immunology of transplantation part 3 W3

Question 1

features of chronic rejection?

Answer 1

progressive renal dysfunction
interstitial fibrosis and vascular disease on renal biopsy

Question 2

differential diagnosis of chronic rejection?

Answer 2

recurrent disease (membranous, MCGN)
obstruction (ultrasound)
renal artery stenosis (doppler of renal artery +/- MRI angiography)

Question 3

features of chronic rejection

Answer 3

recurrent crescentic nephritis
recurrent diabetic nephropathy
interstitial fibrosis
vasculopathy

Question 4

pathogenesis of chronic rejection?

Answer 4

increased HLA mismatch
previous acute rejection
poor drug compliance
prolonged cold ischaemia time of kidney prior to surgery

Question 5

factors promoting graft failure?

Answer 5

delayed graft function
cytomegalovirus (CMV) infection
age of donor and donor disease
poor blood pressure control
proteinuria

Question 6

management of chronic rejection?

Answer 6

no specific treatment
most patients eventually require dialysis and further transplants
optimise immunosuppression
proactive treatment of BP, lipids, proteinuria etc (statins, ACEis)

Question 7

infective risks of immunosuppression - bacterial? how is this prevented?

Answer 7

UTI, chest infection
give prophylactic cotrimoxazole

Question 8

infective risks of immunosuppression - viral? how is this prevented?

Answer 8

CMV, herpes virus, parvo virus, BK virus (cause renal dysfunction)
give prophylactic valganciclovir if recipient is CMV -ve and donor CMV +ve

Question 9

infective risks of immunosuppresion other than bacterial/viral?

Answer 9

TB

Question 10

BK virus infection features?

Answer 10

renal cells have abnormally large nuclei

Question 11

BK virus infection treatment?

Answer 11

reduce immunosuppression to facilitate anti-viral immunity

Question 12

tumour risks of immunosuppression?

Answer 12

incidence of all cancers increased
skin cancers common
post transplant lymphoproliferative disorder (PTLD) - secondary to infection with

Question 13

prophylaxis for skin cancer risk? (tumour risks of immunosuppression)

Answer 13

UV block, avoid sun, skin surveillance

Question 14

treatment for post transplant lymphoproliferative disorder (PTLD)?

Answer 14

reduce immunosuppression, may need chemotherapy/surgery

Question 15

side effects of immunosuppressive drugs

Answer 15

calcineurin inhibitors are nephrotoxic (eg tacrolimus)
increased risk of diabetes (steroids, tacrolimus)
hypertension (steroids and CNI)
osteoporosis (steroids)