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MRCP Renal > Renal Transplant > Flashcards

Renal Transplant Flashcards

1
Q

Most common technical (surgical) complication of renal transplants

A

related to the ureteric anastomosis.

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2
Q

Graft survival is directly related to what “time”?

A

“warm ischaemic time”

=> Long warm ischaemic times increase the risk of acute tubular necrosis

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3
Q

Name the 3 types of organ rejection which can occur following renal transplant

A

Hyperacute
- immediate
- pre-formed antibody (e.g. ABO incompatibility)

Acute
- in first 6 months
- T cell mediated
- causes tissue infiltrates and vascular lesions

Chronic
- after the first 6 months
- Vascular changes predominate

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4
Q

Risk factors for hyperacute rejection of renal transplant

A
  • major HLA mismatch
  • ABO incompatibility.
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5
Q

Describe the appearnce of a hyperacute rejection after completion of the vascular anastomosis and removal of clamps.

A
  • kidney becomes mottled/dusky
  • vessels will thrombose
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6
Q

Treatment of hyperacute rejection

A
  • removal of the graft
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7
Q

If you leave the renal transplant in situ following a hyperacute rejection, what will occur?

A

abscess formation

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8
Q

What increases the risk of a chronic organ rejection

A
  • Previous acute rejections
  • other immunosensitising events
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9
Q

What is the most common cause of a chronic graft rejection? How does this occur?

A

Vascular changes

=> myointimal proliferation leading to organ ischaemia

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10
Q

What technical complication is described below?

Sudden complete loss of urine output

A

renal artery thrombosis

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11
Q

What technical complication is described below?

Uncontrolled hypertension, allograft dysfunction and oedema

A

Renal artery stenosis

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12
Q

What technical complication is described below?

Pain and swelling over the graft site, haematuria and oliguria

A

renal vein thrombosis

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13
Q

What technical complication is described below?

Diminished urine output, rising creatinine, fever and abdominal pain

A

urine leaks

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14
Q

What technical complication is described below?

Common complication (occurs in 15%), may present as a mass, if large may compress ureter

A

lymphocele

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15
Q

Management of transplant associated renal artery thrombosis

A

Immediate surgery may salvage the graft

delays >30 mins = high rate of graft loss

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16
Q

Management of transplant associated renal artery stenosis

A

Angioplasty

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17
Q

Management of transplant associated renal vein thrombosis

A

Management options poor, graft often lost

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18
Q

Findings on investigation of suspected urine leak following renal transplant

A

US-perigraft collection
necrosis of ureter tip

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19
Q

Management of urine leak in renal transplant

A

anastomosis revision

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20
Q

Management of a lymphocele following renal transplant

A

percutaneous drainage and sclerotherapy

OR intraperitoneal drainage

21
Q

What is HLA?

A

human leucocyte antigen (HLA) system is the name given to the major histocompatibility complex (MHC) in humans.

22
Q

Which chromosome codes for HLA?

A

Chromosome 6.

23
Q

give examples of class 1 and class 2 HLA antigens

A

class 1 antigens: A, B and C. Class 2 antigens: DP,DQ and DR

24
Q

Importance of Class 1 vs class 2 HLA antigens in renal tranplsant

A

DR>B>A

25
Q

Rate of graft survival in renal transplants

A

Cadaveric transplants:
1 year = 90%, 10 years = 60%

Living-donor transplants:
1 year = 95%, 10 years = 70%

26
Q

Post-op problems following renal transplant

A

ATN of graft
vascular thrombosis
urine leakage
UTI

27
Q

What type of graft rejection occurs in mins-hours?

A

Hyperacute

28
Q

Cause of hyperacute graft rejection

A
  • pre-existing antibodies against ABO or HLA antigens
    (Type II hypersensitivity)

=> widespread thrombosis of graft vessels → ischaemia and necrosis of the transplanted organ

29
Q

how is a hyperacute graft rejection managed?

A

no treatment is possible and the graft must be removed

30
Q

For how long after transplant is still considered an acute graft rejection?

A

6 months

31
Q

What causes an acute graft rejection?

A
  • mismatched HLA
  • Cell-mediated (cytotoxic T cells)
  • other causes e.g. CMV
32
Q

how can an acute graft rejection be identified?

A
  • picked up by a rising creatinine, pyuria and proteinuria
33
Q

how is acute graft rejection treated?

A

may be reversible with steroids and immunosuppressants

34
Q

What is considered chronic graft rejection?

A

> 6 months post transplant

35
Q

Cause of chronic graft rejection

A
  • antibody and cell-mediated
    fibrosis
  • OR recurrence of original renal disease e.g. MCGN > IgA > FSGS
36
Q

What original renal disease is most likely to represent as chronic graft rejection?

A

MCGN > IgA > FSGS

37
Q

give an example of a usual intial and maintenance immunosuppression regime following transplant

A

Initial:
- Ciclosporin/tacrolimus + MAB

Maintenance:
- ciclosporin/tacrolimus with Mycophenolate Mofetil or sirolimus

38
Q

Calcineurin inhibitor,

(Calcineurin is a phosphotase involved in T cell activation)

A

Ciclosporin

39
Q

Tacrolimus has a lower incidence of acute rejection compared to ciclosporin
TRUE/FALSE

A

TRUE

40
Q

Tacrolimus causes less hypertension and hyperlipidaemia than ciclosporin. TRUE/FALSE?

A

TRUE

41
Q

Tacrolimus has a higher incidence of what side effects compared to ciclosporin?

A

impaired glucose tolerance and diabetes

42
Q

Which immunosuppressant blocks purine synthesis by inhibition of IMPDH?
=> inhibits proliferation of B and T cells

A

Mycophenolate mofetil

43
Q

Common side effects of mycophenolate mofetil?

A

GI and marrow suppression

44
Q

Which immunosuppressant blocks T cell proliferation by blocking the IL-2 receptor?

A

Sirolimus (rapamycin)

45
Q

Side effect of sirolimus

A

hyperlipidaemia

46
Q

Which monoclonal antibodies (IL2 inhibitors) are used in renal transplant immunosuppression?

A

daclizumab
basilximab

47
Q

What should be monitored when patients are on long term immunosuppression following a renal transplant?

A

Cardiovascular disease - (due to s/e of hyperlipidaemia and hyperglycaemia)

Renal failure - look for graft faillure

Malignancy - risk of squamous cell carcinomas and basal cell carcinomas when on immunosuppression

48
Q
A

MRCP Renal (56 decks)

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