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Nephrology > Renal transplant > Flashcards

Renal transplant Flashcards

1
Q

CMV infection

A

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

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2
Q

CMV disease

A

clinical signs of fevers and leukopenia,

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

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3
Q

What are symptoms of CMV disease

A

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

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4
Q

Difference between CMV infection vs CMV dx

A

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

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5
Q

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

A

HIV more than organ transplant pt

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6
Q

CMV dx is more common in (name pt population)

A

CMV positive donors and CMV positive recipients

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7
Q

CMV dx often happens after

A

renal rejection episode and increased immunosuppression

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8
Q

Pt can reactivation of CMV virus or superinfection after

A

introduction with a new donor viral strain

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9
Q

Prophylaxis after having positive CMV in donor or recipient

A

100 days of ganciclovir

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10
Q

Treatment of CMV dx

A

reduction in immunosuppression
OR if severe dx can give ganciclovir

Only stop cyclosporine or tacrolimus if lifethreatening dx

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11
Q

BK virus infection presentation

A

tubulointerstitial nephritis and ureteric stenosis

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12
Q

How to follow BK virus in patients?

A

Check BK PCR or acute organ dysfunction

Kidney biopsy - BK involvement

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13
Q

HSV reactivation happens when after a renal transplant?

A

1st few months after solid organ transplant

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14
Q

HSV reactivation presentation in tranplant pt

A

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

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15
Q

Tacrolimus toxicity presentation

A

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

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16
Q

Toxoplasma gondii infection presentation

A

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

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17
Q

human polyoma virus infection

A

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

18
Q

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

A

tubulointerstitial nephritis and uretic stenosis

19
Q

time to onset of BK infection post transplant

A

10-15 months

seen in older men with DM2 and rejection episodes

20
Q

clinical manifestations of BK virus infection in renal transplant pt

A

no characteristic clinical manifestations other than loss of renal function.

21
Q

treatment of BK virus

A

primary treatment is reduction of immunosuppression.

22
Q

diagnosis of BK virus in transplant pt

A

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.

23
Q

what can you see on urine cytology with BK virus

A

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

24
Q

typical infections in 1st month post transplant

A

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)

25
Q

1-6 months post transplant infections

A 
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
26
Q

> 6 months post transplant

A 
similar to general population
less commonly
late viral: CMV, HSV, JCV, hepatitis B and C
bacterial nocardia and rhodococcus
fungal: aspergillus, mucor
27
Q

what causes acute transplant rejection

A

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

28
Q

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

A

signs and symptoms of acute transplant rejection of kidney

29
Q

BK virus infection happens

A

1 year after transplant

30
Q

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

A

BK virus infection

31
Q

hypertensive nephrosclerosis is seen with

A

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

32
Q

does lupus nephritis recur in transplant pts?

A

yes up to 10% of transplant kidneys get this.

see increased Cr, new proteinuria and hematuria

33
Q

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

A

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

34
Q

tacrolimus toxicity:

A

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)

35
Q

what drugs can increase tacrolimus and cyclosporine levels?

A 
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

36
Q

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

A

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

37
Q

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

A

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

38
Q

do tacrolimus and cyclosporine increase risk for cancer?

A

yes with cutaneous squamous cell cancer

lymphoproliferative disorders.

39
Q

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

A

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

40
Q

tacrolimus toxicity facts

is it dose dependent?
is it reversible?

A

on dose; dose dependent

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

41
Q

Treat calcineurin induced hypertension with hyperkalemia with:

A

thiazide diuretics.

42
Q

renal transplant pts who want to get pregnant need to:

A

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.

Nephrology (26 decks)

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