Renal Transplant Flashcards
Factors for better outcome
Living donor Pre-emptive tx Compatibility
HLA sensitisation RF
Prev tx Prev transfusions Pregnancy
Eligibility 1. Donor 2. Recipient
Donor -low peri op risk -acceptable estimated lifetime ESRF risk -Considerations: Age, HTN, Albuminuria, Smoking, BMI, GFR, Risk of transmission of infection or malignancy Recipient -ESRF requiring dialysis -Reasonable chance of survival aka not very frail -Age is NOT a factor
Calceneurin inhibitors Example A/E
Tacrolimus or Cyclosporin A/E 1. Nephrotoxicity 2. HTN 3. Hyperlip 4. Hair loss (some hirsutism) 5. HypoMg/PO4 esp with PPI use 6. Neurotoxicity *does NOT cause myelosuppression
Antimetabolite Example A/E
MMF (Mycophenolate) or Azathioprine -inhibits IMPDH involved in purine synthesis A/E 1. Myelosuppression 2. Diarrhoea MMF - less acute rejection, more diarrhoea (compared to Aza)
mTORi
Sirolimus or everolimus -initially used to replace Tac but more rejection/graft loss -now used to replace MMF due to less s/e (less infection- CMV/malignancy - esp skin like SCC&BCC/neutropenia/diarrhoea) but generally not well tolerated –>higher discontinuation rate A/E • Wound complications/fluid collection • Proteinuria • Cytopenia • Interstitial pneumonitis • c/I in pregnancy Mouth ulcers, odema, hyperlipid
Cause of Death with graft function
Early (year 1) • Cardiovascular • Infection • Cancer (3%) Late • Cancer (30%) • Cardiovascular (23% • Infection (12%)
Cause of Death with graft loss
Early (year 1) • Graft thrombosis/technical • Rejection • GN (4%) Late • Chronic allograft nephropathy (72%) • GN • Acute rejection (4%) • Non adherence
Chronic allograft nephropathy
Chronic antibody mediated rejection –>leads to graft loss, can take months or years Cause; ? • Early rejection not resolved - clinical or subclinical • Non adherence, low Tac level • Poor HLA matching De novo DSA
Delayed graft function
-usually secondary to post-ischaemic ATN -less common with living donor -other causes -Graft thrombosis - do USS Doppler and MAG3 scan -Obstruction/urine leak - not common -Rejection - can do bx even within 1 week -FSGS -TMA - Oxalosis
Acute Rejection
- Acute rejection a. T cell mediated, antibody mediated or mixed b. Have to do bx c. RF - previous HLA sens, pre-tx ab against donor, older donor, ischaemia time, HLA mismatches d. Treatment i. -IV methypred pulse (1g x 3days), ATG is steroid resistant ii. Plasma exchange, IVIG ?ritux iii. Prophylaxis - PJP, CMV
BK Nephropathy
BK nephropathy a. Polyoma virus. Viruia–>viraemia–>nephropathy b. Screen via serum PCR in the first 12m c. If +ve, need to reduce MMF or anti-metabolite d. Can mimic rejection, causes interstitial nephritis, tubular injury, interstitial fibrosis e. Bx - intranuclear viral inclusions & SV40 (staining). Lives in medulla, can be missed if no medulla on bx sample f. Tx - unclear, can trial steroids or IVIG esp if havent done bx to exclude rejection
Worsening graft function (early <12m) Causes
- Acute rejection 2. CNI Toxicity 3. Renal art stenosis 4. Obstruction, leak, collection 5. BK nephropathy 6. Recurrence of primary disease
CMV
High risk if Donor +ve, Recipient -ve A/w rejection •Primary prophylaxis - causes neutropenia, but risk of inf after cessation. Use valgancyclovir, Can use IV ganciclovir. If valganz resistant - use foscarnet or cidofovir but nephrotoxic
Cancer associated risk
-Non Hodgkin’s Lymphoma, Kidney, Melanoma -Skin cancer - very common, mostly metastatic SCC - common cause of cancer related death post tx -Mx - surveillance, mTORi, avoid AZA, min immunosuppression etc -Death: NHL >Lung>Colorectal (but lung and colorectal are generally high in community)
Infective Organisms based on Time post Tx
