renal transplantation Flashcards
what is the location of a kidney following transplantation?
Transplanted kidney is placed into the iliac fossa and anastomosed to the iliac vessels
Native kidneys usually remain in situ
how are donor kidneys preserved?
Cold storage solutions
Minimize oedema
Preserve integrity of tissues
Buffer free radicals
what are surgical transplant complications?
Bleeding
Usually anastomotic sites
Perirenal haematoma can be arterial or venous
Areterial thrombosis
Venous thrombosis
Lymphocele
Ureteric
Urine leak
Infections
what are available immunosupressive agents?
Corticosteroids
Calcineurin inhibitors
Tacrolimus, Cyclosporine
Anti-proliefratives
Mycophenolate mofetil, Azathioprine
mTOR inhibitors
Sirolimus
Costimulatory signal blockers
Belatacept
Depleting agents
Basiliximab ( anti-CD25), Anti-thymocyte globulin (ATG), Rituximab (anti-CD20)
what are common side effects of immunosupressive agents?
what are induction immunosupression protocols?
Basiliximab
what are maintenance immunosupression protocols?
Tacrolimus + Mycophenolate + steroids
what are deceased donors?
Donation after brain death/ DBD (heart-beating)
- standard / expanded criteria
Donation after cardiac death/DCD (non-heart-beating)
- standard / expanded criteria
what are living donors?
Living Related Donor
Living Unrelated Donors
- spousal
- altruistic
- paired/pooled
what is the criteria for brain death?
Coma, unresponsive to stimuli
Apnoea off ventilator (with oxygenation) despite build up of CO2
Absence of cephalic reflexes
pupillary
oculocephalic
oculovestibular (caloric)
corneal
gag
purely spinal reflexes may be present
Body temperature above 34 C
Absence of drug intoxication
how can living kidney donation be carried out?
Live related donor
Live unrelated donor (e.g. spousal)
Live unrelated donor – altruistic, non-directed
Paired / pooled
ABO incompatible / HLA incompatible
summarise risks of kidney donation?
Similar patient survival to general population.
Lower rate of ESRD compared to general population reduced.
Compensatory increase in GFR of remaining kidney to 70% of pre-donation values
Compensatory increase greater in younger donors.
Older age and high BMI were associated with GFR of <60.
Relatively short follow up time (12 years).
what is acute rejection?
T cell mediated rejection (TCMR)
Tubulointerstitial (Banff I)
Arteritis/endothelialitis (Banff II)
Arterial fibrinoid necrosis (Banff III)
Acute antibody mediated rejection (ABMR)
ATN-like (Banff I)
Capillaries and or glomerular inflammation (Banff II)
Arterial inflammation (Banff III)
what is hyperacute rejection?
(pre-existing alloreactivity to donor)
what are signs of t cell mediated rejection?
Lymphocytic infiltrate
Tubulitis
Endarteritis
Endothelialitis
what are signs of antibody mediated rejection?
Microvascular inflammation
Neutrophil infiltration
Glomeruli
Peritubular capillaries
Donor specific antibodies
Positive C4d
peritubular capillaries
what causes new onset diabetes following transplantation?
what are common modes of infection following renal transplantation?
what is cytomegalovirus?
Most important transplant-related infection
Affects around 8% of trasnplant recipients, despite prophylaxis therapy.
High mortality and morbidity if untreated.
Recipient affected via
Transmission from donor tissue
Reactivation of latent virus
what is CMV viremia?
Pneumonitis
Hepatitis
Retinitis
Gastroenteritis
Colitis
Nephritis
what is polyomadviridae?
BK virus
JC virus
Murine polyoma virus
SV40
what are clinical manifestations of BK virus?
what are risk factors for BKAN?
Intensity of immunosuppression
- tacrolimus, mycophenolate mofetil, antithymocyte globulin
Patient determinants
- older age, male gender, white ethnicity, DM, negative BKV serostatus (paediatric recipients)
Organ determinants
- graft injury, HLA mismatches, ureteral stents
Viral determinants
- changes in epitopes of viral capsid protein VP-1
what is the outcome of BKAN?
Allograft dysfunction
- Loss of graft in 45-80%
