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Renal > Renal Transplantation > Flashcards

Renal Transplantation Flashcards

1
Q

What is a transplant?

A

Tissue taken from one person and placed in another = donor may be living or dead

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2
Q

Why must patients who receive a transplant started on immunosuppression?

A

The transplant is recognised as foreign by the immune system = must be suppressed to prevent rejection

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3
Q

What are some types of donors?

A 
Decreased heart beating donors = brainstem death
Non-heart beating donors
Live donation (altruistic) = directed/undirected, paired donation, financially procured
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4
Q

What must be life expectancy of a patient be for them to be considered to receive a transplant?

A

> 5 years after transplant

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5
Q

How long does it take for a survival benefit from a transplant?

A

3 months after transplant

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6
Q

How are patients assessed before a transplant?

A

Immunology = tissue typing, antibody screening
Virology = HBV, HCV, HIV, EBV, VZV, syphilis
Assess CV risk = ECG, echo +/- ETT, angiogram, CXR
Assess peripheral vessels, bladder function, mental state and any co-morbidities

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7
Q

What are the contra-indications to getting a transplant?

A

Malignancy = known untreated cancer, solid tumour in last 2-5 years
Active HCV/HIV infection or untreated TB
Severe IHD, not amenable to surgery
Severe airways disease or peripheral vascular disease
Active vasculitis or hostile bladder

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8
Q

How are potential donors assessed?

A

Physical fitness for surgery and not being coerced
Anatomically normal kidneys
Enough renal function to remain independent after
Co-morbidities = hypertension, protein/haematuria
Immunologically compatible

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9
Q

What blood groups are compatible with each other?

A

Group O = all blood types
Group A = A and O
Group B = B and O
Group AB = O and AB

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10
Q

Why is HLA matching important?

A

Matching HLA is critical without immunosuppression and gives better graft survival with immunosuppression

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11
Q

What does HLA matching identify?

A

Sensitisation to subsequent transplants

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12
Q

What are sensitising events?

A

Lead to formation of pre-formed antibodies = blood transfusion, pregnancy/miscarriage, previous transplant

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13
Q

What is desensitisation?

A

Active removal of blood group or donor specific antibody = plasma exchange or B cell antibody (rituximab)

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14
Q

What kind of procedure is a transplant?

A

Extraperitoneal = wound usually 15-20cm long, operation lasts 2-3hrs

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15
Q

Where is the transplant inserted?

A

Iliac fossa = attached to external iliac artery and vein, ureter plumbed into bladder with stent

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16
Q

How long is the recovery from the operation?

A

7-10 days in hospital = usually back to normal activities and work in 3 months

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17
Q

What are some of the complications from surgery?

A

Bleeding, arterial stenosis, venous stenosis or kinking, ureteric stricture and hydronephrosis, wound infection, lymphocele

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18
Q

What are the outcomes after transplantation surgery?

A

Immediate graft function, delayed graft function or primary non-function

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19
Q

How can you tell if there is immediate graft function?

A

Good urine output, falling urea and creatine

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20
Q

What are some features of delayed graft function?

A

Post transplant ATN, often need haemodialysis in interim, usually need biopsy to exclude rejection, works within 10-30 days

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21
Q

What is the outcome of primary non-function?

A

Transplant never works

22
Q

What are the types of transplant rejection?

A

Hyperacute, acute, chronic

23
Q

What causes a hyperacute rejection?

A

Preformed antibodies = unsalvageable, transplant nephrectomy required

24
Q

What causes acute rejection?

A

Cellular or antibody mediated = can be treated with increased immunosuppression

25
Q

What causes chronic rejection?

A

Antibody mediated = slowly progressive decline in renal function, poorly responsive to treatment

26
Q

What is the aim of anti-rejection therapy?

A

To reduce T cell activation

27
Q

What is some of the immunotherapy given around the time of the operation?

A

Induction therapy = basiliximab, dacluzimab

IV prednisolone during operation

28
Q

What are some immunosupressives that can be given as maintenance therapy?

A

Prednisolone, tacrolimus and MMF

Prednisolone, cyclosporin and azathioprine

29
Q

What are some anti-rejection treatments?

A

Pulsed IV methylprednisolone (ACR)
Anti-thymocyte globulin (resistant ACR and AMR)
IV immunoglobulin (AMR)
Plasma exchange (AMR)
Rituximab, bortezimab, eculizumab (AMR) and intensification of immunosuppression

30
Q

What are some features of the infections that transplant patients can get?

A

Side effect of suppression, give prophylaxis of PJP
Bacterial = common, UTI, LRTI
Viral = CMV, HSV, BK
Fungal

31
Q

What is an important cause of morbidity in the first three months after a transplant?

A

CMV infection = associated with early graft loss, common if recipient isn’t immune but donor has evidence of previous infection

32
Q

What can CMV infection cause?

A

Renal and hepatic dysfunction, oesophagitis, pneumonitis, colitis, increased risk of rejection

33
Q

What evidence suggests CMV infection?

A

IgM and PCR positive

34
Q

What is the treatment for CMV infection?

A

Prophylactic oral valangciclovir if high risk

IV ganciclovir if evidence of infection

35
Q

Where is BK nephropathy common?

A

Prevalent and indolent in the uro-epithelium

36
Q

What does BK nephropathy reflect?

A

Over-immunosuppression = can mimic rejection

37
Q

How is BK nephropathy treated?

A

No effective anti-viral therapy = treat by reducing immunosuppression
Monitor blood viral load by PCR

38
Q

What are some common malignancies linked with transplants?

A

Non-melanoma skin cancers, lymphoma, solid organs

39
Q

What does post-transplant lymphoproliferative disease depend on?

A

Level of immunosuppression = can occur in all types of transplant

40
Q

What is post-transplant lymphoproliferative disease usually related to?

A

EBV infection = causes polyclonal B cell proliferation then monoclonal proliferation, leads to lymphoma

41
Q

How is post-transplant lymphoproliferative disease treated?

A

Reduce immunosuppression and give chemotherapy

No role for antiviral therapy

42
Q

What are patients assessed for post-transplant?

A

Rejection, hypertension and CV risk, chronic allograft nephropathy, UTI, recurrent primary renal disease, malignancy, viral-mediated graft dysfunction, CKD

43
Q

What are some causes of graft loss?

A

Acute rejection, death with functioning graft, recurrent disease, chronic allograft nephropathy, viral nephropathy, PTLD

44
Q

What are some examples of induction monoclonal antibodies?

A

Basiliximab and dacluzimab = block IL-2 receptor on CD4+ T cells

45
Q

What is the purpose of induction monoclonal antibodies?

A

Prevent activation of CD4+ T cells to prevent rejection = not useful if rejection has already started

46
Q

What is the action of glucocorticoids?

A

Inhibit lymphocyte proliferation, survival and activation = suppress cytokines

47
Q

What are some side effects of glucocorticoids?

A

Weight gain, diabetes, osteoporosis

48
Q

What are some examples of calcineurin inhibitors?

A

Tacrolimus and cyclosporin = inhibit T cell activation to prevent cytokine release

49
Q

What are some side effects of calcineurin inhibitors?

A

Renal dysfunction, hypertension, diabetes, tremor

50
Q

What are some examples of anti-metabolites?

A

Azathioprine and mycophenolate mofetil (MMF)

51
Q

What is the action of anti-metabolites?

A

Block purine synthesis = suppress lymphocyte proliferation

52
Q

What are some side effects of anti-metabolites?

A

Leucopenia, GI upset, anaemia

Renal (36 decks)

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