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Year 3 - Met3b > Kidney Transplantation > Flashcards

Kidney Transplantation Flashcards

1
Q

What are we trying to achieve with transplantation

A

Primary endpoints

  • longer life
  • better quality of lief

secondary endpoints

  • at least 5 years of graft survival
  • best use possible of kidney - responsibility to donor - confident that it will last 5 years in the person using it
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2
Q

How many patients on dialysis are on the transplant list

A

30% of dialysis patients are on the transplant list

- 30% of people on dialysis are suitable for a transplant and are fit enough for one

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3
Q

does a kidney transplant improve survival

A

Yes

  • on the day of having the transplant risk of dying increases due to risk of operation
  • takes a while for risk to come down due to recovery
  • at 100 days risk is back to what it was
  • risk then becomes lower after recovery
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4
Q

How do we determine risk

A

Co morbidities

  • diabetes
  • COPD
  • CV disease
  • elderly - above age of 65
  • fitness
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5
Q

What are the types of transplant

A

Living donors

Deceased donor

  • donation after cardiac death (DCD)
  • donation after brain death (DBD)

Pre-emptive

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6
Q

What has the best donor outcomes

A
  • young living donor pre-emptive
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7
Q

What are the compatibility issues with donors

A
  • Blood group

- Tissue type - HLA

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8
Q

describe the different blood groups

  • A
  • B
  • AB
  • O

in terms of antigen and antibody

A
  • A = antigen A, Antibody = Anti- B
  • B= antigen B, Antibody = Anti- A
  • AB = antigen A and B, Antibody = none
  • O , Antigen = none, Antibody = Anti -A and Anti - B
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9
Q

What are the two classes of HLA

A
  • Class I - HLA-A, HLA-B

* Class II - HLA-DR

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10
Q

What is HLA class 1 present on

A

It is present on most cells

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11
Q

What is HLA class 2 present on

A
  • Present on APC/B cells and activated/injured other cells
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12
Q

How do we inherit HLA

A

inherit 1 set of alleles from each parent

“Closeness of match” - improves results

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13
Q

The closer the HLA match the…

A

better the results

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14
Q

when do you get HLA antibodies

A

They are not naturally occurring you need a sensitising event
• Pregnancies
• Blood transfusion
• Previous transplants

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15
Q

Why is HLA matching important

A
  • Impacts organ survival - increases it

- the better the match the better the organ will form

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16
Q

What can you do if you have incompatible pairs

A
  • Desensitise - where we remove antibodies ahead of the transplant to allow the recipient to accept the kidney
  • Exchange scheme - have two pairs - exchange kidneys to other pair as the donor doesn’t match there recipient
17
Q

list the percentages for graft survival over 10 years

A

For decreased donors
• 1 year graft survival = 80-90%
• 5 year graft survival = 60-70%
• 10 year graft survival = 50-60%

• Better for living donors

18
Q

Where does the kidney go in transplantation

A
  • iliac fossa either the right or left
19
Q

What medication do you need to take after transplantion

A

Steroids
- reduces the production of inflammatory cytokines

inhibit purine synthesis (antimetabolites)

  • Azathioprine
  • MMF

Calcineurin inhibitors - reduce T cell signalling and stops the production of IL-2 therefore prevents clonal expansion of T cells
• Cyclosporin
• Tacrolimus

Stops clonal expansion of T cells
• Rapamycin (sirolimus)

20
Q

How do Calcineurin inhibitors work

A

reduce T cell signalling and stops the production of IL-2 to stop clonal expansion of T cells

21
Q

Name some Calcineurin inhibitors

A
  • Cyclosporin

* Tacrolimus

22
Q

What complications can arise in transplantation

A

Infections

  • Viral - such as CMV/Wart
  • Bacterial - Urine/Resp
  • Fungal - Pneumocystis

Rejection
Malignancy

23
Q

What are the complications to do with the drugs used in transplantation

A
  • Cardiovascular disease / IHD / increase in Bp
  • Diabetes
  • Bone
  • GI
  • Cosmetic - cyclosporin causes hertiusim and tacrolimus causes loss of hair

Tumours (due to immunosuppression)

  • Solid organ
  • skin cancer - more common in immunosuppression
  • PTLD - Post-transplant lymphoproliferative disorders - driven by EBV
24
Q

What is Post-transplant lymphoproliferative

A
  • cancer caused by immunosupression due to medications taken after transplant
  • driven by an EBV infection
25
Q

What are the contradictions to kidney transplant

A

Absolute
- cancer with metastases

Temporary

  • active infection
  • HIV with viral replication
  • unstable CVD

Relative

  • congestive heart failure
  • CVD
26
Q

Transplantation should be ….

A

considered for every patient with or progressing towards stage G5 kidney disease

27
Q

What are the side effects of calcineurin inhibitors

A
  • nephrotoxicity in the graft
  • modification of CV risk factor - increase in blood pressure and increase in cholesterol
  • new onset diabetes after transplantation
28
Q

What are the side effects of anti metabolites such as azathioprine

A
  • anaemia
  • leucopenia
  • GI toxicity
29
Q

What are the side effects of steroids

A
  • blood pressure
  • hyperlipidaemia
  • Diabetes
  • impaired wound healing
  • osteoporosis
  • cataracts
  • skin fragility
30
Q

what type of rejection can you have

A
  • Acute

- chronic

31
Q

What are the two types of acute rejection

A
  • antibody mediated

- cellular mediated

32
Q

What is the treatment of rejection

A
  • high dose steroids
33
Q

What is you increase risk in malignancy in transplant

A

up to 25x risk of cancer with immunosuppression

34
Q

What cancers are you most likely to get after transplantation

A
  • particularly skin
  • post transplant lymphoproliferative disorder
  • gynaecological
35
Q

What factors contribute to graft loss

A
  • donor factors: age, comorbidity, living/decreased
  • rejection
  • infection
  • BP/CVD
  • recurrent renal disease in graft
36
Q

How do Purine synthesis inhibitors (antimetabolites) such as azathioprine and MMF work

A

Blocks purine synthesis therefore inhibitors proliferation of B and T cells

37
Q

describe what medications are used and when in transplant surgery

A
  • Initial = Ciclosporin/tacrolimus with a monoclonal antibody
  • Maintenance = ciclosporin/tacrolimus with MMF or sirolimus
  • Add steroids if there is more than one steroid responsive acute rejection therapy
38
Q

What are the complications of transplant

A

Complications

  • Surgical = bleed, thrombosis, infection, urinary leaks, lymphocele, hernia
  • Delayed graft function = affects up to 40% of grafts
  • Rejection = acute or chronic
  • Infection = increase risk of all infections typically hospital acquired or donor derived
  • Malignancy = 25x risk of cancer
39
Q

Describes the type of rejection

A

Hyper acute (minutes to hours)
- Due to pre-existing antibodies against ABO or HLA antigens
- Leads to widespread thrombosis of graft vessels – ischaemia and necrosis of transplanted organs
Acute (less than 6 months)
- Antibody mediated
- Cellular mediated – more common usually due to mismatched HLA
Chronic graft failure (greater than 6 months)
- Both antibody and cell mediated mechanisms cause fibrosis to the transplanted kidney

Year 3 - Met3b (26 decks)

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