Transplant Flashcards
incidence of transplantation
over 120k people waiting for transplant
kidney most sought organ
# of deceased donors stagnant, 8k
deceased donor transplant
brain dead
non-heart beating
living donor
related
unrelated
paired exchange
altruistic
absolute and relative contraindications to receive organs
malignancy active infection active drug/tobacco/illicit drug abuse noncompliance HIV/AIDS (relative) Morbid Obesity (relative)
Cell Mediated immunity includes:
activated t lymphocytes are triggered by cytokines interleukin 2
cytokines are proteins that induce cell mediated and humoral responses
Humoral or antibody immunity
production of antibodies from B lymphocytes
B cell recognizes matching antigen and digest it, binds to MHC molecule then attracts matching T cell that helps B cell multiply and form antibodies
What are cytokines
cytokines are proteins that induce cell mediated and humoral responses
What is the major histocompatibility complex
a group of genetic loci located on the short arm of chromosome 6 that creates the human leukocytes antigen (HLA) which recognize self and nonself
a total of 6 HLA genes are inherited and indentified via tissue typing
What is panel reactive antibody?
measurement of preformed HLA antibodies
elevated PRA may render a pos. crossmatch and may limit chance of transplant
What is a crossmatch
final test to eval. the reactivity of donor to recip.
performed on all renal tx recip. b4 surgery
retrospective crossmatching performed on all other tx
What is Allograft rejection?
When the recip. immune system realizes graft is nonself
Local and systemic immune responses, may lead to inflammation, deterioration of graft fx and eventual necrosis
Hyperacute rejection
Timing
Type of immune response
Rare
Occurs within minutes
Humorally mediated
Rapid tissue necrosis
Accelerated acute rejection
Timing
Type of immune response
Occurs 1-5 days postop
Cellularly and Humorally mediated
Difficult to treat
Acute rejection
Timing
Type of immune response
Occurs within 1st few months but can occure anytime
Cellularly mediated in 90%
Amenable to tx
Chronic organ rejection
Timing
Type of immune response
Cell mediated and humorally initiated injury to the endothelium and vascular sclerosis
Occurs slowly and leads to eventual graft loss
No definitive tx
S and S of rejection
Graft tenderness
Dependent on organ being rejected
What is immunosuppression
The pharmacological manipulation of the immune system performed to prevent or suppress rejection
When is induction therapy administered and what does it consist of
Induction therapy is administered before or after transplantation for up to 2 weeks to delay the onset of the 1st rejection episode or to limit the initial quantity of calcineurin inhibitors
Consists of monoclonal or polyclonal antilymphocyte antibodies
What does maintenance therapy consist of and how long is it done
Maintenance therapy consists typically of a calcineurin inhibitor, a corticosteroid and a antimetabolite
Maintenance therapy must be provided for the life of the allograph
What to avoid while taking calcineurin
Grapefruit juice can increase plasma drug levels
Meds metabolized via cytochrome P450 enzyme
Hypertension with organ transplant
Can be pre existing or calls to by calcineurin inhibitors or corticosteroids
Use calcium channel blocker however single agent therapy is typically not effective
Avoid hypotension with kidney transplant
Post transplant diabetes mellitus
Maybe directly related to corticosteroid use (glycogenesis) and calcineurin inhibitors (decrease insulin resistance)
Associated with higher incidence of graft loss
Must monitor glycemic index closely
Renal insufficiency with organ transplant
Can be due to nephrotoxicity associated with calcineurin inhibitors
Tx is reducing calcineurin dose, Managing high blood pressure and diabetes and avoiding nephrotoxic meds (NSAIDS, Anti-inflammatory drugs, diuretics, and some antibiotics)
Hyperlipidemia with organ transplant
Immunosuppressive agents, ESPECIALLY SIROLIMUS, raise lipid levels
Increases chance of cardiovascular disease and chronic aallograft nephropathy
Common medications for prophylaxis or rejection
Tacrolimus (prograf), cyclosporine, everolomus, sirolimus, azathioprine, mycophenolate, prednisone, solumedrol
Common medications for induction therapy
Basiliximan, alemtuzumab, antithymocyte globulin (ATG, thymoglobulin), solumedrol
Common medications for treatment of rejection
Rituximab, iv immunoglobulin (gamunex, carimune), solumedrol, belatacept
Side effects of calcineurin inhibitors
Tremors, renal dysfunction, high blood sugar, high blood pressure, hirsutism, gingival hyperplasia
What meds cause myopathy in cardiac recipients
Cyclosporine and hmg-coa
Bone dz with organ transplant
Osteoporosis is common complication
Need baseline and annual bone scans
Tx: minimal corticosteroid use, supplemental calcium, biphosphates, hormone replacement
Malignancy with transplant
Increased incidence lymphoma, skin ca and kaposi’s sarcoma
Lymphomas are related to infection with Epstein barr from positive organs
Tx: minimal or cease immunosuppression, give chemo and radiation
Poor prognosis
Leading cause of death in transplant
Infection
Highest risk 1st 6 months postop
Viral infection with transplantation
Biggest threats are cytomegalovirus and denoviris
Monitor with antigenemia and PCR
Prophylactically treat with ganciclovir or valganciclovir
Fungal infection with transplantation
Most common is candida in liver transplant and aspergillus in lung transplant
Prophylaxis with fluconazole or itraconozole
Give Bactrim from pneumocystis
Bacterial infection with transplantation
Most common type of infection with transplantation
Most common mycobaxterium, tb, pseudomonas, listeria
Hyperacute rejection
rare
occurs within minutes
humorally mediated
rapid tissue necrosis
accelerated acute rejection
occurs 1-5 days postop
cellularly and humorally mediated
difficult to treat
acute rejection
cellularly mediated in 90%
typically occurs within 1st few months but may occur anytime
amenable to tx
chronic rejection
cell mediated and humorally initiated injury to the endothelium and vascular sclerosis
occurs slowly and leas to evenual graft loss
no definitive tx
gold standard for diagnosis of organ rejection
biopsy of allograft
alternative tests are organ specific
tx for organ rejection
high dose corticosteroids, optimizing immunosuppresant regimen and antilymphocytic therapy
subjective findings for kidney rejection
decreased urine output, chills, arthralgias/myalgias, graft tenderness, may be symptomatic
objective findings for kidney rejection
elevated BUN and creatinine, increased resistive indices on US
Subjective findings for liver rejection
fatigue, pruritis, graft tenderness
objective findings for liver rejection
elevated liver enzymes, bilirubin, dark colored urine, jaundice, ascities
subjective findings for lung rejection
cough, sob, fatigue
objective findings for lung rejection
fever, pulmonary effusions and infiltrates, decrease in spirometry, hypoxemia
subjective findings for heart rejection
fatigue, exercise intolerance, sob
objective findings for heart rejection
atrial arrhythmias, new s3, friction rub, JVD, edema, pulmonary edema
subjective findings for pancreas rejection
graft tenderness
objective findings for pancreatic rejection
elevated amylase and lipase, hyperglycemia (late), elevated creatinine (if kidney/pancreas recipient
subjective findings for intestine rejection
malaise, abdomen pain, change in stools, nausea, vomiting
objective findings for intestine rejection
endoscopic eval may reveal edema , erythema, and reduced peristalsis, serum citrulline may be marker for rejection
