Kidney Transplantation Flashcards
What are we trying to achieve with transplantation
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
How many patients on dialysis are on the transplant list
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
does a kidney transplant improve survival
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
How do we determine risk
Co morbidities
- diabetes
- COPD
- CV disease
- elderly - above age of 65
- fitness
What are the types of transplant
Living donors
Deceased donor
- donation after cardiac death (DCD)
- donation after brain death (DBD)
Pre-emptive
What has the best donor outcomes
- young living donor pre-emptive
What are the compatibility issues with donors
- Blood group
- Tissue type - HLA
describe the different blood groups
- A
- B
- AB
- O
in terms of antigen and antibody
- 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
What are the two classes of HLA
- Class I - HLA-A, HLA-B
* Class II - HLA-DR
What is HLA class 1 present on
It is present on most cells
What is HLA class 2 present on
- Present on APC/B cells and activated/injured other cells
How do we inherit HLA
inherit 1 set of alleles from each parent
“Closeness of match” - improves results
The closer the HLA match the…
better the results
when do you get HLA antibodies
They are not naturally occurring you need a sensitising event
• Pregnancies
• Blood transfusion
• Previous transplants
Why is HLA matching important
- Impacts organ survival - increases it
- the better the match the better the organ will form
What can you do if you have incompatible pairs
- 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
list the percentages for graft survival over 10 years
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
Where does the kidney go in transplantation
- iliac fossa either the right or left
What medication do you need to take after transplantion
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)
How do Calcineurin inhibitors work
reduce T cell signalling and stops the production of IL-2 to stop clonal expansion of T cells
Name some Calcineurin inhibitors
- Cyclosporin
* Tacrolimus
What complications can arise in transplantation
Infections
- Viral - such as CMV/Wart
- Bacterial - Urine/Resp
- Fungal - Pneumocystis
Rejection
Malignancy
What are the complications to do with the drugs used in transplantation
- 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
What is Post-transplant lymphoproliferative
- cancer caused by immunosupression due to medications taken after transplant
- driven by an EBV infection
