Renal Replacement Therapy 2 Flashcards
Where is the transplanted kidney usually located in the body?
Iliac fossa
What vessels is the transplanted kidney anastomosed to?
Iliac vessels
What happens to the native kidney when a kidney is transplanted?
Is usually left in situ
What are indicates for native nephrectomy?
Size (polycystic kidneys)
Infection (chronic pyelonephritis)
How is preservation of the donor kidney achieved?
- Cold storage solutions
- Minimise oedema
- Preserve integrity of tissues
- Buffer free radicals
What are some complications with kidney transplants?
- Vascular complications
- Bleeding
- Usually anastomotic sites
- Perirenal haematoma can be arterial or venous
- Arterial thrombosis
- Venous thrombosis
- Lymphocele
- Bleeding
- Ureteric
- Urine leak
- Infections
How is immunosuppression achieved after a kidney transplant?
- Corticosteroids
- Calcineurin inhibitors
- Tacrolimus, cyclosporine
- Anti-proliefratives
- Mycophenolate mofetil, azathioprine
- mTOR inhibitors
- Sirolimus
- Costimulatory signal blockers
- Belatacept
- Deleting agents
- Basiliximab ( anti-CD25), Anti-thymocyte globulin (ATG), Rituximab (anti-CD20)
What are side effects of corticosteroids?
What are side effects of tacrolimus?
What are side effects of cyclosporin?
What are side effects of mycophenolate mofetil?
What are side effects of sirolimus?
What are side effects of belatacept?
What are side effects of ATG?
Explain the typical immunosuppression protocol?
- Induction
- Basiliximab
- Maintenance
- Tacrolimus and mycophenolate and steroids
- Steroid free is possible
- Others
- CNI-free using belatacept
What are some different types of donors?
- Decreased donors
- Donation after brain death/DBD
- Standard/extended criteria
- Donation after cardiac death/DCD
- Standard/extended criteria
- Donation after brain death/DBD
- Living donors
- Living related donor
- Living unrelated donor
- Spousal
- Altruistic
- Paired/pooled
What does DBD stand for?
Donation after brain death
What does DCD stand for?
Donation are cardiac death
What is the criteria to be considered a donor after brain death?
- Coma, unresponsive to stimuli
- Apnoea off ventilator (with oxygenation) despite build-up of CO2
- Absence of cephalic reflexes
- Pupillary
- Oculocephalic
- Oculovestibular
- Corneal
- Gag
- Purely spinal reflexes may be present
- Body temperature above 34oC
- Absence of drug intoxication
What are the 2 kinds of donor criteria?
- Standard criteria (SCD)
- Extended criteria (ECD)
- Donor aged over 60
- Donor aged 50-59 with history of hypertension, death from cerebrovascular accident or terminal creatinine of over 123umol/L
What does SCD stand for?
Standard criteria donor
What does ECD stand for?
Extended criteria donor
When is somone considered to be an extended criteria donor?
- Donor aged 50-59 with history of hypertension, death from cerebrovascular accident or terminal creatinine of over 123umol/L
Is there a gap between supply and demand for kidney transplants?
There is way more demand than supply
Does whether the donor is living or deceased impact the survival time of the person recieving the transplant?
Yes, donations from living donors are better
Are most kidney donations from living or deceased donors?
Deceased donors
What is the average waiting time for a kidney donation for adults and children?
Adults - 845 to 883 days
Children - 205 to 327 days
Does the amount of people on dialysis or with a transplant change depending on age?
Yes, more older people are on dialysis and younger people get transplants
Who could living kidney donations come from?
- Liver related donor
- Liver unrelated donor (such as spousal)
- Liver unrelated donor (altruistic, non-directed)
- Paired/pooled
- ABO incompatible/HLA incompatible
What is paired pool and pooled donation?
The pair may be matched to another couple in a similar situation so that both people in need of a transplant receive a matched organ or part organ. Pooled donation is where more than two pairs of donors and recipients are involved in the swap.
Are the long term consequences for kidney donors severe?
No, they appear to be minor
Summarise the risk of kidney donation for the donor?
- Similar patient survival to general population
- Lower rate of ESRD compared to general population
- Compensatory increase in GFR remaining kidney to 70% of pre-donation values
- Older age and high BMI associated with GFR <60
What are some possible complications after renal transplantation?
- Rejection
- Cell mediated
- Humoral (ab mediated)
- Cardiovascular
- Underlying renal disease
- CRF
- Hypertension
- Hyperlipidaemia
- PT diabetes
- Infective
- Bacterial
- Viral
- Fungal
- Malignancy
- Skin
- Lymphoma
- Solid cancers
What are the 2 different kinds of acute renal rejection?
- T cell mediated rejection (TCMR)
- Tubulointersitial (Banff I)
- Arteritis/endothelilitis (Banff II)
- Arterial fibrinoid necrosis (Banff III)
- Acute antibody mediated rejection (ABMR)
- ATN-like (Banff I)
- Caillaries and or glomerular inflammation (Banff II)
- Arterial inflammation (Banff III)
What does TCMR stand for?
T cell mediated rejection
What does ABMR stand for?
Acute antibody mediated rejection
What is used to classify the biopsies from solid organ translants?
The Banff Classification of Allograft Pathology
What is the most important transplant related infection?
Cytomegalovirus
How are transplant patients infected with cytomegalovirus?
- Transmission from donor tissue
- Reactivation of latent virus
How is the likelihood of cytomegalovirus infection destroying the graft reduced?
Prophylaxis treatment
What are tissue invasive disease that can affect a patient after receiving a kidney transplant?
- Pneumonitis
- Hepatitis
- Retinitis
- Gastroenteritis
- Colitis
- Nephritis
Other than cytomegalovirus, what other virus often affects patients after a kidney transplant?
Polyomaviridae
What are the different kinds of polyomaviridae?
- BK virus
- JC virus
- Murine polyoma virus
- SV40
What is the clinical presentation of the BK polyomaviridae virus?
What does BKAN stand for?
BK virus nephropathy
What are risk factors for BK virus nephropathy (BKVN)?
- Intensity of immunosuppression
- Patient determinants
- Older age, male gender, whte ethnicity, DM
- Organ determinants
- Graft injury, HLA mismatches, ureteral stents
- Viral determinants
- Changes in epitopes of viral capsid protein VP-1
What are BKAN outcomes?
- Allograft dysfunction
- Loss of graft in 45-80%
What is the treatment of BKAN?
- Reduce immunosuppression
- Antiviral therapy
- Cidofovir with or without IVIG
- Leflunomide
What are the most common malignancies that occur after renal transplant?
