Transplant

Question 1

ABO blood compatibility is necessary for all transplants except?

Answer 1

liver

Question 2

Which HLA are most important for compatibility?

Answer 2

HLA A
HLA B
HLA DR (most important overall)

Question 3

Hyperacute rejection

Answer 3

result of preformed anti-HLA antibodies that bind the allograft endothelium leading to vascular thrombosis and ischemic necrosis

Remove allograft immediately

Question 4

accelerated rejection

Answer 4

sensitized T cells that produce a secondary immune response

usually within 1 week of transplant

treat with pulse steroids and muromonab-CD3 (OKT3)

Question 5

acute cellular rejection

Answer 5

cell mediated and involves T lymphocytes (cytotoxic and helper)

usually at 1 week to 1 month after transplant

treat with high dose methylprednisolone

or

treat with anti lymphocyte preparation

Question 6

Chronic rejection

Answer 6

fibrotic process mediated by T and B cells

weeks to years after transplant

suggest humeral immune response

treat w/plasmapharesis, IVIG, rituximab to treat antibody mediated rejection

Question 7

immunosuppression therapy usually has

Answer 7

a calcineurin inhibitor
anti proliferative agent
steroids

Question 8

corticosteroids

Answer 8

dampen immune response by preventing lymphocytes from proliferating and neutrophils from migrating

Question 9

anti proliferative agent/anti metabolite

Answer 9

azathrioprine

mycophenolic acid

Question 10

azathioprine

Answer 10

purine analog that alters DNA and RNA synthesis inhibiting T and B lymphocyte proliferation

used for maintenance therapy

Question 11

mycophenolate (Cell cept)

Answer 11

selectively inhibits lymphocyte proliferation and suppresses T and B lymphocytes

maintenance therapy

Question 12

Calcineurin inhibitors

Answer 12

cyclosporine

tacrolimus

Question 13

mTOR inhibitors

Answer 13

sirolimus

everolimus

Question 14

cyclosporine

Answer 14

inhibits IL-2 production preventing initiation of T cell proliferation

maintenance therapy

Question 15

tacrolimus

Answer 15

10-100 times stronger than cyclosporine

inhibits IL-2

maintenance therapy

Question 16

sirolimus

Answer 16

anti-T cell agent that inhibits mTOR molecule
blocks T cell signal transduction

maintenance therapy

Question 17

everolimus

Answer 17

mechanism and toxicity similar to sirolimus but with great bioavailability

maintenance therapy

Question 18

CMV

Answer 18

can happen at any time but MC 1-4 months post transplant in the absence of prophylaxis

Question 19

dx CMV by

Answer 19

peripheral blood PCR or serologic assays

Question 20

tx of CMV

Answer 20

decreasing immunosuppression

ganciclovir (inhibits DNA synthesis)

Question 21

EBV

Answer 21

can infect B cells at any time after transplant and can be associated with developing PTLD (type of lymphoma usually of monoclonal B cell origin)

Question 22

dx of EBV

Answer 22

physical exam
EBV serology
CT head/chest/abdomen to look for lymph nodes, biopsy

Question 23

tx of EBV

Answer 23

reducing or withdrawing immunosuppression

Question 24

HSV

Answer 24

for renal transplant patients if not on ganciclovir, are given ppl dose of acyclovir

active infections treated with decreasing immunosuppression and acyclovir

Question 25

BK virus

Answer 25

member or polyoma virus family about 90% are seropositive develops in 30% of kidney transplant persistent viremia leads to BK nephropathy which occurs in 10% of transplants in first year no effective tx

Question 26

oral candidiasis

Answer 26

prevented or tx with oral nystatin or fluconazole

Question 27

esophageal candidiasis

Answer 27

treated w/short course of IV amphotericin B or fluconazole

Question 28

serious fungal infections

Answer 28

tx with amphotericin B can also consider capsofungin and anidulafungin (less nephrotoxic)

Question 29

cancers that arise in transplant patients at higher frequencies

Answer 29

``` squamous cell carcinoma basal cell carcinoma kaposi sarcoma lymphomas hepatobiliary carcinoma cervical carcinoma ```

Question 30

Liver allocation is based on

Answer 30

MELD score which predicts 3 month mortality in patients with liver disease given to patients with the highest MELD score

Question 31

MELD score includes

Answer 31

bilirubin creatinine INR ranges from 6-40

Question 32

brain death

Answer 32

absence of pupillary, corneal, vestibule-ocular, and gag reflexes can also do blood flow scan, arteriography, apnea test

Question 33

cold ischemia time for livers

Answer 33

less than 6 hours

Question 34

cold ischemia time for kidneys

Answer 34

less than 24 hours

Question 35

donor livers can be preserved up to

Answer 35

12 hours

Question 36

donor kidneys can be preserved up to

Answer 36

40 hours

Question 37

Early poor function of transplanted kidney

Answer 37

reversible ATN must get renal doppler U/S of tech 99 scan to show good vascular patency

Question 38

lymphocele

Answer 38

lymphatic leak into retroperitoneum after kidney transplant occur 1-2 weeks after Dx with U/S Tx symptomatic lymphocytes with drainage into peritoneum via lap or open

Question 39

renal artery/vein thrombosis

Answer 39

occur first 1-3 days after transplant if transplant kidneys works then stops all of the sudden suspect thrombosis rapid rise in Cr, graft swelling, local pain Dx with tech 99 renal scan or doppler U/S must repair immediately or graft will be lost and transplant nephrectomy will be needed

Question 40

urine leak

Answer 40

anastomotic leak or ureteral sloughing secondary to ureteral blood supply disruption pain, increase Cr, possibly urine draining from the wound get renal scan showing radioisotope outside the urinary tract treat with foley to reduce intravesical pressure and subsequent surgical exploration

Question 41

kidney rejection

Answer 41

inversely correlated with degree of HLA matching treat with pulse steroids

Question 42

cyclosporin is associated with

Answer 42

gallstone formation (tacrolimus too) hirsutism gingival hyperplasia thrombocytopenia

Question 43

which meds are associated with diarrhea, anemia, leukopenia, and neutropenia?

Answer 43

mycophenolate and azathioprine

Question 44

impaired wound healing, thrombocytopenia, mouth ulcers, delayed graft function, interstitial lung disease

Answer 44

mTOR inhibitor (sirolimus and everolimus)

Question 45

MCC of OPSI

Answer 45

pneumococcus (even if had vaccine)

Question 46

biliary strictures

Answer 46

late hepatic artery thrombosis | initially treat non op but retransplant is typically needed eventually to avoid infectious complications

Question 47

MC incision used for liver transplant

Answer 47

bilateral subcostal incision with midline extension to xiphoid process

Question 48

MC methods used for recipient hepatectomy during orthotropic liver transplant

Answer 48

bicaval technique piggyback technique cavocavostomy (side to side caval technique)

Question 49

benefit of cavocavostomy anastomosis with liver transplant

Answer 49

shorter vena caval clamping time minimal changes to HD as the clamp is placed longitudinally only clamping anterior third of vena cava up to 1/2 lumen, lower incidence of caval stenosis lower risk for hepatic vein outflow complications d/t larger anastomosis

Question 50

benefit of piggbag method for liver transplant

Answer 50

requires single vena caval anastomosis which limits warm ischemic time

Question 51

Treatment for post transplant lymphoproliferative disorder

Answer 51

rituximab monoclonal antibody to CD20 | leads to complement and antibody mediated B cell death

Question 52

absolute contraindications for liver transplant

Answer 52

recent intracranial hemorrhage elevated intracranial pressures active substance or alcohol abuse current or recent extra hepatic malignancy uncontrolled sepsis inadequate social and financial support prohibitive cardiopulmonary disease including right heart failure

Question 53

cardiac allograft rejection commonly presents

Answer 53

asymptomatically Dx with perc biopsy steroids are main treatment