Renal transplantation Flashcards
By how much will renal transplant improve GFR?
50
By how much will renal haemodialysis or peritoneal dialysis improve GFR?
7
What are the different types of transplant?
Deceased heart beating donors (brain stem death)
Non-heart beating donors (DCD)
Live donation: directed and undirected, paired donation
How should potential recipients be screened?
Patients with reasonable life expectancy (>5 years)
Patient is safe to undergo the operation: GA, procedure, immunosuppression, fluid (heart failure etc)
What specifically is assessed once someone is eligible for an operation?
Immunology: tissue typing, antibody screening Virology: HBV, HCV, HIV, EBV, CMV, VSV, Toxo, Syphilis Cardioresp risk: ECG, echo, angio, CXR Assesses peripheral vessels Assess bladder function Assess mental state Assess any co-morbidity/ PMHx Independent assessment
What are contraindications to transplant?
Malignancy - solid tumor in last 2-5 years Active HCV/ HIV infection Untreated TB Severe IHD Severe airways disease Active vasculitis Severe PVD Hostile bladder
What does tissue typing involve?
Blood group: O can only get from O
AB can get from everyone
HLA
What are common sensitising events?
Blood transfusion
Pregnancy or miscarriage
Previous transplant
Leads to formation of preformed antibodies to non-self antigens
Where are transplant kidneys grafted?
Onto the iliac vessels (vein and artery) and they graft the ureter to the bladder
What are common surgical complications to kidney transplant?
Bleeding Arterial stenosis Venous stenosis/ kinking Ureteric stricture and hydronephrosis Wound infection Lymphocele
What is an indication of immediate graft function?
Good urine output
Falling urea and creatinine
What is an indication of delayed graft function?
Post-transplant ATN
Often need HD in interim
Usually works within 10-30 days
Usually need biopsy
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
What do anti-rejection therapy aim to do?
Reduce the activation of T cells
Aim is to prevent host V transplant mediated immune response
What is the induction immunosuppressive therapy?
Basiliximab or daclizumab
What immunosuppression is given during the transplant surgery?
IV prednisolone
What immunosuppressive maintenance treatment is used post transplant?
Prednisone, tacrolimus, MMf
OR
Prednisolone, ciclosporin, azathioprine
What are the different anti-rejection treatments?
Pulsed IV methylprednisolone Anti-thymocyte globulin IV immunoglobulin Plasma exchange Rituximab, bortezomib, eculizumab
What is the main aim of immunosuppressive therapy?
Stops IL-2 release
What are common complications of immunosuppression?
Bacterial infection: UTI, LRIT
Prophylaxis for PJP
Viral: CMV, HSV, BK
Fungal infections
What is the prophylaxis for PJP?
Co-trimoxazole
What is CMV disease associated with post transplant?
Most important cause of morbidity in immunosuppressed patients in first 3 months of transplant
Associated with early graft loss
What will CMV disease cause?
Renal and hepatic dysfunction
Oesophagitis, pneumonitis and colitis
Increased risk of rejection
What treatment is given in CMV disease for post-transplant patients?
Prophylactic PO valganciclovir
IV ganciclovir is evidence of infections
How can CMV disease be diagnosed?
IgM
PCR
What cancers are most common in immunosuppressed patients?
Non-melanoma skin cancers
Lymphoma (EBV mediated PTLD)
Solid organs
Describe the pathogenesis of post-transplant lymphoproliferative disease?
EBV infection
Polyclonal B cell proliferation
Monoclonal proliferation
Lymphoma
What is the long term follow up of kidney transplant?
Rejection Hypertension and assessment of CVS Chronic allograft nephropathy UTI Recurrent primary renal disease Surveillance for malignancy Viral mediated graft dysfunction Management of CKD
What do induction monoclonal antibodies do?
Basiliximab or daclizumab
Block IL-2 receptors on CD4 T cells
Prevent activation of these cells and therefore prevent rejection
What is the action of steroids?
Inhibit lymphocyte proliferation, survival and activation
Suppress cytokines
What are the common side effects of steroids?
Weight gain
Diabetes
Osteoporosis
What is the mode of action of calcineurin inhibitors?
Tacrolimus and ciclosporin
Act by inhibiting activation of T cells
Prevent cytokine release
What are the side effects of calcineurin inhibitors?
Renal dysfunction
Hypertension
Diabetes
Tremor
What is the mode of action of anti-metabolites?
Azathioprine and MMF
Blocks purine synthesis causing the suppression of proliferation of lymphocytes
What are the side effects of anti-metabolites?
Leucopenia
GI upset
Anaemia
