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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
Q

Side effects of OKT3?

A

Fever, chills, pulmonary edema, shock

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26
Q

Mechanism of action of Zenapax (Daclizumab)?

A

Human monoclonal ab against IL-2 receptors

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27
Q

When is Zenapax (Daclizumab) used?

A

Used with induction and to treat steroid resistant liver rejection

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28
Q

What is the timeframe and cause of hyperacute rejection?

A

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

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29
Q

Treatment of hyperacute rejection?

A

Emergent retransplant

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30
Q

What is accelerated rejection?

A

(<1 wk) Caused by sensitized T cells to donor antigens; produces secondary immune response

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31
Q

Treatment for accelerated rejection?

A

Increased immunosuppression, pulse steroids.
Renal: plasmapheresis, IVIG.
Liver: if steroid resistant, options include thymo, MMF, basalixumab, sirolimus, tacrolimus.

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32
Q

What is the timeframe and causative agent of acute rejection?

A

1wk to 1month; caused by T cells (cytotoxic and helper T cells)

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33
Q

Treatment of acute rejection?

A

Increased immunosuppression, pulse steroids, possibly OKT3

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34
Q

What is the timeframe and cause of chronic rejection?

A

Months to years; Type IV hypersensitivity reaction (sensitized T cells); Ab formation also plays a role, leads to graft fibrosis and vascular damage

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35
Q

Treatment of chronic rejection?

A

Increased immunosuppression, OKT3 - no really effective treatment

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36
Q

How long can a kidney be stored?

A

48 hours

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37
Q

What is the mortality following kidney transplant from?

A

Stroke and MI

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38
Q

Can a kidney from a patient with a UTI or acute increase in Cr (1.0-3.0) still be used?

A

YES

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39
Q

Transplanted kidney is grafted to what vessel?

A

Iliac vessels

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40
Q

1 complication following kidney transplant?

A

Urine leak

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41
Q

Treatment for urine leaks following kidney transplant?

A

Drainage and stenting usually first; may need reoperation

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42
Q

Other complications of kidney transplant?

A

Renal artery stenosis, lymphocele, postop oliguria, postop diuresis, new proteinuria, postop diabetes, viral infections

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43
Q

How is the diagnosis of renal artery stenosis made? Treatment?

A

Dx: Ultrasound first, but may need MRA or CTA
Tx: PTA with stent; surgery only if resistant HTN or proximal recipient arteriosclerotic disease

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44
Q

What is the most common cause of external compression following kidney transplant? Treatment?

A

Lymphocele; perc drainage, then intraperitoneal marsupialization (can use laparoscopic approach)

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45
Q

What is postop oliguria caused by after kidney transplant?

A

ATN; path shows hydrophobic changes

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46
Q

What is post-op diuresis caused by following a kidney transplant?

A

Urea and glucose

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47
Q

What is new proteinuria caused by following a kidney transplant?

A

Renal vein thrombosis

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48
Q

What causes postop diabetes following kidney transplant?

A

Side effect of CSA, FK, steroids

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49
Q

What makes up a kidney rejection workup?

A

Usually done for increase in Cr; US with duplex and biopsy; empiric increase in CSA or FK; pulse steroids

50
Q

What is the most common complication for living kidney donors?

A

Wound infection

51
Q

What is the most common cause of death in living kidney donors?

A

Fatal PE

52
Q

What happens to the remaining kidney in living kidney donors?

A

Hypertrophies

53
Q

How long can a liver be stored?

A

24 hours

54
Q

What are contraindications to liver transplant?

A

Current EtOH abuse, acute UC

55
Q

What is the most common reason for liver transplant in adults?

A

Chronic hepatitis

56
Q

What are the criteria for emergent liver transplant?

A

Fulminant hepatic failure - Stage III (stupor), stage IV (coma)

57
Q

What is the best predictor of 1-yr survival following liver transplant?

A

APACHE score

58
Q

How can patients with hepatitis B antigenemia be treated following liver transplant?

A

HBIG and lamivudine (protease inhibitor)

59
Q

Is portal vein thrombosis a contraindication to transplant?

A

NO

60
Q

Is hepatocellular CA a contraindication to transplant?

A

NO: if 1 tumor <5cm or 3 <3cm. No evidence of gross vascular invasion; and no regional nodal or distant metastases.

61
Q

What disease is most likely to recur in the new liver allograft?

A

Hepatitis C; reinfects essentially all grafts

62
Q

What is the reinfection rate of Hepatitis B?

A

20% with use of HBIG

63
Q

What % will start using EtOH again?

A

20% (recidivism)

64
Q

What is the #1 predictor of primary nonfunction of liver transplant?

A

Macrosteatosis; extracellular fat globules in the liver allograft

65
Q

Where are drains placed following liver transplant?

A

Right subhepatic, right and left subdiaphragmatic

66
Q

Biliary system depends on what blood supply?

A

Hepatic artery; leaks can develop if this is compromised

67
Q

What is the most common arterial anomaly in liver transplant?

A

Replaced right hepatic off of SMA

68
Q

1 complication following liver transplant?

A

Bile leak

69
Q

Treatment for bile leak?

A

PTC tube and stent

70
Q

What are indications of primary nonfunction of liver transplant?

A

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
Q

Treatment for primary nonfunction of liver transplant?

A

Retransplantation

72
Q

Treatment for hepatic artery thrombosis?

A

Angio (balloon dilation, +/- stent), surgery, retransplantation

73
Q

What are signs of IVC stenosis following liver transplant?

A

Edema, ascites, renal insufficiency

74
Q

Signs of cholangitis on pathology?

A

PMNs around portal triad, NOT a mixed infiltrate

75
Q

Signs of acute rejection of liver transplant?

A

Fever, jaundice, dec. bile output, change in bile consistency; leukocytosis, eosinophilia, inc. LFTs, inc. total bili, inc. PT

76
Q

Pathology findings in acute rejection of liver transplant?

A

Portal lympocytosis, endotheliitis (mixed infiltrate) and bile duct injury

77
Q

Most common predictor of chronic rejection?

A

Acute rejection

78
Q

Signs of chronic rejection of liver transplant?

A

Disappearing bile ducts (Ab and cellular attack on bile ducts), gradually get bile duct obstruction in inc. in alk phos, portal fibrosis

79
Q

Liver retransplantation rate?

A

20%

80
Q

5-yr survival rate following liver transplant?

A

70%

81
Q

What is the arterial supply for pancreas transplant?

A

Donor celiac and SMA

82
Q

What is the venous supply for pancreas transplant?

A

Donor portal vein

83
Q

What is the donor pancreas attached to?

A

Recipient iliac vessels

84
Q

How is the pancreatic duct drained in pancreas transplant?

A

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
Q

Successful kidney/pancreas transplant results?

A

Stabilization of retinopathy, dec. neuropathy, inc. nerve conduction velocity, dec. autonomic dysfunction (gastroparesis), inc. orthostatic hypotension

86
Q

1 complication of pancreas transplant?

A

Thrombosis - hard to treat

87
Q

How is rejection of pancreas transplant diagnosed?

A

Difficulty if pt does not also have a kidney transplant; inc. glucose, amylase or trypsinogen; fever, leukocytosis

88
Q

How long can a heart be stored?

A

6 hours

89
Q

Complications following heart transplantation?

A

Persistent pulmonary hypertension

90
Q

Treatment of persistent pulmonary hypertension following heart transplant?

A

Flolan (PGI2); inhaled NO, ECMO if severe; associated with inc. morbidity and mortality after transplant

91
Q

Pathologic findings of acute rejection following heart transplant?

A

Perivascular infiltrate with inc. grades of myocyte inflammation and necrosis

92
Q

Pathologic findings of chronic rejection following heart transplant?

A

Progressive diffuse coronary atherosclerosis

93
Q

How long can lungs be stored for?

A

6 hours

94
Q

1 cause of early mortality following lung transplant?

A

Reperfusion injury

95
Q

Indication for double lung tranplant?

A

Cystic fibrosis

96
Q

Exclusion criteria for using lungs?

A

Aspiration, moderate to large contusion, infiltrate, purulent sputum, PO2 <350 on 100% FiO2, PEEP 5

97
Q

Pathologic findings of acute rejection following lung transplant?

A

Perivascular lymphocytosis

98
Q

Pathologic findings of chronic rejection after lung transplant?

A

Bronchiolitis obliterans

99
Q

What is the hierarchy for permission for organ donation from next of kin?

A

Spouse –> adult son or daughter –> either parent –> adult brother or sister –> guardian –> any other person authorized to dispose of the body

100
Q

What is bactrim prophylaxis used against?

A

Pneumocystis jiroveci pneumonia

101
Q

What is the major advantage of living donor kidney transplant?

A

longer graft survival

102
Q

Preservation of kidneys and livers with The University of Wisconsin (UW) solution permits what?

A

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
Q

What is CMV Syndrome?

A

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
Q

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.

A

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
Q

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?

A

Small for size graft syndrome

106
Q

Components of MELD?

A

INR, bilirubin, Cr

less than 15 is associated with a mortality rate less than the mortality rate of undergoing liver transplantation

107
Q

What does bile duct atrophy (vanishing bile duct syndrome) mean for a liver transplant?

A

chronic rejection

108
Q

For heart transplant, chronic rejection is manifested by…

A

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
Q

For lung, chronic rejection is manifested as…

A

bronchiolitis obliterans syndrome

is quite common affecting > 1/2 of patients by 5 years

110
Q

For kidney, chronic rejection is manifested by…

A

interstitial fibrosis and tubular atrophy

111
Q

What kinds of vaccines should be given before transplant?

A

live vaccines - varicella

112
Q

What is the most likely benefit of pursuing a simultaneous pancreas-kidney (SPK) transplant?

A

Quality of life is consistently better with SPK as opposed to kidney transplant alone.

113
Q

What is the most common indication for a diabetic patient without renal failure to undergo a pancreas transplant alone?

A

Hypoglycemic unawareness

114
Q

Which immunosuppressive medication is associated with significant potential for neurotoxicity including headache, tremors, and seizure?

A

Tacrolimus

115
Q

All kidney donors are required to have a GFR of greater than or equal to what?

A

80 ml/min

116
Q

Most of the preservation injury that damages transplanted organs occurs when?

A

during reperfusion

117
Q

Delayed graft function is associated with…

A

reduced graft function and survival, and increased risk of rejection

118
Q

What is the minimum safe remnant liver volume for a live liver donor? What is the maximum age?

A

30%. Less is associated with a 4-fold increased risk of donor morbidity.
55 yrs.

119
Q

In order to prevent venous congestion of the intra-abdominal organs during a multi-organ deceased donor procurement…

A

An exsanguination catheter is placed in the distal inferior vena cava.

120
Q

Pulsatile machine perfusion of kidneys compared to cold storage is associated with…

A

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
Q

Major metabolic concerns after pancreas-kidney transplantation may be…

A
  • systemic hyperinsulinemia perhaps resulting in enhanced peripheral and coronary atherosclerosis
  • metabolic acidosis secondary to increased bicarbonate losses from pancreatic secretions in the urine

Copy ABSITE Review: Fiser, Decker, SCORE, UpToDate, TrueLearn (50 decks)

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