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Transplant > Transplant > Flashcards

Transplant Flashcards

1
Q

HLA-A, -B, -DR

A

most important in recipient / donor matching

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2
Q

HLA-DR

A

most important overall

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3
Q

ABO blood compatibility

A

generally required for all transplants (except liver)

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4
Q

Crossmatch

A

detects preformed recipient antibodies by mixing recipient serum with donor lymphocytes; would generally cause hyperacute rejection (except liver)

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5
Q

Panel reactive antibody

A

technique identical to crossmatch; detects preformed recipient antibodies using a panel of typing cells; get a percentage of cells that the serum reacts with; transfusions, pregnancy, previous transplant, and autoimmune diseases can all increase PRA

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6
Q

Mild rejection

A

pulse steroids

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7
Q

Severe or secondary rejection

A

OKT3 or other drugs

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8
Q

Skin cancer

A

1 malignancy following any transplant (squamous cell CA #1)

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9
Q

Posttransplant lymphoproliferative disorder (PTLD)

A

next most common malignancy following transplant (EBV related)
*tx: withdrawal of immunosuppression; may need chemotherapy and XRT for aggressive tumor

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10
Q

Azathioprine (imuran)

A
  • inhibits de novo purine synthesis, which inhibits T cells
  • 6-mercaptopurine is active metabolite (formed in liver)
  • side effects: myelosuppression
  • keeps WBCs > 3
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11
Q

Mycophenolate (cellcept)

A

inhibits T and B cell proliferation as well as antibody production

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12
Q

Cyclosporin (CSA)

A
  • binds cyclophilin protein and inhibits genes for cytokine synthesis (IL-2, IL-3, IL-4, INF gamma)
  • side effects: nephrotoxicity, hepatotoxicity, HUS, tremors, seizures
  • keep trough 200-300
  • undergoes hepatic metabolism and biliary excretion
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13
Q

FK-506 (prograf)

A
  • binds FK-binding protein; actions similar to CSA but 10-100x more potent
  • side effects: nephrotoxicity, mood changes; more GI and neurologic changes than CSA
  • keep trough 10-15
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14
Q

ATGAM

A
  • equine polyclonal antibodies directed against antigens on T cells (CD2, CD3, CD4, CD8, CD11/18)
  • used for induction therapy
  • complement dependent
  • keeps peripheral T cell count > 3
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15
Q

Thymoglobulin (antithymyocyte globulin rabbit)

A

rabbit polyclonal antibodies that cause immunosuppression by acting against human T cell surface antigens and depleting CD4 lymphocytes

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16
Q

OKT3 (muromonab)

A
  • monoclonal antibodies that block antigen recognition function of T cells by binding CD3, inhibiting T cell receptor complex
  • interferes with both class I and II MHC
  • causes CD3 opsonization that is complement dependent
  • used for severe rejection
  • follows peripheral CD3 cells
  • side effects: fever, chills, pulmonary edema, shock
17
Q

zenapax

A

human monoclonal antibody against IL-2 receptors

*used with induction and to treat rejection

18
Q

Hyperacute rejection

A
  • occurs within minutes to hours
  • caused by preformed antibodies that should have been picked up by the crossmatch
  • activates the complement cascade and thrombosis of vessels occurs
  • tx: emergent retransplant
19
Q

Accelerated rejection

A
  • occurs less than 1 week
  • caused by sensitized T cells to donor antigens
  • produces a secondary immune response
  • tx: increase immunosuppression, pulse steroids, possibly OKT3
20
Q

Acute rejection

A
  • occurs 1 week to 1 month
  • caused by T cells (cytotoxic and helper T cells)
  • tx: increase immunosuppression, pulse steroids, OKT3
21
Q

Chronic rejection

A
  • months to years
  • partially a type IV hypersensitivity reaction (sensitized T cells)
  • antibody formation also plays a role; leads to graft fibrosis and vascular damage
  • monocytes and cytotoxic T cells have a role
  • tx: increase immunosuppression or OKT3, no really effective treatment
22
Q

kidney transplantation

A
  • can store kidney for 48 hours
  • need ABO type and crossmatch
  • UTI - can still use kidney
  • acute increase in creatinine (1.0-3.0), can still use kidney
  • mortality primarily from stroke and MI
  • attach to iliac vessels
23
Q

kidney transplant complications

A
  • urine leaks #1; tx: drainage and stenting usually first, may need reop
  • renal artery stenosis - dx with US; tx: PTA with stent
  • lymphocele - most common cause of external compression; tx: 1st percutaneous drainage; if that fails, then need intraperitoneal marsupialization (90% successful)
  • post op oliguria - usually due to ATN (path shows hydrophobic changes)
  • post op diuresis - usually due to urea and glucose
  • new proteinuria - suggestive of renal vein thrombosis
  • post op diabetes - side effect of CSA, FK, steroids
  • viral infections - CMV tx: ganciclovir; HSV tx: acyclovir
24
Q

Kidney transplant rejection

A
  • acute rejection usually occurs in 1st 6 months; path shows tubulitis or vasculitis with more severe form
  • work up - usually for increase in creatinine; US with duplex (to r/o vascular problem and ureteral obstruction) and biopsy; empiric decrease in CSA or FK (these can be nephrotoxic); pulse steroids
  • chronic rejection - usually do not see until after 1 year; no good treatment
  • 5 year graft survival overall - 70% (cadaveric 65%, living donors 75%)
25
Q

Living kidney donors

A
  • most common complication - wound infection (1%)
  • most common cause of death - fatal PE
  • the remaining kidney hypertrophies
  • kidneys transplanted from deceased pediatric donors aged 5 and below have lower graft survival rates than those from older pediatric and young adult donors; at older extreme of age, graft survival rates are also lower
26
Q

Liver transplantation

A
  • can store for 24 hours
  • contraindications to liver TXP - current ETOH abuse, acute UC
  • chronic hepatitis - most common reason for liver TXP in adults
  • criteria for emergent TXP - stage III (stupor), stage IV (coma)
  • patients with hepatitis B antigenemia can be treated with HBIG (hepatitis B immunoglobulin) and lamivudine (protease inhibitor) postoperatively
  • hepatocellular CA - if single tumor < 5 cm or up to 3 tumors each < 3 cm, can still consider TXP
  • portal vein thrombosis - not a contraindication to TXP
  • APACHE sore - best predictor of 1 year survival
  • hepatitis C - disease most likely to recur in the new liver allograft; reinfects essentially all grafts
  • hepatitis B - reinfection rate has been reduced to 20% with the use of HBIG
  • ETOH - 20% will start drinking agin (recidivism)
  • Macrosteatosis - extracellular fat globules in liver allograft; #1 predictor of primary nonfunction; if 50% of cross section is macrosteatatic in potential donor liver, there is a 50% chance of primary nonfunction
  • duct to duct anastomosis is performed
  • hepaticojejunostomy in kids
  • biliary system depends on hepatic artery blood supply
  • most common arterial anomaly - right hepatic coming off SMA
27
Q

Liver Transplant complications

A
  • bile leak #1; tx: PTC tube and stent
  • primary nonfunction: 1st 24 hours - total bilirubin > 10, bile output < 20 cc / 12h, PT and PTT 1.5 x normal; after 96 hours - hyperkalemia, mental status changes, increase LFTs, renal failure, respiratory failure; usually requires retransplantation
  • hepatic artery thrombosis - tx: angio (potentially treated with angiography and balloon dilation +/- stent), surgery, retransplantation; hepatic vein thrombosis rare
  • abscesses - most common from chronic hepatic artery thrombosis
  • IVC stenosis - edema, ascites, renal insufficiency
  • cholangitis - get PMNs around portal triad, not mixed infiltrate
28
Q

Liver transplant rejection

A
  • acute rejection - T cell mediated against blood vessels; — clinical: fever, jaundice, decrease bile output, change in bile consistency
  • labs: leukocytosis, eosinophilia, increase LFTs, total bili, and PT
  • path: shows portal lymphocytosis, endotheliitis (mixed infiltrate), and bile duct injury
  • usually occurs in 1st 2 months
  • chronic rejection - disappearing bile ducts (antibody and cellular attack on bile ducts); gradually get bile duct obstruction with increase in alkaline phosphatase, portal fibrosis (acute rejection most common predictor)
  • retransplantation rate 20%
  • 5 year survival rate 70%
29
Q

Pancreas Transplantation

A
  • need donor celiac and SMA for arterial supply
  • need donor portal vein for venous drainage
  • attach to iliac vessels
  • most use enteric drainage for pancreatic duct; take second portion of duodenum from donor along with ampulla of Vater and pancreas, then perform anastomosis of donor duodenum to recipient bowel
  • successful pancreas/kidney TXP results in stabilization of retinopathy, decrease neuropathy, increase nerve conduction velocity, decrease autonomic dysfunction (gastroparesis), decrease orthostatic hypotension
  • no reversal of vascular disease
30
Q

Pancreas transplant comlications

A
  • thrombosis #1 - hard to treat
  • rejection - hard to diagnose if patient does not also have a kidney transplant; can see increase glucose, amylase, or trypsinogen; fever, leukocytosis
31
Q

Heart transplantation

A
  • can store for 6 hours
  • need ABO compatibility and crossmatch
  • for patients with life expectancy < 1 year
  • persistent pulmonary HTN after heart transplant; tx: Flolan (PGI2); inhaled nitric oxide, ECMO if severe; assoc with increase morbidity and mortality after heart TXP
32
Q

Heart TXP rejection

A
  • acute rejection: shows perivascular infiltrate with increase grades of myocyte inflmmation and necrosis
  • chronic rejection - progressive diffuse coronary atherosclerosis
33
Q

Lung transplant

A
  • can store for 6 hours
  • need ABO compatibility and crossmatch
  • for patients with life expectancy < 1 year
  • # 1 cause of early mortality - reperfusion injury
  • indication for double lung TXP - cystic fibrosis
  • exclusion criteria for using lungs - aspiration, mod to large contusion, infiltrate, purulent sputum, PO2 < 350 on 100% FiO2 and PEEP 5
  • acute rejection - perivascular lymphocytosis
  • chronic rejection - bronchiolitis obliterans
34
Q

Opportunistic Infection

A
  • viral - CMV, HSV, VZV
  • protozoan - Pneumocystis jiroveci (P carinii) pneumonia (reason for Bactrim for prophylaxis)
  • fungal - Aspergillus, candida, cryptococcus
35
Q

Hierarchy for permission for organ donation from next of kin

A
  1. spouse
  2. adult son or daughter
  3. either parent
  4. adult brother or sister
  5. guardian
  6. any other person authorized to dispose of the body

Transplant (1 decks)

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