Kidney transplantation Flashcards
Describe what HLA is and what HLA matching means in kidney transplantation
HLA = cell surface proteins and cause immune response if non-self
When tissue typing kidneys for transplant there are 3 important types HLA: HLA A, HLA B, HLA Dr
There are many different types of HLA, each person has 2 sets (haplotypes) of HLA, 1 haplotype is inherited from each parent
Why is it important to immunosuppress someone when they are recieving a kidney transplant? What if this is too little or too much?
Donor will form Abs, natural killer cells, cytotoxic t cells against tissue
If too much immunosuppression:
- BK virus
- cytomegalovirus
- pneumocystitis jirovecii
- non-melanoma skin cancer
- post-transplant lymphoma
If too little - rejection:
- graft dysfunction
- graft loss
What is the difference between: -hyperacute -acute -chronic rejection in kidney transplantation?
Hyperacute:
-minutes, due to positive cross match, unsalvageable, remove kidney
Acute:
-usually early due to T/B cell mediated response, treat with increased immunosupression
Chronic:
- immunological and vascular deterioration of transplant
- no treatment yet
What is the difference in immunosuppression: -induction -consolidation -maintainence in kidney trnapslant
Induction:
- steroids/MMF/CyA/Tacrolimus/Abodies
- short term
Consolidation:
- Steroids/MMf/CyA/Tacrolimus
- medium term
Maintenence:
-Steroids/MMF/CyA/Tacrolimus (long term)
What three different therapies are used as ‘anti-rejection therapies’ for kidney transplant?
Reduce activation of T/B cells, use in combination
Calcineurin inhibitors - cyclosporin/tacrolimus:
-inhibit T cells
Azathioprine/mycophenalate:
-inhibits lymphocytes/B cells
Steroids:
-inhibits T cells and B cells
What different donor kidney types exist?
DBD: deceased brain dead
DCD: deceased cardiac dead
Live donor
Kidney-pancrease dual
How is a patient assessed for suitability for transplant kidney?
- life expectancy more than 5 year and should not get cardaveric transplant more than 6months prior to starting dialysis
- allocations based on tissue typing then time on register
What is included in the assessment for patients for kidney transplant?
Cardiovascular risk: ECG/cholesterol/ETT/coronary angiogram/Echo
Virology: HBV, HCV, HIV, CMV, EBV
CXR
Ix - any comorbities
Bladder assessment: if PHx urological problems
What are absolute contraindications to renal transplant?
- malignancy (if untreated or history solid tumour within 2 yrs)
- untreated TB
- severe ischaemic heart disease
- severe airway disease
- severe peripheral vascular disease
- active vasculitis
What is included in liver donor assessment for kidney transplant?
- ECG, CXR, Virology, GFR
- quantification of proteinuria
- 24hr BP monitoring
- Renal angiogram
- Cross match against recipient
Describe the operation: -time it takes -wound length -complications -post transplant care for kidney transplant
3-4hours, wound 15-20cm long
Complications:
- bleeding
- arterial/venous thrombosis/stenosis
- wound infection
- ureteric stricture and hydronephrosis
Post Tx:
- HDU
- central line
- O2, fluids, bladder catherter to monitor UO
What is involved in monitoring the kidney transplant?
Immediate graft function:
- good urine output
- falling creatinine/urea
Delayed:
-transplant should work after 30days, will need HD in interim, difficult to detect rejection and needs biopsy to do this
What is involved in post Tx care after kidney transplant for a functioning and a non-functioning transplant?
Functioning transplant:
- maintain hydration
- daily monitor U+E/drug levels
- regular MSU for infection
- Discharge after a week
Non-functioning transplant:
- USS and renograms for blood flow assessment
- biopsy to see if rejection, acute tubular necrosis, cortical necrosis
- time (dialysis to manage CRF and maintain fluids)
- decrease dose meds.
What is involved in the long term follow up for a renal transplant?
- treatment of late acute rejection
- high BP and CVD risk
- UTI
- recurrent primary renal disease
- surveillence skin cancer
Transplant survival:
- why may graft be lost?
- survival of graft depends on what?
Graft can be lost to:
- chronic rejection
- cyclosporin/tacrolimus rejection
- recurrent disease
- ischaemia
survival depends on:
-type/matching of graft
