Renal Transplant Flashcards
what are the options of renal replacement therapy (and how much GFR do they give you)
haemodialysis- 7%
peritoneal dialysis- 7%
transplant- 50%
what is the best treatment for end stage renal disease
transplant before you need dialysis
what are the benifits of transplants
survival benefit
improve QoL
financial benefit to patients
what are the types of transplant
Deceased Heart Beating Donors
Brain stem death (DBD)- organs taken whilst patient still being ventilated and have circulation but no activity on brain stem/ signs of life
non heart beating donors- switch of ventilator, if heart stops within a short period of time then taken to theatre to remove organs (if heart takes a while to stop then will have prolonged organ ischeamia then called of)
Live Donation (altruistic)
Directed (for specific patient) and undirected
Paired Donation
Financially procured (illegal in most countries)
how do you assess potential recipients
life expectancy >5 years
safe to undergo anaesthetic, surgery, immunosuppression, post of period (no survival benefit until after 3 months)
assessment: Immunology – tissue typing & antibody screening Virology (exclude active infection) HBV, HCV, HIV, EBV, CMV, VZV, Toxo, Syphilis Assess Cardiorespiratory risk ECG, Echo +/- ETT, Coronary angio CXR, +/- PFT, CPEX Assess peripheral vessels Assess bladder function Assess mental state Assess any co-morbidity/PMHx which may influence transplant or be exacerbated by immunosuppression Independent assessment
what are the contraindications for a transplant
malignancy active HCV/HIV infection untreated TB severe IHD severe airways disease active vasculitis severe PVD hostile bladder
how do you asses a live donor
Physical fitness for surgery? Enough renal function to remain independent after nephrectomy? Anatomically normal kidneys? Any co-morbidities? Hypertension, Proteinuria, Haematuria? Immunologically compatible? Less of an issue now Psychologically compatible? Coming forward without coercion?
what is the universal acceptor blood type
O
what is the universal donor blood type
AB
how do you tissue type someone
blood group
HLA, B or DR
what is the importance of HLA matching
is what recognises non self and up-regulates immune response
in transplant:
-without immunosuppression =critical
- with immunosuppression =better graft survival
prevents sensitisation to subsequent transplants
what can cause a sensitising event
blood transfusion
pregnancy/ miscarriage
previous transplant
lead to the formation of pre formed antibodies to non self antigens (makes it harder to get transplant later)
how do you allocate kidneys
paediatric recipient- any match
0,0,0 mismatch= ideal match
1,0,0/0,1,0/1,1,0 favourable mismatch
other match= unfavourable
what is paired donation
where direct donator doesnt match recipient but matches which another direct donation who also doesnt match their recipient
give kidney to other recipient so that both get matched kidney
what is disensitisation
Active removal of blood group or donor specific antibody
- plasma exchange
- B cell antibody (rituximab)
do you remove the native kidneys
no unless source of infection/ polycystic
describe the transplant procedure
Extra peritoneal procedure
Transplant inserted in iliac fossa
-Attached to external iliac arterty & vein
-Ureter plumbed into bladder with stent
what are the possible surgical comps
bleeding arterial stenosis venous stenosis/ kinking ureteric stricture and hydronephrosis wound infection lymphocele
how do you tell if the transplant is working
Immediate Graft Function
Good urine output
Falling urea & creatinine
Delayed Graft Function Post-transplant acute tubular necrosis Often need HD in interim Usually works within 10-30days Usually need biopsy (difficult to detect rejection)
Primary Non Function
Transplant never works
what are the types of transplant rejection
Hyperacute rejection (should never happen- antibody screen prevents this)
Due to preformed antibodies
Unsalvageable
Transplant nephrectomy required
Acute Rejection
Cellular or Antibody mediated
Can be treated with increased immunosupression
Chronic Rejection
Antibody mediated slowly progressive decline in renal function. Poorly responsive to treatment.
what is the immunosuppressive therapy
Induction Treatment Basiliximab/Dacluzimab Prednisolone iv during operation Maintainance Treatment: Prednisolone, tacrolimus, MMF
what are the possible complications of immunosuppression
bacterial infection (UTI, LRTI)
viral infections (CMV. HSV, BK nephropathy)
fungal infections
Pneumocystis jiroveci Pneumonia
cancers (non melanoma skin, lymphoma, solid organs)
what causes CMV disease
Renal & Hepatic dysfunction
Oesophagitis, Pneumonitis & Colitis
Increased risk of rejection
associated with early graft rejection
is is post transplant lymphoproliferative disease
Occurs in all forms of transplantation
Depends on level of immunosupression
Usually related to EBV infection
causes B cell and monoclonal proliferation leading to lymphoma
what is the treatment for post transplant lymphoproliferative disease
reduce immunosuppression
chemo
what are the induction monclonal antibodies
Basiliximab or Dacluzimab
Block IL-2 receptor on CD4 T-cells
Prevent activation of these cells therefore prevent rejection
Not useful if rejection has already started
how do glucocorticoids work
Inhibit lymphocyte proliferation, survival & activation.
Suppress cytokines
what are the calcineurin inhibitors, how do they work and what are the SEs
Tacrolimus & Ciclosporin
Act by inhibiting activation of T-cells
Prevent cytokine release
Side effects Renal dysfunction Hypertension Diabetes Tremor
what are the antimetabolites how do they work and what are the SEs
Azathioprine & Mycophenolate Mofetil (MMF)
Block purine synthesis suppression of proliferation of lymphocytes
Side Effects
Leucopenia
GI upset
Anaemia
