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Clinical 2.0 > Renal Transplant > Flashcards

Renal Transplant Flashcards

1
Q

benefits of transplant

A

longer survival
health care cost savings
improved quality of life
not life saving - renal replacement therapy

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2
Q

3 things considered for kidney allocation

A

medical need
utility
justice

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3
Q

types of living kidney donors

A

direct donation
kidney paired exchange
altruistic

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4
Q

types of decreased kidney donors

A

neurological determination death
donation after cardiac death
medical assistance in dying

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5
Q

who are highly sensitized kidney transplant recipients

A

PRA >95%

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6
Q

what are human leukocyte antigens

A

markers on most cells that identify self from foreign

match between A, B, DR, DQ types

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7
Q

degree of HLA difference = ______________

A

degree of immunologic risk

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8
Q

what are some sensitizing events that can lead to antiHLA antibody

A

pregnancy
blood transfusions
previous transplant

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9
Q

what is panel reactive antibody screening

A

degree of transplatability

ex 95% incompatible for transplant with 95 out of 100 potential donors

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10
Q

what is cross matching, whats a positive result

A

a test between donor and recipient

positive is bad means the recipients cells can recognize and attack donor cells, increased risk of rejection

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11
Q

what is a common cause of someone developing antibodies to the donor after the transplant

A

often result of non compliance

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12
Q

what is used in induction therapy

A

intense immunosuppressive therapy at time of transplant to reduce risk of acute rejection

  1. deplete antibodies with thymoglobulin
  2. non depleteing antibodies : basiliximab
  3. corticosteroids: prednisone
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13
Q

ex calcineurin inhibitors

A

cyclosporine

tacrolimus

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14
Q

ex corticosteroids

A

prednisone

methylprednisilone

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15
Q

ex antiproliferatives

A

azathioprine

mycopehnolate

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16
Q

ex rapamycins

A

sirolimus

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17
Q

what is the standard therapy for adult kidney transplant

A

tacrolimus: inhibits early in tcell activation
mycopehnolate mofetil: decrease t cell proliferation
prednisone: inhibits lymphocytes

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18
Q

calcineurin inhibitor AE

A 
increase BG - TAC
increase BP, K, uric acid 
increase lipids (CSA)
decrease Mg, P 
tremor 
nephro and hepato toxicity 
gingival hyperplasia 
hair growth CSA
hair loss TAC
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19
Q

calcineurin inhibitor are substrates and inhibitors for

A

cyp3A4 and pgp

CSA > inhibitor

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20
Q

what can cause loss of pgp

A

diarrhea can cause sloughing of intestinal endothelium

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21
Q

inhibitors of cyp 3A4 that increase CSA and TAC

A 
azoles
macrolides
non DHP CCB
grapefruit juice
protease inhibitors
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22
Q

inducers of cyp 3A4 that increase CSA and TAC

A 
rifampin 
phenytoin 
carbamazepine 
phenobarbital 
stjohns wort
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23
Q

minoxidil + csa

A

hirsutism

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24
Q

phenytoin, nifedipine + CSA

A

gum hyperplasia

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25
Q

statins, dig , capsofungin _ CSA

A

decreased clearance

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26
Q

colchicine + CSA

A

increased myopathy and hepatotoxicity

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27
Q

glyburide + CSA

A

increase CSA level

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28
Q

repaglinide + CSA

A

increased repaglinide exposure

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29
Q

warfarin + CSA

A

decrease INR and CSA levels

30
Q

potassium sparing diuretics + CSA

A

hyperkalemia

31
Q

which statins might be ok to use with CSA

A

pravastatin and fluvastatin

32
Q

tecrolimus DI

A

potassium sparing diuretics cause hyperkalemia
metoclopramide increase tacrolimus - not a worry
statins - atorv low dose ok

33
Q

NOACs and CI

A

dabigatran not recommended
rivaroxiban unknown
apixaban likely safe

34
Q

which drugs have additive nephrotoxicity with CI

A 
nsaids 
ACei 
aminoglycosides
amphotericin B 
renal sparin = CCB
35
Q

sirolimusAE

A

increased lipids, proteinuria, delayed wound healing, anemia, hypertension
caution in liver and lung transplant - hepatic artery stenosis, bronchial anastomotic dehiscence

36
Q

spacing of cyclosporin and sirolimus

A

give CSA 4 hours before or will get increase concentrations of sirolimus

37
Q

sirolimus DI

A

cyp 3A4 substrate

same as CI

38
Q

azathioprine AE

A

bone marrow suppression
hepatotoxicity
use TPMT phenotype to guide dosin (enzymes that metabolizes azathioprine)

39
Q

mycopehnolate AE

A

leukopenia

GI intolerance

40
Q

azathioprine DI

A

allopurinol - increase AZA
ACEi - increased neutropenia
warfarin - decreased INR

41
Q

mycophenolate DI

A

antibiotics - may change enterohepatic recirculation
cholestyramine - prevents reabsorption via enterohepatic recirculation
PPIs - decreases myco levels
antacids - separate by 2 hours
iron preps

42
Q

prednisone AE

A 
increase lipids, BG, BP
sleep disturbance 
increased appetite and weight
mood swings, osteoporosis 
acne fluid retention
43
Q

general drugs to avoid

A

immmune stimulants duh
decongestants - increase BP
PPIs - use lowest dose
NSAIDs, aminoglycosides, amphotericin B

44
Q

blood concentration must correlate with

A

exposure

clinical outcomes - therapeutic and toxic

45
Q

trough level within 30 min pre dose target CSA

A

50-150mcg/L

depends on time since transplant and individual patient

46
Q

trough level target in tacrolimus

A

correlated well with AUC

6-8mcg/L

47
Q

sirolimus trough level target

A

correlates well with drug exposure

6-10mcg/L depends on time since transplant and patient

48
Q

mycophenolate trough level targets

A

wide individual variability
no time point accurately reflects exposure
dont measure levels

49
Q

what else do you want to know if get dyslipidemia on therapy

A 
BMI 
diet and exercise 
smoking 
CVD history 
renal function
50
Q

effects of statins and immunisuppressants

A

lipids and CV disease is common
myopathy with CSA
increased statin exposure
atorva, prava, fluva, simv safe at lose dose esp tacrolimus

51
Q

what do you recommend for dyslipidemia after transpalnt

A

diet exercise
smoking cessation
start low dose statin and monitor for side effects

52
Q

fibrates?

A

no outcome data

53
Q

ezetimibe?

A

no data in renal transplant

54
Q

resin?

A

drug binding, absorption interference

55
Q

niacin?

A

glucose issues

increased uric acid

56
Q

fish oil?

A

no benefit but not harmful

57
Q

how long do we prophylactically treat pcp

A

3 months

co-trimoxazole

58
Q

treatment for pcp

A

septrafor 3 weeks

59
Q

when and what prophylaxis do you give for cmv

A

give valganciclovir for 6 months in people with mismatched CMV status to their donor or with use of induction agents
(donor +, and recipient - biggest risk)

60
Q

pre emptive treatment for cmv

A

routine screening using PCR

treatment until 2 negative PCR

61
Q

treatment of cmv in invasive tissue disease

A

severe leukopenia can occur

ganciclovir IV, valganciclovir po

62
Q

why is routine screen screening for BK viraemia and graft dysfunction important

A

BK virus common in general pop may be reactivated in immunosuppressed state leading to nephropathy and graft failure

63
Q

treatment of BK virus

A

no good treatment
reduce baseline immunosuppression
switch to cyclosporin

64
Q

EBV is associated with devellpment of post transplant lymphoproliferative disorder when should routine screening occur

A

if EBV mismatch at time of transplant

65
Q

treatment for EBV

A

lower immunosuppressive therapy

66
Q

most common infection post transplant

A

UTI

67
Q

complications of pyelonephritis

A

sepsis

graft dysfunction and failure

68
Q

UTI prophylaxis

A

in first 3 months TMPSMX

69
Q

vaccines in renal transplant

A

avoid live

can get flu shot after 3 months and vaccines after 6

70
Q

the “ABCDEs” we should know

A 
anemia - lots of blood work, takes time for kidney to start epo production 
analgesia
bone density - decrease due to steroids and renal bone disease 
blood pressure - increase 
cholesterol - increase
cancer risk 
BG - increased
depression - steroid use
eyes- cataracts from steroids
exercise
71
Q

mycophenolate and fertility

A

teratogenic in females
unknown for sure effects in males
switch to azathioprine if planning for pregnancy, wait at least 1 year post transplant

72
Q

goals of transplant

A

prolong graft survival
prevent rejection episodes
min long term complication s

Clinical 2.0 (24 decks)

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