Kidney Transplantation

Question 1

Which kidney is preferred?

Anastamosis of vessels?

Answer 1

Left kidney b/c longer renal vein

Renal vein and artery anastamosis to recipient right external iliac vein and artery

donor ureter anastamose to recipient bladder

Question 2

Warm ischemia vs. Cold ischemia

Answer 2

warm = time from cardiac death to cold = 60 min

cold = cold perfusion to recipient = 24-36 hrs

Question 3

3 criteria for donor kidneys

Answer 3

1) Standard SCD = organs perfused until cross clamp
2) After death DCD = incr warm ischemia time and risk of delayed function
3) ECD = old patient or donor with PMHx assoc with 70% graft failure; for patients with high mortality on dialysis

Question 4

MHC presentation

Answer 4

1) MHC = HLA bind peptide antigens

2) present to T cells via T cell receptor

Question 5

Class 1 vs. Class II HLA

Answer 5

Class 1 = on all nucleated cells; presenting cytosolic peptides (viral) to CD8+

Class 2 = present on specific APC presenting to extracellular proteins (endocytosis) to CD4+

Question 6

binding of HLA protein to antigen depends on :

Answer 6

1) amino acid structure of HLA protein

2) immunogenic epitope in antigenic peptide molecule

Question 7

donor HLA antigens will be recog by recipient as ___ resulting in ___

Answer 7

“non-self” resulting in immune rejection unless recipient undergoes immunosuppression

Question 8

What to look at for 6 HLA matches?

Answer 8

HLA-A
HLA-B
HLA-DR loci

Question 9

HLA inheritance

Answer 9

1 set of HLA from each patient = co-dominantly expressed so 6 matches

Question 10

Does HLA matching impact risk of acute rejection?

Answer 10

NOT IMPACT ACUTE REJECTION

decision to transplant not depend on HLA match but does affect level of immunosuppression after

Question 11

what happens immunologically after transplanting kidney

Answer 11

1) recipient or donor antigen presenting cell presents foreign donor HLA molec
2) activates recipient T cell
3) after 2nd co-stim event, dephos of NFAT by calcineurin and IL-2 production
4) T cell prolif and clonal expansion

Question 12

CD8+ T cells induce damage how

Answer 12

direct cytotoxicity
1) cell apoptosis
or
2) release cytotoxic proteins (FasL and granzyme B)

Question 13

CD4+ T cells induce damage how

Answer 13

provide prolif signals for CD8+ T, B, macrophages –> APC

Question 14

Triple therapy for kidney transplant recipient

Answer 14

1) calcineurin inhib
2) prolif signal inhib
3) prednisone

Question 15

all immunosuppressive agents

side effects

Answer 15

incr risk of infection and cancer

Question 16

Names of calcineurin inhib

Names of prolif inhib

Answer 16

1) cyclosporin
2) tacrolimus

1) mycophenolate mofetil inhibits purine synthesis
2) mTOR inhib inhib MTOR proliferation signlaing

Question 17

Additional pre-renal AKI with transplant

Answer 17

1) volume depletion
2) transplanted renal artery/vein thrombosis = emergency
3) calcineurin effect on afferent arteriole

Question 18

Additional post-renal AKI with transplant

Answer 18

1) transplant ureter obstruction from fluid collection (lymphocele, hematoma)
2) urine leak from breakdown of transplant ureter to bladder anastamosis, incr creatinine, require ureteral stent

Question 19

Additional intra-renal AKI with transplant

Answer 19

1) recurrence of primary renal disease
2) infection (UTI, pyelo, CMV, BK virus)
3) T-cell or B cell rejection

Question 20

treatment of CMV

treatment of BK virus

Answer 20

1) ganciclovir

2) reduction of immunosuppression

Question 21

treatment of T cell rejection

treatment of B cell rejection

Answer 21

high doses steroids/T cell depletion with thymoglobulin

plasmapharesis and IVIG/rituximab

Question 22

histology of T cell rejection

histology of B cell rejection

Answer 22

tubular + large vessel inflamm

small vessel + glomerular inflamm
complement damage

Question 23

approach to kidney transplant AKI

Answer 23

1) n/diarrhea, volume status

2) US for post-renal
calcineurin inhib drug level
UA for infection/proteinuria
serum for BK or anti-HLA antibodies

3) renal transplant biopsy