dialysis + transplant

Question 1

3 types of haemodialysis

Answer 1

arteriovenous fistula
arteriovenous graft
tunnelled central venous catheter

Question 2

tunnelled central venous catheter

Answer 2

catheter into subclavian or internal jugular vein with tip in SVC orRA
–> 2 lumen blood exits (red), blood enters (blue)

Question 3

pros and cons of tunnelled central venous catheter

Answer 3

pros = easy to insert + use immediatelt

cons = high risk of infections, can become blocked, stenosis thrombosis to central veins

Question 4

gold standard for dialysis vascular access

Answer 4

arteriovenous fistula

Question 5

pros + cons of arteriovenous fistula

Answer 5

pros = good flow, less likely to cause infection

con = requires surgery, maturation of 6-12weeks, limit flow to distal arm (steal syndrome), thrombosis/stenosis

Question 6

what is steal syndrome

Answer 6

inadequate blood flow to limb distal to AV fistula -> distal ischaemia

(fistula “steals” blood)

Question 7

haemofiafiltration

Answer 7

removal + replacement of >21L per session

increasingly convective in nature

Question 8

why choose haemodiafiltration?

Answer 8

smoother, less symptomatic treatment that HD
enhance recovery time, improve survival

achievable + similar cost to HD

**BUT quality of life and restrictions*

Question 9

cons of haemodiafiltration

Answer 9

BUT not efficient, min 4hrs 3x a week - poor quality of life

restrictions

• 1L per day - including food
• low salt
• low potassium
• low phosphate

Question 10

types of renal transplant

Answer 10

decreased heart beating donors (DBD) - brain dead
non-heart beating donors (DCD)
live donation (altruistic) - paired

Question 11

how are donors matched

Answer 11

HLA type A B C on chromosome 6

blood

Question 12

kidney allocation steps

Answer 12

1. paeds - any match
2. 000 mismatch = ideal
3. 100, 010 etc mismatch = favourable
4. other match = unfavourable

Question 13

signs of immediate graft function post renal transplant

Answer 13

good urine output

falling urea + creatinine

Question 14

delayed graft function

Answer 14

post-transplant acute tubular necrosis
needs haemolyisis in meantime
10-30days
biopsy to check

Question 15

side effect of tacrolimus

Answer 15

tremor

immunosupressive, life long post transplant

Question 16

lifelong immunosupression post transplant

Answer 16

prednisolone
tacrolimus
mycophonolate

Question 17

management of post-transplant lymphoproliferative disease`

Answer 17

reduce immunosuppression

Question 18

sensitising events and their importance in renal transplants

Answer 18

blood transfusion, pregnancy/miscarriage, previous transplant

(previous formation of antibodies to non-self antigens can cause rejection)

Question 19

acute anti-rejection treatments

Answer 19

pulsed IV methylprednisolone (ACR)
antithymocyre globulin
IV immunoglobulin

Question 20

induction monoclonal antibodies post transplant

Answer 20

basiliximab or dacluzimab

block IL-2 receptors on CD4 T cells

(prevent rejection, not useful if already started)

Question 21

MoA of glucocorticoids

Answer 21

inhibits lymphocyte proliferation, survival + activation

supress cytokines

Question 22

calcineurin inhibitors in renal transplant

Answer 22

tacrolimus + ciclosporin

inhibit activation of T cells + prevent cytokine release

Question 23

MoA of azathioprine + mycophonolate mofetil (MMF)

Answer 23

block purine synthesis - supress proliferation of lymphocytes

SE = leucopenia, GI upset, anaemia