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Host and Defense > EXAM 4 Transplantation > Flashcards

EXAM 4 Transplantation Flashcards

1
Q

what are the indications for a kidney transplant?

A
  • diabetes
  • hypertension
  • glomerulonephritis
  • polysystic kidney disease
  • reflux nephropathy
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2
Q

what are the indications for a liver transplant?

A
  • viral hepatitis
  • overdose
  • alcohol
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3
Q

what are the indications for a pancreas transplant?

A

diabetes mellitis

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4
Q

what are the indications for a heart transplant?

A

coronary artery disease and idiopathic cardiomyopathy

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5
Q

what are the indications for a lung transplant?

A
  • COPD
  • cystic fibrosis
  • idiopathic pulmonary fibrosis
  • alpha-1 antitrypsin deficiency
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6
Q

what are the indications for a bone marrow transplant?

A
  • leukemia
  • lymphoma
  • multiple myeloma
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7
Q

is a small bowel an indication for a bowel transplant?

A

yes

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8
Q

what are the expected survival rates for kidney, liver, heart, lung, and bone marrow transplants? (reported as percentages)

A
  • kidney - 90%
  • liver - 75%
  • heart - 70-75%
  • lungs - 50%
  • bone marrow - 60%
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9
Q

which type of immunity is extracellular, B-cell mediated response with antibody production?

A

humoral

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10
Q

which type of immunity is T-lymphocyte mediated response with recognition of MHC and regulation of B and other T cells

A

cellular

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11
Q

what year was the first successful transplant?

A

1954

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12
Q

what is the major immunity target in transplantation?

A

allo-MHC on surface of donor cells with T-cell recognition of alloantigen

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13
Q

immunity in transplantation is an ___ response

A

adaptive

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14
Q

T cells are activated in transplantation. what is the function of the activated T cells?

A

direct cytotoxicity and help for B-cell antibody production

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15
Q

what is a host versus graft reaction?

A

rejection of the transplant

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16
Q

what are the two stages of transplant rejection?

A
  • 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
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17
Q

what are contributing factors of a net state of immunosuppression?

A

immunosuppressive therapy (current and past), mucocutaneous-barrier integrity, neutropenia, underlying diseases, metabolic conditions, infections, nutritional status

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18
Q

what are the major classes of immunosuppression used during transplants?

A
  • calcineurin inhibitors
  • mTOR inhibitors
  • antiproliferative agents
  • antibodies
  • corticosteroids
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19
Q

describe the two phases of immunosuppression

A
  • 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
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20
Q

what are the post HSCT phases?

A

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
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21
Q

describe pre-transplant dental care (gingivitis and periodontitis)

A
  • 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
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22
Q

what are 5 components of pre-transplant dental care?

A
  • consultation with MD
  • educate patient about oral hygiene
  • perform dental prophylaxis
  • careful with certain drugs
  • evaluate dental status (clinically and radiographically), treat as indicated
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23
Q

patients should avoid flossing if they have ___ and ___

A

severe leukopenia and thrombocytopenia

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24
Q

what are important considerations with patients who are immunosuppressed and wear dentures?

A
  • 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
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25
Q

what are risks of endocarditis associated with dental care?

A
  • 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
26
Q

the following are common affects of what treatment?

decreased production of saliva

mouth ulcers - difficult chewing, speaking, and swallowing

A

radiation/chemotherapy

27
Q

what are the risk factors for infectious complications?

A
  • presence of acute, chronic, and latent infections
  • underlying disease
  • use of prophylactic antimicrobials
  • mucosal barrier loss
  • development of GVHD
  • medications
28
Q

what are the bacterial complications associated with immunosuppression?

A

dental abscess and bacteremia

29
Q

what are the fungal complications associated with immunosuppression?

A
  • candidiasis (mostly candida albicans)
  • aspergillus
  • histoplasma
  • mucor
30
Q

what are the viral complications associated with immunosuppression?

A
  • HSV (more severe and slow healing)
  • VZV
  • CMV
  • HHV-8 (Kaposi’s sarcoma)
  • EBV (hairy leukoplakia)
  • HPV and other non-herpes viruses
31
Q

___ is the most frequent complication post bone marrow transplant

A

mucositis

peaks 5-7 days post transplant and resolves spontaneously 15-22 days post transplant

32
Q

mucositis affects ___ mucosal surfaces. what are examples?

A

nonkeratinized

  • ventral and lateral tongue
  • floor of the mouth
  • soft palate
  • buccal mucosa
  • inner lips
33
Q

infectious complications are major risk factors for bacteremia with ___

A

viridans streptococci

34
Q

GVHD is an interaction of ___ and ___ immune systems

A

innate and adaptive

35
Q

what are the oral manifestations of GVHD?

A
  • xerostomia
  • mucosal lichenoid
  • papular lesions
  • erythema
  • tongue surface atrophy
  • ulceration
36
Q

what are manifestations, other than oral, of GVHD?

A
  • skin rash
  • liver (jaundice, transaminitis)
  • GI (diarrhea, nausea, vomiting)
  • eyes
  • lungs
37
Q

can GVHD worsen oral hygeine?

A

yes

treated with immunosuppression (increases infection)

reducing oral microbial load with treatment of pre-existing conditions improves outcome

38
Q

___ can cause gingival hyperplasia

A

cyclosporine

25-30% of patients are affected, more common in children

39
Q

gingival hyperplasia is worse if cyclosporine is combined with ___

A

calcium channel blockers (nifedipine > amlodipine, verapamil, diltiazem)

40
Q

describe the genetic predisposition for gingival hyperplasia

A
  • HLA-DR1 phenotype - protective
  • HLA-DR2 and HLA-B37 - increased risk
41
Q

is gingival hyperplasia more common in males or females?

A

males

42
Q

describe the epidemiology of gingival hyperplasia

A
  • 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
43
Q

describe attention to medications for transplant patients

A
  • 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
44
Q

DM, neurotoxicity, HTN, and nephorotoxicity are major toxicities for what immunosuppressive drug?

A

tacrolimus

45
Q

gingival hyperplasia is a major toxicity for what immunosuppressive drug?

A

cyclosporine

46
Q

mucosisit, oral ulcers, poor wound healing, and bone marrow suppression are major toxicities for what immunosuppressive drug?

A

sirolimus/everolimus

47
Q

leukopenia and thrombocytopenia are major toxicities for what immunosuppressive drug?

A

azathioprine

48
Q

leukopenia, GI disturbances, and skin cancer are major toxicities for what immunosuppressive drug?

A

mycophenolate/MMF

49
Q

HTN, cushing, DM, and osteoporosis are major toxicities for what immunosuppressive drug?

A

steroids

50
Q

stomatitis, nausea, and headache are major toxicities for what immunosuppressive drug?

A

cyclophosphamide

51
Q

bone marrow suppression and coagulopathy are major toxicities for what immunosuppressive drug?

A

anti-thymocyte globulins

52
Q

bone marrow suppression is a major toxicity for what immunosuppressive drug?

A

alemtuzumab

53
Q

___ should be removed immediately post-transplant

A

dentures and orthodontic appliances

54
Q

peak immunosuppression of transplant patients is ___

A

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
55
Q

what are special considerations of some transplant patients?

A
  • indwelling central venous catheters
  • avoid tongue piercing
  • emergent procedures: consider antibiotic prophylaxis if profoundly immunosuppressed
56
Q

what is the organ specific care for heart transplant?

A
  • high risk of bleeding
  • anesthesia without epinephrine
57
Q

what is the organ specific care for lung transplant?

A
  • caution with narcotics
  • avoid combustible products if on supplemental O2
58
Q

what is the organ specific care for liver transplant?

A
  • avoid drugs metabolized in liver
  • coagulopathy
59
Q

what is the organ specific care for kidney transplant?

A

drug dose adjustment with renal elimination

60
Q

what is the organ specific care for pancreas transplant?

A

glucose management

61
Q

what is the organ specific care for bone marrow transplant?

A

mucositis, hemorrhage, GVHD

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