Renal Transplantation Flashcards
progression to renal transplant?
CKD (stage 3-4) > end stage renal disease (CKD stage 5) > renal replacement therapy
- haemodialysis/peritoneal dialysis > transplant = last result
which is better, transplant or dialysis>
transplant
dialysis has fairly high mortality (esp in older people)
dialysis damages blood vessels increasing cardiovascular risk
transplant = better QoL
transplant = cheaper
3 types of kidney transplant?
decreased heart beating donor - DBD (people who are brain stem dead) non-heart beating donor (DCD) live donation (altruistic) - directed and undirected - paired donation - financially procured (illegal)
criteria for a transplant recipient?
reasonable life expectancy >5 yrs
safe to undergo procedure (anaesthetic, immunosuppression etc)
no survival benefit of kidney transplant is seen until how long after transplant?
3 months
first 3 months is actually worse than dialysis
how is a potential kidney transplant recipient assessed?
immunology (tissue typing and antibody screening) virology (exclude active infection) assess cardiorespiratory risk assess peripheral vessels assess bladder function assess mental state (risk of steroids) any co-morbidity
contraindications to transplant?
malignancy (immunosuppression will cause tumour to grow faster) active HCV/HIV infection untreated TB severe ischaemic heart disease, not amenable to surgery severe airway disease active vasculitis severe peripheral vascular disease hostile bladder
how is a potential donor assessed?
fitness for surgery
good enough renal function for 1 kidney to be enough
anatomically normal kidneys
any co-morbidities
immunologically compatible
psychologically compatible
coming forward to offer kidney without coercion
what blood types can donate to each other?
O can donate to all types
A can donate to A and AB
B can donate to B and AB
AB can only donate to AB
how is tissue type matched?
blood group
HLA
why is HLA matching so important?
can sensitise to foreign material creating antibodies
therefore antibodies will attack any potential subsequent transplants
what can cause sensitisation to foreign DNA etc which can impact future transplants?
blood transfusion
pregnancy/miscarriage (exposure to paternal DNA via foetus’s blood)
previous transplant
how is a kidney donation allocated?
1st line = paediatric recipient (any match)
2nd = ideal match
3rd = slight mismatch
4th = any other match
what is paired donation?
2 couples
in each couple, one wants to give to the other but isn’t a match
however the donor in each couple is a match for the recipient in the other couple
simultaneous transplants are performed on opposite partners
what is desensitisation?
used in people who are very sensitive so therefore have a very small pool of potential donors
involves active removal of blood group or donor specific antibody
can be done via
- plasma exchange
- B cell antibody (rituximab)
kidney transplant comes with what?
comes with an artery, vessel and ureter
attached onto the iliacs
how is a kidney transplant performed?
extra-peritoneal
transplant inserted into iliac fossa and attached to external iliac artery and vein
ureter plumbed into bladder with stent
surgical complications of transplant?
bleeding stenosis of vessels ureteric stricture/hydronephrosis infection lymphocele (space filled with lymph)
immediate vs delayed graft function?
immediate - good urine output - falling urea and creatinine delayed graft function - post transplant acute tubular necrosis (needs haemodialysis and biopsy to detect at rejection)
what is hyperacute rejection?
due to preformed antibodies
unsalvageable
transplant nephrectomy required
what is acute rejection?
cellular or antibody mediated
can be treated with increased immunosuppression
what is chronic rejection?
antibody mediated slowly progressive decline in renal function
poorly responsive to treatment so usually needs to be removed
how does anti-rejection therapy work?
reduces activation of T cells
prevents host vs transplant mediated immune response
describe immunosuppressive therapy used in transplant
induction treatment = basiliximab/dacluzimab
IV prednisolone during surgery
prednisolone, tacrolimus, MMF or prednisolone, ciclosporin, azathioprine
what infections are common after kidney transplant and how is this risk managed?
bacterial infection (UTI, LRTI) pneumocystis jirovecci is common - co-trimoxazole is given as prophylaxis viral infections (CMV, HSV, BK) fungal infections
what cancers commonly occur following kidney transplant?
non-melanoma skin cancers
lymphoma (EBV mediated PTLD)
solid organs
should be monitored for malignancy (regular derm review etc)
anti-rejection treatment?
pulsed IV methylprednisolone anti-thymocyte globulin IV immunoglobulin plasma exchange rituximab, bortezimab, eculizumab
