Complications Flashcards
Risk factors for AIH recurrence following LT
- Increasing time post-tx
- DC of steroids
- Poorly controlled AIH pre-txp
- Concomitant autoimmune diseases
Islet Cell Txp Complications
- Bleeding
- PVT (2/2 txp procedure via protal vein; consider ppx)
- Pain
- Mild AST/ALT elevations (engraftment in liver; should resolve)
- Sensitization (risk inc with # of donors)
Panc Txp vs Islet Cell Txp
- Insulin Independence
- Adverse events
- Duration hospitalization
- Insulin Independence: Panc wins
- Adverse events: Islet cell wins (panc has more thrombosis, relap, CMV reactivation)
- Duration hospitalization: Islet cell wins
Risk factors for FSGS recurrence
- 1st txp failed dt recurrence
- Rapid progression to ESRD
- Young age at time of diagnosis
Indications for kidney bx per KDIGO
9.1: We recommend kidney allograft biopsy when there is a persistent, unexplained increase in serum creatinine. (1C)
9.2: We suggest kidney allograft biopsy when serum creatinine has not returned to baseline after treatment of acute rejection. (2D)
9.3: We suggest kidney allograft biopsy every 7–10 days during delayed function. (2C)
9.4: We suggest kidney allograft biopsy if expected kidney function is not achieved within the first 1–2 months after transplantation. (2D)
9.5: We suggest kidney allograft biopsy when there is:
• new onset of proteinuria (2C);
• unexplained proteinuria ≥3.0 g/g creatinine or ≥3.0 g per 24 hours. (2C)
KDIGO recs for FSGS recurrence screening
Screen for proteinuria • daily for 1 week (2D); • weekly for 4 weeks (2D); • every 3 months, for the first year (2D); • every year, thereafter. (2D)
KDIGO recs for IgA/MPGN/anti-GBM/ANCA recurrence screening
Screen for proteinuria, microhematuria:
• once in the first month to determine a baseline (2D);
• every 3 months during the first year (2D);
• annually, thereafter. (2D)
Treatment of recurrent FSGS
We suggest plasma exchange if a biopsy shows minimal change disease or FSGS
in those with primary FSGS as their primary kidney disease.
Treatment of recurrent anti-GBM/ANCA
We suggest high-dose corticosteroids and cyclophosphamide in patients with recurrent ANCA-associated vasculitis or anti-GBM disease
Cause of pre-kidney txp secondary hyperparathyroidism? Implications on phos, Ca, Vit D?
Renal function declines –> reduction in phosphate reabsorption in the nephrons via FGF23 –> PTH increases to maintain phosphate balance
Phos: Elevated
Ca: Dec (dt inc PTH, bone resorption)
Vit D: Dec (dt dec 1a hydroxylase in kidney to conver to active vit D)
Treatment of secondary hyperparathyroidism post-txp
- Calcimimetics if elevated PTH
- Vit D or calcitriol pending 25HD level
- Surgical parathyroidectomy PRN
Monitoring of secondary hyperparathyroidism post-txp
Immediately post-txp: Monitor Ca and Phos at least weekly
Then, monitor PTH, Ca, Phos with frequency depending on abnormalities
Requirements to be within Milan Critera
- Solitary tumor <5 CM OR - Up to 3 tumor nodules (each < 3CM) AND No extra hepatic or vascular invasion
Which type of pancreas txp has the highest risk of rejection?
PTA
Islet allograft survival: donor and recipient factors
- Induction
- Calcineurin inhibitor maintenance
- > 500 000 islet equivalents infused
- Recipient age >35
- Donor BMI >30 with A1c <6.5%
- <43 units/day pretransplant insulin requirements
Recommended volume for islet cell txp
Preferred: >7k IE/kg from single donor
Acceptable: >5k IE/kg
Anti-inflammatory medications that improve islet cell engraftment & insulin independence
Block inflammatory reaction:
- Anti-TNF (Etanercept)
- IL-1 receptor antagonist (Anakinra)
Non-Anti-inflammatory medications that improve islet cell engraftment and/or insulin independence
- Heparin (UFH or LMWH to target aPTT): counteract thromobogenic effects of islets
- Insulin to target normoglycemia: anti-inflammatory properties
- GLP-1 Receptor Agonists: augment insulin production by islets
Risk for bacteremia post-intestinal txp
- Liver graft
- Pre-op bili >5
- Pediatrics
Note: G+ > G- > fungal
Foods that cause dumping syndrome
- Insoluble cellulose
- Simple carbohydrates
Risk factors for PTLD post-intestinal txp
- ITx
- Primary EBV infxn
- Depleting induction
- Young recipient age
Risk factors for poor outcomes post-heart txp (donor & recip & surgical)
Donor
- Older age (>50)
- Gender mismatch
- Size mismatch
- LV thickness >1.4 cm
Recipient
- Pre-txp amio use
- The usual: older age, DM, HTN, obesity, vascular dz, frailty
Surgical
- Ischemic tima (ideal <4 hr; max 6 hr)
Ideal vasoactives post-heart txp
- Something with minimal vasodilation (likely vasoplegic after OR) - NOT isoproterenol
- Chronotropy - Anything with beta/milrinone
- Increased contractility (stunted from cold time) - Anything with beta/milrinone
- Decreased arrhythmia risk - NOT isoproterenol, epi
What decrease in FEV1 is considered significant for lung dysfunction?
10%+
