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Copy ABSITE Review: Fiser, Decker, SCORE, UpToDate, TrueLearn > Chapter 12 - Transplant++ > Flashcards

Chapter 12 - Transplant++ Flashcards

1
Q

Which HLA antigens are most important in recipient/donor matching?

A

HLA -A, -B, -DR (-DR most important overall)

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2
Q

ABO blood compatibility is not required for which transplant?

A

Liver

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3
Q

How is a crossmatch performed?

A

By mixing recipient serum with donor lymphocytes

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4
Q

What does a crossmatch detect?

A

Detects preformed antibodies; would generally cause hyperacute rejection

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5
Q

What is a panel reactive antibody (PRA)?

A

Technique identical to crossmatch; detects preformed recipient antibodies using a panel of typing cells

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6
Q

What can increase PRA?

A

Transfusions, pregnancy, previous transplant, autoimmune diseases

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7
Q

Treatment for renal transplant acute rejection?

A

Dx: biopsy
Pulse steroids: IV methylprednisone, then oral prednisone taper.
Add IVIG and rituximab.
If within 1 yr, add plasmapheresis.
If T-cell component at least Banff 1b, add ATG (thymo) w/ bacterial and viral ppx x3mo.
Augment maintenance to add or increase tacrolimus and mycophenolate.
Should respond within 1 week. If no Cr decrease by 20-30%, redo biopsy.

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8
Q

Treatment for severe or secondary rejection?

A

OKT3 or other drugs

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9
Q

1 malignancy following any transplant?

A

Skin cancer (squamous cell CA #1)

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10
Q

2 most common malignancy following transplant?

A

Posttransplant lymphoproliferative disorder (EBV-related)

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11
Q

Psx and tx for PTLD?

A

Psx: small bowel mass with or without GI bleeding, new lymphadenopathy, nonspecific and persistent symptoms like malaise, or as a CNS mass causing headache.
- Does not typically present as a febrile illness.
- Does not cause signs or symptoms of rejection.
Tx: withdrawal of immunosuppression; may need chemo/XRT for aggressive tumor. This is the 2nd MC cancer in transplant, EBV related.
- If CD20 expressed, add rituximab.

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12
Q

Mechanism of action of Azathioprine (Imuran)?

A

Inhibits de novo purine synthesis (which inhibits T cells); active metabolite is 6-mercaptopurine

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13
Q

Side effects of Azathioprine?

A

Myelosuppression, monitor CBC to keep WBC >4K and PLT >150K.

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14
Q

Mechanism of action of steroids in anti-rejection?

A

Inhibit genes for cytokine synthesis (IL-1, IL-6) and macrophages

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15
Q

Mechanism of cyclosporin (CSA)?

A

Binds cyclophilin protein and inhibits genes for cytokine synthesis (IL-2, IL-3, IL-4, INF-gamma)

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16
Q

Side effects of cyclosporin (CSA)?

A

Nephrotoxicity, elevated bilirubin, neurotoxicity, HTN, hyperglycemia, hirsutism, gingival hyperplasia

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17
Q

Mechanism of action of FK-506 (Prograf, tacrolimus)?

A

Binds FK-binding protein; similar to CSA but 10-100x more potent

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18
Q

Side effects of Prograf (FK-506, tacrolimus)?

A

Nephrotoxicity, mood changes, more GI and neurological side effects than CSA

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19
Q

Mechanism of action of ATGAM?

A

Equine polyclonal antibodies directed against antigens on T cells (CD2, CD3, CD4, CD8, CD11/18)

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20
Q

What is ATGAM used for?

A

Induction therapy

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21
Q

ATGAM is dependent on what to work?

A

Complement dependent

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22
Q

Mechanism of action of thymoglobulin?

A

Rabbit polyclonal antibody; similary action as ATGAM, causes rapid T-cell depletion

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23
Q

Mechanism of action of OKT3?

A

Monoclonal abs that block antigen recognition function of T cells by binding CD3, inhibiting T cell receptor complex; causes CD3 opsonization that is complement dependent

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24
Q

What is OKT3 used for?

A

Severe rejection. Not often used.

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25
Side effects of OKT3?
Fever, chills, pulmonary edema, shock
26
Mechanism of action of Zenapax (Daclizumab)?
Human monoclonal ab against IL-2 receptors
27
When is Zenapax (Daclizumab) used?
Used with induction and to treat steroid resistant liver rejection
28
What is the timeframe and cause of hyperacute rejection?
Within minutes to hours; caused by preformed antibodies that should have been picked up by the crossmatch; activates complement cascade and thrombosis of vessels occurs
29
Treatment of hyperacute rejection?
Emergent retransplant
30
What is accelerated rejection?
(<1 wk) Caused by sensitized T cells to donor antigens; produces secondary immune response
31
Treatment for accelerated rejection?
Increased immunosuppression, pulse steroids. Renal: plasmapheresis, IVIG. Liver: if steroid resistant, options include thymo, MMF, basalixumab, sirolimus, tacrolimus.
32
What is the timeframe and causative agent of acute rejection?
1wk to 1month; caused by T cells (cytotoxic and helper T cells)
33
Treatment of acute rejection?
Increased immunosuppression, pulse steroids, possibly OKT3
34
What is the timeframe and cause of chronic rejection?
Months to years; Type IV hypersensitivity reaction (sensitized T cells); Ab formation also plays a role, leads to graft fibrosis and vascular damage
35
Treatment of chronic rejection?
Increased immunosuppression, OKT3 - no really effective treatment
36
How long can a kidney be stored?
48 hours
37
What is the mortality following kidney transplant from?
Stroke and MI
38
Can a kidney from a patient with a UTI or acute increase in Cr (1.0-3.0) still be used?
YES
39
Transplanted kidney is grafted to what vessel?
Iliac vessels
40
#1 complication following kidney transplant?
Urine leak
41
Treatment for urine leaks following kidney transplant?
Drainage and stenting usually first; may need reoperation
42
Other complications of kidney transplant?
Renal artery stenosis, lymphocele, postop oliguria, postop diuresis, new proteinuria, postop diabetes, viral infections
43
How is the diagnosis of renal artery stenosis made? Treatment?
Dx: Ultrasound first, but may need MRA or CTA Tx: PTA with stent; surgery only if resistant HTN or proximal recipient arteriosclerotic disease
44
What is the most common cause of external compression following kidney transplant? Treatment?
Lymphocele; perc drainage, then intraperitoneal marsupialization (can use laparoscopic approach)
45
What is postop oliguria caused by after kidney transplant?
ATN; path shows hydrophobic changes
46
What is post-op diuresis caused by following a kidney transplant?
Urea and glucose
47
What is new proteinuria caused by following a kidney transplant?
Renal vein thrombosis
48
What causes postop diabetes following kidney transplant?
Side effect of CSA, FK, steroids
49
What makes up a kidney rejection workup?
Usually done for increase in Cr; US with duplex and biopsy; empiric increase in CSA or FK; pulse steroids
50
What is the most common complication for living kidney donors?
Wound infection
51
What is the most common cause of death in living kidney donors?
Fatal PE
52
What happens to the remaining kidney in living kidney donors?
Hypertrophies
53
How long can a liver be stored?
24 hours
54
What are contraindications to liver transplant?
Current EtOH abuse, acute UC
55
What is the most common reason for liver transplant in adults?
Chronic hepatitis
56
What are the criteria for emergent liver transplant?
Fulminant hepatic failure - Stage III (stupor), stage IV (coma)
57
What is the best predictor of 1-yr survival following liver transplant?
APACHE score
58
How can patients with hepatitis B antigenemia be treated following liver transplant?
HBIG and lamivudine (protease inhibitor)
59
Is portal vein thrombosis a contraindication to transplant?
NO
60
Is hepatocellular CA a contraindication to transplant?
NO: if 1 tumor <5cm or 3 <3cm. No evidence of gross vascular invasion; and no regional nodal or distant metastases.
61
What disease is most likely to recur in the new liver allograft?
Hepatitis C; reinfects essentially all grafts
62
What is the reinfection rate of Hepatitis B?
20% with use of HBIG
63
What % will start using EtOH again?
20% (recidivism)
64
What is the #1 predictor of primary nonfunction of liver transplant?
Macrosteatosis; extracellular fat globules in the liver allograft
65
Where are drains placed following liver transplant?
Right subhepatic, right and left subdiaphragmatic
66
Biliary system depends on what blood supply?
Hepatic artery; leaks can develop if this is compromised
67
What is the most common arterial anomaly in liver transplant?
Replaced right hepatic off of SMA
68
#1 complication following liver transplant?
Bile leak
69
Treatment for bile leak?
PTC tube and stent
70
What are indications of primary nonfunction of liver transplant?
Total bili >10, bile output <20cc/hr, PT and PTT 1.5x normal; after 96 hours: hyperkalemia, mental status changes, inc. LFTs, renal failure, repsiratory failure
71
Treatment for primary nonfunction of liver transplant?
Retransplantation
72
Treatment for hepatic artery thrombosis?
Angio (balloon dilation, +/- stent), surgery, retransplantation
73
What are signs of IVC stenosis following liver transplant?
Edema, ascites, renal insufficiency
74
Signs of cholangitis on pathology?
PMNs around portal triad, NOT a mixed infiltrate
75
Signs of acute rejection of liver transplant?
Fever, jaundice, dec. bile output, change in bile consistency; leukocytosis, eosinophilia, inc. LFTs, inc. total bili, inc. PT
76
Pathology findings in acute rejection of liver transplant?
Portal lympocytosis, endotheliitis (mixed infiltrate) and bile duct injury
77
Most common predictor of chronic rejection?
Acute rejection
78
Signs of chronic rejection of liver transplant?
Disappearing bile ducts (Ab and cellular attack on bile ducts), gradually get bile duct obstruction in inc. in alk phos, portal fibrosis
79
Liver retransplantation rate?
20%
80
5-yr survival rate following liver transplant?
70%
81
What is the arterial supply for pancreas transplant?
Donor celiac and SMA
82
What is the venous supply for pancreas transplant?
Donor portal vein
83
What is the donor pancreas attached to?
Recipient iliac vessels
84
How is the pancreatic duct drained in pancreas transplant?
Enteric drainage; 2nd portion of duodenum from donor along with ampulla of Vater and pancreas, then perform anastomosis of donor duodenum to recipient bowel
85
Successful kidney/pancreas transplant results?
Stabilization of retinopathy, dec. neuropathy, inc. nerve conduction velocity, dec. autonomic dysfunction (gastroparesis), inc. orthostatic hypotension
86
#1 complication of pancreas transplant?
Thrombosis - hard to treat
87
How is rejection of pancreas transplant diagnosed?
Difficulty if pt does not also have a kidney transplant; inc. glucose, amylase or trypsinogen; fever, leukocytosis
88
How long can a heart be stored?
6 hours
89
Complications following heart transplantation?
Persistent pulmonary hypertension
90
Treatment of persistent pulmonary hypertension following heart transplant?
Flolan (PGI2); inhaled NO, ECMO if severe; associated with inc. morbidity and mortality after transplant
91
Pathologic findings of acute rejection following heart transplant?
Perivascular infiltrate with inc. grades of myocyte inflammation and necrosis
92
Pathologic findings of chronic rejection following heart transplant?
Progressive diffuse coronary atherosclerosis
93
How long can lungs be stored for?
6 hours
94
#1 cause of early mortality following lung transplant?
Reperfusion injury
95
Indication for double lung tranplant?
Cystic fibrosis
96
Exclusion criteria for using lungs?
Aspiration, moderate to large contusion, infiltrate, purulent sputum, PO2 <350 on 100% FiO2, PEEP 5
97
Pathologic findings of acute rejection following lung transplant?
Perivascular lymphocytosis
98
Pathologic findings of chronic rejection after lung transplant?
Bronchiolitis obliterans
99
What is the hierarchy for permission for organ donation from next of kin?
Spouse --> adult son or daughter --> either parent --> adult brother or sister --> guardian --> any other person authorized to dispose of the body
100
What is bactrim prophylaxis used against?
Pneumocystis jiroveci pneumonia
101
What is the major advantage of living donor kidney transplant?
longer graft survival
102
Preservation of kidneys and livers with The University of Wisconsin (UW) solution permits what?
Longer cold ischemia times. Reduction in delayed graft function after kidney transplantation but is associated with an increase in biliary complications with preservation times >12 hours.
103
What is CMV Syndrome?
Fever, bone marrow suppression, malaise, myalgia, and arthralgia. Most likely in transplant recipients who are CMV seronegative prior to transplant receiving an organ from a seropositive donor who had a prior infection.
104
Patient does not meet the criteria for establishing a diagnosis of brain death. The patient’s primary team predicts a poor prognosis, and the patient family is still interested in organ donation.
Consider the patient for possible donation after cardiac death (DCD). Patient is removed from ventilator support until cardiac arrest occurs. Only after cardiac death has been determined, can organ procurement proceed.
105
What occurs when a partial liver graft is unable to meet the functional demand of the recipient resulting in early graft dysfunction - coagulopathy, prolonged cholestasis, significant ascites, and poor bile production?
Small for size graft syndrome
106
Components of MELD?
INR, bilirubin, Cr | less than 15 is associated with a mortality rate less than the mortality rate of undergoing liver transplantation
107
What does bile duct atrophy (vanishing bile duct syndrome) mean for a liver transplant?
chronic rejection
108
For heart transplant, chronic rejection is manifested by...
cardiac allograft vasculopathy, a form of accelerated arteriosclerosis very common, affecting greater than 1/3 of grafts at 5 years and 1/2 at 10 yrs
109
For lung, chronic rejection is manifested as...
bronchiolitis obliterans syndrome | is quite common affecting > 1/2 of patients by 5 years
110
For kidney, chronic rejection is manifested by...
interstitial fibrosis and tubular atrophy
111
What kinds of vaccines should be given before transplant?
live vaccines - varicella
112
What is the most likely benefit of pursuing a simultaneous pancreas-kidney (SPK) transplant?
Quality of life is consistently better with SPK as opposed to kidney transplant alone.
113
What is the most common indication for a diabetic patient without renal failure to undergo a pancreas transplant alone?
Hypoglycemic unawareness
114
Which immunosuppressive medication is associated with significant potential for neurotoxicity including headache, tremors, and seizure?
Tacrolimus
115
All kidney donors are required to have a GFR of greater than or equal to what?
80 ml/min
116
Most of the preservation injury that damages transplanted organs occurs when?
during reperfusion
117
Delayed graft function is associated with...
reduced graft function and survival, and increased risk of rejection
118
What is the minimum safe remnant liver volume for a live liver donor? What is the maximum age?
30%. Less is associated with a 4-fold increased risk of donor morbidity. 55 yrs.
119
In order to prevent venous congestion of the intra-abdominal organs during a multi-organ deceased donor procurement...
An exsanguination catheter is placed in the distal inferior vena cava.
120
Pulsatile machine perfusion of kidneys compared to cold storage is associated with...
A lower incidence of delayed graft function, but is associated with greater costs. It does not impact the incidence of graft thrombosis, ureteral complications, or patient survival.
121
Major metabolic concerns after pancreas-kidney transplantation may be...
- systemic hyperinsulinemia perhaps resulting in enhanced peripheral and coronary atherosclerosis - metabolic acidosis secondary to increased bicarbonate losses from pancreatic secretions in the urine

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