Renal Transplantation Flashcards by Chloe Lee

How is a renal transplantation carried?

Transplanted kidney is placed into the iliac fossa and anastomosed to the iliac vessels

Native kidneys usually remain in situ

Indications for native nephrectomy include size (polycystic kidneys) and infection (chronic pyelonephritis)

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Name transplant surgical complications

Vascular complications:
• Bleeding: usually anastomotic sites and perirenal haematoma can be arterial or venous
• Areterial thrombosis
• Venous thrombosis
• Lymphocele

Ureteric:
• Urine leak

Infections

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How do immunosuppression drugs work?

Several are used to block multiple signals of the T-cell activation

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Name different types of immunosuppressive agents

Corticosteroids
Calcineurin inhibitors
Anti-proliefratives
mTOR inhibitors
Costimulatory signal blockers
Depleting agents

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Give examples of calcineurin inhibitors

Tacrolimus, cyclosporin

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Give examples of anti-proliferatives

Azothioprine

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Give an example of mTOR inhibitors

Sirolimus

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Give an example of costimulatory signal blockers

Belatacept

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Give an example of depleting agents

Basilixmab (anti-CD25), anti-thymocyte globulin (ATG), rituximab (anti-CD20)

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What are the side effects of corticosteroids?

Hypertension, hyperglycemia, infections, bone loss, GI bleeding

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What are the side effects of tacrolimus?

Hyperglycemia, AKI, tremor

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What are the side effects of cyclosporin?

Hirsuitism (excessive body hair), hypertension, AKI, gout

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What are the side effects of Mycophenolate mofetil?

Cytopenia (reduce no. of RBCs), GI upset

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What are the side effects of sirolimus?

Lipidogenic, diabetogenic, pneumonia

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What are the side effects of belatacept?

Infections and malignancy

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What are the side effects of ATG?

Infections and PTLD

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State the immunosuppressive protocols

Induction: Basiliximab
Maintenance: Tacrolimus + Mycophenolate + steroids
Steroid free is possible
Others: CNI-free using Belatacept

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What are the two types of donors?

Deceased and living donors

What are the types of deceased donors?

Donation after brain death (DBD)

* Donation after cardiac death (DCD)

What types of live donors are there?

• Living related donor
• Living unrelated donors:
  - Spousal 
  - Altruistic 
  - Paired/pooled

What is the Brain Death Criteria for DBD?

Coma, unresponsive to stimuli
Apnoea off ventilator
Absence of cephalic reflexes (pupillary, corneal, gag etc)
Body temp > 34C
Absence of drug intoxication

What is the standard criteria of donors?

If donor is < 60yrs

What is the extended criteria of donors?

Donor > 60yrs
Donor aged 50-59yrs + history of hypertension, death from cerebrovascular accident or terminal creatinine > 132 —> this gives a higher chance of delayed graft function

Describe the gap between demand and donation

Donor numbers always a lot less than those on transplant list

What is the relationship between age and transplantation?

Increase number of transplantations up ~55yrs and as the age increases more people go on dialysis

Describe paired donation

In living donation, if a donor is not a match for their family member who requires a transplant, they swap with another pair if each donor is a match for other's family member

Describe pooled donation

Within a family, not all members can donate to each other. So an alturstic donor donates their kidneys to one family member, which allows other family donor to donate their kidneys to other family members • Increase number of transplants in family

What are CVS complications after renal transplantation?

* Underlying renal disease * Chronic Renal Failure * Hypertension * Hyperlipidaemia * PT Diabetes

What are the infective complications after renal transplantation?

* Bacterial * Viral * Fungal

What are the malignant complications are malignancy?

* Skin * Lymphoma * Solid cancers

How does rejection occur after renal transplantation?

* Cell mediated | * Humoral (Ab mediated)

What is the mechanism behind acute rejection of renal transplants?

T cell mediated rejection (TCMR): • Tubulointerstitial (Banff I) • Arteritis/endothelialitis (Banff II) • Areterial 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 are features of T cell mediated rejection?

Lymphocytic infiltrate: • Tubulitis (in walls of renal tubule) • Endarteritis • Endothelialitis

What are features of Antibody mediated rejection?

Microvascular inflammation • Neutrophil infiltration • Glomeruli • Peritubular capillaries * Donor specific antibodies * Positive C4d: peritubular capillaries

What is the most important post-transplantation infection?

Cytomegalovirus

How is cytomegalovirus acquired after transplantation?

* Transmission from donor tissue | * Reactivation of latent virus

What is Polyomaviridae?

Family of viruses which have the capability to produce multiple tumors

What are the two main Polyomaviridae?

BK virus (lies dormant in body and becomes active when immunosuppressed) and JC virus Also: Simian virus 40 (SV40)

What types of cells does the human polyomavirus infect?

Kidney, brain, liver, retinal, lung, blood, lymphoid, heart, muscle, and vascular endothelial cells.

What are the clinical manifestations of BK virus after a renal transplantation?

* Ureteral stenosis * Interstitial nephritis * ESR

What are the clinical manifestations of BK virus after a bone marrow transplantation?

* Haemorrhagic cystitis * Pneumonitis * Hepatitis

What are the clinical manifestations of BK virus in AIDS?

* Nephritis * ESRF * Retinitis * Meningoencephalitis * Pneumonitis

What types of malignancies can occur after renal transplantation?

* 20% risk - non-melanoma skin, non-hodgkins lymphoma * 15% - renal * 5% - melanoma * 3% - testicular, bladder