Renal Replacement Therapy Transplantation Flashcards
Where is the transplanted kidney placed?
Placed into the iliac fossa and anastomosed to the iliac vessels
What are the indications for native nephrectomy?
Indications for native nephrectomy include size (polycystic kidneys) and infection (chronic pyelonephritis)
What are the transplant surgical complications of renal transplantation?
Vascular - bleeding (usually anastomotic sites, perirenal haematoma can be arterial or venous)
Arterial thrombosis
Venous thrombosis
Lymphocele - collection of lymphatic fluid in the body not bordered by epithelial lining
Ureteric - urine leak
Infections
What are the immunosuppressive agents?
Corticosteroids
Calcineurin inhibitors
¤Tacrolimus, Cyclosporine
Anti-proliefratives
¤Mycophenolate mofetil, Azathioprine
mTOR inhibitors
¤Sirolimus
Costimulatory signal blockers
¤Belatacept
Depleting agents
¤Basiliximab ( anti-CD25), Anti-thymocyte globulin (ATG), Rituximab (anti-CD20)
What are the side effects of corticosteroids, tacrolimus, cyclosporin, mycophenolate mofetil, sirolimus, belatacept?
Immunosuppresion protocols
Induction: Basiliximab
Maintenance: Tacrolimus + Mycophenolate + steroids
Steroid free is possible
Others: CNI-free using Belatacept
What are the types of donors?
Deceased donors (after brain death or cardiac death)
Living donors
(living related donor, unrelated - spousal, alturistim, paired / pooled)
Pooled donation
What is the compensatory increase in GFR of remaining kidney after donation?
Compensatory increase in GFR of remaining kidney to 70% of pre-donation values
Compensatory increase is greater in younger donors
What are the complications after renal transplantation?
Rejection
¤Cell mediated
¤Humoral (Ab mediated)
Cardiovascular
¤Underlying renal disease
¤CRF (chronic renal failure)
¤Hypertension
¤Hyperlipidaemia
¤PT Diabetes (new onset)
Infective
¤Bacterial
¤Viral
¤Fungal
Malignancy
¤Skin
¤Lymphoma
¤Solid Cancers
What are the mechanisms of acute rejection?
T cell mediated rejection (TCMR)
Acute antibody mediated rejection (ABMR)
What is the most important transplant related infection?
Cytomegalovirus - affects 8% of transplant recipients
HIgh mortality and morbidity
How is cytomegalovirus infection stimulated?
Transmission from donor tissue
Reactivation of latent virus
What are examples of cytomegalovirus viraemias - tissue invasive disease?
Pneumonitis
Hepatitis
Retinitis
Gastroenteritis
Colitis
Nephritis
Define polyomaviridae
Family of viruses
Name two polyomaviridae
BK - associated with patients who have had a kidney transplant - remains latent until immunocompromised - clinical manifestations include renal dysfunction, abnormal urinalysis. BK nephropathy.
JC virus - when immunocompromised such as in the case of AIDs or immunosuppression - causes progressive multifocal leukoencephalopathy (PML)
Others include SV40 virus and murine polyoma virus
What are the clinical manifestations of BK virus?
Renal transplantation: Ureteral stenosis, interstitial nephritis, ESRF
Bone Marrow transplantation: Haemorrhagic cystitis, pneumonitis, hepatitis
ADIS: Nephritis, ESRF, Retinitis, meningioencephalitis, pneumonitis
What are the risk factors for BKVAN (BK virus associated nephropathy)
Intensity of immunosuppression
- tacrolimus, mycophenolate mofetil, antilymphocyte globulins
Patient determinants
- older age, male gender, white ethnicity, DM, negative BKV serostatus (paediatric recipients)
Organ determinants
- graft injury, HLA mismatches, ureteral stents
Viral determinants
- changes in epitopes of viral capsid protein VP-1
What is the outcome of BKVAN
Allograft dysfunction
Loss of graft in 45-80
Wha is the treatment for BKAN?
Reduce immunosuppression
Antiviral therapy:
- Cidofovir +/- IVIG
- Leflunomide
What are the common malignancies after renal transplantation?
