SM 210 Transplant Flashcards
What group has the highest incidence of ESRD?
Mostly late and middle aged patients
What is the most common treatment for ESRD?
Hemodialysis
What is the best treatment for ESRD?
Pre-emptive kidney transplant
What ethnic groups have higher rates of ESRD?
African and Native Americans
Where is ESRD most prevalent geographic?
Areas with high population density and low SES, which leads to disparities as transplants are based on geographic location
What are the four treatments of ESRD?
Do Nothing
Dialysis
Deceased Donor Kidney Transplant
Living Donor Kidney Transplant
Which group has better survival outcomes, Dialysis or Transplant, in ESRD?
Transplant has much better outcomes and survival
Why do most ESRD patients not get a transplant if it’s the best treatment?
Super long waitlist and not enough supply
What had happened as transplant patients became older?
Over time, older patients were getting on the transplant list and receiving kidneys more often than younger patients because there are many more older patients that needed a kidney
What are the two principles considered by NOTA, the National Organ Transplant Act?
The Principles of Justice and Medical Utility
What is the Principle of Justice?
Recognizing the patients with the greatest need
Pediatric px
Px who wait the longest
Px who are highly sensitized
Who does the Principle of Justice prioritize?
Pediatric px
Px who wait the longest
Px who are highly sensitized (lots of Ab which make matching hard)
What is the Principle of Medical Utility?
Greatest good for most people
Promotes longest survival of organs
Minimizes wastage of organs
What does the Principle of Medical Utility prioritize?
Promotes longest survival of organs
Minimizes wastage of organs
What are the current kidney distribution priorities?
CRPA (antibodies that make it hard to match)
Kidney + extra renal organ (sickest)
Zero antigen match (best possible outcome)
Prior living donors (gave one away already)
Pediatric (most deserving)
What is the first barrier to getting a transplant?
Getting on the transplant list to begin with - you need to have access to healthcare for that, and ESRD effects people of low SES disproportionately
Pro’s and con’s of a waiting time only waitlist?
Predictability for the transplant center on who to contact is an advantage
No effort to maximize outcomes with biologic matching is a disadvantage
Pro’s and con’s of a random lottery?
Advantage of not playing favorites
Disadvantage of being unpredictable in terms of which patients to work up and determine compatibility
Pro’s and con’s of age matching?
Advantage is that it seems fair and uses some biologic factors to maximize outcomes
Disadvantage that donors are younger than candidates, so older candidates get fewer transplants
Also illegal according to DOJ - ageism
What is the current kidney allocation policy?
Waiting time driven system that awards points for HLA matching and gives priority to multi organ and pediatric transplants
Also introduces longevity matching so longest lasting kidneys end up with longest living recipients
Who benefits the most from transplant over dialysis?
Younger people - they live longer with transplant than dialysis
Why do we discard up to 2/3 of kidneys?
Harsh outcomes measures disincentivize using kidneys that aren’t perfect
How has equity changed with the new transplant system?
Equity is improved with the current kidney allocation policy
What is the biggest factor effecting access to transplant?
DSA - where you live
What is paired kidney donation?
Can be an n-way exchange where people give kidneys between pairs so that everyone eventually swaps
What is the Norwood Act?
Act that decriminalized paired kidney donation in the US
What makes some DSA’s better than other’s?
The number of organ procurement organizations, which can speed up delivery of a kidney from a donor to a recipient
What is multi-listing?
Organ waitlists are first come first served, with people signing up for multiple lists and just traveling wherever can get them an organ first - assuming they’re rich
What is the new UNOS liver distribution system?
Based on concentric circles of 250 nautical miles around a hospital
How does the immune system effect transplants?
Immune system recognizes the transplant as foreign and rejects it, so it needs to be suppressed, but not too much or you get opportunistic infectious and malignancy
What immune inhibitors are used for transplants?
Tarcrolimus
Mycophenolate
Steroids or Induction Agents
What potential diseases arise from transplant immunosuppression?
CMV, HSV< BK Polyoma Virus
Lymphoma, Skin Cancer
When are the transplant medicines discontinued after a transplant?
Never - it’s for life, and missing a dose can be dangerous
Is the old kidney replaced?
No, kidney’s are transplanted heterotopically and the old one stays
What can cause elevated creatinine after a transplant?
Medication, dehydration, medication, rejection, allergic reactions
Can a transplant be rejected without creatinine elevations?
Yes
How can subacute rejection be detected without creatinine or biopsy?
Differential gene expression profiles
What is chimerism?
Stem cells are taken from the host and facilitating cells are used to induce tolerance in the transplanted organ, at the risk of graft vs host disease
