Lecture 17 - Renal Replacement 2

Question 1

Transplanted kidney is placed in the ____ fossa and anastomosed with _______.

Answer 1

Iliac fossa

Iliac vessels

Question 2

What are indications for native nephrectomy?

Answer 2

Size - e.g. polycystic kidneys

Infection, e.g. chronic pyelonephritis

Question 3

What is involved in a kidney transplant?

Answer 3

(Living donor nephrectomy)
Preservation of donor kidney (cold storage solutions, minimise oedema, preserve integrity of tissues, buffer free radicals)
Transplant

Question 4

What are surgical complications of renal transplant?

Answer 4

Vascular - bleeding (usually anastomotic sites, perirenal haematoma), arterial/venous thrombosis, lymphocele
Ureteric - urine leak
Infections
Rejection

Question 5

What immunosupressive agents can be used after renal transplant?

Answer 5

Prednisolone
Calcineurin inhibitors - tacrolimus, cyclosporine
Antiproliferatives - mycophenolate, mofetil, azathioprine
mTOR inhibitors - sirolimus
Costimulatory signal blockers - belatacept
Depleting agents - rituximab etc.

Question 6

What are side effects of corticosteroids?

Answer 6

Hypertension 
Hyperglycaemia
Infections
Wound healing delay 
Bone loss
GI bleeding

Question 7

What are SEs of tacrolimus?

Answer 7

Hyperglycaemia
AKI
Tremor

Question 8

What SEs of cyclosporin?

Answer 8

Hirsutism
Hypertension
AKI
Gout

Question 9

What are SEs of mycophenolate mofetil?

Answer 9

Cytopenia

GI upset

Question 10

What agent is used to induce immunosupression for renal transplant?

Answer 10

Basiliximab

Question 11

What agents can be used for maintenance of immunosupression for renal transplant?

Answer 11

Tacrolimus + mycophenolate + steroids

Question 12

Is less or more time on dialysis associated with better outcomes?

Answer 12

Less

Question 13

What is the brain death criteria?

Answer 13

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

Question 14

What is the difference between the standard and extended criteria donor?

Answer 14

Extended = donor >60y, or 50-59 + hx HTN, death from cerebrovascular accident or terminal cr >132micromol/l

Question 15

What are the risks of kidney donation?

Answer 15

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

Question 16

How long are kidney donors followed up for?

Answer 16

12 years

Question 17

What two types of rejection can occur post-kidney transplant?

Answer 17

Cell mediated

Humoral (Ab) mediated

Question 18

What are CV complications post-kidney transplant?

Answer 18

Underlying renal disease
CRF
HTN
Hyperlipidaemia
PT diabetes

Question 19

What malignancies are those who undergo renal transplant more at risk of?

Answer 19

Skin
Lymphoma
Solid cancers

Question 20

What are the three Banff types of T cell mediated rejection?

Answer 20

Tubulointerstitial (Banff I)
Arteritis/endothelialitis (Banff II)
Areterial fibrinoid necrosis (Banff III)

Question 21

What are the three Banff types of acute antibody mediated rejection?

Answer 21

ATN-like (Banff I)
Capillaries and or glomerular inflammation (Banff II)
Arterial inflammation (Banff III)

Question 22

After renal transplant, patients are given prophylaxis against which organism for 6 months?

Answer 22

CMV

Question 23

What is the most important transplant related infection?

Answer 23

CMV

Question 24

How can a recipient be infected with CMV?

Answer 24

Via transmission from donor tissue

Reactivation of a latent virus

Question 25

What kind of virus is CMV?

Answer 25

A herpes virus

Question 26

It is thought that ___% of people have been exposed to the CMV virus although it only usually causes disease in the ______.

Answer 26

50% | Immunocompromised

Question 27

What do cells infected with CMV appear like?

Answer 27

Owl's eye appearance due to intranuclear inclusion of bodies

Question 28

What are some common patterns of CMV disease?

Answer 28

``` Congenital CMV infection CMV mononucleosis CMV retinitis CMV encephalopathy CMV pneumonitis CMV colitis ```

Question 29

What are features of a congenital CMV infection?

Answer 29

``` Growth retardation Pinpoint petechial blueberry muffin skin lesions Microcephaly Sensorineural deafness Encephalitis (seizures) Hepatosplenomegaly ```

Question 30

How does CMV mononucleosis tend to present?

Answer 30

IM type illness

Question 31

Who is CMV retinitis more common in?

Answer 31

HIV patients with a low CD4 count (<50)

Question 32

How does CMV retinitis present?

Answer 32

Visual impairment, e.g. blurred vision

Question 33

What do you see on fundoscopy in those with CMV retinitis?

Answer 33

Retinal haemorrhages and necrosis - retina looks like a pizza

Question 34

What is the treatment of choice for CMV retinitis?

Answer 34

IV ganciclovir

Question 35

What is the big issue with CMV in kidney transplant?

Answer 35

CMV infection reduces graft survivial

Question 36

What two other viruses can be problematic post transplant?

Answer 36

BK virus | JC virus

Question 37

How can BK virus present post-renal transplant?

Answer 37

Ureteral stenosis Interstitial nephritis ESRF Leads to graft dysfunction

Question 38

What is the treatment for BK infection?

Answer 38

Reduce immunosupression | Antivirals

Question 39

What are some complications of AV fistulas?

Answer 39

Infection Thrombosis Stenosis Steal syndrome

Question 40

What does an AV fistula create that is essential for haemodialysis?

Answer 40

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