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transplant Flashcards

1
Q

most important HLA for recipient/donor matching?

A

HLA-DR***, A and B (on all nucleated cells)
type IV hypersensitivity

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2
Q

what does cross match entail? reagents.

A

recipient serum with donor lymphocytes.
to r/o hyperacute rejection.= type II hypersensitivity

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3
Q

1 and 2 malignancy after transplant

A

squamous skin ca&raquo_space;> PTLD (EBV)

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4
Q

how to tx post-txp EBV

A

reduce immunosuppression; and rule out PTLD

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5
Q

how to tx PTLD

A

decrease immunosuppression
rituximab (anti CD20) decrease
+/- chemotherapy or XRT to decrease size of tumor

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6
Q

mycophenalate mofetil MOA?

A

inhibit de novo purine synthesis to stop T CELL GROWTH.

adverse: GI mostly, nausea, dyspepsia, diarrhea, bloating, leukopenia, anemia, thrombocytopenia (PANCYTOPENIA!)

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7
Q

cyclosporin MOA?

A

binds cyclophilin to inhibit calcineurin to decrease cytokine (IL-2) synth.
metabolism: LIVER.

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8
Q

tacrolimus MOA?

A

like cyclosporin (calcineurin inhibitor/IL-2) but more potent. via FKBP/p450.
metabolism: less LIVER.

adverse: tremor, HA, seizure, nephrotox, HTN, alopecia, hyperK, hypoMg, GI sx, DM

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9
Q

what txp med has more DM, GI, mood changes?

A

tacrolimus

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10
Q

cyclosporine vs tacrolimus excretion

A

LIVER… but more in cyclosporine

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11
Q

sirolimus MOA?

A

binds FKBP like tac but inhibits mammalian target of rapamycin (mTOR) to decrease T and B cell response to IL-2.
LESS* NEPHROTOX* compared to tac or cyclosporin.

side effects: hyperTg, impaired wound healing, thrombocytopenia, leukopenia, anemia

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12
Q

sirolimus side effect?

A

interstitial lung dz and wound healing issues

has no nephrotoxicity (unlike tacrolimus and cyclosporine)

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13
Q

antithymocyte globulin MOA?

A

POLYCLONAL Abs against T cell antigens CD2,3,4…. then cytolytic (via COMPLEMENT)

SE: cytokine release syndrome, PTLD, myelosuppression

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14
Q

types of rejection?

A

hyperacute, accelerated, acute cellular, acute humeral, chronic.

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15
Q

hyperacute rejection?

A

min-hrs = preformed Abs Type II (I.e. ABO)
tx: re-transplant

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16
Q

accelerated rejection?

A

<1 wk = sensitized T cells to donor HLA
tx: increase Rx, steroids

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17
Q

acute cellular rejection?

A

after 1 wk.
T cells to HLA Ag
tx: immunosuppresion

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18
Q

acute humeral rejection?

A

after 1 wk.
Abs to donor Ags
tx: steroids, Ab therapy, plasmapharesis.

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19
Q

chronic rejection?

A

mos-years.
Abs formed and T cells sensitized… partially type IV +Ab formation
MC: HLA incompatibility
tx: immunosuppresion, retxp

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20
Q

new proteinuria after kidney txp?

A

renal vein thrombosis.

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21
Q

pathology of acute rejection in kidney txp?

A

1-6 mos…
Bx: tubulitis (vasculitis with more severe form), lymphocytic infiltration of the graft… membrane damage… apoptosis of graft cells

sx: fever, chills, malaise, arthralgia, AKI obv

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22
Q

5 yr kidney graft survival?

A

70%.
65 cad, 75 liv

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23
Q

MC cause of death after kidney transplant?

A

MI

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24
Q

how long extended survival after kidney transplant?

A

15 years.

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25
UC and liver txp?
cannot txp if active ulcerative colitis.
26
MC cause of liver txp?
HCV.
27
what MELD has survival benefit after txp?
> 15.
28
HBV treatment after liver txp?
HBIG and lamivudine to prevent re infection.
29
MC arterial anomaly in liver txp?
RHA off SMA
30
early vs late hepatic aa thrombosis sx?
early: fulminant hepatic failure. late: biliary strictures (blood supply from aa) and **MC: ABSCESSES**
31
acute rejection in liver txp?
T cells against blood vessels path: portal triad lymphocytosis, endothelitis, bile duct injuries
32
chronic rejection in liver txp?
disappearing bile ducts (Ab and T cells attack ducts) and get obstruction with portal fibrosis
33
5 yr survival rate liver txp
70%.
34
how long does it take for liver to regenerate?
6-8 weeks.
35
what is donor hepatectomy in adult vs child?
adult: RIGHT lobectomy child: left lateral (2 + 3)
36
pancreatic txp arterial and venous supply from donor?
celiac aa and SMA; portal
37
pancreatic enteric supply from donor?
D2 with ampulla and pancreas (anastomose: donor duo to recipient bowel)
38
where does pancreas go to txp?
on iliacs.
39
benefits of simult PK txp?
fix retinopathy fix neuropathy fix nerve conduction slowing fix autonomic dysfunction (gastroparesis) fix orthostatic hypotension
40
what will not REVERSE with simult PK txp for DM?
microvascular disease.
41
MC complication after PK txp?
venous thrombosis (hard to tx).
42
rejection signs in PK txp
increase glucose, amylase fever WBC
43
storage of donor organs?
heart: 6 hr lung: 6 hr liver: 24 hr kidney: 48 hr
44
what bx to you get routinely after heart txp?
RV to assess for rejection.
45
acute rejection path in heart txp?
perivascular lymphocytic infiltrate with grades of myocyte inflammation and necrosis
46
cause of early vs late death after heart txp?
early: infection late: chronic rejection = chronic allograft vasculopathy (coronary atherosclerosis)
47
survival increase after heart transplant
transplant <1 yr prognosis... get 10 years (median)
48
survival increase after lung transplant
transplant < 1 yr prognosis... get 5 years (median)
49
cause of early vs late death after lung txp?
early: reperfusion injury like ARDS late: chronic rejection = chronic bronchiolitis obliterans
50
Merkel cell carcinoma
rare cutaneous malignancy that often arises in elderly males and in those with a history of immunosuppression LOCALLY AGGRESSUCE RISK OF METS Tx: WLE 1-2 margin with SLNB Radiate postop if 1+ cm No chemotherapy
51
dx of merkels cell carcinoma
Bx (IHC) [negative]: cytokeratin 20 [negative] and TTF-1 (lung), S100 (melanoma) [positive]: CK and LMW CK markers with paranuclear dot like pattern
52
workup of merkels cell
must r/o regional mets before LN resection
53
living donor risk index favorable factors?
younger than 40, death due to trauma, cold ischemic time less than 8 hours, local organ procurement, and a whole ***non-DCD organ
54
warm ischemia time
cessation of arterial inflow to the kidney to the time of perfusion with preservation solution. The length of warm ischemia time is particularly important in determining postoperative organ function.
55
cold ischemia time
initiation of cold perfusion to the time of reestablishment of arterial inflow in the transplanted kidney
56
how to assess donor kidney function PRECISELY?
Isotropic methods, such as a MAG-3 or DTPA renal scans. measure the glomerular filtration rate (GFR).
57
azathioprine
MOA: adverse: dose related bone marrow suppression (reduce dose, or stop), HEPATOtoxicity, pancreatitis, neoplasia, anemia, pulmonary fibrosis
58
transplant renal artery stenosis
<5% cases 75% of all post transplant vascular complication usually within first 6 mos (can occur whenever tho) dx: duplex, peak systolic > 200 cm/sec = dx >>>> MRA or CTA tx: perc transluminal angioplasty +/- stent
59
muromonab-CD3
antiCD3 murine mab binds CD3 associated with T cell receptor, leading to initial activation and cytokine release followed by blockage
60
basiliximab
anti-CD25 chimeric mab bind IL-2R CD25 on activated T cells preventing IL2 mediated activation
61
alemtuzumab
anti CD 52 humanized mab binds to CD52 expressed on most T/B ... depletes
62
belatacept
CTLA-4 Ig homolob binds CD80/CD86 and prevents costim through CD28
63
testing hepatic arterial flow
if celiac is stenosed, then need to test the SMA-GDA-proper flow before you take the GDA
64
panel reactive antibody
detects preformed RECIPIENT Abs via panel of HLA typing cells (mix donor lymphocytes with recipient serum just like crossmatch) if high PRA, CI to TXP (increased risk of hyperacute rejection)
65
minimal acceptable WBC # in immunosuppression
3K
66
MC complication kidney txp
urine leak
67
MC presentation of a external ureteral compression after txp
lymphocele in 3 weeks.... decreased UOP with fluid collection tx: perc drainage vs peritoneal window
68
pathology of ATN
hydrophobic changes ... dilation and loss of tubules
69
postop diuresis mediators
urea and glucose
70
lab abnormality of acute venous thrombosis after kidney txp
new proteinuria
71
how much life is gained from a kidney txp
15 years
72
5 yr kidney graft survival
70% ; 65% cad, 74% living
73
HCV in retransplanted liver
you'll reinfect itH
74
HBV with treatment in retransplanted
reinfection decrease by 20%
75
pretreatment txp with hepatocellular carcinoma
usually get neoadjuvant chemo with tumor ablation or TACE
76
macrosteatosis
in donor liver... is risk factor for primary nonfunction
77
MC complication liver txp
bile leak
78
Mc cause postop abscess after liver txp
hepatic artery thrombosis
79
cholangitis pathology
PMN around portal triad (NOT A MIXED INFILTRATE OR WHATEVER)
80
liver acute rejection pathology
T cell mediated to blood vessels (HLA Ag in kidney) portal triad lymphocytosis, endothelitis (MIXED INFILTRATE), bile duct injry in 1-2 mos
81
liver chronic rejection pathology
1. disappearing bile ducts (Ab and cellular attack) 2. gradually bile duct obstruction with increase in AlkPhos 3. portal fibrosis
82
retransplantation rate liver
20%
83
5 yr survival rate LIVER
70%
84
how long to regerate liver
6-8 wks
85
indication for heart txp
<1 yr survival
86
pulmonary HTN after heart txp
early mortality tx with inhaled NO (ECMO if severe)
87
acute heart rejection pathology
perivascular lymphocytic infiltrate with varying grades of myocyte inflammation and necrosis
88
exclusion criteria for lung donor
aspiration mod-large contusion purulent sputum infiltrate PO2 < 350 on 100% FiO2 and PEEP 5
89

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