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Renal > Renal Transplant > Flashcards

Renal Transplant Flashcards

1
Q

what are the options of renal replacement therapy (and how much GFR do they give you)

A

haemodialysis- 7%
peritoneal dialysis- 7%
transplant- 50%

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2
Q

what is the best treatment for end stage renal disease

A

transplant before you need dialysis

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3
Q

what are the benifits of transplants

A

survival benefit
improve QoL
financial benefit to patients

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4
Q

what are the types of transplant

A

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)

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5
Q

how do you assess potential recipients

A

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
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6
Q

what are the contraindications for a transplant

A 
malignancy 
active HCV/HIV infection 
untreated TB
severe IHD
severe airways disease 
active vasculitis 
severe PVD
hostile bladder
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7
Q

how do you asses a live donor

A 
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?
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8
Q

what is the universal acceptor blood type

A

O

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9
Q

what is the universal donor blood type

A

AB

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10
Q

how do you tissue type someone

A

blood group

HLA, B or DR

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11
Q

what is the importance of HLA matching

A

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

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12
Q

what can cause a sensitising event

A

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)

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13
Q

how do you allocate kidneys

A

paediatric recipient- any match
0,0,0 mismatch= ideal match
1,0,0/0,1,0/1,1,0 favourable mismatch
other match= unfavourable

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14
Q

what is paired donation

A

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

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15
Q

what is disensitisation

A

Active removal of blood group or donor specific antibody

  • plasma exchange
  • B cell antibody (rituximab)
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16
Q

do you remove the native kidneys

A

no unless source of infection/ polycystic

17
Q

describe the transplant procedure

A

Extra peritoneal procedure
Transplant inserted in iliac fossa
-Attached to external iliac arterty & vein
-Ureter plumbed into bladder with stent

18
Q

what are the possible surgical comps

A 
bleeding
arterial stenosis 
venous stenosis/ kinking 
ureteric stricture and hydronephrosis 
wound infection 
lymphocele
19
Q

how do you tell if the transplant is working

A

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

20
Q

what are the types of transplant rejection

A

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.

21
Q

what is the immunosuppressive therapy

A 
Induction Treatment
Basiliximab/Dacluzimab
Prednisolone iv during operation
Maintainance Treatment:
Prednisolone, tacrolimus, MMF
22
Q

what are the possible complications of immunosuppression

A

bacterial infection (UTI, LRTI)
viral infections (CMV. HSV, BK nephropathy)
fungal infections
Pneumocystis jiroveci Pneumonia
cancers (non melanoma skin, lymphoma, solid organs)

23
Q

what causes CMV disease

A

Renal & Hepatic dysfunction
Oesophagitis, Pneumonitis & Colitis
Increased risk of rejection
associated with early graft rejection

24
Q

is is post transplant lymphoproliferative disease

A

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

25
Q

what is the treatment for post transplant lymphoproliferative disease

A

reduce immunosuppression

chemo

26
Q

what are the induction monclonal antibodies

A

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

27
Q

how do glucocorticoids work

A

Inhibit lymphocyte proliferation, survival & activation.

Suppress cytokines

28
Q

what are the calcineurin inhibitors, how do they work and what are the SEs

A

Tacrolimus & Ciclosporin
Act by inhibiting activation of T-cells
Prevent cytokine release

Side effects
Renal dysfunction
Hypertension
Diabetes
Tremor
29
Q

what are the antimetabolites how do they work and what are the SEs

A

Azathioprine & Mycophenolate Mofetil (MMF)
Block purine synthesis  suppression of proliferation of lymphocytes

Side Effects
Leucopenia
GI upset
Anaemia

Renal (27 decks)

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