RRT - Transplant Flashcards by Peter Savage

When are native kidneys removed in transplantation?

Size - Cystic kidneys

Infection - chronic pyelonephritis

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Where are transplanted kidneys placed?

Iliac fossa

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What vascular complications are associated with transplant?

Bleeding
Venous thrombosis
Arterial thrombosis
Lymphocele

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What complications are associated with transplant?

Vascular
Ureteric
Infections

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Which agents are used as immunosuppressives in transplantation?

Corticosteroids
Calcineurin inhibitors
(Tacrolimus, ciclosporin) 
Anti-proliferatives
(Azathioprine, MM)
mTOR inhibitors
(sirolimus)
Costimulatory signal blockers
(Belatacept)
Depleting agents
(-ximab)

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What side effects are associated with corticosteroids?

Hypertension
Hyperglycaemia 
Infections
Bone loss
GI bleed

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What side effects are associated with tacrilimus?

Hyperglycaemia
AKI
tremor

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What side effects are associated with ciclosporin?

Hirsutism
Hypertension
AKI
gout

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What side effects are associated with Mycophenolate mofetil?

Cytopenia

GI upset

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What side effects are associated with sirolimus?

Lipidogenic
Diabetogenic
Pneumonia

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What side effects are associated with Betalacept?

Infections

Malignancy

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What side effects are associated with ATG?

Infections

PTLD

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What drug is used to induce immunosuppression in transplant?

Basiliximab

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What are the immunosuppression protocols in transplant?

Induction
Maintenance
Steroid free if possible

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What drug is used to maintain immunosuppression in transplant?

Tacrolimus
\+
Mycophenolate
\+
Steroids

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What are the different forms of deceased donation?

Donation after brain death

Donation after cardiac death

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What are the different forms of living donation?

Related
Spousal
Altruistic
Paired/pooled

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What are the criteria for brain death?

Coma 
Apnoea off ventilator 
Absence of cephalic reflexes
Body temp >34C
Absence of intoxication

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Which cephalic reflexes are criteria for brain death?

Pupillary
Oculocephalic
Oculovestibular 
Corneal 
Gag
NOT SPINAL

What are the extended criteria for brain death?

Donor age >60y

Donor 50-59 + history HTN, death for cerebrovascular accident or terminal creatinine >132umol/L

Why is it more difficult for asian patients to find donors in the UK?

Asian largely group B

UK mostly A/O

What is paired donation?

Donor A with recipient B,

Donor B with recipient A

How do survival rates of transplant patients compare to dialysis?

Greater risk before 100 days

Lower risk continuing for years

What risks are associated with kidney donation?

Compensatory GFR increase (greater in younger donors)

Older age and high BMI associated with GFR<60

What complications are associated with renal transplantation?

``` Rejection Infection Malignancy New onset DM Hypertension Hyperlipidaemia CRF ```

Hyperacute rejection is associated with what?

Pre-existing alloreactivity to donor

What are the main types of acute rejection?

T-cell mediated (TMCR) | Acute antibody mediated (ABMR)

What classes are used for kidney transplant rejection?

BANFF (1-3)

T-cell mediated rejection is associated with what?

Lymphocytic infiltrate Tubulitis Endarteritis Endothelialitis

Antibody mediated rejection is associated with what?

Microvascular inflammation (neutrophil --> glomeruli, peritubular capillaries) Donor specific antibodies Positive C4d

New onset DM after transplantation is associated with what?

Tacrolimus and steroids

What is the most important transplant-related infection?

Cytomegalovirus | 8% of recipients

How is a transplant patient infected with Cytomegalovirus?

Transmission from donor | Reactivation of latent virus

Which polyomaviridae are associated with transplant?

BK virus JC virus Murine polyoma virus SV40

BK virus is associated with what conditions?

Renal transplant Bone marrow transplant AIDS

How does BK virus present in renal transplant?

Ureteral stenosis Interstitial nephritis ESRF

How does BK virus present in bone marrow transplant?

Haemorrhagic cystitis Pneumonitis Hepatitis

How does BK virus present in AIDS?

``` Nephritis ESRF Retinitis Meningoencephalitis Pneumonitis ```

What are the risk factors for BK associated Nephropathy?

Intensity of immunosuppression Patient determinants Organ determinants Viral determinants

What immunosuppressives are associated with BK associated Nephropathy?

Tacrolimus Mycophenolate mofetil Antilymphocyte globulins

What patient determinants are associated with BK associated Nephropathy?

``` Older age Male gender White ethnicity DM Negative BKV serostatus (children) ```

What organ determinants are associated with BK associated Nephropathy?

Graft injury HLA mismatch Ureteral stents

What viral determinants are associated with BK associated Nephropathy?

Changes in epitopes of viral capsid protein VP-1

How is BK associated Nephropathy managed?

``` 45-80% graft loss Reduce immunosuppression Antivirals - Cidofovir +/- IVIG - Leflunomide ```

What malignancies are associated with renal transpantation?

Renal Non-melanoma skin Non-hodgkins lymphoma Kaposi sarcoma