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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
Q

UC and liver txp?

A

cannot txp if active ulcerative colitis.

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26
Q

MC cause of liver txp?

A

HCV.

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27
Q

what MELD has survival benefit after txp?

A

> 15.

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28
Q

HBV treatment after liver txp?

A

HBIG and lamivudine to prevent re infection.

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29
Q

MC arterial anomaly in liver txp?

A

RHA off SMA

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30
Q

early vs late hepatic aa thrombosis sx?

A

early: fulminant hepatic failure.
late: biliary strictures (blood supply from aa) and MC: ABSCESSES

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31
Q

acute rejection in liver txp?

A

T cells against blood vessels
path: portal triad lymphocytosis, endothelitis, bile duct injuries

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32
Q

chronic rejection in liver txp?

A

disappearing bile ducts (Ab and T cells attack ducts) and get obstruction with portal fibrosis

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33
Q

5 yr survival rate liver txp

A

70%.

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34
Q

how long does it take for liver to regenerate?

A

6-8 weeks.

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35
Q

what is donor hepatectomy in adult vs child?

A

adult: RIGHT lobectomy
child: left lateral (2 + 3)

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36
Q

pancreatic txp arterial and venous supply from donor?

A

celiac aa and SMA; portal

37
Q

pancreatic enteric supply from donor?

A

D2 with ampulla and pancreas (anastomose: donor duo to recipient bowel)

38
Q

where does pancreas go to txp?

A

on iliacs.

39
Q

benefits of simult PK txp?

A

fix retinopathy
fix neuropathy
fix nerve conduction slowing
fix autonomic dysfunction (gastroparesis)
fix orthostatic hypotension

40
Q

what will not REVERSE with simult PK txp for DM?

A

microvascular disease.

41
Q

MC complication after PK txp?

A

venous thrombosis (hard to tx).

42
Q

rejection signs in PK txp

A

increase glucose, amylase
fever
WBC

43
Q

storage of donor organs?

A

heart: 6 hr
lung: 6 hr
liver: 24 hr
kidney: 48 hr

44
Q

what bx to you get routinely after heart txp?

A

RV to assess for rejection.

45
Q

acute rejection path in heart txp?

A

perivascular lymphocytic infiltrate with grades of myocyte inflammation and necrosis

46
Q

cause of early vs late death after heart txp?

A

early: infection
late: chronic rejection = chronic allograft vasculopathy (coronary atherosclerosis)

47
Q

survival increase after heart transplant

A

transplant <1 yr prognosis… get 10 years (median)

48
Q

survival increase after lung transplant

A

transplant < 1 yr prognosis… get 5 years (median)

49
Q

cause of early vs late death after lung txp?

A

early: reperfusion injury like ARDS
late: chronic rejection = chronic bronchiolitis obliterans

50
Q

Merkel cell carcinoma

A

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
Q

dx of merkels cell carcinoma

A

Bx (IHC)
[negative]: cytokeratin 20 [negative] and TTF-1 (lung), S100 (melanoma)
[positive]: CK and LMW CK markers with paranuclear dot like pattern

52
Q

workup of merkels cell

A

must r/o regional mets before LN resection

53
Q

living donor risk index favorable factors?

A

younger than 40, death due to trauma, cold ischemic time less than 8 hours, local organ procurement, and a whole ***non-DCD organ

54
Q

warm ischemia time

A

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
Q

cold ischemia time

A

initiation of cold perfusion to the time of reestablishment of arterial inflow in the transplanted kidney

56
Q

how to assess donor kidney function PRECISELY?

A

Isotropic methods, such as a MAG-3 or DTPA renal scans.

measure the glomerular filtration rate (GFR).

57
Q

azathioprine

A

MOA:

adverse: dose related bone marrow suppression (reduce dose, or stop), HEPATOtoxicity, pancreatitis, neoplasia, anemia, pulmonary fibrosis

58
Q

transplant renal artery stenosis

A

<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
Q

muromonab-CD3

A

antiCD3 murine mab

binds CD3 associated with T cell receptor, leading to initial activation and cytokine release followed by blockage

60
Q

basiliximab

A

anti-CD25 chimeric mab
bind IL-2R CD25 on activated T cells preventing IL2 mediated activation

61
Q

alemtuzumab

A

anti CD 52 humanized mab

binds to CD52 expressed on most T/B … depletes

62
Q

belatacept

A

CTLA-4 Ig homolob

binds CD80/CD86 and prevents costim through CD28

63
Q

testing hepatic arterial flow

A

if celiac is stenosed, then need to test the SMA-GDA-proper flow before you take the GDA

64
Q

panel reactive antibody

A

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
Q

minimal acceptable WBC # in immunosuppression

66
Q

MC complication kidney txp

A

urine leak

67
Q

MC presentation of a external ureteral compression after txp

A

lymphocele in 3 weeks…. decreased UOP with fluid collection

tx: perc drainage vs peritoneal window

68
Q

pathology of ATN

A

hydrophobic changes … dilation and loss of tubules

69
Q

postop diuresis mediators

A

urea and glucose

70
Q

lab abnormality of acute venous thrombosis after kidney txp

A

new proteinuria

71
Q

how much life is gained from a kidney txp

72
Q

5 yr kidney graft survival

A

70% ; 65% cad, 74% living

73
Q

HCV in retransplanted liver

A

you’ll reinfect itH

74
Q

HBV with treatment in retransplanted

A

reinfection decrease by 20%

75
Q

pretreatment txp with hepatocellular carcinoma

A

usually get neoadjuvant chemo with tumor ablation or TACE

76
Q

macrosteatosis

A

in donor liver… is risk factor for primary nonfunction

77
Q

MC complication liver txp

78
Q

Mc cause postop abscess after liver txp

A

hepatic artery thrombosis

79
Q

cholangitis pathology

A

PMN around portal triad (NOT A MIXED INFILTRATE OR WHATEVER)

80
Q

liver acute rejection pathology

A

T cell mediated to blood vessels (HLA Ag in kidney)

portal triad lymphocytosis, endothelitis (MIXED INFILTRATE), bile duct injry
in 1-2 mos

81
Q

liver chronic rejection pathology

A
  1. disappearing bile ducts (Ab and cellular attack)
  2. gradually bile duct obstruction with increase in AlkPhos
  3. portal fibrosis
82
Q

retransplantation rate liver

83
Q

5 yr survival rate LIVER

84
Q

how long to regerate liver

85
Q

indication for heart txp

A

<1 yr survival

86
Q

pulmonary HTN after heart txp

A

early mortality

tx with inhaled NO (ECMO if severe)

87
Q

acute heart rejection pathology

A

perivascular lymphocytic infiltrate with varying grades of myocyte inflammation and necrosis

88
Q

exclusion criteria for lung donor

A

aspiration
mod-large contusion
purulent sputum
infiltrate
PO2 < 350 on 100% FiO2 and PEEP 5

ABSITE (33 decks)

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