Renal Transplant Flashcards
1
Q
compare the renal function with dialysis and transplant
A
- dialysis will give a GFR of around 7
- transplant will give one of 50
2
Q
age restrictions for transplant?
A
there are none, however co-morbidities accumulate with age that discourage transplantation
3
Q
altruistic donation
A
- live donation
- directed (family/friend/spouse)/undirected
- paired pool donation
- financially procured
4
Q
what is the difference in out comes between DCD and BSD donors
A
there is none
5
Q
when does the benefit of a transplant begin
A
after around 3 months, before this there are greater risks
6
Q
outline the patient assessment process
A
- reasonable life expectance - around 5 years
- safe to undergo operation
- Immunology – tissue typing and antibody screening
- Virology to exclude active infection. Problems can be encountered e.g. if the kidney has been exposed to CMV and the patient hasn’t
- Assess cardiorespiratory risk:
- ECG, ECHO ± ETT, coronary angiography
- CXR ± PFT, CPEX (cardio-pulmonary exercise testing – measure VC, ECG and HR)
- Assess peripheral vessels
- Asses bladder function – important
- Assess mental state
- Assess any co-morbidities/PMH
- Independent assessment out-with transplant team
7
Q
must the patient recieve independent assessment outwith the transplant team
A
yes
8
Q
patient contraindications to transplant
A
- malignancy
- active infection
- Hep C
- HIV
- untreated TB
- severe CV disease
- hostile bladder
9
Q
what effect could IS have on malignancy
A
allow it to grow faster
10
Q
what is the criteria for malignancy contraindicating transplantation
A
- known untreated
- 2-5 years clear of treated cancer
- watch out for eg breast cancer, which has late recurrence
11
Q
is IS required when transplanting between monozygotic twins
A
epigenetics means they are slightly genetically different, so yes
12
Q
what determines ones blood group
A
sugar on red cell surface
13
Q
what sugars does blood group O have
A
- none, can donate to anyone
- can only take from O though
14
Q
outline which blood groups can donate to which
A
15
Q
which chromosome is HLA found on
A
chromosome 6
16
Q
HLA action
A
code for MHC molecules which recognise anything non-self and activate immune system to destroy it
17
Q
whicih 2 immunological things are importnat to match
A
blood group and HLA
18
Q
what is the benefit of HLA matching
A
- critical
- gives better graft survival even with IS - 10% improvement at 3 years
19
Q
what are the consequences of a bad HLA match
A
- person will be more sensitive to subsequent transplants if required
20
Q
what is a sensitising event
A
periods in a person’s life where they become exposed to foreign antigens which they become immunologically primed to and develop pre-formed antibodies to the non-self antigen e.g.
- blood cell transfusion
- pregnancy or miscarriage
- previous transplant
21
Q
what is the most common type of sensitising event
A
previous transplant
22
Q
can a pregnancy and miscarriage both be classed as a sensitising event
A
yes, exposure of maternal blood to foetaa blood via placenta
23
Q
in what circumstances does a sensitising event often cause problems in donations (maternal blood)
A
eg husband donating to wife if they have a child together
24
Q
describe the systemi of kidney allocation
A
25
where do paediatric recipients fit into kidney allocation
get first choice irrespective of match
26
what is required with a eg 100 mismatch
additional IS as there is a greater chance of mismatch
27
what is a good way to overcome Ab.blood group incompatibitlity between donor and recepient
paired donation - can be done with multiple matches
28
Desensitisation
* the active removal of blood group or donsor specific antibody
* can be done by plasma exchange or B cell antibody (eg rituximab) to kill Ab producing cells
* Ab levels are monitored until they are low enough to proceed and then the transplant can proceed
29
outline the transplant procedure
* Transplant is placed extraperitoneally - inserted into iliac fossa and attached to the external iliac artery and vein
30
renal transplant: wound size, operation length, hospital time, recovery time
* Wound 15-20 cm long
* Average 2-3 hour operation
* 7-10 days in hospital
* Seen regularly after, follow up for life
* 3 months to get back to full activities
31
what are some surgical complications of a transplant
* Bleed – terminal
* Arterial stenosis, thrombosis
* Venous stenosis/kinking
* Ureteric stricture, hydronephrosis
* Wound infection
* Lymphocele - collection of lymphatic fluid in the body not bordered by an epithelial lining
32
33
how is the immediate graft function monitored
urine ouput, urea and creatinine
34
delayed graft function
* the graft takes 10-30 days to work
* often need HD in the iterim
* would biopsy regularly to make sure nothing else is going on
35
primary non function
this is where the graft never works
36
hyperacute rejection
* occurs within minutes of transplantation
* this is due to preformed Ab against HLA type 1 antigens
* unsalvageable
37
how is a hyperacute rejection managed
* unsalvageable so a transplant nephrectomy is required (removal)
38
how common is hyperacute rejection
rarely seen these days due to HLA matching
39
acute rejection
* cellular mediated - cytotoxic T cell mediated with primary activation of T cells
40
time frame of acute rejection
under 6 months
41
what virus can cause acute rejection
CMV
42
mangement of acute rejection
immunosuppression eg steroids
43
how may acute rejection present
* May present with fever, tachycardia, pain and tenderness over kidney, which may be enlarged
* Hypertension, raised creatinine and urea etc.
44
why does acue rejection usually occur
mismatched HLA
45
chronic rejection
* chronic allograft nephropathy
* this is a slow progressive decline in renal function which is Ab mediated
46
how does chronic rejection usually manifest
gradual reduction in renal function associated with proteinuria and exacerbated hypertension
47
induction IS treatment
* Basiliximab/Dacluzimab
48
what type of IS is given during surgery
high dose IV steroids eg prednisolone
49
maintenance IS treatment
* Prednisolone, tacrolimus, MMF
* Prednisolone, ciclosporin, azathioprine
50
how do Basiliximab/Dacluzimab work
* induction treatment - preventative
* prevent T cells being activated by blocking IL-2 receptors on CD4+ T cells
51
what is the mainstay of IS treatment
* steroids eg prednisolone
* suppres cytokines and inhibit lymphocyte proliferation, survival and action
52
name 2 calcineurin inhibitors
* Tacrolimus and ciclosporin
53
name 2 anti-metabolite drugs used in IS
* Azathioprine and MMF
54
what is teh most common side effect of IS
infection - often UTI, LRT
55
what organism are IC individuals particularly at risk of (causes pneumonia)
* *Pneumocystic jirovecii*
56
what clinical signs would make you susepct Pneumocystic jirovecii infection
* Fever, dry cough, SOB, weight loss and night sweats
* absence of chest signs
57
management of increased Pneumocystic jirovecii risk
prophylaxis: co-trimixazole
58
which virus is associated with acute rejection and early graft loss
CMV - upregulates immune system
59
importance of CMV post transplant
* most common and important
* cause of morbidity in first 3 months
* causes higher rates of acute rejection
60
how does CMV infection arise
* reactivation of previous infection due to IS
* donor kidney exposed to CMV but recipient not
61
clinical features of CMV
* *Fever \> pneumonitis \> colitis \> hepatitis \> retinitis*
* clinically very similar to glandular fever, lymphadenopathy, arthralgia, fatigue, hepatomegaly, jaundiced sclera
* atypical pneumonia
* chorioretinitis -- can lead to irreversible blindness
* congenital infection and foetal damage
62
how is CMV risk managed
* Treat prophylactically with antivirals:
* PO valganciclovir in high risk patients
* IV gangciclovir if there is evidence of infection
63
BK nephropathy
* *Source of infection:*
* Transmission occurs through donor kidney
* Reactivation in the recipient renal epithelium after transplantation – over IS
* can mimic rejection, manifests as renal dysfunction
64
how does BK virus present
* can mimic rejection
* resp infection - eg cold cough that wont go away
65
management of BK infection
there is no effective anti-viral therapy, so treatment is reducing immunotherapy
66
cancer in the IS
* there is a higher risk - accumulative risk and IS
* have a high index of suspicion
67
what is the most common type of malignancy post transplant
* dermatological -50% have cutaneous lesions by ten years
* significantly increased risk of SCC (also melanoma)
68
PTLD
* can occur in all forms of transplant
* there is B cell proliferation due to therapeutic IS after transplant
* increased risk with increased IS
* usually occurs 6 months post transplant
69
what are the majority of PTLD cases caused by
EBV
70
treatment of PTLD
* decrease IS
* chemotherapy with B cell antibody
* good outcomes
71
name 4 complications following transplant
* Atheromatous vascular disease
* Raised blood pressure
* Thrombosis
* Infections due to suppressed T cell immunity
72
graft vs host disease
* caused by engraftment of donor lymphocytes in several IS recipients
* Can occur with blood transfusions, when it is usually mild unless there is severe immunocompromise, but in its severe form is usually associated with bone marrow transplantation
73
how can graft vs host disease present
skin rash and diarrhoea
74
graft survival: cadaveric vs living donor transplant
60%:70%
