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METABOLIC > RENAL - DIALYSIS AND RENAL TRANSPLANTATION > Flashcards

RENAL - DIALYSIS AND RENAL TRANSPLANTATION Flashcards

1
Q

What are the advantages of transplantation over dialysis?

A

• removes burden of life long dialysis
• Improves renal clearance - dialysis only provides a GFR of about 10ml/min
• Restores endocrine functions of kidney e,g, EPO production and 1-alpha hydroxylation of vitamin D
• Improves life expectancy of appropriately selected candidates.
• Transplantation allows freedom from dietary and fluid restrictions

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2
Q

What are the disadvantages of dialysis?

A

• significant periopertive mortality risk - largely cardiovascular mortality. 2% risk.
• Lifelong burden of immunosuppression
◦ Infections (particularly opportunistic), cancer risk (non melanoma skin, cervix and lymphoma)
• New onset post transplant diabetes - 12-20% of patients develop this

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3
Q

What are the absolute contraindications of transplantation?

A

• active infection
• Active cancer and wait 2-5 years following cure
• Active drug misuse
• Uncontrolled major psychiatric disease (that would disrupt ability to take medication)
• Active non-concordance with treatment
• Short life expectancy (<5 years)

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4
Q

Who governs the kidney transplantation scheme?

A

Human Tissue Act 2004

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5
Q

What are the 2 types of cadaveric donors?

A

DBD - donation after brain death
DCD - donation after cardiac death (non heart beating)

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6
Q

Why is the transplanted kidney not placed where the other kidneys are?

A

As only the upper 3rd of the ureter is supplied with blood by the renal artery so you can only transplant this bit as the rest will be ischaemic

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7
Q

Where are HLA class 1 antigens found?

A

On all nucleated cells

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8
Q

Where are HLA class 2 antigens found?

A

On APC< B lymphocytes and activated T cells

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9
Q

Which HLA types are the most important to match?

A

HLA types A, B and DR

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10
Q

What is a 0,0,0 mismatch?

A

When HLA types A, B and DR are all the same

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11
Q

What is a 2,2,2 mismatch?

A

Then none of the A, B or DR antigens are the same

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12
Q

What is hyper acute rejection?

A

When the recipient had antibodies to the donor kidneys so within minutes we get organ rejection

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13
Q

What is acute organ rejection?

A

occurs days or weeks after transplantation and can be caused by specific lymphocytes in the recipient that recognize human leukocyte antigens in the tissue or organ grafted

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14
Q

What are the 3 signals for T cell activation?

A

APC presents MCH to CD3 on T cells
CD28 on T cells provide signal 2
Expressed IL-2 which binds CD25 is signal 3
This upregulates the immune response

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15
Q

What drugs can we give to prevent organ rejection?

A

Calcineurin inhibitors
Rapamycin target inhibitors
Purine synthesis inhibitors
Pyrimidine synthesis inhibitors
Monoclonal antibodies
Steroids

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16
Q

What are examples of calcineurin inhibitors?

A

Tacrolimus
Cyclosporin

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17
Q

What are examples of rapamycin target blockers?

A

Sirolimus

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18
Q

What are examples of purine synthesis inhibitors?

A

Azathioprine
Mycophenolate mofetil

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19
Q

What are examples of monoclonal antibodies used to prevent organ rejection?

A

Anti-CD3
Anti-CD52
Anti-CD25

20
Q

What are some early post-transplant complications?

A

Bleeding, wound infection, delayed wound healing
Vascular thrombosis
Urine leak
New onset diabetes
Electrolyte disturbance and fluid overload
Acute calcineurin inhibitor toxicity
Focal segmental glomerulosclerosis

21
Q

What are some later post-transplant complications?

A

Chronic calcineurin inhibitor toxicity
IgA nephropathy
Systemic autoimmune disease
Malignancy
Epstein-Barr virus associated lymphoma
CVD
Post transplant osteoporosis due to steroid use
Post-transplantation lymphoproliferative disorders

22
Q

Who is peritoneal dialysis recommended for?

A

Children under 2
People who still have some limited kidney function
Adults who do not have other serious health conditions

23
Q

Who is haemodialysis recommended for?

A

People unable to carry out peritoneal dialysis themselves e.g. visually impaired, have dementia or are in a poor state of health

24
Q

What are th advantages of haemodialysis?

A

You have 4 dialysis free days a week
Flexibility to choose a convenient time to dialyse including overnight
You can do dialysis in your own home and so don’t need to travel to a dialysis centre
Greater sense of control from being independant and doing treatment yourself

25
Q

What are the disadvantages of haemodialysis?

A

If sessions are in a dialysis clinic you need to travel there regularly
Diet and fluid intake must be restricted
Can cause fatigue, low bp, sepsis, muscle cramps, itchy skin
Both you and your dialysis partner must attend training
Less privacy as other people are doing dialysis at the same time
Family and friends can’t be with you during treatment in centre

26
Q

What are the advantages to peritoneal dialysis?

A

Can be done at home
Fewer restrictions on diet and fluid intake compared with haemodialysis
PD is more portable and doesn’t use needles

27
Q

What are the disadvantages to peritoneal dialysis?

A

It may not be appropriate for those who are morbidly obese or had prior abdominal surgeries.
increased risk of peritonitis
Visually - catheter left in your belly permanently
Needs to be carried out every day which can be disruptive
In rare cases the peritoneum may gradually become thickened and scarred and people may need to switch to haemodialysis after a few years to stop this happening
Dialysis fluid used can cause a reduction in protein levels which can lead to a lack of energy and malnutrition
Increased risk of developing hernias due to a strain on the muscles
It may cause weight gain as the dialysate fluid contains sugar molecules

28
Q

Outline renal transplantation vs haemodialysis cost effectiveness?

A

The cost of patient therapy by haemodialysis at end-stage renal disease is far greater than performing transplantation and maintenance by almost 3.5 times. Quality of life is also said to be 20% greater in transplant patients

29
Q

What are the advantages to dialysis over transplants?

A

No shortage so is available to all kidney patients
No need for immunosuppressant drugs

30
Q

What are the advantages to kidney transplants over dialysis?

A

Patients can lead a more normal life without having to limit their diet and fluid intake
Cheaper for the NHS overall
Less impact on life as no regular dialysis sessions

31
Q

How long do kidneys from a kidney transplant last?

A

Living donor - 20-25 years
Deceased donor - 15-20 years

32
Q

What is the human tissue authority?

A

a regulator set up in 2005 following events in the 1990s that revealed a culture in hospitals of removing and retaining human organs and tissue without consent. They now regulate organisations that remove, store and use human tissue for research, medical treatment, post-morgen examination, education and training, and display in public. They also give approval for organ and bone marrow donations from living people.

33
Q

What are the 5 offences under the HTA 2004 act?

A

1- Removing, storing or using human tissue for Scheduled Purposes without appropriate consent.
2 - Storing or using human tissue donated for a Scheduled Purpose for another purpose.
3 - Trafficking in human tissue for transplantation purposes.
4 - Carrying out licensable activities without holding a licence from the HTA
5 - Having human tissue with the intention of its DNA being analysed without the consent of the person from whom the tissue came or of those close to them if they have died.

34
Q

What are some ethical considerations for organ transplantation?

A

The donor bears almost all risk and the recipient is the primary beneficiary
Donor may gain psychosocial benefits
Donor may have life long health problems, may have difficulties getting insurance etc
Issues with informed consent e.g. pressure, coercion
Selling organs or having financial incentives

35
Q

What are some excluded groups of the opt out system?

A

Those under the age of 18
Those without capacity to understand the new arrangements and take necessary action
Visitors to England
Those living in England involuntarily
Those who only lived in England for less than a year before their death

36
Q

What are the 3 tests that need to be carried out on donor and recipient blood prior to transplantation?

A

Blood typing
Tissue typing
Cross matching

37
Q

What is blood typing?

A

Measuring blood antibodies that react with different blood groups

38
Q

Explain which blood donors can donate to which recipients?

A

Donors with blood type A can donate to recipients with blood types A and AB.
Donors with blood type B can donate to recipients with blood types B and AB.
Donors with blood type AB can donate to recipients with blood types AB only.
Donors with blood type O can donate to recipients with all blood types

39
Q

Why is tissue typing important?

A

The better the HLA match, the more successful the transplant will be
Complete compatibility at A, B and DR loci offers the best long-term. Outcomes

40
Q

What is a serum cross match?

A

A blood test that you and the donor will have multiple times, including right before your transplant surgery
Cells from the donor are mixed with your serum. If your serum has antibodies against the donor’s cells, the antibodies will bind the donor cells and be detected using a fluorescent detection method. If these antibodies are at high levels, the donor cells will be destroyed = positive cross match and transplant cannot take place as would result in an immediate rejection of the kidney.

41
Q

What does the opt-out law say about organ donation?

A

Everyone in England over the age of 18 will be considered to be in favour of donating their organs and tissues after death unless:
- they have said they don’t want to donate their organs
- they have appointed a representative to decide for them after their death
- they are in one of the excluded groups – under the age of 18, ordinarily resident in England for less than 12 months before their death, or lack mental capacity for a significant period before their death

42
Q

Will organ donation be done before speaking to the family?

A

No. The family of the deceased will always be consulted first and will be able to provide information on their loved ones wishes
If they have information that their loved one would not have wanted to donate their organs then organ donation will not go ahead

43
Q

Why was the organ donation law changed to opt-out?

A

The government has decided to change the law because there is a shortage of available organs in England. Three people die waiting for an organ each day.
Although 80% of people say they would be happy to donate their organs after their death, only 37% are registered as donors. To increase the number of donors, the government changed the law in line with what the majority of people want to do.

44
Q

What is a hard opt out system?

A

Doctors can remove organs from every adult who dies unless they have registered to opt out

45
Q

What is a soft opt out system?

A

Doctors can remove organs from every adult who dies unless they registered to opt out or the persons relatives tell doctors not to take organs

METABOLIC (43 decks)

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