Renal Transplantation Flashcards
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)
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
How do immunosuppression drugs work?
Several are used to block multiple signals of the T-cell activation
Name different types of immunosuppressive agents
- Corticosteroids
- Calcineurin inhibitors
- Anti-proliefratives
- mTOR inhibitors
- Costimulatory signal blockers
- Depleting agents
Give examples of calcineurin inhibitors
Tacrolimus, cyclosporin
Give examples of anti-proliferatives
Azothioprine
Give an example of mTOR inhibitors
Sirolimus
Give an example of costimulatory signal blockers
Belatacept
Give an example of depleting agents
Basilixmab (anti-CD25), anti-thymocyte globulin (ATG), rituximab (anti-CD20)
What are the side effects of corticosteroids?
Hypertension, hyperglycemia, infections, bone loss, GI bleeding
What are the side effects of tacrolimus?
Hyperglycemia, AKI, tremor
What are the side effects of cyclosporin?
Hirsuitism (excessive body hair), hypertension, AKI, gout
What are the side effects of Mycophenolate mofetil?
Cytopenia (reduce no. of RBCs), GI upset
What are the side effects of sirolimus?
Lipidogenic, diabetogenic, pneumonia
What are the side effects of belatacept?
Infections and malignancy
What are the side effects of ATG?
Infections and PTLD
State the immunosuppressive protocols
- Induction: Basiliximab
- Maintenance: Tacrolimus + Mycophenolate + steroids
- Steroid free is possible
- Others: CNI-free using Belatacept
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
