Kidney Pancreas Flashcards
1
Q
Indications for Referral for Kidney Transplant include…
A
- Any condition that leads to ESRD
- Stage 2-5 CKD (mild to severe decrease in GFR - 60 or less)
2
Q
Indications for Kidney Transplant include…
A
- Chronic Kidney Disease
- Cystic Disorders
- Urinary Tract Abnormalities
- Obstructive Disorders
- Autoimmune Disorders
- Tubular Disorders
- Hemolytic Disorders
- Nephrotoxic Agents
- Congenital Disorders
3
Q
Indications related to Chronic Kidney Disease include…
A
- Diabetes Melitus
- Hypertension
- Glomerulonephritis
4
Q
Indications related to Cystic disorders include…
A
- Polycystic kidney disease
- Meduliary cystic disease
- Acquired cystic disease
5
Q
Indications related to Urinary Tract Abnormalities include…
A
- Reflux nephropathy
- Posterior urethral valves
- Prune belly syndrome
6
Q
Indications related to Obstructive disorders include…
A
- Renal calculi
- Retroperitoneal fibrosis
- Prostatic Hypertrophy
7
Q
Indications related to Autoimmune disorders include…
A
- Systemic lupus erythematosis
- Wegener’s disease
- IgA nephropathy
8
Q
Indications related to Tubular disorders include…
A
- renal tubular acidosis
- Fanconi’s syndrome
9
Q
Indications related to Hemolytic disorders include…
A
- hemolytic-uremic syndrome
- thrombotic thrombocytopenic purpura
10
Q
Indications related to Nephrotoxic Agents include…
A
- calcineurin inhibitors
- NSAIDs
- antibiotics
11
Q
Indications related to Congenital disorders include…
A
- renal agenesis
- renal dysplasia
12
Q
Indications related to Other disorders include…
A
- amyloidosis
- oxalosis
- FSGS
13
Q
The most common causes of ESRD for candidates on the waitlist include…
A
- Diabetes (most common)
- Hypertension
14
Q
Additional causes of ESRD for candidates on the waitlist include…
A
- Polycystic Kidney Disease
- Glomerulonephritis
- Glomerulosclerosis
- Graft failure
15
Q
Absolute Contraindications to Transplantation include…
A
- Active malignancy or metastatic cancer
- Severe myocardial dysfunction or peripheral vascular disease
- Liver cirrhosis (unless simultaneous liver transplant is planned)
- Active psychiatric illness or mental incapacity without an adequate support system
- Other severe irreversible extra renal disease
- Chronic infection or untreated current infection
- Persistent non-adherence to treatment regimen
16
Q
Advantages of Kidney Transplant versus Dialysis include…
A
- Survival Advantage
- Normal activity (exercise, travel)
- Ability to bear children
- Volume and BP management
- Correction of acidosis/K+/phos
- Prevent uremic complications
- No fluid restrictions
- Minimal diet restrictions
- Cost savings
17
Q
Typical laboratory testing for Kidney evaluation includes…
A
- Urine studies:
- UA, Culture, 24 hour urine for protein
- Blood typing
- HLA typing and analysis:
- PRA and antibody specificities
18
Q
Normal Lab Value: BUN
A
7-20 mg/dL
19
Q
Normal Lab Value: Creatinine
A
0.6-1.2 mg/dL
20
Q
Normal Lab Value: AST
A
10-40 units per liter
21
Q
Normal Lab Value: ALT
A
7-45 units per liter
22
Q
Normal Lab Value: Total bilirubin
A
0.3 to 1.2 milligrams per deciliter
23
Q
Normal Lab Value: Amylase
A
40-140 U/L
24
Q
Normal Lab Value: Lipase
A
0-160 U/L
25
Normal Lab Value: c-peptide
0.5 to 2ng/ml
26
Normal Lab Value: PSA
* 4.0 nanograms per milliliter (ng/ml) of blood
* men 50s or younger should be below 2.5
* men older than 50's slightly higher
27
A Urological assessment for Kidney transplant evaluation may include…
* Neurogenic bladder
* Reflux
* Enlarged Prostate
* Atrophied bladder
* Congenital abnormalities
28
Types of Deceased Donors eligible for Kidney donation include…
* Deceased donors:
* Donation after Brain death
* Donation after Circulatory Death Donors (DCD)
* PHS risk criteria donors
* Consent required:
* KDPI \> 85 requires consent
29
Types of Living Donors eligible for Kidney donation include…
* Directed
* Non-directed
* Kidney Paired Donation KPD
30
Donation after Circulatory Death (DCD) is possible, provided the following takes place…
* Once treatment withdrawal has occurred, expiration must occur within 60 min
* Age:
* Can be as young as 6 months
* Maximum age is 65-75 years
* National average is 50 years and younger
31
A genetic match in kidney transplant is important for the following reasons…
* Quality of match generally correlates positively with graft survival
* Potential for less immunosuppression medication
* Less medicine means less toxicity and/or infection
* Decreases incidence of rejection
32
Important factors considered in the allocation of kidneys include…
* Kidney Donor Profile Index (KDPI of the donor)
* Estimated Post Transplant Survival (EPTS of the recipient)
* Calculated Panel Reactive Antibody (cPRA of the recipient)
33
The Kidney Donor Profile Index (KDPI) represents…
* How long a kidney offer is likely to function when compared with all other offers
* Expressed as a percentage
* Low KDPI indicates likely longer function
* High KDPI indicates likely shorter function
34
10 Factors that are used in the clinical formula for KDPI include…
* Donor age
* Height
* Weight
* Ethnicity
* History of hypertension
* History of diabetes
* Cause of death
* Serum creatinine
* HCV status
* DCD status
35
Estimated Post Transplant Survival (EPTS) represents…
* Presence and duration of factors that negatively impact the patient
* These make the score higher
* Low % is better
36
The 4 factors that contribute to the EPTS calculation include…
* Candidate Age
* Time on Dialysis
* Prior Organ Transplant
* Diabetes Status
37
Panel Reactive Antibody (PRA) is the amount of antibody present in …
* the recipient’s serum (expressed as a percentage) against a panel of cells from 60 people with different HLA proteins
* Higher % PRA makes finding a donor more difficult
38
cPRA is ...
* a mathematical calculation done in UNET, based on the prevalence of the identified antibodies in the general population
* A low % is better
39
Candidates that are highly sensitized receive offers from a larger pool of donors. Candidates with a cPRA = 100% are given priority…
on a national level
40
Candidates that are highly sensitized receive offers from a larger pool of donors. Candidates with a cPRA = 99% are given priority…
on a regional level
41
Candidates that are highly sensitized receive offers from a larger pool of donors. Candidates with a cPRA = 98% are given priority…
on a local level
42
Increased Access for Blood Type B Candidates (A2/A2B eligibility) is given to…
* Candidates with blood type B who meet defined clinical criteria will be eligible to accept kidneys from donors with blood type A2 or A2B
* Clinical criteria set by each transplant program
* Reporting in UNet required every 90 days
43
Kidney allocation is based on a ranking of points that are influenced by KDPI, EPTS, cPRA, and the following circumstances:
* Sensitization
* Time on dialysis
* Being a prior living organ donor
* Pediatric candidate
44
Categories of information required in the OPTN Waitlist Information system includes…
* Candidate information
* Clinical Information
* General Medical Factors
* Kidney Medical Factors
45
Required OPTN Waitlist information - Candidate Information includes…
* Demographic data:
* Zip Code
* Ethnicity
* Citizenship
* Education level
* Working for income
* Functional Status
* Source of payment
46
Required OPTN Waitlist information - Clinical Information includes…
* Height
* Weight
* ABO
* Primary Diagnosis
47
Required OPTN Waitlist information - General Medical Factors includes…
* Diabetes
* Symptomatic peripheral vascular disease
* Previous malignancy
* Serum albumin
48
Required OPTN Waitlist information - Kidney Medical Factors includes…
* Exhausted vascular access
* Exhausted peritoneal access
* Age of diabetes onset
49
Management of Waitlisted Patients for Kidney transplant includes…
* Antibody screening:
* Sensitized: Monthly
* Not sensitized: Every 3 months
50
Per OPTN Policy, the host OPO must provide all the following information for all deceased donor kidney offers…
1. Anatomical description, including number of blood vessels, ureters, and approximate length of each
2. Biopsy results, if performed
3. Human leukocyte antigen (HLA) information as follows: A, B, Bw4, Bw6, C, DR, DR51, DR52, DR53, DQA1, DQB1, and DPB1 antigens prior to organ offers
4. Injuries to or abnormalities of blood vessels, ureters, or kidney
5. Kidney perfusion information, if performed
6. Kidney laterality
51
Role of Transplant Coordinator in Pre-operative Care of Recipients includes…
Prior to surgery patients should receive dialysis treatment if labs warrant
Crossmatch
52
Kidney transplant usually require a prospective crossmatch. A prospective crossmatch is obtained…
prior to transplant
53
An HLA prospective crossmatch determines if…
the patient has HLA antibodies to a particular donor
54
An HLA prospective crossmatch is a test that…
combines the recipient serum and the donor cells
55
If the recipient has antibody to the donor, the crossmatch is…
positive (Positive is NOT good)
56
During Kidney transplant surgery, the kidney is placed…
* in the extra-peritoneal region
* The right lower quadrant is preferred due to accessibility of vessels vascular anastomosis to iliac vessels.
57
Kidney surgery usually lasts…
2.5 to 3 hours
58
During Kidney transplant surgery, the non-functioning kidney(s) is/are…
usually not removed
59
During immediate Post-operative Care, the patient will be monitored for…
* Vital signs every hour x 16 hours
* Intake and output every hour x 16 then every 4 hours
* Oxygen to keep O2 saturations \> 93% Close nursing care (ICU or IMC) due to large diuresis & IV fluid replacement x 24 hours
* Foley catheter
* Central line, CVP monitoring
60
Within the first 48 hours, nursing care priorities related to the evaluation of fluid volume status include...
* Avoid high dextrose solutions, can contribute to hyperglycemia.
* Monitor CVP closely first 16 hrs (prevent CHF, pulmonary edema)
* Monitor labs:
* Creatinine, BUN
* Electrolytes
* Drug trough levels
61
Within the first 48 hours, nursing care priorities related to monitoring labs include...
* Monitor labs:
* Creatinine, BUN
* Electrolytes
* Drug trough levels
62
Within the first 48 hours, nursing care priorities related to the evaluation of hemodynamic status include...
* Aim for normotension or slightly hypertensive, hypotension contributes to development of ATN.
* Inducers of hypotension early p/o include:
* Volume depletion
* Narcotics
* Anesthesia
* Antihypertensive
63
With a successful graft, within the first 48 hours, BUN and creatinine will…
begin to gradually decrease each day urine volumes will be high.
64
Suspicion of High-output ATN is warranted when…
there is a large volume of urine output but the BUN & Creatinine remain elevated.
65
Suspicion of Oliguric/anuric ATN is warranted when…
there is a small amount or absence of urine output
66
Suspicion of ATN may require…
* dialysis
* ultrasound and/or renal scan required to evaluate cause
* If ATN:
* renal transplant biopsy to rule out rejection
* consider crossmatch or DSA for donor specific antigens
67
Complications from surgery may include…
* Urine leaks
* Renal vein stenosis
* Ureteral obstructions
* Renal artery thrombosis
* Renal vein thrombosis
* Lymphocele
68
Complications related to urine leaks may include…
* May occur days to weeks after transplant
* Often caused by necrosis of distal ureter tip
* May need surgical intervention
* Can be very painful
69
Complications related to renal vein stenosis may include…
* Incidence 2-12%
* Usually presents 3 months to 2 years post transplant
* Can be treated with angioplasty
70
Complications related to ureteral obstructions may include…
* Can occur early or late (months to years) after transplant
* Elevated creatinine
* Confirmed by ultrasound and nuclear scan: report delayed excretion of contrast into bladder
* Percutaneous nephrostomy tube to relieve hydronephrosis
* Placement of stent until obstruction cause is identified
* May require surgery
71
Complications related to renal artery thrombosis may include..
* Incidence \<1%
* Rarely able to salvage the kidney
* Characterized by unexpected/explained anuria
72
Complications related to renal vein thrombosis may include…
* Incidence 4-6%
* Recovery of kidney function is more likely if return to surgery quickly
* Characterized by anuria or sudden loss of urine output
73
Complications related to lymphoceles may include…
* Incidence 2-10%
* Collection of lymph fluid around kidney
* Characterized by elevated creatinine, leg edema, fever
74
Monitor for Post-operative Non-surgical Complications that may include…
* Delayed graft function (elevated BUN/Creatinine)
* Acute tubular necrosis (ATN): Newly transplanted kidney does not function in absence of rejection or obstruction
* Rejection
* Infection
75
Post-transplant causes of ATN/Delayed Graft Function may include…
* Prolonged cold ischemia time (\> 24hrs)
* Warm ischemia time
* Cadaveric donor events (Hypotension, pressors, bleeding, hypoperfusion, cardiac arrest)
* hypotension, cardiac events, hypovolemia
76
Signs and symptoms of ATN may include…
* Increased BUN and creatinine
* Anuria or oliguria
* pulmonary edema
* elevated potassium and magnesium levels
* increased weight
77
Clinical signs and symptoms of acute rejection include…
* Fever Pain over graft
* Decreased urine output
* Edema (depends on severity)
* \>90% of time no physical symptoms at all
78
Possible causes of acute rejection may include…
* Drug nephrotoxicity
* HUS (hemolytic uremic syndrome)
* Chronic changes or recurrent disease
79
Laboratory diagnostics for acute rejection may include…
* Elevated BUN and creatinine
* Ultrasound reports increased RI and size of kidney
* Nuclear scans
* Kidney biopsy to confirm or diagnose rejection (ultrasound guided)
* Based on tubulointerstitial inflammation
80
The categories of Banff 2017 Classification of T-Cell Mediated Rejection Include:
* Normal
* Type IA
* Type IB
* Type IIA
* Type IIB
* Type III
81
Biopsy findings indicative of a normal Banff Classification would include…
none: no findings
82
Biopsy findings indicative of a Type IA Banff Classification would include…
moderate tubulitis involving one or more tubules, significant interstitial inflammation
83
Biopsy findings indicative of a Type IB Banff Classification would include…
severe tubulitis, significant interstitial inflammation
84
Biopsy findings indicative of a Type IIA Banff Classification would include…
mild to moderate intimal arteritis in at least one arterial cross section with or without interstitial inflammation and/or tubulitis
85
Biopsy findings indicative of a Type IIB Banff Classification would include…
Severe arteritis with or without interstitial inflammation and/or tubulitis
86
Biopsy findings indicative of a Type III Banff Classification would include…
Transmural arteritis and/or arterial fibrinoid necrosis of smooth muscle
87
Diagnostic categories of the Banff 2017 Classification system provide…
* Histologic evidence of acute tissue injury
* Serologic evidence of DSA or C4d positivity in the presence of MVI
* Evidence of current/recent antibody interaction with vascular endothelium, including at least one of the following:
* Positive C4D staining
* Moderate microvascular inflammation (MVI)
* Increased expression of validated gene transcripts/classifiers
88
Biopsy findings for Chronic Active ABMR will present with…
* Morphologic evidence of chronic tissue injury
* Antibody endothelium interaction
* DSA or MVI + C4d
89
Treatment for Acute Rejection may include…
* Mild cellular rejection: Corticosteroid bolus followed by oral prednisone taper
* Severe cellular or vascular rejection treated with Thymoglobulin
* Antibody-mediated rejection - Rituximab, IVIG, Plasmapheresis:
* Monitor for side effects - pulmonary edema, fevers, chills, malaise
90
Long term consequence of Acute Rejection may include…
* Permanent scar/fibrosis of kidney cells which do not recover
* Factors which determine outcome after rejection:
* Previous insults to kidney
* Host factors
* Severity of rejection episodes
* Patient adherence
91
Chronic Rejection is indicative of a…
Gradual loss or decline in renal function over time:
92
The highest incidence of chronic rejection is in individuals who have had early or repeated…
episodes of rejection
93
Chronic Rejection occurs more often in patients who are…
non-adherent to their medication regimen re-transplant patients
94
Medical strategies to delay the effects of chronic rejection include…
* Decrease nephrotoxic agents
* Good blood pressure control
* Aggressive diabetic management
* Routine labs and clinic follow-up
95
Early Post-Transplant Infections include:
* Urinary Tract Infections - if stent in at time of diagnosis - remove prior to antibiotic completion
* Central Line Sepsis
* Wound Infections (varies from local seroma to complete dehiscence) Immunosuppression adjustment many times necessary
96
Late Post-Transplant Infections include:
* Urosepsis (most common) - those at higher risk include females, diabetes and males with prostate enlargement
* Viral infections - CMV, HIV, varicella, EBV, BK
* Fungal infections - histoplasmosis, cryptosporidiosis, aspergillus
* PCP - pneumocystis pneumonia
* PTLD - post-transplant lymphoproliferative disease
97
Graft Dysfunction: Causes of Graft Loss include:
* Acute/Chronic Rejection
* Vascular/Arterial Thrombosis
* Infections
* Recurrent Disease (Autoimmune, Focal segmental glomerulosclerosis (FSGS) commonly recurs , Diabetes)
* Hemolytic uremic syndrome - HUS
* Nephrotoxicity - Leads to chronic vascular scar
* Hypertension
* Cardiac failure or event (Low perfusion)
98
Common diseases which may be recurrent include…
* Systemic lupus erythematosus (SLE)
* IgA nephropathy
* Focal Segmental glomerulosclerosis (FSGS)
* Membranous glomerulonephritis
* Membranoproliferative glomerulonephritis
* Amyloidosis
99
Post-Transplant follow up discharge planning should include…
* Discharge may occur at post-op day 3 or 4
* Length of stay is prolonged (ATN/graft dysfunction or Infection)
* Education for home monitoring:
* Blood pressure
* Weight
* Temperature
100
Three types of pancreas transplant include…
* pancreas alone transplant (PAT)
* simultaneous kidney-pancreas transplants (SKP) (SPK)
* pancreas after kidney transplants (PAK)
101
Indications for Pancreas Alone Transplant (PAT) include…
* type 1 diabetics with life threatening complications
* hypoglycemic unawareness
* extremely labile blood glucose levels
* individuals requiring total pancreatectomy
* graft survival 91.8% 1 yr and 78.2% 5 yr
102
Indications for Simultaneous Kidney-Pancreas transplants include…
* individuals with type 1 DM and progressive kidney dysfunction
* pancreas protects the transplanted kidney from diabetic nephropathy
* the most common procedure performed
* easier to recognize graft rejection
* graft survival 96.9% 1 yr and 89.6% 5 yr
103
Indications for Pancreas after Kidney transplants include…
* individuals with type 1 DM
* stable renal function following deceased or living kidney transplant
* graft survival 100% after 1yr and 91.1% 5r
104
Absolute Contraindications to pancreas transplant include…
* Active or metastatic malignancy
* Active infection
* irreversible large vessel cardiovascular disease
* severe peripheral vascular disease
* morbid obesity
* psychiatric illness impairing consent and adherence
* limited irreversible rehabilitative potential
105
Specific evaluation for pancreas transplant include…
* Hypo/hyperglycemic episodes
* Hypoglycemic unawareness
* Ketoacidosis
* Secondary complications of Type 1 DM
* Gastroparesis
* Peripheral vascular disease
* Retinopathy
* Peripheral neuropathy
106
Lab data requirements are similar to Kidney. Additional pancreas lab data required includes…
* Fasting C-peptide \< 0.8 ng/ml (normal 0.8-4.0 ng/ml)
* C-peptide is low or absent in individuals whose pancreas is not making insulin
* Hemoglobin A1C
* Anti insulin antibody, Anti GAD antibody, Anti 1A-2 antibody
* Amylase, lipase
* Urine tests: 24 hour urine for creatinine clearance, protein, microalbuminuria
107
Each candidate registered on the pancreas waiting list must meet one of the following requirements:
* Be diagnosed with diabetes
* Have pancreatic exocrine insufficiency-amylase, lipase and protease deficient
108
In addition to the regular listing information, the pancreas specific medical factors that must be listed with OPTN includes…
age of diabetes onset
109
During the surgical procedure, the native kidneys and pancreas are…
not removed
110
The two surgical approaches to pancreas transplant include…
* Enteric drainage (ED)
* Bladder drainage (BD)
111
During an enteric drainage procedure, the donor portal vein is anastomosed to the recipient's…
superior mesenteric vein
112
During an enteric drainage procedure, the donor's duodenal segment is attached to the recipient's…
jejunum
113
The advantages of an enteric drainage procedure include…
* more physiologic
* fewer metabolic imbalances because pancreatic secretions are reabsorbed systemically
* less post-op complications
114
The disadvantages of an enteric drainage procedure include…
* rejection is harder to detect
* infections due to possible enteric contamination
* fistula or abscess formation (can lead to sepsis)
* vascular thrombosis - highest in the first 6 months post tx
* more invasive procedures to correct complications
115
During a bladder drainage procedure, the donor duodenal segment is anastomosed to the recipient's…
urinary bladder
116
Rejection can be detected after a bladder drainage technique…
by monitoring urine amylase levels
117
The advantages of a bladder drainage technique include…
* direct monitoring of graft exocrine function
* easier to perform a biopsy
* less invasive treatment if complications arise
118
The disadvantages of a bladder drainage technique include…
* dehydration
* cystitis and/or UTIs
* metabolic acidosis - loss of bicarb in urine, need supplements
* urine leak
* hematuria
* 10 to 25% go on to need an enteric conversion pancreatitis
119
Early Post-operative management of the pancreas recipient requires monitoring hemodynamic stability for…
* Cardiac stability
* Vital signs
* Monitor for excessive bleeding
* Fluid and Electrolyte balance
* Post-op ileus, nausea and vomiting common
* Strict hourly measurements
* Fluid and electrolyte imbalance most common in BD patients
* Dehydration can occur rapidly
* Notify MD/PA/NP if urine output \<50ml or \>200ml per hour
* Perfusion
* Pancreas is a low flow graft
* Hypotension with sbp\<100 increases risk of thrombosis
* Early pancreatitis increases pressure within the graft
120
Blood glucose monitoring in the pancreas recipient is required because…
* hyperglycemia may be steroid induced or from delayed graft function.
* May require an insulin drip
121
Pancreatic graft function can be monitored via…
* Serum Amylase: 23-85 U/L
* Serum Lipase: 0-160 U/L
* C-peptide: 0.5 - 2 g/ml
* HgA1c: Normal: 4-5.6%
Pre-Diabetic: 5.7 - 6.4%
Diabetic: 6.5% or >
122
Post-transplant complications may include…
* Thrombosis
* pancreatitis
* hematuria
* anastomotic leak
* urine leak
123
The complication Thrombosis, may occur within…
the first 24-48 hours post transplant
124
The most common thrombosis type is…
venous
125
Arterial thrombosis can cause…
an abrupt rise in glucose levels while amylase remains stable
126
Thrombosis may present with the following:
* Acute abdominal pain
* High blood glucose
* Increased serum amylase
* Surgical exploration necessary
* Graft appears large, engorged and dark blue
* Pancreatectomy may be necessary
* Can be prevented with heparin and warfarin
127
Pancreatitis may occur within…
the first 48-96 hours
128
With pancreatitis, amylase levels…
may be mildly elevated
129
Late pancreatitis may be caused from an…
anastomotic stricture
130
Hematuria may be related to…
anticoagulation
131
Persistent hematuria may require a …
cystoscopy
132
In a pancreas recipient, UTIs are most likely due to…
* increased risk due to foley catheter placement
* neurogenic bladder
* bladder drainage procedure
133
In a pancreas recipient, Opportunistic infections may include…
CMV which can lead to ulceration, perforation and leak of the duodenal segment
134
In a pancreas recipient, deep wound infections may be related to…
* the placement of the organ:
* retroperitoneum placement increases risk of infection
* intraperitoneum placement less risk of infection
135
In a pancreas recipient, sepsis can lead to…
death. It is attributed to acidic pancreatic enzymes and needs urgent aggressive treatment
136
An anastomotic leak may present with…
* Fever
* Increased WBC
* Abdominal pain
* Elevated serum amylase
* Elevated serum creatinine
137
A urine leak may present with…
* Lower abdominal pain
* Fever
* Elevated amylase
138
Rejection following SPK frequently occurs…
in 1-2 years
139
Rejection following PTA/PAK frequently occurs…
in 2-3 years
140
Rejection is difficult to detect and must be confirmed by…
a biopsy
141
Rejection may present with…
* Pain at graft site
* Increased pancreatic enzymes
* Decreased urinary amylase with bladder drained transplant
* Hyperglycemia is late sign of rejection
142
Long-term management of pancreas recipients includes…
* Continued monitoring for long standing complications of diabetes
* Monitor for graft dysfunction and rejection
* Monitor for immunosuppression side effects
* Routine well care follow-up
