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Urinary system > Renal replacement therapy - transplantation > Flashcards

Renal replacement therapy - transplantation Flashcards

1
Q

Describe renal transplantation

A
  • Transplanted kidney is placed into the iliac fossa and anastomosed to the iliac vessels
  • Native kidneys usually remain in situ
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2
Q

When is native nephrectomy indicated?

A

Indications for native nephrectomy include size (polycystic kidneys) and infection (chronic pyelonephritis)

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3
Q

How are donor kidneys preserved?

A

o Cold storage solutions
o Minimize oedema
o Preserve integrity of tissues
o Buffer free radicals

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4
Q

List some complications associated with transplant surgery

A

Vascular complications
o Bleeding
• Usually anastomotic sites
• Perirenal haematoma can be arterial or venous
o Arterial thrombosis
o Venous thrombosis
o Lymphocele - collection of lymphatic fluid within the body not bordered by epithelial lining

Urine leak from ureters

Infections

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5
Q

What immunosuppressive agents are used in transplant patients?

A

Corticosteroids

Calcineurin inhibitors - Tacrolimus, Cyclosporine

Anti-proliferatives - Mycophenolate mofetil, Azathioprine

mTOR inhibitors - Sirolimus

Costimulatory signal blockers - Belatacept

Depleting agents - Basiliximab (anti-CD25), Anti-thymocyte globulin (ATG), Rituximab (anti-CD20)

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6
Q

What calcineurin inhibitors are used for transplant patients?

A

Tacrolimus, Cyclosporine

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7
Q

What anti-proliferative are used for transplant patients?

A

Mycophenolate mofetil, Azathioprine

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8
Q

What mTOR inhibitor is used for transplant patients?

A

Sirolimus

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9
Q

What costimulatory signal blockers is used for transplant patients?

A

Belatacept

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10
Q

What depleting agents are used for transplant patients?

A

Basiliximab (anti-CD25)
Anti-thymocyte globulin (ATG)
Rituximab (anti-CD20)

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11
Q

List some side effects of corticosteroids

A 
Hypertension
Hyperglycaemia
Infections
Bone loss
GI bleeds
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12
Q

List some side effects of tacrolimus

A

Hyperglycaemia
AKI
Tremor

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13
Q

List some side effects of cyclosporin

A

Hirsutism
Hypertension
AKI
Gout

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14
Q

List some side effects of Mycophenolate mofetil

A

Cytopenia

GI upset

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15
Q

List some side effects of sirolimus

A

Lipidogenic
Diabetogenic
Pneumonia

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16
Q

List some side effects of Belatacept

A

Infections

Malignancy

17
Q

List some side effects of Anti-thymocyte globulin (ATG)

A

Infections

Post-transplant lymphoproliferative disorder (PTLD)

18
Q

Describe the normal protocol for immunosuppression

A
  • Induction: Basiliximab
  • Maintenance: Tacrolimus + Mycophenolate + steroids
  • Steroid free is possible
  • Others: CNI-free using Belatacept
19
Q

What types of organ donors are there?

A 
Deceased Donors
o	Donation after brain death/ DBD
-	Standard / extended criteria
o	Donation after cardiac death/DCD
-	Standard / extended criteria 
Living Donors
o	Living Related Donor
o	Living Unrelated Donors
-	Spousal
-	Altruistic
-	Paired/pooled
20
Q

What is the brain death standard criteria for organ donation?

A

Coma, unresponsive to stimuli

Apnoea off ventilator (with oxygenation) despite build up of CO2

Absence of cephalic reflexes
•	Pupillary
•	Oculocephalic
•	Oculovestibular (caloric)
•	Corneal
•	Gag
•	Purely spinal reflexes may be present

Body temperature above 34 C

Absence of drug intoxication

21
Q

What is the extended criteria for donation?

A

o Donor aged > 60y
o Donor aged 50-59 + history of hypertension, death from cerbrovascular accident or terminal creatinine of >132µmol/L

Donors with medical complexities

22
Q

Describe paired donation

A

Kidney Paired Donation (KPD) or Paired Exchange, is an approach to living donor kidney transplantation where patients with incompatible donors swap kidneys to receive a compatible kidney. KPD is used in situations where a potential donor is incompatible

23
Q

Is it safe to donate a kidney?

A

95% confidence intervals for the probability of survival among kidney donors.

24
Q

What is the risk of kidney donation?

A
  • Similar patient survival to general population.
  • Lower rate of ESRD compared to general population reduced.
  • Compensatory increase in GFR of remaining kidney to 70% of pre-donation values
  • Compensatory increase greater in younger donors.
  • Older age and high BMI were associated with GFR of <60.
  • Relatively short follow up time (12 years).
25
Q

List some complications of renal transplantation

A

Rejection - Cell mediated or Humoral (Ab mediated)

Cardiovascular
o	Underlying renal disease
o	CRF
o	Hypertension
o	Hyperlipidaemia
o	Post-transplant Diabetes

Infective
o Bacterial
o Viral
o Fungal

Malignancy
o Skin
o Lymphoma
o Solid Cancers

26
Q

Describe T cell mediated rejection

A

Acute rejection

  • Lymphocytic infiltrate
  • Tubulitis
  • Endarteritis
  • Endothelialitis
27
Q

Describe antibody mediated rejection

A

Chronic rejection

Microvascular inflammation
o Neutrophil infiltration
o Glomeruli
o Peritubular capillaries

Donor specific antibodies

Positive C4d
o Peritubular capillaries

Biopsy shows the capillary loops of the glomerulus contain neutrophils and red cells, the lumina are obscured by swollen endothelial cells, and the peritubular capillaries contain scattered neutrophils

On an immunofluorescence micrograph of a cryostat section stained with monoclonal antibody to C4d, the peritubular capillaries are brightly outlined (green), a finding typical of acute humoral rejection

28
Q

What is the most important transplant related infection?

A

Cytomegalovirus

  • Affects around 8% of transplant recipients, despite prophylaxis therapy.
  • High mortality and morbidity if untreated.
29
Q

How does CMV affect transplant patients?

A

Recipient affected via
o Transmission from donor tissue
o Reactivation of latent virus

30
Q

What does CMV cause in transplant patients?

A

CMV viremia

Tissue invasive disease:
o	Pneumonitis
o	Hepatitis
o	Retinitis
o	Gastroenteritis
o	Colitis
o	Nephritis
31
Q

What normally asymptomatic family of viruses can cause widespread disease in the immunocompromised?

A

Polyomaviridae

Family includes:
•	BK virus
•	JC virus
•	Murine polyoma virus
•	SV40
32
Q

What are some risk factors for BCAN?

A

Intensity of immunosuppression
o Tacrolimus, mycophenolate mofetil, antilymphocyte globulins

Patient determinants
o Older age, male gender, white ethnicity, DM, negative BKV serostatus (paediatric recipients)

Organ determinants
o Graft injury, HLA mismatches, ureteral stents

Viral determinants
o Changes in epitopes of viral capsid protein VP-1

33
Q

Describe the outcome and management of BCAN

A

Outcome
o Allograft dysfunction
o Loss of graft in 45-80%

Treatment	
o	Reduce immunosuppression
o	Antiviral therapy
o	Cidofovir +/- IVIG
o	Leflunomide
34
Q

What malignancies are common following renal transplantation?

A 
Colon
Lung
Breast
Testicular
Bladder
Melanoma
Leukaemia
Cervical
Renal

Urinary system (22 decks)

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