Lecture 16 Renal Replacement Therapy 2 (Transplantation) Flashcards
Transplanted kidneys are placed where and what vascular system are they attached to
Iliac fossa
Iliac vessels
What happens to the diseased kidneys after a renal transplant
Remain in situ
What indications are there for a native kidney to undergo nephrectomy
Increase in size- polycystic
Infection- chronic pyelonephritis
What is the timeline of a kidney once it is is removed for transplantation
• Preservation of donor kidney o Cold preservation solutions o Continuous pulsatile hypothermic machine perfusion o Minimize oedema o Preserve integrity of tissues o Buffer free radicals • Transplantation
What are the vascular complications of kidney transplant
• Bleeding – Usually anastomotic sites – Perirenal haematoma can be arterial or venous • Arterial thrombosis • Venous thrombosis • Lymphocele
Name a ureteric complication of a kidney transplant
Urine leak
Name another complication of a kidney transplant
Infection
Name types of immunosuppressive agents
Corticosteroids Calcineurin inhibitors Anti-proliferatives mTOR inhibitors Costimulatory signal blockers Depleting agents
What type of immunosuppressive agent is Tacrolimus, Cyclosporine
Calcineurin inhibitors
What type of immunosuppressive ageists are Mycophenolate mofetil, Azathioprine
Anti-proliferatives
What type of immunosuppressants is Sirolimus
mTOR inhibitors
What type of immunosuppressant is Belatacept
Costimulatory signal blocker
Wha type of immunosuppressant is Basiliximab ( anti-CD25), Anti-thymocyte globulin (ATG), Rituximab (anti-CD20)
Depleting agents
What are the side effects of corticosteroids
Hypertension, hyperglycemia, infections, bone loss, GI bleeding
What are the side effects of Tacrolimus
Hyperglycemia, AKI, tremor
What are the side effects of cyclosporin
Hirsuitism, hypertension, AKI, gout
What are the side effects of Mycophenolate mofetil
Cytopenia, GI upset
What are the side effects of Sirolimus
Lipidogenic, diabetogenic, pneumonia
What are the side effects of Belatacept
Infections, malignancy
What are the side effects of ATG
Infections, PTLD
Describe the immunosuppression protocol
- Induction-Depleting agent
2. Maintenance- Anti-prof, Calcineurin inhibitor, steroid
Name the 2 types of donors
Deceased- donation after brain death/cardiac death
Living donor: relative, spouse, altruistic, paired/pooled
What s the brain death criteria
- Coma, unresponsive to stimuli
- Apnoea off ventilator (with oxygenation) despite build up of CO2
- Absence of cephalic reflexes
- Body temperature above 34 C
- Absence of drug intoxication
What is the expanded criteria donors
– Donor aged > 60y
– Donor aged 50-59 + history of hypertension, death from cerbrovascular accident or terminal creatinine of >132µmol/L
What types of renal transplant rejections are there
Cell mediated
Humoral (Ab mediated)
Name cardiovascular complications after renal transplant
o Underlying renal disease o CRF o Hypertension o Hyperlipidaemia o PT Diabetes
Name infective complications after a renal transplant
o Bacterial
o Viral
o Fungal
Name malignant complications after a Renal transplant
Skin
Lymphoma
Solid cancers
What are the 2 types of acute rejection
T cell mediated
Acute antibody mediated
What are the classifications within T cell mediated acute rejection
Tubulointerstitial (Banff I) Arteritis/endothelialitis (Banff II)
Areterial fibrinoid necrosis (Banff III)
What are the classifications of acute antibody mediated rejection
ATN-like (Banff I)
Capillaries and or glomerular inflammation (Banff II)
Arterial inflammation (Banff III)
What are the features of T cell mediated rejection
- Lymphocytic infiltrate
- Tubulitis- presence of inflammatory cells in the tubular wall
- Endarteritis- inflammation of the inner lining of an artery.
- Endothelialitis- inflammation of the endothelium
What are the features of antibody mediated rejection
• Microvascular inflammation o Neutrophil infiltration o Glomeruli o Peritubular capillaries • Donor specific antibodies • Positive C4d o peritubular capillaries
New Onset Diabetes Mellitus after Transplantation
Name conventional infections that a patient may contract after transplant
- Viral- HSV
- Bacterial- Wound pneumonia related
- Hepatitis B
Name unconventional infections a patient may contract after a transplant
- Viral- CMV, EBV, VZV, Papova adenovirus
- Fungal- TB, Penumocystitis
- CNS- Aspergillus, toxoplasma, cryptococcus]- Listeria
- Onset of Non-A, Non-B Hepatitis
What other infections may a renal transplant patient be at risk from
UTI: bacteraemia, pyelitis, relapse
What is the most important transplant related infection
Cytomegalovirus
How is a recipient of a kidney infected with cytomegalovirus
o Transmission from donor tissue
o Reactivation of latent virus
How can survival of an infection of cytomegalovirus be increased
anti-CMV prophylaxis
Name the most common types of Polyomaviridae
BK
JC
Murine polyoma
SV40
What can BK virus cause
nephropathy, ureteral stenosis, interstitial nephritis, ESRF
What are the risk factors for BK virus associated nephropathy
Intensity of immunusuppresion
- older age, male gender, white ethnicity, DM, negative BKV serostatus (paediatric recipients)
Graft injury, HLA mismatch, ureteral stents
- changes in epitopes of viral capsid protein VP-1
What is the outcome of BK virus associated nephropathy
- Allograft dysfunction
* Loss of graft
How is BK virus associated nephropathy treated
- Reduce immunosuppression
* Antiviral therapy- Cidofovir, Leflunomide
What malignancies are seen in patients after renal transplant
- Colon, lung, breast
- Testicular, bladder
- Melanoma, leukaemia, cervical
- Renal- most common
- Non-melanoma skin, Kaposi Sarcoma, Non Hodgkins Lymphoma (PTLD)- most common
What are the most common malignancies seen after renal transplant
- Renal- most common
* Non-melanoma skin, Kaposi Sarcoma, Non Hodgkins Lymphoma (PTLD)- most common
