Renal Transplantation Flashcards
What are the mechanisms for HLA sensitisation?
previous transplant, pregnancy, blood transfusions
Why do ABO incompatible transplants have similar long term outcomes to ABO compatible transplants?
because you can remove the antibodies to acceptable titres prior to transplantation via plasma exchange
Why are older living donors at a decreased risk of ESKD post donation compared to younger donors?
because ESKD takes time to develop
Is there an age cutoff for renal transplantation?
no
What are the two main agents for induction?
basiliximab and anti-thymocyte globulin
What are the side effects of calcineurin inhibitors?
nephrotoxicity, hypertension, hyperlipidaemia
Do calcineurin inhibitors cause bone marrow suppression?
no
Are calcineurin inhibitors safe in pregnancy?
yes
What are the benefits of tacrolimus compared to cyclosporin?
less acute rejection, less de novo DSA, less gum hypertrophy, less hirsuitism, less drug interaction
What are the benefits of cyclosporin compared to tacrolimus?
Less diabetes, less hypo Mg/PO4, less tremor/neurotoxicity, less hair loss
How is mycophenolate affected by cyclosporin?
cyclosporin lowers mycophenolate levels
What is the mechanism of action of mycophenolate?
inhibits IMPDH involved in purine synthesis
At what time period does mycophenolate cause bone marrow suppression/cytopaenia?
2-6 months
Is mycophenolate safe in pregnancy?
no - need to change to azathioprine
Which causes less acute rejection - mycophenolate or azathioprine?
mycophenolate
Which causes more diarrhoea - mycophenolate or azathioprine?
mycophenolate
What are the benefits of mTOR inhibitors?
less cancer risk, less CMV infection
What are the side effects of mTOR inhibitors?
wound complications, proteinuria, cytopaenias, hyperlipidaemia, mouth ulcers, oedema, interstitial pneumonitis, contraindicated in pregnancy
How is it best to use mTOR inhibitors?
in combination with calcineurin inhibitors at a lower dose
What are the benefits of using an mTOR inhibitor with calcineurin inhibitor?
less CMV, less skin malignancy, less neutropaenia, less diarrhoea
What is the most common cause of overall graft loss?
death with graft function
What is the most common cause of death with graft function in the first year?
cardiovascular
What is the most common cause of death with graft function?
cancer
What is the most common cause of graft loss without death in the first year?
graft thrombosis
What is the most common cause of graft loss without death after the first year?
chronic allograft nehpropathy
What are the causes of chronic allograft nephropathy?
chronic antibody mediated rejection (under immunosuppression and poor HLA matching) and CNI toxicity
What causes delayed graft function?
usually post ischaemic ATN, but can also be graft thrombosis, obstruction/urine leak, rejection or early recurrences of FSGS/TMA/oxalosis
What are the risk factors for post ischaemic ATN?
deceased donor, donor AKI, donor age, DCD, cold ischaemic time
What are the causes of early worsening graft function?
acute rejection, CNI toxicity, renal artery stenosis, obstruction/leak/collection, BK nephropathy, recurrent disease
What are the different types of acute rejection?
T cell mediated, antibody mediated or mixed
What is the treatment for T cell mediated rejection?
pulse methyld pred, optomise immunosuppression, if steroid resistant give anti thymoglobulin
What is the treatment for antibody mediated rejection?
plasma exchange, IVIG
What prophylaxis is required in transplant patients?
PJP, CMV
How do you prevent BK nephropathy?
screening by serum PCR in first 12 months
What is the treatment for BK nephropathy?
reduce immunosuppression
What are the risk factors for CMV?
D+R- status and higher level immunosuppression
Which patients need CMV prophylaxis?
D+R- or D-R+ or D+R+
What limits duration of prophylaxis for CMV?
neutropaenia
What is the treatment for CMV?
oral valganciclovir and cautious immunosuppression reduction
What cancers are more common in renal transplant paients?
NHL, kidney, melanoma, skin cancer
