EXAM 4 Transplantation Flashcards
what are the indications for a kidney transplant?
- diabetes
- hypertension
- glomerulonephritis
- polysystic kidney disease
- reflux nephropathy
what are the indications for a liver transplant?
- viral hepatitis
- overdose
- alcohol
what are the indications for a pancreas transplant?
diabetes mellitis
what are the indications for a heart transplant?
coronary artery disease and idiopathic cardiomyopathy
what are the indications for a lung transplant?
- COPD
- cystic fibrosis
- idiopathic pulmonary fibrosis
- alpha-1 antitrypsin deficiency
what are the indications for a bone marrow transplant?
- leukemia
- lymphoma
- multiple myeloma
is a small bowel an indication for a bowel transplant?
yes
what are the expected survival rates for kidney, liver, heart, lung, and bone marrow transplants? (reported as percentages)
- kidney - 90%
- liver - 75%
- heart - 70-75%
- lungs - 50%
- bone marrow - 60%
which type of immunity is extracellular, B-cell mediated response with antibody production?
humoral
which type of immunity is T-lymphocyte mediated response with recognition of MHC and regulation of B and other T cells
cellular
what year was the first successful transplant?
1954
what is the major immunity target in transplantation?
allo-MHC on surface of donor cells with T-cell recognition of alloantigen
immunity in transplantation is an ___ response
adaptive
T cells are activated in transplantation. what is the function of the activated T cells?
direct cytotoxicity and help for B-cell antibody production
what is a host versus graft reaction?
rejection of the transplant
what are the two stages of transplant rejection?
- sensitization stage (recognition of alloantigens)
- direct pathway - host T cells recognize allo-MHC molecules as non-self
- indirect pathway - T cells recognize processed alloantigen presented by self-APCs
- effector stage
- inflammatory response to the injury
- B cell activation with Ab production
- further cell recruiting, NKs, apoptosis
what are contributing factors of a net state of immunosuppression?
immunosuppressive therapy (current and past), mucocutaneous-barrier integrity, neutropenia, underlying diseases, metabolic conditions, infections, nutritional status
what are the major classes of immunosuppression used during transplants?
- calcineurin inhibitors
- mTOR inhibitors
- antiproliferative agents
- antibodies
- corticosteroids
describe the two phases of immunosuppression
- SOT (solid organ transplant)
- induction
- acute post-transplant
- maintenance
- (rejection treatment)
- HSCT (hematopoeitic stem cell transplant) - autologous vs allogeneic
- induction/conditioning
- consolidation/intensification
- maintenance
- GVHD treatment
what are the post HSCT phases?
factors for infection risk
- phase I (pre-engraftment) - day 0-30
- prolonged neutropenia
- damage to mucocutaneous barriers
- phase II (post-engraftment) - day 31-100
- impaired cell-mediated immunity
- GVHD
- phase III (late) - day >100
- depends on immunosuppression
describe pre-transplant dental care (gingivitis and periodontitis)
- perform dental prophylaxis/cleaning
- treat all active dental disease
- remove all potential sources of acute or chronic infection
- remove all non-restorable teeth
- reinforce oral hygiene and home care instructions
- perform necessary denture adjustments
- daily use of antibacterial mouthwash
what are 5 components of pre-transplant dental care?
- consultation with MD
- educate patient about oral hygiene
- perform dental prophylaxis
- careful with certain drugs
- evaluate dental status (clinically and radiographically), treat as indicated
patients should avoid flossing if they have ___ and ___
severe leukopenia and thrombocytopenia
what are important considerations with patients who are immunosuppressed and wear dentures?
- dentures cause tissue trauma
- colonized with microbial pathogens
- remove and leave out until sores heal
- disinfect before each use and rinse before placing back in mouth
what are risks of endocarditis associated with dental care?
- antibiotics commonly given
- low risk for non-invasive procedures without underlying cardiac conditions
- tooth extraction, periodontal and/or endodontic treatment, apicoectomy, implant, placement of orthodontic appliances
the following are common affects of what treatment?
decreased production of saliva
mouth ulcers - difficult chewing, speaking, and swallowing
radiation/chemotherapy
what are the risk factors for infectious complications?
- presence of acute, chronic, and latent infections
- underlying disease
- use of prophylactic antimicrobials
- mucosal barrier loss
- development of GVHD
- medications
what are the bacterial complications associated with immunosuppression?
dental abscess and bacteremia
what are the fungal complications associated with immunosuppression?
- candidiasis (mostly candida albicans)
- aspergillus
- histoplasma
- mucor
what are the viral complications associated with immunosuppression?
- HSV (more severe and slow healing)
- VZV
- CMV
- HHV-8 (Kaposi’s sarcoma)
- EBV (hairy leukoplakia)
- HPV and other non-herpes viruses
___ is the most frequent complication post bone marrow transplant
mucositis
peaks 5-7 days post transplant and resolves spontaneously 15-22 days post transplant
mucositis affects ___ mucosal surfaces. what are examples?
nonkeratinized
- ventral and lateral tongue
- floor of the mouth
- soft palate
- buccal mucosa
- inner lips
infectious complications are major risk factors for bacteremia with ___
viridans streptococci
GVHD is an interaction of ___ and ___ immune systems
innate and adaptive
what are the oral manifestations of GVHD?
- xerostomia
- mucosal lichenoid
- papular lesions
- erythema
- tongue surface atrophy
- ulceration
what are manifestations, other than oral, of GVHD?
- skin rash
- liver (jaundice, transaminitis)
- GI (diarrhea, nausea, vomiting)
- eyes
- lungs
can GVHD worsen oral hygeine?
yes
treated with immunosuppression (increases infection)
reducing oral microbial load with treatment of pre-existing conditions improves outcome
___ can cause gingival hyperplasia
cyclosporine
25-30% of patients are affected, more common in children
gingival hyperplasia is worse if cyclosporine is combined with ___
calcium channel blockers (nifedipine > amlodipine, verapamil, diltiazem)
describe the genetic predisposition for gingival hyperplasia
- HLA-DR1 phenotype - protective
- HLA-DR2 and HLA-B37 - increased risk
is gingival hyperplasia more common in males or females?
males
describe the epidemiology of gingival hyperplasia
- develops 1-3 months after starting drugs
- begins at interdental papillae, affecting marginal and papillary tissue
- edentulous areas not affected
- grandual gingival lobulations, hyperemic and easily hemorrhagic
- epithelium invated by candida hyphae
- occasional cauliflower appearance
- may alter teeth positioning, with fibrotic enlargement affecting esthetics, mastication, and speech
describe attention to medications for transplant patients
- doses may vary according to renal function
- check for interactions with immunosuppressants
- cyclosporine - gingival hypertrophy
- avoid NSAIDs
- prolonged use of steroids - risk of addisonian crisis with high stress
DM, neurotoxicity, HTN, and nephorotoxicity are major toxicities for what immunosuppressive drug?
tacrolimus
gingival hyperplasia is a major toxicity for what immunosuppressive drug?
cyclosporine
mucosisit, oral ulcers, poor wound healing, and bone marrow suppression are major toxicities for what immunosuppressive drug?
sirolimus/everolimus
leukopenia and thrombocytopenia are major toxicities for what immunosuppressive drug?
azathioprine
leukopenia, GI disturbances, and skin cancer are major toxicities for what immunosuppressive drug?
mycophenolate/MMF
HTN, cushing, DM, and osteoporosis are major toxicities for what immunosuppressive drug?
steroids
stomatitis, nausea, and headache are major toxicities for what immunosuppressive drug?
cyclophosphamide
bone marrow suppression and coagulopathy are major toxicities for what immunosuppressive drug?
anti-thymocyte globulins
bone marrow suppression is a major toxicity for what immunosuppressive drug?
alemtuzumab
___ should be removed immediately post-transplant
dentures and orthodontic appliances
peak immunosuppression of transplant patients is ___
first 3-6 months
- do only emmergency treatment in hospital environment during this time
- elective procedures should be postponed for 3-6 months after transplant or periods of profound immunosuppression
- wait for remission after chemotherapy for leukemia
what are special considerations of some transplant patients?
- indwelling central venous catheters
- avoid tongue piercing
- emergent procedures: consider antibiotic prophylaxis if profoundly immunosuppressed
what is the organ specific care for heart transplant?
- high risk of bleeding
- anesthesia without epinephrine
what is the organ specific care for lung transplant?
- caution with narcotics
- avoid combustible products if on supplemental O2
what is the organ specific care for liver transplant?
- avoid drugs metabolized in liver
- coagulopathy
what is the organ specific care for kidney transplant?
drug dose adjustment with renal elimination
what is the organ specific care for pancreas transplant?
glucose management
what is the organ specific care for bone marrow transplant?
mucositis, hemorrhage, GVHD
