Bladder, Kidney, Ureter, Urethra Flashcards
Tacrolimus
- Calcineurin inhibitor
- More potent than cyclosporine
- Used to prevent kidney graft rejection
- But, also potentially nephrotoxic and can cause AKI
- Same is true for other calcineurin inhibitors
- Side effects include:
- Nephrotoxicity
- Hyperkalemia
- HTN
- Glucose intolerance (diabetogenicity)
- Neurotixicity
- Hypomegnesemia
- CNS symptoms (headaches, tremors, seizures)
Etiology of uremic platelet dysfunction
- In uremia, urea accumulates
- In the setting of elevated urea, some ammonia is instead converted to guanidinosuccinic acid (GSA)
- GSA then accumulates and, given its similarity to L-arginine, is used to produce NO
- NO causes both venodilation and direct inhibition of paletlet adhesion and aggregation
Definition of chronic renal failure
- Kidney damage of > 3 months duration
- AND/OR GFR < 60 mL/1.73 m2/min
CKD stages
Induction immunosuppression
Anti-thymocyte globulin is typically used, which is a mixture of polyclonal IgG against CD2, CD3, CD4, CD25, among others
Alternatively, daclizumab or basiliximab (monoclonal anti-IL2R antibodies) may be utilized. These new agents hvae early data suggesting lower rejection rates than polyclonal anti-thymocyte globulin.
Alemtuzumab (monoclonal antobidy against CD-52) has also been used off-label for induction therapy and in treatment of acute graft rejection.
Cyclosporine
- Calcineurin inhibitor
- Inhibits IL-2 production and thus T cell proliferation
- Side effects:
- Nephrotoxicity
- Hypertension
- Gingival hyperplasia
- Hyperkalemia
Serolimus
- aka Rapamycin
- Targets mTOR
-
Less nephrotoxic than cyclosporine A and tacrolimus, but has other side effects:
- Thrombocytopenia
- Hyperlipidemia
- Poor wound healing
Dietary considerations for CKD
- Really only become relevant when GFR approaches ~20
-
Potassium:
- Dietary potassium restriction is sufficient to avoid hyperkalemia
-
Phosphorus:
- Must be controlled to avoid secondary and tertiary hyperparathyroidism, as well as uncontrolled metabolic acidosis
- Methods include
- Dietary phosphate restriction
- Phosphate binders
- Administration of synthetic 1-25-OH-D
- Subtotal parathyroidectomy (if full 2o or 3o hyperparathyroid)
LVH in CKD
- Two major stimuli:
- Hypertension
-
Anemia
- Anemia may actually be the more potent stimulus in untreated CKD. Treating anemia aggressively with EPO helps to prevent LVH.
Features of uremic neurological dysfunction
-
Uremic encephalopathy
- A form of delirium comparable to hepatic encephalopathy
- Also with asterixis
-
Uremic peripheral neuropathy
- Motor: motor neuron dysfunction
- Sensory: sensory impairment
- Autonomic: Often manifests as postural or persistent hypotension in patients on dialysis
Classification of hemodialysis catheters
- Temporary access (days)
- Intermediate-term access (weeks-months)
For critically ill hospitalized patients with uremia without other access, ___ to establish access is rapid and safe.
For critically ill hospitalized patients with uremia without other access, cannulation of the femoral vein to establish access is rapid and safe.
___ are generally not utilized for hemodialysis catheter placement due to high risk of thrombosis and subsequent stenosis
Subclavian veins are generally not utilized for hemodialysis catheter placement due to high risk of thrombosis and subsequent stenosis
Note: This is so bad because it also eliminates this arm for future arterial-venous fistula creation for future dialysis
Brescia-Cimino fistula
- Artificial fistula created between the radial artery and cephalic vein in the non-dominant wrist
- # 1 procedure for establishment of AVF for long-term hemodialysis
Advantages of AV fistula over AV graft
AVF is lower risk of infection and has a longer average lifespan than AVG
In the US, patients are considered for dialysis when their GFR falls below. . .
. . . 20 mL/min/1.73m2
Living donor kidney transplant survival rate at 10 years is approximately. . .
. . . 50%
Table of immunosuppressive medications for transplant medicine
Standard maintenance immunosuppression therapy regimen
- Combination of:
- Calcineurin inhibitor OR Serolimus
- Steroid
-
Antiproliferative agent:
- azathioprine
- mycophenylate mofetil
Symptoms of acute kidney graft rejection
- Occurs w/in first few weeks-months following transplant
- Fever, malaise, HTN, oliguria, weight gain, AKI
- Tenderness over transplanted kidney
- Confirm with biopsy
- Tx with high dose steroids or monoclonal antibodies
Infections in the peritransplant period
- Account for 50% of the mortality during this period
- Common etiologies:
- PCP pneumonia
- Aspergillus
- Toxoplasma
- Cryptococci
- Bocardia
- Blastomycosis
- PPx against PCP pneumonia with bactrim
Post-transplant lymphoproliferative disorder is best treated by. . .
. . . letting up on the immunosuppression by a bit
Most common post-transplant malignancies
- Mostly viral related
- Lymphoproliferative disorders associated with CMV, EBV
- Kaposi sarcoma (HHV8)
- Squamous cell carcinoma and cervical cancer (HPV)
- Hepatocellular carcinoma (Hep B and C)
Chronic allograft nephropathy
- Term for the nephropathy caused by the cumulative small insults to a kidney allograft
- May represent micro-acute rejections, chronic rejection, infection, ischemia-reperfusion, and co-occurence of underlying nephropathies (diabetes, amyloid, HTN, etc)
- There is no way to treat this condition, and it will eventually progress to late graft failure
Clinically suspicious rejection episodes are treated . . .
. . . empirically when no other etiology is identified
However, a biopsy is often taken as it can be useful for confirmation. A negative biopsy should never be an argument against treatment, as false negative rate is high.
Extended criteria donor
- Kidney donor who:
- Has age > 60
- Has age 50-60 with history of HTN, DM, increased serum creatinine, or death from stroke
Typical kidney donor criteria
- Age 3-60
- No history of HTN, DM, kidney disease, stroke
HIV and kidney transplant recipients
HIV is no longer a contraindication to transplantation IF the patient is receiving HAART with CD4 > 200 reliably.
Two major causes of mortality in the ESRD population
- Infection
- Dialysis access complication
Dialysis can improve encephalopathy, metabolic function, and platelet function, but it cannot improve. . .
. . . immune function in CKD
Median waitlist time for kidney transplant recipients in the US
~40 months
ADPKD
Treatment is mostly supportive, but vaptans (V2 antagonsits) may slow disease progression
