Renal Transplant

Question 1

Which renal replacement therapy is the best in terms of patient survival and QOL?

Answer 1

• Renal Transplant

Question 2

What are the contraindications for kidney transplant?

Answer 2

• Active infection/malignancy
• Severe heart disaese
• Severe lung disease
• Reversible renal disease
• Uncontrolled substance abuse, psychiatric illness
• Non adherence to ongoing treatment
• Short life expectancy (<2 years)
• Malignant melanoma within the previous 5 years

Question 3

What are the 3 ways of obtaining a kidney transplant?

Answer 3

• Living related donor transplant (best option)
• Living unrelated donor transplant
• Deceased donor transplant (most common)

Question 4

What are the 4 forms used in Living unrelated donor transplant?

Answer 4

• live-donor paired exchange
• live-donor/deceased-donor exchange
• live-donor chain
• altruistic donation

Question 5

What are the two types of deceased donors?

Answer 5

• Donation after Brainstem Death (DBD)
• Donation after Circulatory Death (DCD)

Question 6

What induction tx is used at the moment of transplantation?

Give example

Answer 6

• potent immunosuppressive
• Methylprednisolone + (any of following)
  
  • basiliximab
  • thymoglobulin
  • alentuzumab
  • rituximab

Question 7

What maintenance tx is used immediately after transplant?

Answer 7

• prednisolone
• Calcineurin inhibitors: tacrolimus, cyclosporine, voclosporin
• Antimetabolites: mycophenolate, azathioprine
• Rapamycin inhibitors: sirolimus, everolimus
• T cell regulation: Belatacept, belimumab

Question 8

What is the long term care of transplant patients?

Answer 8

• Frequent followup in first month
• Monitor GFR, Calcineurin Inh. levels, proteinuria, Ca, Phosphate, PTH, lipids, glucose
• Screen for infections
• Vaccinate (except live)
• Control CVS disease, bone and mineral metabolism disease
• Screen for malignancies
• Contraception for first year (mandatory)

Question 9

What surgical techniques are used in renal transplant?

*think donor retrieval and recipient

Answer 9

Donor retrieval procedure

• Dead donor
  
  • Cold perfusion of iliac artery
  • Kidneys, renal arteries, patch of aorta, renal veins, patch of IVC, ureters removed
• Live donor
  
  • Laparoscopic nephrectomy
  • Left kidney preferred - longer renal vein

Recipient procedure

• graft placed extraperitoneally in illiac fossa
• terminolateral anastamoses between donor renal vein and recipient external illiac vein
• ureteroneocystostomy - ureter anstamose with bladder

Question 10

What are the cx of renal transplant?

Answer 10

• Delayed graft function
• Early vascular cx
  
  • renal artery/vein thrombosis
• Late vascular cx (several months)
  
  • renal artery stenosis
• ureteric leaks
• urinary tract obstruction
• CVS disease
• recurrent infections
• DM - New Onset Diabetes after Transplant (NODAT)
• malignancy

Question 11

What infection type would you consider with the three types of time frame?

Answer 11

• < 4 weeks: nosocomial infections
• 1m - 1y: activation of latent infection, opotunistic infections, community acquired
• >1y: community acquired

Question 12

What type of germs would you consider in renal transplant patients?

Answer 12

• CMV
• Hep B
• HSV
• VZV
• EBV
• Aspergillus
• Pneumocystis Jirovecii
• MT
• Toxoplasma Gondii

Question 13

What are the types of simultaneous kidney transplant?

Answer 13

• Liver-kidney: pt with liver failure
• Pancreas-kdiney: pt with T1D