Kidney/Pancreas Transplant Flashcards
What are the 2 main reasons for referral for kidney transplant?
- Any condition that leads to ESRD
- Stage 2-5 CKD (decrease in GFR - 60 or less)
What are the top 3 causes of chronic kidney disease?
- Diabetes Mellitus
- Hypertension
- Glomerulonephritis
What are the 3 kidney Cystic disorders?
- Polycystic kidney disease
- Medullary cystic disease
- Acquired cystic disease
What are the 3 main causes of urinary tract abnormalities?
- Reflux neuropathy
- Posterior urethral valve
- Prune belly syndrome
What are the 3 main causes of kidney-related obstructive disorders?
- Renal calculi
- Retroperitoneal fibrosis
- Prostatic Hypertrophy
What are the 3 main conditions in Autoimmune kidney disorders?
- Systemic lupus erythematosis
- Wegener’s disease
- IgA neuropathy
What 2 conditions are related to tubular kidney disorders?
- Renal tubular acidosis
- Fanconi’s syndrome
What 2 conditions are related to hemolytic kidney disorders?
- Hemolytic-uremic syndrome
- thrombotic thrombocytopenic purpura
What are the 2 most common congenital kidney disorders?
- renal agenesis
- renal dysplasia
What is amyloidosis?
When proteins build up in organs and tissues (including the kidneys).
Why does oxalosis cause kidney failure?
Oxalate builds up in the body, which leads to calcium and oxalate crystals in the kidneys.
What is Focal Segmental Glomerulosclerosis (FSGS)?
kidney disease characterized by scarring of the glomeruli
What conditions are included in the urological assessment for kidney transplant?
5 items
- Neurogenic bladder
- Reflux
- Enlarged prostate
- Atrophied bladder
- Congenital abnormalities
Within what time frame must expiration of the donor occur for a Donation after Circulatory Death (DCD) donor?
Expiration must occur within 60 min of treatment withdrawal.
What are the 3 scores/factors calculated in allocation of kidneys?
- Kidney Donor Profile Index (KDPI)
- Estimated Post Transplant Survival (EPTS)
- Calculated Panel Reactive Antibody (cPRA)
A low score for all of these results indicates a higher chance of successful transplant and graft survival.
What does a Kidney Donor Profile Index (KDPI) represent?
How long a kidney offer is likely to function in comparison to other offers.
What 10 factors are included in the calculation for KDPI?
- Donor age
- Height
- Weight
- Ethnicity
- History of HTN
- History of diabetes
- Cause of death
- Serum creatinine
- HCV status
- DCD status
What does Estimated Post Transplant Survival (EPTS) represent?
The presence and duration of factors that negatively impact the patient.
The 4 contributing factors include: Candidate age, Time on Dialysis, Prior organ transplants, and Diabetes status.
Panel Reactive Antibody (cPRA) is the amount of antibody present in…
the recipient’s serum
How is a Panel Reactive Antibody (cPRA) score expressed? What does it mean?
Expressed in a percentage.
Tested against a panel of cells from 60 people with different HLA proteins. Is based on the prevelance of identified antibodies in the general population.
Candidates with a cPRA of 100%, 99%, and 98% are given priority on what levels?
100% - national
99% - regional
98% - local
Kidney blood type B candidates may also accept kidneys from what 2 other blood types (as guided by the transplant program)?
A2 and A2B
In addition to the KDPI, EPTS, and cPRA, what else is considered when allocating kidneys?
4 items
- sensitization
- time on dialysis
- being a prior living organ donor
- pediatric candidates
What is the preferred location for placement of a transplanted kidney?
In the extra-peritoneal region of the RLQ.
This is preferred d/t the accessibility of vessels –> vascular anastomosis to iliac vessels
Kidney transplant surgery typically lasts how long?
2.5 - 3 hours
Why does treatment aim for normotension or slight hypertension in a post-transplant kidney patient?
To prevent development of ATN.
What induces hypotension early after a kidney transplant?
2 items
- volume depletion
- medications
- Narcotics
- Anesthesia
- Anti-HTN
Within the first 48 hours of a successful kidney transplant, what will happen to BUN, creatinine, and urine volumes?
1. Creatinine, BUN, and urine volumes will gradually rise.
2. Creatinine, BUN, and urine volumes will gradually decrease.
3. Creatinine and BUN will gradually rise and urine volumes will gradually decrease.
4. Creatinine and BUN will gradually decrease and urine volumes will be high.
4
What lab values will you see when high-output ATN is suspected?
1. Creatinine is high
2. BUN is high
3. Creatinine is low
4. BUN is low
5. Urine output is very large
6. Anuria
7. 1, 2, and 5
8. All of the above
7
What may cause a urine leak in a kidney transplant patient?
necrosis of distal ureter tip
How is a urinary leak in a kidney transplant treated?
surgical intervention
What is the treatment for renal vein stenosis?
Angioplasty
When does renal vein stenosis typically present post transplant?
3 months to 2 years post transplant
What will happen to the creatine in a uretral obstruction?
Creatine will increase
What are possible treatments for ureteral obstruction?
3 items
- Percutaneous nephrostomy tube (to relieve hydronephrosis)
- Placement of stent
- Surgery
What is the main sign of a renal artery thrombosis or renal vein thrombosis?
sudden loss of urine output
What is a lymphocele?
A fluid collection around the kidney
What are the 3 main signs of a lymphocele?
- elevated creatinine
- leg edema
- fever
What is ruled out prior to diagnosis of ATN?
2 items
- rejection
- kidney obstruction
What can cause ATN or delayed graft function?
2 items
- cold or warm ischemia
- cadaveric or recipient blood volume events (hypotension, bleeding, hyperperfusion, cardiac arrest)
What electrolyte imbalances would you see in ATN?
1. increased sodium and potassium
2. increased potassium and magnesium
3. decreased potassium and magnesium
4. decreased sodium and potassium
2
What 4 main signs are associated with acute kidney rejection?
- fever
- pain over graft site
- Edema
- Decreased UOP
What percentage of the time are there no physical symptoms in acute kidney rejection?
> 90% of the time
What are 4 possible causes of acute kidney rejection?
- drug nephrotoxicity
- hemolytic uremic syndrome
- chronic changes
- recurrent disease
What are the categories of the Banff 2017 Classification of T-Cell Rejection?
Normal
Type IA
Type IB
Type IIA
Type IIB
Type III
What patterns/comparisons do you notice in the table of Banff 2017 Classification of T-Cell Rejection that will help you remember the info?
See table in answer.
- Type I classifications have varying degrees of tubulitis and significant interstitial inflammation.
- Type II classifications have varying degrees of arteritis.
- Type III has transurethral arteritis and/or arterial fibrinoid necrosis of smooth muscle.
What are 3 biopsy findings of kidney antibody-mediated rejection?
- chronic tissue injury
- Antibody endothelium interaction
- DSA
What is the treatment for mild cellular rejection (kidney)?
corticosteroid bolus followed by oral prednisone
What is the treatment for severe cellular rejection (kidney)?
Thymoglobulin
What is the treatment for antibody-mediated rejection (kidney)?
3 items
- Rituximab
- IVIG
- plasmapheresis
What is the most common kidney late post-transplant infection?
Urosepsis
those at higher risk include females, diabetes, and males with prostatic hypertrophy
What are common kidney late post-transplant viral infections?
5 items
- CMV
- HIV
- Varicella
- EBV
- BK
What are common kidney late post-transplant fungal infections?
3 items
- histoplasmosis
- cryptosporidiosis
- aspergillus
What does PCP stand for?
This is a common late post-transplant infection.
pneumocystis pneumonia
What are the 3 most common types of kidney early post-transplant infections?
*UTIs
*central line sepsis
* wound infections
What are causes of kidney graft loss?
8 items
- acute/chronic rejection
- Vascular/arterial thrombosis
- infections
- recurrent disease
- HUS
- Nephrotoxicity
- HTN
- cardiac event (low perfusion)
What kidney diseases may be recurrent post-transplant?
6 items
- systemic lupus erythematosus (SLE)
- IgA nephropathy
- Focal Segmental glomerulosclerosis (FSGS)
- Membranous glomerulonephritis
- Membranoproliferative glomerulonephritis
- amyloidosis
What are the 3 types of pancreas transplant?
- pancrease alone transplant (PAT)
- simulataneous kidney-pancreas transplant (SKP) or (SPK)
- pancrease after kidney transplant (PAK)
What are indications for pancreas alone transplant (PAT)?
3 items
- Type 1 DM (with life threatening complications)
- hypoglycemic unawareness
- labile blood glucose levels
Requires total pancreatectomy
What is the cause for a Sumulatenous Kidney-Pancreas transplants (SKP)?
- Type 1 DM with progressive kidney dysfunction
Why can it be better to have a simultaneous kidney-pancreas transplant in regards to rejection?
It’s easier to recognize graft rejection. If one organ is rejecting, then so is the other.
What is a requirement for Pancreas after Kidney transplant?
Stable renal function following transplant
Evaluation for a pancreas transplant includes:
a. Hypoglycemia
b. Hyperglycemia
c. Ketoacidosis
d. Hypermagnesemia
e. a, b, and c only
f. All of the above
E
What does a low c-peptide lab value indicate?
A c-peptide is low or absent in individuals whose pancreas is not making insulin
(normal levels are 0.5-2 ng/mL)
What are the 2 requirements to being registered on the pancreas wait list?
- diagnosis of DM
- pancreatic exocrine insufficiency (amylase, lipase, and protease)
What are the 3 requirements to being registered on the kidney-pancreas wait list?
- diagnosis of DM
- pancreatic exocrine insufficiency
- renal insufficiency
pancreatic exocrine insufficiency = amylase, lipase, and protease deficient
In addition to regular listing information, the pancreas-specific medical factor that must be included with UNOS listing is…
age of diabetes onset
What are the 2 surgical approaches to pancreas transplant?
- enteric drainage (ED)
- bladder drainage (BD)
During an enteric drainage (ED) procedure, the donor’s portal vein is anastomosed to the recipients…
superior mesenteric vein
During an enteric drainage (ED) procedure, the donor’s duodenal segment is attached to the recipient’s…
jejunum
What are 2 advantages to an enteric drainage (ED) pancreas transplant?
- fewer metabolic imbalances
- fewer post-op complications
Pancreatic secretions are reabsorbed sysematically rather than being excreted through the bladder.
What are 5 disadvantages to an enteric drainage (ED) pancreas transplant?
- rejection is harder to detect
- infection
- fistula or absess formation
- vascular thrombosis
- more invasive to correct complications
- infection can lead to sepsis.
- vascular thrombosis is highest in the first 6 months post transplant
During a bladder drainage (BD) pancreas transplant, the donor duodenal segment is anastomosed to the recipient’s…
bladder
During a bladder drainage (BD) pancreas transplant, systemic bladder drainage directs venous outflow and insulin drainage into the recipient’s…
iliac vein
After a bladder drainage (BD) transplant, rejection can be tracked by monitoring what? Would the levels be high or low?
urine amylase levels
low
What are 3 advantages of a bladder drainage (BD) transplant?
- direct monitoring of graft exocrine function
- easier to perform a biopsy
- less invasive complication treatments
What are the disadvantages of a bladder drainage (BD) transplant?
5 items
- dehydration
- cystitis/UTIs
- metabolic acidosis
- urine leak
- hematuria
- metabolic acidosis caused by loss of bicarb in urine
- 10-25% go on to needing an enteric conversion
What are 2 common reasons for hyperglycemia post-pancreas transplant?
- steroid-induced
- delayed graft function (may be normal)
- treated with an insulin drip is common
An arterial thrombosis post pancreas transplant will show which of the following?
a. low glucose levels
b. low amylase levels
c. high glucose levels
d. high amylase levels
e. stable glucose levels
f. stable amylase levels
g. a and c only
h. b and d only
i. c and f only
j. depending on the situation, could be all of the above
I
abrupt high glucose levels and stable amylase levels
With pancreatitis, amylase levels will be…
a. normal
b. mildy elevated
c. severely elevated
d. mildy low
f. severely low
B
What is a common cause for late pancreatitis?
An anastomotic stricture
What virus may cause ulceration, performation, or duodenal segment leak in a post-pancreas patient?
CMV
Rejection in a bladder drainage (BD) transplant will show which of the following changes?
a. elevated serum amylase
b. low serum amylase
c. elevated urine amylase
d. low urine amylase
e. a and c only
f. b and d only
g. a and d only
h. b and c only
G
A pancreas transplant anastomic leak may show what signs?
5 items
- fever
- increased WBC
- abdominal pain
- Elevated amylase
- Elevated creatinine
