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1
Q

what are spectrum of CMV disease?

A

CMV infection with syndrome: fever, fatigue, leukopenia, low plt)
tissue invasive CMV disease: pneumonitis, hepatitis, colitis, esopahgitis, cholecystitis, duodenitis, retinitis, CNS, AKI

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2
Q

common timing of CMV disease?

A

1-4m post CRT, chorioretinitis usually late

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3
Q

CMV association?

A 
acute and chronic rejection
PCP, candida, aspergillus
HHV6 / HHV7 reactivation
HCV
NODAT
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4
Q

Risk factor for CMV?

A 
CMV+ donor to CMV- recipient
ATG use
comorbid
neutropenia
rejection
MMF
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5
Q

CMV prevention?

A

pre-emptive: Tx if pp65 > 40
prophylaxis (if D+): 3m valgan 900 daily or 6m if depleting Ab used or D+R- (covered with ganciclovir 5mg/kg/d when induction)
Acyclovir 400mg bd x 3m if both - (for HSV)

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6
Q

CMV Tx?

A

Valgal 900mg bd
If severe / high viral load / GI absorption problem: ganciclovir 5mg/kg Q12H IV
Treat till s/s subsided, negative pp65 / QNAT / min 2 weeks
reduce immunosuppresant
2nd prophylaxis 1-3m (Valgan 450-900mg daily)

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7
Q

refractory CMV Tx?

A

IVIG
UL97: cidofovir / foscarnet
UL54: multiple drug resistance
Letemovir

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8
Q

ganciclovir S/E?

A 
low WCC / plt
fever, rash, seizure, nausea, myalgia
dLFT, pancreatitis
increase seizure with imipenem
BM suppression with AZA, MPA, septrin
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9
Q

highest prvalance of BKV?

A

2-3m viruria, 3-6m viremia

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10
Q

cutoff for serum BK?

A

10000 copies /ml

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11
Q

BKN patho?

A

BK inclusion in tubular cell nuclei, glom parietal epithelium, insterstitial mononuclear inflam with plasma cell, degenerative change in tubule, focal tubulitis

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12
Q

BKV Tx?

A 
reduce or stop MPA / AZA
reduce CNI / steroid
FK switch to CsA or SRL
? MMF to SRL or leflunomide
? cidovovir, leflunomide, FQ
IVIG
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13
Q

BKVN + rejection Tx?

A

Tx acute rejection then decrease maintenance immunosuppresion
IVIG
CNI to mTOR switch or antiviral agent

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14
Q

Who needs INH prophylaxis?

A

Hx of tuberculin test+ or IFN gamme+
Hx of TB disease without adequete treatment
old granulomatous disease on CXR and epi risk factor
known prolonged exposure with active TB
In endemic areas
known history of past treated TB

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15
Q

What is duration of INH prophylaxis?

A

9 months

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16
Q

How to Tx MMF related GI S/E?

A

dose reduction
into 4 divided dose
EC MPS

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17
Q

fungal prophylaxis post CRT?

A

PO nystatin during 1st month

fluconazole if liver / pancreas Tx or after ATG

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18
Q

Norovirus post CRT Tx?

A

supportive
antimotility
reduce immunosuppresant
nitazoxanide (anti protozoan)

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19
Q

post CRT malignancy which are common?

A

EBV related: HL, NHL
HHV8 related: kaposi
HBV / HCV related: liver
HPV related: cervix, vulva, vagina, penis, anus, oral, non melanocytic skin

20
Q

malignancy no need wait time for CRT?

A 
T1 incidental RCC
CIS bladder
CIS cervix
microscopic prostate
non melanoic non metastatic skin
21
Q

malignancy CI to CRT?

A

MM
uncontrolled CA
CA colon Duke D
CA breast stage III

22
Q

PTLD common time?

A 
1st year (median 18m) after CRT
EBV- generally late (>5yr)
23
Q

PTLD risk factors?

A

organ: kidney 1%, 33% in SB / multiple organ
Age: common in children
IC use: CNI, mTOR protective ? but conflicting results
MMF / AZA unrelated
ATG increase risk but not IL2 / CD52 alemtuzumab
balatacept (costimulatory blocker) CI if EBV-
EBV D+R-
HCV+

24
Q

PTLD sym?

A

fever, night sweat, weight loss
respi: tonsillar / gingival, lung infection, mass
GI: diarrhea, pain, perforation, bleeding, mass
LN
CNS

25
PTLD Tx?
reduce or off MMF, CsA, FK ? mTOR switch RTX chemo if above 2 unresponsive, aggressive, CHOP based surgery +/- RT for local disease Acyclovir / ganciclovir unproven benefit adoptive immunotherapy with EBV specific T cell new
26
prognositc factor of PTLD?
poor WHO performance status 3-4 (chairbound), late onset disease, high LDH, CNS disease, severe organ dysfunction, AKI at diagnosis, T cell disease
27
prevention of PTLD?
? monitor EBV and preemptive IC reduction +/- ganciclovir ? RTX to prevent transmission D+R- prophylactic antiviral not useful
28
BCC / SCC more common in CRT?
SCC
29
CA after CRT Mgt?
CNI to mTOR or CNI minimization with mTOR metastatic cancer IC change probably futile and increase rejection mTOR switch useful in skin cancer / RCC but other CA unknown
30
What is ECD?
``` DBD with > 60y/o or > 50y/o with 2/3 of: - HT - CVA - Cr > 130 ```
31
KDRI parameters?
Age, Ht, Wt, Race, HT, DM, HCV, CKD, DCD, mode of death
32
CRT Recipient workup?
Infection: HBV, HCV, HIV, EBV, CMV, TB (CXR) Malignancy: age appropriate pap, mammogram, PSA Sensitization: HLA typing, ABO, Ab screening CV: ECG, LFT, CaPO4, PTH Review prior CKD diagnosis
33
CA that needs to wait > 5 years before CRT?
Breast III, CRC Duke C, Extensive cervical, melanoma, symptomatic RCC
34
Decreased donor criteria for donating?
GFR > 60, proteinuria < 0.5
35
CRT living donor workup?
Infection: HBV, HCV, HIV, EBV, CMV, Syphilis, TB Malignancy: Age appropriate pap, mammogram, PSA Sensitization: HLA typing, ABO Renal: RFT, urine RBC, TP/CR ratio CV risk: ECG, CaPO4, PTH, urate
36
renal stone CI as donor?
< 1.5mm, not bilateral / recurrent
37
post CRT AKI causes?
< 1 week: hypoVol, ureteric leak / obstruction, TRAS / RVT, ATN, accelerated rejection < 12 weeks hypoVol, rejection, infection (BK, CMV, bacterial), drug (CNI), recurent disease, vascular thrombosis, ureteric obstruction > 12 weeks hypoVol, rejection, infection (BK, CMV, bacterial), drug (CNI), recurent disease, vascular thrombosis, ureteric obstruction, PTLD, CAN
38
TMA post CRT cause?
``` CNI induced ABMR infection: HIV, CMV, B19 SLE / APS HUS / TTP ```
39
PCP Tx and Px?
Septrin 15mg/kg x 21 days (SE nephrotoxic, pancreatitis, BM supp) + steroid if severe (Pred 60mg / day) IV pentamidine 4mg/kg/d clindamycin 600mg QID + primaquine 30mg daily Px: Septrin 480mg daily x 6m Pentamidine IN 300 monthly
40
CsA SE?
``` Renal: nephrotoxic, RTA4, HT Haemat: TMA Metabolic: HT, DM, dyslipidemia, gout Dermato: gum hypertrophy, hirsutism Neuro: myopathy, tremor, encephalopathy ```
41
FK SE?
``` Renal: nephrotoxicity, RTA4 GI: diarrhea haemat: TMA Metabolic: HT, DM, Dermat: alopecia Neuro: Encephalopathy, tremor, myopathy ```
42
MMF SE:
GI: diarrhea, gastritis, oral ulcesr Neuro: PML Haemat: pancytopenia
43
AZA SE
GI | Haemat pancytopenia
44
mTOR SE
``` Nephrotoxic with CNI Delayed wound healing, stomatitis Proteinuria TMA pneumonitis reflex sympathetic dystrophy ```
45
rejection Tx?
TCMR: MP 500mg x 3 ATG 1-1.5mg/kg IV x 7-14days if Banff II or III, or alemtuzumab 30 - 60mg daily x 1/2 at day 2 ``` ABMR: TPE 1-1.5 PV x 5 sessions alt day IVIG 100 -200mg/kg post TPE RTX if refractory Bortezomib 1.3mg/m2 x 4 over 1-2wk Eculizumab 600 - 1200mg / week x 4 (for prevention in XM+) ``` To FK / MMF / Pred
46
AIN in CRT?
Rejection Infection: BK Drug

Renal (10 decks)

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