Immunology and Organ Transplant Flashcards by Poton David

BLOOD PRESSURE and VENT MANAGEMENT

(RULE OF 100s)  Maintain SYSTOLIC BLOOD PRESSURE greater than 100 mmHg with minimal inotropic support (e.g. dopamine, neosynephrine, levophed)  Ensure the URINE OUTPUT is at least 100-300 cc/hr  Ensure that pO2 is at least 100 mmHg on the least amount of FiO2

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Experimental immunosuppressive agents demonstrated that _____ rejection could be prevented

Acute Rejection

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Types of living donor

Living Related Donors 2. Living Non-related Donors

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Screening for Kidney Donors

 Electrolytes  Blood Urea Nitrogen (BUN), Creatinine

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Central in the rejections of grafts

T cells

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Transplant from one body to the same body

Auto graft

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Chromosomal location of HLA/MHC gene

Chromosome 6 short arm (6p)

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Types of Rejection

Hyperacute Rejection Acute Rejection (humoral/cellular) Chronic Rejection

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Treat Diabetes Insipidus in a donor using?

DDAVP or vasopressin (Do not administer within 4 hours of procurement)

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Refers to a series of living donor transplants in which one donor donates to the highest recipient on the waiting list and the transplant center utilizes that donation to facilitate multiple transplants

Domino Transplant

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The final commmon pathway for the cytolytic processes is _______ in the target cell.

triggering of apoptosis

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happen within the first few weeks after transplantations

Acute Rejection (humoral/cellular)

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Transplantation of tissue or organ into a position it normal does not occupy

Heterotopic graft

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initiated within minutes of re-establishing the blood supply to the transplant

Hyperacute Rejection

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the result of the immune system recognizing new, foreign antigens

Acute Rejection (humoral/cellular)

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Criteria for Lung Donors

 Chest X-ray  Bronchoscopy  ABG on 100% FiO2, then serial ABGs

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causes direct cleavage of procaspase 3 and indirect actiavtion of procaspase 9

Granzyme B

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Maintain Urine output at:

1-3 cc/kg/hr

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Transferring of one organ, tissue or cell to another site in same person of another person

Transplantation

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the standard form of immunosuppressive treatment until late 70s

Azathioprine and steroids

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Factors contributing to the effector mechanisms

 Alloantigen-dependent factor  Alloantigen-independent factor

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Characterized by a progressive decline in graft function

Chronic Rejection

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Classic hallmark of chronic rejection:

Smooth muscle cell proliferation in the medial layer of vessel lumen

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Became the treatment of choice for the next 20 years; Permitted the successful introduction of hearts and liver transplantation program

Cyclosporine

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Patients who will donate the organs

Donor

Screening for Pancreas donors

 Serial blood glucose  Amylase and lipase level

Transplantation between two different species

Xenograft

Types of Deceased donors

1. Brain dead donors 2. Cardiac Death donors

Electrolyte imbalance associated with adverse outcomes in liver transplantation

Elevated sodium

Criteria for the patient to receive the transplant organ

 End stage disease of the organ, no other organ replacement  For paired organs: both organs are diseased OR a single organ is diseased and no longer able fully to function, endangering the life of the patient  No other possible options

Transplant from one body to another body of the same species

Allograft

Primary cause of Chronic Rejection

Antigraft immune response

The antigens responsible for rejection of genetically disparate tissues

Histocompatability Antigens

Placing or firmly securing an organ, tissue, cells, or devices into the body

Implantation

Screening for Heart Donors

 ECG, Chest x-ray  Echocardiogram  Cardiac catheterization (male \>40, female \>45)  Creatinine kinase (CK), isoenzyme of CK with muscle and brain subunits (CK-MM and CK-MB), troponin levels

Screening of potential donors

 Basic laboratory values: CBC, electrolytes, glucose, arterial blood gas  ABO blood typing  Human leukocyte antigen (HLA) typing  Blood cultures  Sputum: Gram stain, culture and sensitivities  Urinalysis, culture and sensitivities  HIV, Epstein-Barr virus (EBV), cytomegalovirus (CMV), human T-cell leukemia virus type 1 (HTLV-1), and hepatitis B and C virus serology  Venereal disease research laboratory (VDRL) test or rapid plasma reagent (RPR) test  Inguinal lymph nodes tested for evaluation or recipient sensitivity

Class II MHC is expressed on what cell types?

antigen-presenting cells (APC) such as dendritic cells, activated macrophages, and B cells

Organs derived from these donors generally have inferior outcomes when transplanted; Organs harvested should be transplanted AT ONCE!

Donors after Cardiac Death

Steroid Treatment regimen

Administer 15-30 mg/kg Solu-Medrol every 8-12 hours

Maintain CVP at:

4-12 mmHg

The most rapid and aggressive form of transplant rejection; Mediated by pre-existing circulating antibodies against the graft

Hyperacute Rejection

Targeted or destroys graft endothelial cells

Acute Rejection (humoral/cellular)

Transplantation of tissue to its normal anatomic position; Placed to the same site from where it was removed

Orthotopic graft

Indications for Organ Transplant

 When patient has end-stage organ failures  No other options or options exhausted  By choice: example is indefinite dialysis vs. transplantation

Stages of Rejection Reaction

1) Sensitization stage 2) Effector stage

the time a tissue, organ, or body part remains at body temperature after its blood supply has been reduced or cut off but before it is cooled or reconnected to a blood supply

Warm ischemia time

Inflammatory infiltrate of mononuclear leukocytes adherence to vessel endothelium  infiltrations under the endothelium  edema and separation of endothelial layers

Acute Rejection (humoral/cellular)

Areas for Patient Monitoring

Lines Vitals Temperature

Screening for liver donors

 Liver function tests (LFTs)  Liver biopsy for donors with: o BMI \>32 o \>72 years old (60 years old if with DM) o Past liver disease o Alcohol abuse o Fatty liver disease o Confirm hepatitis serologies  Prothrombin time  aPTT (partial thromboplastin time)

When to suspect Diabetes Insipidus in a Donor?

 Urine output is greater than 3 cc/kg/hr  Urinary specific gravity of less than or equal to 1.005

Anti-ABO antibodies responsible for the transfusion reaction when patients receive an ABO-mismatched blood transfusion

Hyperacute Rejection

time between the chilling of a tissue, organ, or body part after its blood supply has been reduced or cut off and the time it is warmed by having its blood supply restored

Cold Ischemic time

development of chronic rejection is strongly associated with previous episodes of acute rejection, and also with the degree of HLA mismatch

Antigraft immune response

Present extracellular antigens such as extracellular bacteria to CD4 cells; .

Class II MHC

Usually develops slowly and insidiously over months and years

Chronic Rejection

Types of Donors

Living donors Deceased donors

Responsible for presenting antigenic peptides from within the cell (e.g. antigens from the intracellular viruses, tumor antigens, self-antigens) to CD8 cells; found on all nucleated cells

Class I MHC

remains the most formidable barrier to transplantation as a routine medical treatment

Immune System

In this stage, the CD4 and CD8 T cells, via their T cell receptors, recognize the alloantigen expressed on the cells of the foreign graft

Sensitization stage

Criteria for Brain dead

o Correction of potentially reversible causes of coma o Absence of brainstem reflexes (cornea, pupillary reflexes, oculovestibular, gag, oculocephalic) o Lack of respiratory effort (apnea test) with pCO2 rise to \> 50-60 mmHg o Confirmatory EEG, isotopic flow study, transcranial Doppler; repeated after 2-24 hour interval to eliminate observer error and show persistence of clinical state

Risk Factors of Chronic Rejection

o Ischemia/reperfusion injury o Immunosuppressive drug toxicity o Hyperlipidemia o Infections