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Nephrology Fellowship Reviewer > Kidney Transplant Part 1 > Flashcards

Kidney Transplant Part 1 Flashcards

1
Q

The allograft expresses class I and Class II MHC molecules that differ from the recipient’s MHC molecules and can directly stimulate recipient T cells

A

direct allorecognition

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2
Q

donor antigens can be processed and peptide fragments presented by the host MHC molecules on self-APCs, indirectly stimulating recipient T cells

A

Indirect allorecognition

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3
Q

Ultimate goal of immunosuppression

A

Induce specific tolerance to the graft

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4
Q

State of unresponsiveness to specific antigens derived from either self or non-self proteins

A

immune tolerance

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5
Q

plays central role in presenting foreign antigenic peptide molecules to T cells in a way that they can be recognized by the antigen-specific T cell receptors (TCRs)

A

MHC/HLA

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6
Q

provides the strongest Mixed Lymphocyte Reaction (MLR) stimulues

A

HLA-DR

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7
Q

target for anti-HLA antibodies involved in antibody mediated rejection

A

HLA-DQ

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8
Q

recognized only by primed or previously immunized cells

A

HLA-DP

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9
Q

HLA-A, B, C

A

Class I HLA

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10
Q

HLA D

A

Class II HLA

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11
Q

antibodies react with both B and T lymphocytes

A

Anti-Class I

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12
Q

react with B, but not T , lymphocytes

A

Anti-Class II

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13
Q

most important in the first 6 months after transplant

A

HLA-DR matching

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14
Q

effect is during the first 2 years

A

HLA-B

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15
Q

does not have effect before 3 years

A

HLA-A

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16
Q

primary and central event that initiates allograft rejection.

A

T cell recognition of alloantigens on the APCs

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17
Q

recognize processed antigen on MHC class I molecules

A

CD8 Cytotoxic T cells

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18
Q

on MHC Class II molecules

A

CD4 Helper T cells

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19
Q

important regulators of rejection, targets of immuntherapy

A

adhesion molecules

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20
Q

best-characterized costimulatory molecule, expressed on the surface of essentially all CD4+ and 50% of CD8+ peripheral T lymphocytes

A

CD28

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21
Q

proteins that function for growth, activation and diffferentiation

A

Cytokines

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22
Q

chemoattractants of inflammatory cells to a site of immune response

A

chemokines

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23
Q

alloimmune response against the graft, cellular or humoral

A

Acute rejection

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24
Q

normally in the first 3 months, but can occur anytime

A

Acute Cellular Rejection

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25
Q

mononuclear cellular interstitial infiltrate, edema and tubulitis

A

acute cellular rejection

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26
Q

requires CD4+ T cells and preformed anti-HLA; peritubular C4d staining within the allograft; detection of circulating anti-HLA antibodies

A

Acute humoral rejection

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27
Q

histologic changes of neutrophilic infiltration of the peritubular capillaries;

A

acute humoral rejection

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28
Q

slow progressive deterioration in kidney function; increasing creatinine, proteinuria, progressive hypertension; tubular atrophy, interstitial fibrosis, fibrous non-intimal thickening of arterial walls

A

chronic rejection; chronic allograft nephropathy, interstitial fibrosis and tubular atrophy

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29
Q

swollen glomeruli, infiltration by mononuclear cells, mesangial matrix expansion mesangiolysis, splitting of the GBM with subendothelial deposition of electron lucent material

A

transplant glomerulopathy

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30
Q

C4d staining

A

antibody mediated injury

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31
Q

modulates immune response by regulating transcription of genes for IL-1, IL-2, IFN alpha, TNF alpha and IL-6

A

corticosteroids

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32
Q

purine analog, enzymatically converted to 6-mercaptopurine; antimetabolite; incorporated into the DNA, inhibits purine nucleotide synthesis and alteration of RNA synthesis

A

azathioprine

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33
Q

blocks DNA replication and prevents lymphocyte proliferation after antigenic stimulation

A

azathioprine

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34
Q

Adverse effects: severe leukopenia, thrombocytopenia, GI disturbances, hepatotoxicity, increased risk for neoplasia

A

azathioprine

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35
Q

reversible inhibitor of inosine monophosphate dehydrogenase, the rate-limiting enzyme in the de novo synthesis of guanosine nucloetide and nucleosides

A

mycophenolic acid

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36
Q

main active metabolite of MMF; decreased by CyA, but not by tacrolimus or FK 506

A

mycophenolic acid glucuronide (MPAG); lower dose if given with tacrolimus

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37
Q

small cyclic peptide of fungal origin; blocks the expression of cytokine genes produced by T cells

A

cyclosporine

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38
Q

blocks the calcium-dependent component of the TCR signal transduction pathway; inhibits calcineiruin, prevents transcription of gene for IL-2

A

cyclosporine

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39
Q

macrolide antibiotic produced by fungi, inhibit the phosphatase activity of calcineurin

A

tacrolimus

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40
Q

adverse effect of cyclosprine

A

hirsutism, gingival hyperplasia

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41
Q

adverse effect of tacrolimus

A

alopecia and neurotoxicity

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42
Q

macrolide antibiotic, also binds to same family of FKBP isomerase proteins
-binds to mTOR and prevents phosphorylation of p70- S6 kinase in the CD28 costimulatory and IL-2R signal transduction pathways

A

sirolimus; mammaliana target of rapamycin inhibitors

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43
Q

blocks T cell proliferation during the late G1 phase of the cell cycle, before S phase; potent inhibitors of vascular endothelial growth factor

A

mTOR

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44
Q

phagocytic cells, natural killer (NK ) cells,

complement

A

natural or innate immunity

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45
Q

immune reactants that
specifically recognize foreign molecules or antigens
from the microbial world

A

adaptive immunity/specific (T and B cells

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46
Q

development of antigen specific clones of T and B
cells but the full force of rejection involves components
of BOTH innate and adaptive immunity

A

acute rejection

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47
Q

Polyclonal antibody against human T cells, prepared by
immunization of animals (rabbit or horse) with human
lymphoid cells

A

thymoglobulin

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48
Q

complement dependent lysis in
blood and apoptosis and phagocytosis in peripheral
lymphoid tissue, antibodies against adhesion molecules

A

thymoglobulin

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49
Q

dose of thymoglobulin

A

1.5 mkd for 7-14 days for 3 days

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50
Q

Side effects of thymoglobulin

A

fever, chills, hypotension, cardiovascular; serum sickness after 10-15 days

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51
Q

anti-CD52 for CLL; long lasting depletion of T and B cell lymphocytes

A

alemtuzumab

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52
Q

chimeric monoclonal antibody;
immunoglobulin G1 antibody directed against the alpha
chain of the IL2 receptor (CD25 antigen) on activated T lymphocytes; inhibits key T lymphocyte proliferation
signaling

A

basiliximab

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53
Q

dose of basiliximab

A

30 mg IV on day of KT and day 4 post KT

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54
Q

chimeric , anti CD20, cytolytic
monoclonal antibody; used for PTLD, non Hodgkins lymphoma, CLL, and
rheumatoid arthritis; targets normal B lymphocytes; used in desensitization and treatment of acute humoral rejection

A

rituxumab

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55
Q

dose of rituximzb

A

375 mg/m2

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56
Q

more sensitive tissue crossmatching

A

flow cytometric crossmatch

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57
Q

options for desensitization

A

high dose IVIG/anti-CD20 vs low dose IVIG/plasmapharesis based

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58
Q

high viscosity, difficult to flush, multi organ transplant, high K

A

University of Wisconsin

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59
Q

Low K, low viscosity, buffer of histidine

A

histidine, tryptophan-ketoglutarate (HTK) solution

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60
Q

for living donor KTs with short ischemia time

A

heparinized lactated ringers with procaine

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61
Q

most common cause of delayed graft function

A

ischemic ATN

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62
Q

defines a group of recipients with moderate
early graft dysfunction. Serum creatinine level higher than 3 mg/ dL at 1
week posttransplantation

A

slow graft function

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63
Q

rejection, cyanosis and mottling of the kidney
and anuria occur minutes after the vascular anastomosis is
established

A

classic hyperacute rejection

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64
Q

Histology: widespread, small vessel endothelial damage and

thrombosis, usually with neutrophils incorporated into the thrombus.

A

hyperacute rejection

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65
Q

Rejection occurring roughly 2 to 5 days after
transplantation; Occurs in recipients with pre transplantation
sensitization to donor alloantigens; (+) low titer pretransplantation antidonor antibodies; rapid post transplantation antibody production by memory B cells

A

accelerated rejection

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66
Q

Sudden anuria ; absent arterial and venous blood flow to graft,
no pain; absent arterial and venous blood flow; no graft perfusion on renography

A

arterial thrombosis

67
Q

treatment of arterial thrombosis

A

graft nephrectomy

68
Q

local swelling, pain and hematuria; doppler ultrasound presence of arterial flow, no diastolic flow

A

venous thrombosis

69
Q

Transplant renal artery or renal vein thrombosis usually occurs in

A

first 72 hours to 10 weeks

70
Q

most common cause of allograft

loss in the first week

A

acute vascular thrombosis

71
Q

Tx for pseudoaneurysm

A

transplantation nephrectomy , vascular reconstruction, excision
with extraanatomic bypass

72
Q

lymphatic fluid collection from the severed lymphatics , or

lymphatic drainage of the graft

A

lymphocoele

73
Q

drainage : fluid has high lymphocyte

count and creatinine concentration similar to serum

A

lymphocoele

74
Q

Usually asymptomatic except for increasing creatinine; low grade fever, oliguria , and graft pain or tenderness may
occur; most common in the first 6 months post transplant

A

acute cellular rejection

75
Q

treatment of acute cellular rejection

A

Uncomplicated ACR is generally treated with a short course of high dose steroids. –. Methylprednisolone , 250 to 500 mg IV , 3 to 5 days,

76
Q

failure of improvement in urine; output or plasma creatinine level within 5 days of starting pulse treatment

A

Steroid resistant ACR (Banf II-III)

77
Q

Tx of steroid resistant aCR

A

depleting antibodies

78
Q

resistant to treatment with anti-lymphocyte antibody

A

refractory ACR

79
Q

allograft dysfunction and at least two of the following:
(1) histologic features, including peritubular capillaritis, glomerulitis, thrombi in glomerular capillaries, arterioles
or small arteries, and arterial fibrinoid necrosis; (2) diffusely positive staining of peritubular capillaries for C4d; (3) serologic evidence of antibody against donor HLA or ABO antigens

A

Acute antibody mediated rejection

80
Q

Management of ABMR

A

: Plasma exchange to remove DSA and/or intrave
nous immunoglobulins and anti CD20 monoclonal antibody to
suppress DSA

81
Q

Graft dysfunction associated with severe tremor (neurotoxicity), moderate increase in plasma creatinine
(>25% over baseline), high trough blood CNI concentrations (e.g.,
cyclosporine levels >350 ng / mL or tacrolimus levels >20
ng/mL

A

Acute CNI toxicity

82
Q

Management of Acute CNI toxicity

A

Reduce dose, repeat crea and drug levels within 48-96 hours

83
Q

Desired level of cyclosporine in early post transplant vs late post transplant

A

C0: 150-300 vs 100-200
C2: 1400-1800 vs 800-1200

84
Q

Tacrolimus desired level early post transplant

A

standard: 5-15; low 3-7

85
Q

CNIs are metabolized by

A

cytochrome P450

isoenzyme CYP3A5,

86
Q

the dosage of CNI should be reduced when taken with

A

diltiazem, verpamil, ketoconazole, macrolide antibiotics

87
Q

these meds lower CNI level hence dose should be increased

A

rifampin, phenobarbital, phenytoin

88
Q

foor that can increase cni level

A

grapefruit juice

89
Q

herb that can decrease cni level

A

st john’s wort

90
Q

Increasing plasma creatinine and lactate dehydrogenase levels,
thrombocytopenia, falling hemoglobin level, schistocytosis , and low
haptoglobin concentrations

A

acute thrombotic microangiopathy

91
Q

Management of acute TMA

A

cessation of CNI, control of htn, plasma exchange, eculizumab

92
Q

biomarker associated with acute rejection by up to 10 days

A

urinary mRNA levels of perforin and granzyme B

93
Q

predict the reversibility of acute rejection and identify patients at high risk for graft loss

A

FoxP3 mRNA in urinary cells

94
Q

biomarker of acute allograft injury

A

donor derived, cell free DNA

95
Q

common causes of acute pyelonephritis in KT

A

gram negative bacilli, cons, enterococci

96
Q

diagnostic of choice if with recurrent pyelonephritis

A

VCIG

97
Q

mononuclear cell and eosinophil infiltration of the transplanted kidney

A

acute allergic interstitial nephritis

98
Q

duration of dialysis and negative anti-GBM serology before transplant in patients with ant-gbm disease

A

6 months

99
Q

HUS-TTP should be quiescent for how long before transplant

A

6 months

100
Q

fluid collection with higher creatinine than plasma, renal scintigraphy with extravasation of tracer

A

urine leaks (infarction of the ureter, breakdown of anastomosis, severe obstruction, rupture)

101
Q

management of urine leaks

A

surgical exploration and repair

102
Q

most common vascular complication

A

renal artery stenosis

103
Q

clinically significant ras

A

> 70%

104
Q

CINICAL MANIFESTATIONS: Worsening or difficult to control
hypertension, an unexplained deterioration in kidney function, or
azotemia associated with the introduction of an ACE or ARB

A

transplant renal artery stenosis

105
Q

management of ras

A

angioplasty and stent placement

106
Q

quantitative plasma PCR testing for polyoma virus

A

monthly (3-6 months), q3 months (1st year), unexplained rise in crea and after treatment of acute rejection

107
Q

threshold of plasma viral titers when biopsy is advocated for polyoma virus

A

> 104 copies

108
Q

biopsy findings in polyoma virus

A

intranuclear tubule cell inclusions, (+) SV40 staining

109
Q

treatment of bk nephropathy

A

reduction in immunosuppression (discontinue MMF, reduce CNI by 30-50%)

110
Q

positive C4d staining

presence of circulating antidonor antibodies

morphologic evidence of chronic tissue injury, such as
glomerular double contours and/or peritubular capillary basement membrane
multilayering and/or IF/TA and/or fibrous intimal thickening in arteries.

positive peritubular capillary immunostaining for the complement split product, C4d

A

chronic active antibody mediated rejection

111
Q

slow decline in hypertension and often heavy proteinuria

A

chronic active antibody mediated rejection

112
Q

Striped cortical fibrosis or new onset arteriolar hyalinosis; tubular microcalcification

A

CNI toxicity

113
Q

Cold ischemia time associated with poorer graft survival

A

> 24 hours

114
Q

Extended criteria donors

A

> 60 years old, 50-59 with 2 of the following criteria: CVA as cause of death; history of htn, terminal crea > 1.5 mg/dL

115
Q

principal cause of hyperkalemia in post KT

A

Principal cause: CNI induced impairment of tubular

potassium secretion.

116
Q

indication for post transplantation parathyroidectomy

A

severe symptomatic hypercalcemia in early post transplantation, persistent moderately severe hypercalcemia for more than 1 year after transplantation or if with calciphylaxis

117
Q

procedure of choice for hyperparathyroidism

A

subtotal parathyroidectomy

118
Q

dose of azathioprine if used with allopurinol

A

75% of the original dose or change to MMF

119
Q

Dexa scanning indicated post transplant for patients on steroids with risk factors (HPT, vitamin D deficiency, phosphate depletion, DM)

A

3 months post transplant

120
Q

Tx within 1 year transplant GFR > 30, low BMD

A

vitamin D, calcitriol. alfacalcidol, bisphosphonate

121
Q

target Hba1c level for post transplant DM

A

7-7.5

122
Q

CNI that may increase statin blood levels

A

cyclosporine

123
Q

CNI risk factor for post transplant DM

A

tacrolimus

124
Q

drug of choice for post transplant DM if with normal GFR

A

metformin

125
Q

Tx for post transplant lymphoproliferative disorder

A

immunosuppression reduction, rituximab, CHOP (cyclophospamide, doxorubicin, vincristine and prednisone)

126
Q

treatment for cmv infection

A

immunosuppression and oral valganciclovir (if severe start with IV ganciclovir)

127
Q

prophylaxis for P. jiroveci

A

SMX-TMP

128
Q

immunization should be completed before transplantation

A

at least 4 weeks

129
Q

immunization should be avoided in the

A

first 6 months post transplantation

130
Q

vaccines contraindicated after transplantation

A

live vaccines

131
Q

CD$ count for hiv to proceed with transplant

A

200/m3

132
Q

pregnancy post kt can be allowed

A

good general health more than 18 months before conception, stable allograft Crea < 1.5, minimal hypertension, proteinuria, immunosuppresion maintenance doses, no dilation

133
Q

indications for graft nephrectomy

A

allograft failure with symptomatic rejection (graft pain), infarction due to thrombosis, severe infection (emphysematous pyelonephritis), allograft rupture

134
Q

Adequate glomeruli in post transplant biopsy donor

A

> 25 glomeruli, > 2 arteries

135
Q

Banff classiciation: normal biopsy or nonspecific changes

A

Cat 1

136
Q

Banff: antibody mediated changes

A

Cat 2

137
Q

Banff borderline changes

A

Cat 3

138
Q

TCMR Banff

A

Cat 4

139
Q

Tx for acute abmr

A

Pulse steroids + plasmapharesis + IVIG + Rituximab

140
Q

Mild/moderate tcmr

A

Steroid pulse

141
Q

Severe tcmr tx

A

steroid pulse/thymoglobulin

142
Q

occurs when an individual is exposed to nonself HLA epitopes via pregnancy prior transplant or blood transfusion

A

sensitization

143
Q

describe the perfentage of donors in a candidate donor population to whom recipient may have dsa

A

Panel reactive antibody

144
Q

predictor of adverse graft outcomes

A

Moderate to severe ifta

145
Q

hallmark of chronic active tcmr and abmr

A

Allograft vascular involvement

146
Q

Arterial intimal fibrosis with mononuclear cell infiltration and neointima formation, key feature of chrinic active abmr

A

chronic allograft arteriopathy

147
Q

first line of tx for acute tcmr

A

Steroid pulses

2: ATG and alemtuzumab

148
Q

Banff grade 2 tcmr or higher

A

Antibodies + corticosteroids

149
Q

anti-IL 2R class

A

Basiliximab

150
Q

serine threonine phosphatase that dephosphorylates the cytosolic component if the nuclear factpr of activated t cells (nfat)

A

calcineurin

151
Q

first iv immunosuppressive agent that was marketed

A

belatacept

152
Q

chimeric murine/human monoclonal ab directed against CD20

A

Rituximab

153
Q

reversible inhibitor of the 26S proteasome

A

bortezomib

154
Q

humanized monoclonal antibody that targets the complement C5a component

A

eculizumab

155
Q

humanized monoclonal antibody directed at the soluble and membrane forms of IL6R

A

tociluzimab

156
Q

Implantation of the ureter to the bladder to minimize urinary reflux into thenureter

A

Lich Gregoir

157
Q

where is a kidney allograft placed?

A

extra peritoneal iliac fossa

158
Q

procedure of choice for live donor nephrectomy

A

laparoscopic approach

159
Q

high K cold storage preservation solution

A

wisconsin

160
Q

most impt side effect of azathioprine

A

Myelosuppression

161
Q

cpra that needs to be sensitized

A

more than or equal to 20

162
Q

period during donor sx between aortic cross clamping or asystole and establishment of cold preservation

A

donor warm ischemia time

163
Q

period between removal of kidney from coldstorafe to reperfusion of graft

A

graft warm ischemia time

164
Q

time that the kidney spends in cold preservarion

A

cold ischemia time

Nephrology Fellowship Reviewer (29 decks)

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