Renal Transplantation Flashcards
What are the risks of giving immunosuppression to patients having transplants?
Increased risk of infections
Bone marrow suppression
Increased risk of cancer
What are the 4 areas involved in working up a patient for a transplant?
Check:
Cardiac
Respiratory
Mitotic lesions
Vascular supply in lower legs
How do you check the heart health is suitable for a transplant during work up?
ECG
Myocardial perfusion scan while exercising
Dobutamine stress ECHO
How do you check the respiratory health is suitable for a transplant during work up?
CXR
Spirometry
Sats
Why is having low mitotic figures extremely important in the work up of a transplant patient?
The immunosuppression given after the transplant can lead to the cancer rapidly progressing
How can you check a patient for mitotic lesions when working up for a transplant?
PMH
FHX
SHx for cancer risk
Red flags:
Weight loss
SOB
Bloody stools
Bloody urine
US abdomen
Why do you check the vascular supply to the legs is suitable for a transplant during work up?
Transplanted kidney gets inserted into the external iliac artery which then becomes the common femoral which supplies the entire lower limb
If pateitn has claudication before transplant highly likely will develop lower limb ischaemia
Who should receive a renal transplant?
Patients with End Stage Renal failure on dialysis.
OR
Patients predicted to enter into end stage renal failure (preemptive transplant)
What is dialysis vintage?
Longer a patietn is on dialysis, the higher this value is and the less likely they will be able to have a transplant
How are donor kidneys matched to a recipient?
How is it scored?
3 gene loci assessed
DP
DQ
DR
The likelihood of rejection for each of these loci is then scored with a score 0 to 2 for each
Scores of 0 for all 3 means unlikely to mismatch
But scores of 2 for all 3 means its very likely to mismatch and reject
What medications are given to induce immunosuppression before and after surgery to prevent acute rejection?
Infusions of:
-Basiliximab
Or
-alentuzumab (Campat)
What types of drugs are then used as maintenance to maintain immunosuppression to prevent graft/transplant rejection?
Calcineurin inhibtors
Steroids
Anti-Proliferative agents
mTOR inhibitors
What is the best example of a calcineurin inhibitor to maintain immunosuppression following transplantation?
Tacrolimus
What is the best example of steroids used to maintain immunosuppression following transplantation?
Prednisolone (aim to taper down ASAP)
What are some examples of anti-Proliferative agents used to maintain immunosuppression following transplantation?
Mycophenolate motif
Azathioprine
What is an example of an mTOR inhibitor for maintaining immunosuppression following transplantation?
Sirolimus
What 3 other types of medications do we give immediately after transplantation?
Antibiotics
Antivirals
Antifungals
What antibiotics are typically given post transplant?
Co-trimoxazole
What antiviral is typically given post transplantation?
Valgancyclovir
What antivfungal is typically given post transplantation?
Fluconazole
What virus do you give a longer course of valgancyclovir for if the donor is positive for it but the recipient is negative for it?
CMV
Do you give the anti-microbials for long term maintenance?
No eventually stop them
What are 5 immediate complications of renal transplantation?
Infections
Acute rejection
Renal vein thrombosis
Acute renal artery occlusion
Hydronephrosis
What are the 2 types of rejection for a transplant?
T cell mediated rejection
Or
Antibody mediated rejection
What do you do if you suspect acute rejection?
Ultrasound the kidney
Then BIOPSY it
(Look for inflammatory cells in tubules) to confirm acute rejection
Management determined by type of rejection
How do you manage an acute T cell mediated rejection?
Increase the dose of the steroids (Prednisolone)
How do you manage an acute antibody mediated rejection?
Do plasma exchange to remove all antibodies
Then anti B cell agents like RITUXIMAB (anti-CD20)
How do you manage immediate complications like renal vein thrombosis, hydronephrosis, acute renal artery stenosis?
Surgical referral
What are the 3 types of intermediate complications of renal transplantation?
Infection
Rejection
Calcineurin inhibitor toxicity
Why is infection an intermediate and long term complication of renal transplantation?
Ceased the anti microbials by this point
What are some unusual opportunistic infections caused by immunosuppression?
Cytomegalovirus (CMV)
Pneumocystis jiroveci
TB
What are some other potential causes of infection as an intermediate complication of transplantation?
CMV
PCP and PCJ
TB
Pneumonia
Sepsis
UTI
EBV
Shingles
Cryptosporidium
What is the management for a transplant patient that has developed an infection?
What is the exception to this?
Need to reduce levels of immunosuppression
If infection is CMV, reduce levels of immunosuppression and also give valgancyclovir
How do you manage chronic rejection post renal transplantation?
BIOPSY
T cell mediated = steroid increase
Antibody mediate = plasma exchange if suitable + rituximab
How do you assess Calcineurin toxicity?
Measure levels of Tacrolimus (Calcineurin inhibitor) in the blood
How does Calcineurin toxicity (Tacrolimus) present?
HTN
Tremors
Hair loss
Gum hypertrophy
Neurotoxicity (delirium/myoclonic jerk)
How do you manage Calcineurin inhibitor toxicity?
Reduce dose of Tacrolimus or cyclosporin
If doesn’t work switch to the mTOR inhibitor Sirolimus
What are the long term complications of renal transplantation?
MALIGNANCY
Infection
Chronic rejection
Calcineurin inhibitor toxicity
What malignancies are patients at increased risk of developing following Renal transplantation?
Squamous cell carcinomas
(Other skin cancers like basal cell carcinoma)
Non Hodgkin lymphoma/Post Transplant Lymphoproliferative disorder
How do you change your management if a patient develops malignancy following transplantation?
Why?
Reduce the dose of anti-Proliferative like Mycophenolate motif
To allow the bodies immune cells a chance to fight the malignancy
What issues can steroids cause when being used for immunosuppression?
How can some of this be mediated?
Cushings symptoms
T2DM
Peptic ulcers
Osteoporosis
Wean down ASAP
Give PPIs (omeprazole for gastroprotection)
Zolendronic acid, Vit D and calcium for bone protection
What individuals are at a higher risk of rejection?
Those with:
-autoimmune conditions
-chronic illness
-poor medication complicance
-malignancy
