Fiser ABSITE Ch. 12 Transplant Flashcards by Carlos Altamirano

Three most important HLAs for recipientdonor matching?

Most important overall?

HLA-A, -B, -DR

-DR

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ABO blood compatibility required for all transplants except ___

liver

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Crossmatch detects preformed recipient antibodies by mixing recipient serum with donor lymphocytes that would generally cause ___ (except liver)

hyperacute rejection

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Technique identical to crossmatch; detects preformed recipient antibodies using a panel of typing cells. Transfusions, pregnancy, pervious transplant, and autoimmune diseases can all increase.

Panel reactive antibody (PRA)

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Tx for mild rejection.

Pulse steroids

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What is the number one malignancy following any transplant?

skin CA (squamous cell CA #1)

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What is the second most common malignancy following transplant?

Posttransplant lymphoproliferative disorder (PTLD)

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What virus is associated with Posttransplant lymphoproliferative disorder (PTLD)?

epstein-barr

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What is the tx for posttransplant lymphoproliferative disorder (PTLD)?

Withdrawal of immunosuppression; may need chemotherapy and XRT for aggressive tumor

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Antirejection drug that inhibits de novo purine synthesis, which inhibits T cells. 6-Mercaptopurine is the active metabolite (formed in the liver). Side effects: myelosuppression. Keeps WBCs > 3.
Also, there is another drug with similar action.

Azathioprine (Imuran)

Mycophenolate

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What antirejection drug works by inhibiting genes for cytokine synthesis (IL-1, IL-6) and macrophages.

steroids

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What antirejection drug works by binding cyclophilin protein and inhibits genes for cytokine synthesis (IL-2, IL-3, IL-4, INF-gamma).

Cyclosporin (CSA)

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What is the route of metabolism and excretion of cyclosporin?

hepatic metabolism and biliary excretion

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What antirejection drug binds FK-binding protein; actions similar to CSA but 10-100x more potent. Side effects include: nephrotoxicity, mood changes, more GI and neurologic changes than CSA

FK-506 (Prograf)

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What antirejection drug is equine polyclonal antibodies direct against antigens on T cells (CD2, CD3, CD4, CD8, CD1118). Used for induction therapy. Complement dependent. Keeps peripheral T-cell count >3?
Also there is another drug that has similar action but is rabbit polyclonal antibodies.

ATGAM

Thymoglobulin

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What type of rejection occurs within minutes to hours?

Hyperacute rejection

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What is hyperacute rejection caused by?

preformed antibodies that should have been picked up on crossmatch

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What is the tx for hyperacute rejection.

Emergent retransplant

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What type of rejection occurs less than 1 week?

accelerated rejection

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What is accelerated rejection caused by?

sensitized T cells to donor antigens

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What is the tx for accelerated rejection?

increase immunosuppression, pulse steroids, and possibly OKT3

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What type of rejection occurs in 1 week to 1 month?

acute rejection

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What is acute rejection caused by?

cytotoxic and helper T cells

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What is the treatment for acute rejection?

increase immunosuppression, pulse steroids and possibly OKT3

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What type of rejection occurs in months to years?

chronic rejection

What type of hypersensitivity reaction is chronic rejection? (Antibodies, monocytes and cytotoxic t cells also play a role)

Type IV

What is the tx for chronic rejection?

increase immunosuppression or OKT3 - no really effective tx

How long can you store a kidney?

48 hours

Can you still use a kidney with UTI or acute increase in Cr (1.0-3.0)

yes

2 main causes of mortality in kidney transplant?

stroke and MI

What vessels are donor kidney attached to?

external iliac

Number one complication of kidney transplant? tx?

urine leaks; | drainage and stenting; may need reoperation

Most common cause of external compression after kidney transplant? Tx 1st and if that fails

lymphocele | percutaneous drainage, intraperitoneal marsupialization (90% successful)

After kidney transplant, postop oliguria is usually due to ___ (pathology shows hyrophobic changes)

ATN

After kidney transplant, postop diuresis is usually due to ___ and ___

urea and glucose

New proteinuria after kidney transplant is usually suggestive of what?

renal vein thrombosis

Postop diabetes after kidney transplant is usually due to what?

side effects of rejection meds: CSA, FK, steroids

Kidney rejection workup (usually for increase in Cr): ___ to rule out vascular problem and ureteral obstruction; bx; empiric decrease in CSA or FK because they can be nephrotoxic; what tx?

US with duplex; | pulse steroids

What is the 5-year graft survival for kidney transplant?

70% (65 cadaveric, 75 living)

Living kidney donors: most common complication? most common cause of death?

``` wound infection (1%); fatal PE ```

How long can you store a liver for transplantation?

24 hours

2 contraindications to liver TXP

current ETOH abuse, acute ulcerative colitis

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

chronic hepatitis

Criteria for emergent liver TXP - stage III (___), stage IV (___)

stupor, coma

What are two postoperative tx for pts with Hep B after TXP?

HBIG (hep B immunoglobulin) and lamivudine (protease inhibitor)

What are the tumor size limitations on considering TXP with hepatocellular carcinoma

single tumor less than 5 cm; | 3 tumors each less than 3 cm

Is portal vein thrombosis a contraindication to liver TXP?

What is the best predictor of 1 year survival after liver TXP?

APACHE score

What is more likely to occur in liver allograft, Hep B or C

Hep C (Hep B reduced to 20% with the use of HBIG)

What percentage of liver TXP pts will start drinking again?

20%

What is the #1 predictor of primary nonfunction in liver TXP?

Macrosteatosis (extracellular fat globules in allograft); (if 50% of cross section is macrosteatatic, there is 50% chance of primary nonfunction)

What is the difference in liver TXP procedure in adults vs. kids?

Duct-to-Duct in adults | Hepatico jejunostomy in kids

Location of drains after liver TXP

Right subhepatic, Right and Left subdiaphragmatic

What is the most common hepatic arterial anomaly?

right hepatic coming off SMA

#1 complication of liver TXP? Tx?

Bile leak; PTC tube and stent

What are the signs and sx of primary nonfunction after liver TXP in the 1st 24 hrs

total bilirubin > 10, bile output less than 20 cc/12h, PT and PTT 1.5x normal

What are the signs and sx of primary nonfunction after liver TXP after 96 hours?

hyperkalemia, mental status changes, increased LFTs, renal failure, respiratory failure

What is the tx of primary nonfunction after liver TXP?

usually requires retransplantation

Most common cause of liver abscesses after TXP?

chronic hepatic artery thrombosis

Tx for hepatic artery thrombosis after liver TXP?

angio, surgery, retransplantation

Edema, acites, renal insufficiency after liver TXP could be due to what?

IVC stenosis

After liver TXP: fever, jaundice, decreased bile output, change in bile consistency. leukocytosis, eosinophilia, increased LFTs, total bilirubin, PT. Pathology shows portal lymphocytosis, endotheliitis, bile duct injury. Dx?

acute rejection

After liver TXP: disappearing bile ducts, gradual bile obstruction with increased alk phos, portal fibrosis. Dx?

chronic rejection

What is the most common predictor of chronic rejection in liver TXP?

acute rejection

Liver TXP retransplantation rate?

20%

LIver TXP 5 year survival rate?

70%

How long can a heart for TXP be stored?

6 hours

What is the life expectancy needed for a heart TXP?

Less than 1 year

What is the tx for persistant pulmonary hypertension after heart transplant?

Flolan (PGI2); inhaled nitric oxide, ECMO if severe

After heart TXP: perivascular infiltrate with increasing grades of myocyte inflammation and necrosis. Dx?

acute rejection

After heart TXP: progressive diffuse coronary atherosclerosis. Dx?

Chronic rejection

How long can a lung for transplantation be stored?

6 hours

What is the life expectancy needed for a lung TXP?

Less than 1 year

What is the number one cause of early mortality after lung TXP?

reperfusion injury

What is the indication for double-lung TXP?

cystic fibrosis

Exclusion criteria for using lungs for TXP includes: aspiration, moderate to large contusion, infiltrate, purulent sputum, PO2

350

What is the sign of acute lung rejection? chronic?

perivasculare lymphocytosis | bronchiolitis obliterans