Lecture 17 - Renal Replacement 2 Flashcards
Transplanted kidney is placed in the ____ fossa and anastomosed with _______.
Iliac fossa
Iliac vessels
What are indications for native nephrectomy?
Size - e.g. polycystic kidneys
Infection, e.g. chronic pyelonephritis
What is involved in a kidney transplant?
(Living donor nephrectomy)
Preservation of donor kidney (cold storage solutions, minimise oedema, preserve integrity of tissues, buffer free radicals)
Transplant
What are surgical complications of renal transplant?
Vascular - bleeding (usually anastomotic sites, perirenal haematoma), arterial/venous thrombosis, lymphocele
Ureteric - urine leak
Infections
Rejection
What immunosupressive agents can be used after renal transplant?
Prednisolone
Calcineurin inhibitors - tacrolimus, cyclosporine
Antiproliferatives - mycophenolate, mofetil, azathioprine
mTOR inhibitors - sirolimus
Costimulatory signal blockers - belatacept
Depleting agents - rituximab etc.
What are side effects of corticosteroids?
Hypertension Hyperglycaemia Infections Wound healing delay Bone loss GI bleeding
What are SEs of tacrolimus?
Hyperglycaemia
AKI
Tremor
What SEs of cyclosporin?
Hirsutism
Hypertension
AKI
Gout
What are SEs of mycophenolate mofetil?
Cytopenia
GI upset
What agent is used to induce immunosupression for renal transplant?
Basiliximab
What agents can be used for maintenance of immunosupression for renal transplant?
Tacrolimus + mycophenolate + steroids
Is less or more time on dialysis associated with better outcomes?
Less
What is the brain death criteria?
Coma, unresponsive to stimuli
Apnoea off ventilator (with oxygen) despite build up of C)2
Absence of cephalic reflexes (pupillary, oculocephalic, oculovestibular (caloric), corneal, gag)
Body temp above 34C
Absence of drug intoxication
What is the difference between the standard and extended criteria donor?
Extended = donor >60y, or 50-59 + hx HTN, death from cerebrovascular accident or terminal cr >132micromol/l
What are the risks of kidney donation?
Similar patient survival to general pop
Lower rate ESRD compared to general pop
Compensatory increase in GFR of remaining kidney to 70% pre-donation values
How long are kidney donors followed up for?
12 years
What two types of rejection can occur post-kidney transplant?
Cell mediated
Humoral (Ab) mediated
What are CV complications post-kidney transplant?
Underlying renal disease CRF HTN Hyperlipidaemia PT diabetes
What malignancies are those who undergo renal transplant more at risk of?
Skin
Lymphoma
Solid cancers
What are the three Banff types of T cell mediated rejection?
Tubulointerstitial (Banff I)
Arteritis/endothelialitis (Banff II)
Areterial fibrinoid necrosis (Banff III)
What are the three Banff types of acute antibody mediated rejection?
ATN-like (Banff I)
Capillaries and or glomerular inflammation (Banff II)
Arterial inflammation (Banff III)
After renal transplant, patients are given prophylaxis against which organism for 6 months?
CMV
What is the most important transplant related infection?
CMV
How can a recipient be infected with CMV?
Via transmission from donor tissue
Reactivation of a latent virus
What kind of virus is CMV?
A herpes virus
It is thought that ___% of people have been exposed to the CMV virus although it only usually causes disease in the ______.
50%
Immunocompromised
What do cells infected with CMV appear like?
Owl’s eye appearance due to intranuclear inclusion of bodies
What are some common patterns of CMV disease?
Congenital CMV infection CMV mononucleosis CMV retinitis CMV encephalopathy CMV pneumonitis CMV colitis
What are features of a congenital CMV infection?
Growth retardation Pinpoint petechial blueberry muffin skin lesions Microcephaly Sensorineural deafness Encephalitis (seizures) Hepatosplenomegaly
How does CMV mononucleosis tend to present?
IM type illness
Who is CMV retinitis more common in?
HIV patients with a low CD4 count (<50)
How does CMV retinitis present?
Visual impairment, e.g. blurred vision
What do you see on fundoscopy in those with CMV retinitis?
Retinal haemorrhages and necrosis - retina looks like a pizza
What is the treatment of choice for CMV retinitis?
IV ganciclovir
What is the big issue with CMV in kidney transplant?
CMV infection reduces graft survivial
What two other viruses can be problematic post transplant?
BK virus
JC virus
How can BK virus present post-renal transplant?
Ureteral stenosis
Interstitial nephritis
ESRF
Leads to graft dysfunction
What is the treatment for BK infection?
Reduce immunosupression
Antivirals
What are some complications of AV fistulas?
Infection
Thrombosis
Stenosis
Steal syndrome
What does an AV fistula create that is essential for haemodialysis?
It arterialises the vein due to the high pressure of the artery
Shunted blood flow causes an increase in growth factors + hypertropies the venous wall
