Renal Transplantation Flashcards
What is the criteria for initiating renal replacement therapy (RRT)?
GFR < 10mL/min + symptomatic
At what level of renal function should a patient meet with the transplantation team
GFR < 20ml/min
What are absolute contraindications to renal transplantation?
- Unable to adhere to medication regimen
- Active infection
- Active malignancy
- Mentally challenged
- Reversible cause of renal failure
- High probability of peri-operative mortality
- Anatomic issues (significant vascular disease)
What renal diseases have a high risk of recurring in the transplanted kidney?
- FSGS
- Hemolytic uremic syndrome
- Membranoproliferative glomerulonephritis
- Primary Oxalosis
What renal diseases have an intermediate risk of recurring in the transplanted kidney?
- Sickle cell
- Amyloidosis
- Fabry disease
- IGA nephropathy
- HTN nephropathy
- Diabetic Nephropathy
What renal diseases do NOT recur in a transplanted kidney?
- ADPCKD
- Cystinosis
- Renal dysplasia
- Alport syndrome (without anti-GBM antibodies)
How do you manage malignancy in transplant candidates?
Need to ensure disease cure, with disease free period dependent on type of CA. Oncology consults should be obtained to determine risk of recurrence, surveillance and long term prognosis. Patients should be screened for malignancy appropriate to age and gender
Melanoma - 5 years
Any metastatic malignancy - 5 years
High grade, invasive urothelial CA - 5 years
Any localized malignancy - 2 years
When is cholecystectomy advised prior to receiving a transplant?
- Gallbladder polyps greater than 1cm
2. Patients with diabetes and gallstones (increased morbidity in acute cholecystitis after transplantation)
What should a patient be assessed for prior to transplantation?
- Peripheral vascular system (claudication, past vascular procedures, femoral pulses) - if concerns doppler U/S or CT to assess
- Abdominal exam for surgical scars and information about past surgical history
What are the indications for a pre-transplant nephrectomy?
- Symptomatic renal stones not cleared by minimally invasive techniques or lithotripsy
- Polycystic kidneys that are symptomatic, extend below the iliac crest, have been infected or have solid tumors.
- Persistent anti-GBM antibody levels
- Significant proteinuria not controlled with medical nephrectomy or angioablation
- Recurrent pyelonephritis, or chronically infected kidney
- Grade 4 or 5 VUR with urinary tract infections
How should bladder outlet obstruction be managed in the transplant patient?
First line: medical management - alpha blockers and 5-alpha reductase inhibitors
Second line: TURP = should NOT be performed in anuric/oliguric patients as high risk contracture and strictures
Third line: CIC or indwelling catheterization
What are the guidelines for determination of neurologic death? (DND kidney)
- Complete cessation of all brain stem function (must be irreversible)
Determined by coma + absence of brainstem reflexes - Apnea challenge
Determined by no respiratory effort at PaCo2 60 or greater - Negative confirmatory tests if doubt exists.
What are the criteria for donation after circulatory death (DCD)?
- Donor does not meet neurologic death criteria, despite being comatose
- Decision made by family to withdraw cardio-pulmonary support.
- Death declared by absence of spontaneous respiration and sustained systole for 5 minutes.
What are the steps in the harvest of organs from a deceased donor?
- Median sternotomy and midline incision
- Organ inspection for signs of disease
- Vascular control - above and below organs for donation
- Cannulas inserted for the administration of preservation solution inserted into aorta, clamps are applied, venous effluent is vented and organs are flushed.
- Organs are extirpated.
- Immediately are cooled with slush once removed.
- Spleen and lymph node sections removed for histocompatibility.
How are kidneys preserved once extirpated?
- Hypothermia (4C) reduces energy expenditure
- Pulsatile preservation pumps may reduce vascular spasm
- Preservation solution (wisconsin solution) designed to maintain intracellular electrolyte composition
What are the contents of Wisconsin solution?
K lactobionate, KH2PO4, MgSO4, Raffinose, Adenosine, Insulin, glutathione, dexamethasone, allopurinol, penicillin, potassium, sodium
What are the four categories of kidney donors?
- Standard criteria donor younger than 35
- Standard criteria donor older than 35
- Expanded criteria donor
- Donation after circulatory death
What are the criteria of an expanded criteria donor?
- Age over 60
- Age between 50-59 with 2 or more of (death from stroke, HTN, elevated Cr just before organ recovery (1.5mg/dL)
*ECD has 80% 2 year graft survival versus 88% for SCD)
What happens in ABO incompatibility?
Acute rejection - antibodies bind to perceived antigen, trigger complement cascade, leading to coagulation, thrombosis and rapid graft loss.
What two classes of HLA’s are used in kidney allocation
HLA Class I (HLA-A, HLA-B, HLA-C)
- expressed by all nucleated cells through MHC
HLA Class II (HLA-DR, HLA-DQ, HLA-DP)
-Expressed by antigen presenting cells (dendritic cells, monocytes, macrophages, and B-lymphocytes)
What increases the risk of antibody and cellular rejection?
- Pregnancy
- Blood transfusion
- Prior transplantation
- Some infections
These things increase risk of forming HLA antibodies
individuals with antibodies directed at 20% of population are said to be sensitized
highly sensitized if antibodies directed at 80% of the population.
What are the three classes of renal rejection?
- Hyperacute - immediate (ABO incompatibility)
- Acute - 5 days after allogenic transplant (cellular +/- Ab bx to determine
- Chronic - gradual deterioration (vascular
What are contraindications to donation of a kidney?
- Renal disease (GFR < 80)
- Transmissible infection
- Active malignancy
- Mental disorder (incompetent)
- High operative risk
- Minor
- Anatomic unfeasibility
What are the indications for dialysis
- Acidosis (metabolic)
- Electrolytes (hyper-K)
- Intoxicants
- Volume overload
- Uremia (pericarditis, pericardial effusion)
What is the differential diagnosis of a fluid collection found post-operatively from a renal transplant
- Seroma
- Lymphocele
- Abscess
- Hematoma
- Urinoma
When should you intervene in a post-operative renal transplant fluid collection?
- Fever
- Pain
- Obstruction
- If may be contributing to decreased renal function
List causes of early graft dysfunction?
- ATN
- Calcineurin inhibitor toxicity
- Rejection
- Infection
- Obstruction
- Hyperglycemia
What is the definition of delayed graft function?
Requirement for dialysis during the first week of transplantation.
What are the classes of immunosuppressants and how do they work?
- Antiproliferative agents (azathioprine, and MMF) - Block DNA/RNA prodction
- Calcineurin inhibitors (cyclosporin and tacrolimus) - inhibit T-cell activation
- Monoclonal antibodies (Anti-CD25, basiliximab, daclizumab) - block IL2 receptor
- Rapamycin - mTOR inhibitor
- Corticosteroids - inhibit gene transcription and IL2 activity
