Transplant

Question 1

Orthotopic vs heterotopic transplant

Answer 1

Orthotopic: transplant graft placed in its anatomic position. Heterotopic: graft placed at different site

Question 2

Brain death declaration criteria for adults

Answer 2

No cerebral function (in coma); no brainstem function (no CN functions, no CN reflexes such as papillary, conreal, cold water calorics, Doll’s eyes, or gag); no spontaneous breathing (as shown by apnea test)

Question 3

Brain death criteria for peds

Answer 3

TWO exams/apnea tests/EEGs 12-48 hrs apart (depending on age, younger needs longer time in between exams)

Question 4

What are the MHC alleles?

Answer 4

MHC I: A, B, C. MHC II: DR, DQ, DP

Question 5

Which of the MHC alleles are used for tissue typing?

Answer 5

A, B, and DR. DR is the most important to match

Question 6

Why does matching paradoxically result in worse outcomes in liver transplant?

Answer 6

HLA presents viral peptides to T cells, and compatibility may potentiate the inflammatory phase of viral reinfection after transplant, increasing chance of recurrence of original disease

Question 7

Steroids

Answer 7

Medium dose for maintenance, high dose for rejection

Question 8

Cyclosporine (CsA)

Answer 8

Calcineurin inhibitor, used for maintenance only. P450 metabolism. Side effects include: nephrotoxicity, HTN, hypertricosis, gingival hyperplasia, hepatoxicity

Question 9

Mycophenolate mofetil (MMF)

Answer 9

Aka Cellcept, used for maintenance or rejection. Works by inhibiting purine metabolism. Side effects: diarrhea, nausea.

Question 10

Azathioprine

Answer 10

Inhibits DNA synthesis. Used for maintenance only. Side effects: leukopenia, hepatotoxicity (don’t use in liver tx)

Question 11

FK-506, aka tacrolimus

Answer 11

Used for maintenance, preferred drug in liver transplant. Calcineurin inhibitor, way more potent than cyclosporine. Side effects: nephrotoxicity, neurotoxicity, diabetogenic

Question 12

Rapamycin

Answer 12

Calcineurin inhibitor. Side effects: hyperTG

Question 13

Antibodies used in transplant management

Answer 13

Antithymocyte globulin (ATG), OKT3 (antibody to CD3). Usually used for rescue in steroid-resistant rejection but also can be used for induction and maintenance.

Question 14

Post-transplant lymphoproliferative disorder

Answer 14

Caused by EBV -> monoclonal B-cell lymphoma. Tx: stop or lower immunosupression, and it can be reversible (not always)

Question 15

Hyperacute rejection

Answer 15

Immediately following graft reperfusion. Caused by pre-existing host antibody binding to donor tissue, initiating complement mediated lysis -> thrombosis of graft. No treatment, graft will be lost. Prevent by ABO typing and negative crossmatch.

Question 16

Delayed vascular rejection

Answer 16

A variant of hyperacute rejection in which the level of host antibodies is too low to be detected by usual assays. Rejection occurs around POD 3

Question 17

Acute rejection

Answer 17

Occurs between POD 5 and 6 months, occurs to some degree in all transplants unless btw identical twins. Due to normal T cell activity. Dx: biopsy. Tx: steroids, immune globulins if refractory. Over 90% of transplants salvaged with treatment.

Question 18

Chronic rejection

Answer 18

Occurs over months to years. Due to cumulative effect of recognition of donor MHC by recipient immune system, likely antibody AND cell mediated.

Question 19

Histology of chronic rejection

Answer 19

Chronic rejection in heart grafts is felt to be manifest by accelerated graft atherosclerosis. Kidneys with chronic rejection have fibrosis (scarring) and damage to the microvasculature. Livers: decreased number of bile ducts on biopsy, “vanishing bile duct syndrome”. Transplanted lungs: “bronchiolitis obilterans” a scarring problem in the substance of the lung.

Question 20

Most common causes of ESRD, adults

Answer 20

1. DM
2. HTN
3. Glomerulonephritis

Peds: congenital uro/renal stuff

Question 21

Complications specific to kidney transplant, early

Answer 21

Delayed graft function (must operate), graft thrombosis (must repair), urine leak (usu at VUJ, must repair), bleeding

Question 22

Complications specific to kidney transplant, late

Answer 22

Lymphocele (perinephric fluid collection compressing iliac vein and ureter, may have to drain), ureteral stricture (rising creatinine, balloon dilate or surgery), renal artery stenosis (HTN, fluid retention, angioplasty or surgery)

Question 23

Delayed graft function

Answer 23

Delayed graft function is a form of acute renal failure resulting in post-transplantation oliguria, increased allograft immunogenicity and risk of acute rejection episodes, and decreased long-term survival.

Question 24

Indication for pancreatic transplant

Answer 24

Type I insulini dependent diabetes,

Question 25

Two types of drainage for pancreatic transplant

Answer 25

Bladder (can measure urinary amylase, if decreased it is sign of rejection) or enteric (pro is no need for bicarb replacement). Equal efficacy, mortality, etc.

Question 26

Preferred immunosuppresive drug in liver transplant

Answer 26

Tacrolimus (remember, nephrotoxic). Also, steroids, azathioprine, cyclosporine. May have steroid + 1-2 calcineurin inhibitor(s), or wean down to just 1 calcineuron inhibitor.

Question 27

Small bowel transplant

Answer 27

This is a thing apparently

Question 28

Most common cause of perioperative death in cardiac transplant?

Answer 28

Infection (PNA, mediastinitis, CLABSI, UTI)

Question 29

Calcineurin inhibitors MOA

Answer 29

Ultimately inhibits release of IL-2, which is necessary for stimulating T cell expansion and differentiation

Question 30

OKT3 side effects

Answer 30

Fevers and headaches from cytokine release. Noncardiogenic pulmonary edema, encephalitis, nephrotoxicity, aseptic meningitis