (ACR) histological findings

A

(in order of worsening severity)

  • T cell infiltrates
  • tubulitis
  • cellular involvement of larger blood vessels
  • hemorrhage
56
Q

antibody mediated rejection (AMR) histological findings

A

(in order of worsening severity)

  • PERItubular capillaritis
  • staining for C4d
  • duplication of endothelial BMs
  • positive DSA
57
Q

ACR treatment

A
  • pulse steroids

- thymoglobulin if more severe

58
Q

AMR treatment

A
  • plasmapheresis
  • IVIG
  • rituximab
59
Q

treatment response to ACR

A

aggressive presentation, but may respond well

60
Q

treatment response to AMR

A

often insidious onset and poor response if caught late

61
Q

preformed DSA, although very rare, can lead to

A

hyperacute rejection

62
Q

which type of rejection has better outcome?

A

ACR

63
Q

MC type of cancer post-transplant

A

squamous cell skin cancer

64
Q

rare cancer caused by EBV post-transplant

A

post-transplant lymphoproliferative disorder (PTLD)

65
Q

post-transplant lymphoproliferative disorder (PTLD) risk factors

A
  • EBV negative recipients

- greater intensity and duration IS

66
Q

treatment for post-transplant lymphoproliferative disorder (PTLD)

A
  • taper IS as tolerated

- heme/onc

67
Q

MCC of death w/ functional graft

A

CVD

68
Q

CNIs inhibit metabolism of statins which leads to increased risk of

A

rhabdomyolysis

69
Q

vaccines to AVOID post-transplant

A
  • avoid LIVE vaccines
  • varicella
  • INHALED influenza
  • MMR
  • meningococcal
70
Q

vaccines that should be received post-transplant

A
  • INJECTABLE influenza

- pneumococcal

71
Q

recurrence uncommon, but can be severe immediately post-transplant

A

FSGS

72
Q

treatment for FSGS that occurs post-transplant

A

plasmapheresis

73
Q

does HPT improve after transplant?

A

yes, partially

74
Q

does fracture risk improve after transplant?

A

no

75
Q

does fracture risk improve post-transplant if steroids are tapered off?

A

no, they are still at increased risk compared to general population

76
Q

is infertility reversed after kidney transplant?

A

yes; should use contraception if not planning on conceiving

77
Q

risks to mother in pregnancy after transplantation

A
  • rejection

- preeclampsia

78
Q

risks to fetus in post-transplant mother

A
  • fetal loss
  • low birth weight
  • teratogens (MMF and sirolimus; must be stopped before pregnancy)
  • infection; CMV
79
Q

indication for pancreas transplant

A

hypoglycemic transplant

80
Q
  • usually occurs after rapid d/c’ing of IS
  • fatigue
  • fever
  • gross hematuria
  • allograft tenderness
A

graft intolerance syndrome

81
Q

treatment of graft intolerance syndrome

A

restart IS w/ higher dose steroids

82
Q

patients with bladder-drained pancreata develop

A

metabolic acidosis (loss of bicarb into bladder)

83
Q

immunohistochemistry positive for SV40 (looks brown)

A

BK nephropathy

84
Q

second line treatment for BK nephropathy after reduction of IS

A
  • IVIG

- or leflunomide or cidofovir

85
Q

treatment for post-transplant erythrocytosis (PTE) (hb > 17 g/dl, hct > 51%)

A

ACEI

86
Q

which medication group can improve nephrotoxic effects of cyclosporine?

A

CCBs

87
Q

biggest risk factor for post-transplant lymphoproliferative d/o with belatacept

A

EBV negative recipient

88
Q

sirolimus induced proteinuria will likely show up on biopsy as

A

podocytopathy causing FSGS

89
Q

ABO incompatible transplant is a/w

A

significantly higher risk of infection and hemorrhagic complications

90
Q

highest rate of recurrence post-transplant

A

diabetic nephropathy (40%)

91
Q

second highest rate of recurrence post-transplant

A

FSGS (20-30%)

92
Q
  • one of the MCC of allograft failure in early post-transplant period
  • sudden anuria
  • tenderness around allograft
A

early graft thrombosis

93
Q

HF before surgery with UF > 1.5-2 kg may be a strong predictor of

A

intraoperative hypotension

94
Q
  • progressively worsening HTN
  • unresponsive to meds
  • worsening renal function
  • recurrent flash pulmonary edema
A

transplant renal artery stenosis (TRAS)

95
Q

transplant renal artery stenosis (TRAS) treatment

A

angiographic stenting

96
Q

IS medication that causes alopecia

A

tacrolimus

97
Q

IS medication that causes hair growth and hirsutism

A

cyclosporine

98
Q

how to diagnose CMV in a post-transplant patient with symptoms

A

serum CMV PCR

99
Q

does SLK have lower immunological risk for kidney rejection?

A

yes

100
Q

medication used in treatment of resistant hypomagnesemia

A

amiloride

101
Q

treatment for lymphocele

A

laparoscopic peritoneal window creation

102
Q

brown crap on immunohistochemistry in setting of AMR

A

C4D positivity

103
Q

management of major surgery in post-transplant patient on sirolimus for IS

A
  • hold sirolimus x 5-10 days before surgery (wound healing)

- add steroids if not already on any

104
Q

on histology, BK nephropathy mimics

A

ACR

105
Q

difference in nephrotoxicity between tacrolimus and cyclosporine

A

same, but tacrolimus is less nephrotoxic at lower doses

106
Q

what solution is infused during plasmapheresis? and is a possible adverse effect?

A
  • citrate for AC

- hypocalcemia

107
Q

expected post transplant survival (EPTS) score is based on which 4 factors?

A
  • age
  • DM
  • time on dialysis
  • previous solid organ transplant status
108
Q

what factors are a/w increased risk of PTLD?

A
  • recipient EBV negative

- number of HLA mismatches (especially HLA-B or HLA-DR)

109
Q

is BK shedding in urine (BK viruria) common?

A

yes, about 30%

110
Q

donor risk of ESRD post-nephrectomy

A

8-10 fold increase

111
Q

compensatory hypertrophy post-nephrectomy returns GFR to

A

75% of baseline at long-term f/u

112
Q

BK nephropathy initial test for diagnosis

A

serum BK PCR

113
Q

is weight or body fat composition different at 1 year in patients on steroids vs steroid-avoidance protocols?

A

no

114
Q

acute cellular rejection types

- 4 cells infiltrated per tubule AND TUBULITIS

A

type 1

115
Q

acute cellular rejection types

- > 10 cells infiltrated per tubule AND ENDOTHELIALITIS

A

type 2

116
Q

acute cellular rejection types

  • lymphocytic cell infiltration AND interstitial hemorrhage
  • vasculitis
  • fibrinoid changes
A

type 3

117
Q

T cell activation cascade signals

- which medications block signal 1?

A
  • thymoglobulin
  • alemtuzumab
  • tacrolimus
  • cyclosporine
118
Q

T cell activation cascade signals

- which medications block signal 2?

A

belatacept

119
Q

T cell activation cascade signals

- which medications block signal 3?

A
  • basiliximab
  • sirolimus
  • everolimus
  • MMF
  • azathioprine
  • leflunomide
120
Q

treatment of ACR typically involves increasing which T cell activation cascade signal blockers?

A

signal 1 and 3

121
Q

medications that increase CSA levels (cyclosporine toxicity)

A 
# abx
- macrolides
# CCB
- verapamil
- diltiazem
# mTOR inhibitors
- sirolimus
- everolimus
#antifungals
- ketoconazole
- fluconazole
122
Q

what is the MOST appropriate INDUCTION IS?

- Caucasian recipients of two-haplotype-identical, living, related allograft

A

no induction required (low risk for rejection)

123
Q

what is the MOST appropriate INDUCTION IS?

  • second transplant
  • sensitized recipients
  • transplant across ABO blood type
A

antithymocyte globulin (ATG)

124
Q

what is the MOST appropriate INDUCTION IS?

- first line agent

A

basiliximab

125
Q

MMF MOA

A

inhibits inosine monophosphate dehydrogenase (IMPD), a key enzyme in purine synthesis

126
Q

azathioprine MOA

A
  • inhibits both DNA and RNA synthesis
  • also suppresses purine synthesis
  • action on cell cycle is not precisely defined
127
Q

which IS in a KTR should be avoided to prevent lowering sperm count?

A

mTOR inhibitors

128
Q

MCC of anemia is a post-renal transplant patient

A

poor graft function

129
Q

histopathological finding that is an independent risk factor for anemia in a post-renal transplant patient

A

IFTA from prolonged CIT

130
Q

MOST strongly a/w new onset DM after kidney transplantation (NODAT)?

A

advanced recipient age

131
Q

relative risk of malignancy post-renal transplant

- NHL

A

40-50%

132
Q

relative risk of malignancy post-renal transplant

- Kaposi’s sarcoma

A

400-500%

133
Q

relative risk of malignancy post-renal transplant

- SCC

A

15-20%

134
Q

relative risk of malignancy post-renal transplant

- melanoma

A

8-10%

135
Q

relative risk of malignancy post-renal transplant

- Ca of vulva/anus

A

100%

136
Q

highest ABSOLUTE risk of malignancy post-renal transplant

A

SCC

137
Q

BK polyoma viral infection progression is characterized by what stages?

A

urinary decoy cells –> viruria –> viremia –> BK nephropathy

Nephrology Board Review Pearls (10 decks)

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