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Renal > Transplant > Flashcards

Transplant Flashcards

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
Q

PTLD Tx?

A

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
Q

prognositc factor of PTLD?

A

poor WHO performance status 3-4 (chairbound), late onset disease, high LDH, CNS disease, severe organ dysfunction, AKI at diagnosis, T cell disease

27
Q

prevention of PTLD?

A

? monitor EBV and preemptive IC reduction +/- ganciclovir
? RTX to prevent transmission D+R-
prophylactic antiviral not useful

28
Q

BCC / SCC more common in CRT?

29
Q

CA after CRT Mgt?

A

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
Q

What is ECD?

A 
DBD with > 60y/o
or > 50y/o with 2/3 of:
- HT
- CVA
- Cr > 130
31
Q

KDRI parameters?

A

Age, Ht, Wt, Race, HT, DM, HCV, CKD, DCD, mode of death

32
Q

CRT Recipient workup?

A

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
Q

CA that needs to wait > 5 years before CRT?

A

Breast III, CRC Duke C, Extensive cervical, melanoma, symptomatic RCC

34
Q

Decreased donor criteria for donating?

A

GFR > 60, proteinuria < 0.5

35
Q

CRT living donor workup?

A

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
Q

renal stone CI as donor?

A

< 1.5mm, not bilateral / recurrent

37
Q

post CRT AKI causes?

A

< 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
Q

TMA post CRT cause?

A 
CNI induced
ABMR
infection: HIV, CMV, B19
SLE / APS
HUS / TTP
39
Q

PCP Tx and Px?

A

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
Q

CsA SE?

A 
Renal: nephrotoxic, RTA4, HT
Haemat: TMA
Metabolic: HT, DM, dyslipidemia, gout
Dermato: gum hypertrophy, hirsutism
Neuro: myopathy, tremor, encephalopathy
41
Q

FK SE?

A 
Renal: nephrotoxicity, RTA4
GI: diarrhea
haemat: TMA
Metabolic: HT, DM, 
Dermat: alopecia
Neuro: Encephalopathy, tremor, myopathy
42
Q

MMF SE:

A

GI: diarrhea, gastritis, oral ulcesr
Neuro: PML
Haemat: pancytopenia

43
Q

AZA SE

A

GI

Haemat pancytopenia

44
Q

mTOR SE

A 
Nephrotoxic with CNI
Delayed wound healing, stomatitis
Proteinuria
TMA
pneumonitis
reflex sympathetic dystrophy
45
Q

rejection Tx?

A

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
Q

AIN in CRT?

A

Rejection
Infection: BK
Drug

Renal (10 decks)

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