Renal transplant

Question 1

CMV infection

Answer 1

CMV IgM positive antibodies, 4x increase in pre existing CMV IgG titers
CMV antigen detection infected cells,
CMV DNAemia in blood
Viral isolation by throat culture, buffy coat or urine tests

Question 2

CMV disease

Answer 2

clinical signs of fevers and leukopenia,

organ involvement: hepatitis, pneumonitis, pancreatitis, colitis, meningoencephalitis, chorioretinitis and myocarditis

Question 3

What are symptoms of CMV disease

Answer 3

see mononucleosis like disease with clinical low grade fever, malaise, leukopenia and some degree of organ involvement

Question 4

Difference between CMV infection vs CMV dx

Answer 4

CMV infection is detection of CMV antigen, antibodies or virus without significant clinical symptoms whereas CMV dx is clinical symptoms

Question 5

CMV eye dx is seen in (name population of pt)

Answer 5

HIV more than organ transplant pt

Question 6

CMV dx is more common in (name pt population)

Answer 6

CMV positive donors and CMV positive recipients

Question 7

CMV dx often happens after

Answer 7

renal rejection episode and increased immunosuppression

Question 8

Pt can reactivation of CMV virus or superinfection after

Answer 8

introduction with a new donor viral strain

Question 9

Prophylaxis after having positive CMV in donor or recipient

Answer 9

100 days of ganciclovir

Question 10

Treatment of CMV dx

Answer 10

reduction in immunosuppression
OR if severe dx can give ganciclovir

Only stop cyclosporine or tacrolimus if lifethreatening dx

Question 11

BK virus infection presentation

Answer 11

tubulointerstitial nephritis and ureteric stenosis

Question 12

How to follow BK virus in patients?

Answer 12

Check BK PCR or acute organ dysfunction

Kidney biopsy - BK involvement

Question 13

HSV reactivation happens when after a renal transplant?

Answer 13

1st few months after solid organ transplant

Question 14

HSV reactivation presentation in tranplant pt

Answer 14

oral genital lesions, esophagitis, pneumonitis, hepatitis, and encephalitis

Question 15

Tacrolimus toxicity presentation

Answer 15

acute nephrotoxicity, HTN, neurotoxicity (tremor), metabolic disturbances (high blood sugars)

Question 16

Toxoplasma gondii infection presentation

Answer 16

rarely happens: see lymphadenopathy, hepatosplenomegaly, pneumonitis, myocarditis, brain abscess, chorioretinitis

Question 17

human polyoma virus infection

Answer 17

high prevalence of seropositivity of polyoma virus (BK or JC) in general population but they only cause dx in immunocompromised pts

Question 18

BK virus (polyoma virus) manifestations in a renal transplant patinet

Answer 18

tubulointerstitial nephritis and uretic stenosis

Question 19

time to onset of BK infection post transplant

Answer 19

10-15 months

seen in older men with DM2 and rejection episodes

Question 20

clinical manifestations of BK virus infection in renal transplant pt

Answer 20

no characteristic clinical manifestations other than loss of renal function.

Question 21

treatment of BK virus

Answer 21

primary treatment is reduction of immunosuppression.

Question 22

diagnosis of BK virus in transplant pt

Answer 22

Renal biopsy is similar to CMV and most people will have antibodies to BK virus.
Diagnosis is via characteristic cytopathology + positive antibodies against BK on immunohistorchemistry tests.

Question 23

what can you see on urine cytology with BK virus

Answer 23

can see cells with single large basophilic intranuclear inclusion
- suggests BK virus but doesn’t prove it.

Question 24

typical infections in 1st month post transplant

Answer 24

similar to post operative pts

Aspiration (pseudomonas) line infection (MRSA) wound infection and c diff.

Rarely: Ols, infections due to donar allograft contamination HIV, histoplasma, rabies or recipient colonization of aspergillosus)

Question 25

1-6 months post transplant infections

Answer 25

``` with PCP/antiviral prophylaxis - viral BK polyoma, hep C, adenovirus, influenza, - bacterial C diff colitis and TB WITHOUT PCP and antiviral prophylaxis (in addition to above) - Viral: CMV, HSV, VZV, EBV, hep B fungal: PCP bacterial listeria, nocardia parasitic: strongyloides, toxoplasma ```

Question 26

> 6 months post transplant

Answer 26

``` similar to general population less commonly late viral: CMV, HSV, JCV, hepatitis B and C bacterial nocardia and rhodococcus fungal: aspergillus, mucor ```

Question 27

what causes acute transplant rejection

Answer 27

presents early after surgery or within 6 months due to non compliance or over aggressive reduction in immunosuppression.

Question 28

asymptomatic but also can have graft pain and tenderness, fever, hypertension, oliguria, acute renal failure, pyuria, and proteinuria and increased graft size on imaging

Answer 28

signs and symptoms of acute transplant rejection of kidney

Question 29

BK virus infection happens

Answer 29

1 year after transplant

Question 30

see rising Cr, abnormal urinalysis with proteinuria and hematuria and casts and see tubulointerstitial nephritis

Answer 30

BK virus infection

Question 31

hypertensive nephrosclerosis is seen with

Answer 31

longstanding history of uncontrolled HTN and see slowly rising cr and mild protineuria

Question 32

does lupus nephritis recur in transplant pts?

Answer 32

yes up to 10% of transplant kidneys get this. see increased Cr, new proteinuria and hematuria

Question 33

What can cause an acute increase in tacrolimus or cyclosporine concentration in someone who uses them for immunosuppression for renal transplant?

Answer 33

tacrolimus and cyclosporine are metabolized by the hepatic cytochrome P450 system and excreted bin bile. So any drugs that interact with P450 can increase or alter drug level and effect. Lansoprazole and grapefruit juice can increase drug levels of tracrolimus

Question 34

tacrolimus toxicity:

Answer 34

see nephrotoxicity with acute rise in serum Cr, tubular dysfunction and bland urinlaysis Can see hypertension, neurotoxicity with tremor, headache, visual difficulties, see metabolic changes (hyperglycemia, hyperkalemia, hypomagnesemia)

Question 35

what drugs can increase tacrolimus and cyclosporine levels?

Answer 35

``` antibiotics like macrolides antifungals (itraconazole) cardiac (ACEi and CCB) GI drugs (Lansoprazole) Dietary :grapefruit juice ``` these can increase concentrations and cause toxicity of these immunosuprressive drugs need to get a drug level and adjust it

Question 36

common drug interactions that can lower the levels of tacrolimus and cyclosporines

Answer 36

antibiotics (nafcillin, rifabutin) antiseizure (carbamazepine, phenytoin other (octreotide, St. John's wort, orilstat)

Question 37

what are the most common side effects of tacrolimus and cyclosporine toxicity ? (Too much of it)

Answer 37

renal: most common side effect with acute renal failure and bland UA Vascular: HTN Neurotoxicity: tremor, headache, visual difficulties Metabolic: hyperglycemia, hyperkalemia, hypomagnesemia Infection: increased risk malignancy: cutaneous squamous cell cancer and lymphoproliferative disorders

Question 38

do tacrolimus and cyclosporine increase risk for cancer?

Answer 38

yes with cutaneous squamous cell cancer lymphoproliferative disorders.

Question 39

for someone who has worsening kidney function and AKI with electrolyte abnormalities in a renal transplant what to do?

Answer 39

biopsy is often done to rue out acute rejection; look for histological findings (interstitial inflammation, intimal inflammation tubulitis) are non specific calcineurin inhibitor toxicity is suggested with absence of signs of acute rejection

Question 40

tacrolimus toxicity facts is it dose dependent? is it reversible?

Answer 40

on dose; dose dependent | treatment is with decreasing dose and generally reversible. some pts can have a chronic renal dysfunction.

Question 41

Treat calcineurin induced hypertension with hyperkalemia with:

Answer 41

thiazide diuretics.

Question 42

renal transplant pts who want to get pregnant need to:

Answer 42

need to wait 1-2 years with stable allograft before attemtping conception also need to stop mycophenoalte mofetil and sirolimus and everolimus because teratogenic. needs to be replaced by azathioprine which is safer in pregnancy.