Renal transplant Flashcards
Best renal replacement therapy?
- Kidney transplant - best for patient survival and quality of life
What does kidney transplant require to see if suitable?
- Careful evaluation to establish if candidate
- It is important to document immunisation episodes eg blood transfusion, pregnancies and prior transplants as these people are harder to find a match for
Contraindications to transplant of kidney
- Active infection or malignancy
- Severe heart disease not suitable for correction
- Severe lung disease
- Reversible renal disease
- Uncontrolled substance abuse or psychiatric illness
- On going treatment non adherance
- Short life expectancy
Types of transplant origin
- Living related donor
- Living non related donor
- Deceased donor
Living related donor transplant
- Best possible transplant
- Transplantation can happen within months
- Elective procedure with selected donor
4 forms of living unrelated donor transplant
- Live-donor paired exchange
- Live-donor/deceased- donor exchange
- Live-donor chain
- Altruistic donation
How long does living unrelated donor transplant take?
Months
Deceased donor transplant - how common?
- 60% of transplants
How does deceased donor transplant happen
Patient receives kidney (or two from same receipient) with little time for prep
Time for deceased donor transplant
Years
Deceased donor vs live donor survival of kidney
Survival of kidney allograft and patients are significantly low compared to live donor transplant
What is the induction treatment for transplant?
- Potent immunosupressive drugs are used to create tolerance for graft
- Hyperacute rejection is now rarely seen due to this
Examples of immunosupressive drugs used in induction treatment
Methylprednisolone with any of the following:
* Basiliximab and thymoglobulin
* Alentuzumab and rituximab (less common)
Maintenance treatment post transplant - when is this used
Immediately after transplant and for long term to prevent acute or chronic rejection
Drugs commonly used for maintenance treatment
- Steroids - prednisolone
- Calcineurin inhibitors - tacrolimus, cyclosporine, voclosporin
- Antimetabolite - mycophenolate, azathioprine
- Rapamycin inhibitors - sirolimus, everolimus
- T cell regulation - Belatacept, Belimumab
Long term care for transplant patient
- First few months follow up happens multiple times a month, after 6 months –> less often
- Screen for infections
- Vaccinate (except live/live attenuated viral vaccines)
- Monitor and control CV disease, bone and mineral metabolism disease
- Screen for malignancies - 3x more likely to have any cancer
- Annual skin checks for skin cancer
- Contraception - obligatory in first year, counsel about pregnancy 1 yer after
Monitoring tests for transplant patient
- eGFR
- Calcineurin inhibitors levels
- Proteinuria
- Ca+
- Phosphate
- PTH
- Lipids
- Glucose
What is mortality from transplant related to?
- Cardiovascular disease
- Infections
- Malignancies
Complications of transplant - what is usually the cause of acute ones within first month?
Related to surgery or infection
Timeframe for transplant infections
- Less than 4 weeks - hospital infections or related to donor
- 1-12 months - activation of latent infections, relapsed, residual or opportunistic infections
- More than 12 months - community acquired
Important germs to consider in infection of transplant patient
- CMV
- Hepatitis B
- Herpes simplex virus
- Varicella zoster
- EBV
- BK virus
- Aspergillus
- Pneumocystis jirovecii
- Listeria
- Mycobacterium tuberculosis
- Toxoplasma gondii
What can some patients develop within the first year of transplant?
- New onset diabetes after transplant (NODAT)
- Important to remember personal risk factors and new factors such as medications (steroids and calcineurin inhibitors) and new gluconeogenic kidney
What do we do because of increased risk of cancer in transplant patients?
- Screen for skin, cervic, breast, prostate, renal, urothelial, liver, colorectal and lymphoporliferative disease
- Lymphoproliferative disease is common on patients with EBV
What is simultaneous kidney transplant?
- Patients with liver failure and cirrhosis and ESRF can have liver and kidney transplant at same time
- Selected T1DM patients can have pancreas and kidney
- Patients with kidney transplant who progress into ESRF can be retransplanted
