TRANSPLANT Flashcards
1
Q
Class I HLA antigen are found on what cells
A
all nucleated cells
2
Q
Class II HLA are found on wet cells
A
antigen presenting cells: Macrophage Dendritic cells B. lymphocytes Monocytes
3
Q
corticosteroid
use, mechanism, side effects
A
maintenance, rejection
IL1 released
Posttransplant diabetes, hypertension, osteonecrosis, Cushing’s
4
Q
azathioprine
use, mechanism, side effects
A
maintenance
Azathioprine (purine) block
Inhibits nuclaic acid syntheis (DNA) - the we will do him suppressing proliferation of activated B and T-cells
bone marrow depression, hepatic venoocclusive disease, pancreatitis, RBC achalasia, arthralgia
5
Q
cyclosporine
use, mechanism, side effects
A
maintenance
C=C CALCINEURIN cyst is in
L2 secretion and formation inhibition
Inhibits calcineurin
Nephrotoxic-interstitial fibrosis and arteriolar lesions blood Hepatotoxicity Hypertension Hyperkalemia Hirsutism Gingival hyperplasia Tremors Headache
6
Q
drug inhibits IL-2 synthesis
A
tacrolimus
7
Q
tacrolimus
use, mechanism, side effects
A
(FK506, Prograft)
maintenance refractory rejection (rescue)
IL-2 synth / production
Nephrotoxic
Glucose intolerance
Neuro toxic
hypertension
8
Q
mycophenolate mofetil
use, mechanism, side effects
A
(CellCept)
Maintenance
Inosine monophosphate dehydrogenase inhibition
Neutropenia
GI
9
Q
Sirolimus
use, mechanism, side effects
A
maintenance
TOR inhibitor
( target of rapamycin)
THROMBOCYTOPENIA
neutropenia
Impaired wound healing
Dyslipidemia
10
Q
OKT3
use, mechanism, side effects
A
(Monoclonal antibody)
treatment of rejection
Depletion of T cells
receptors surface T-cell
fever/chills
Pulmonary edema
LYMPHOPROLIFERATIVE disorder
11
Q
Polyclonal anti-lymphocyte
use, mechanism, side effects a
A
induction therapy
treatment of rejection
Decreased lymphocytes
ANAPHYLAXIS Leukopenia Thrombocytopenia LYMPHOPROLIFERATIVE disorder cytokine release syndrome Fever
12
Q
Daclizumab and Basiliximab
A
induction therapy
IL2 receptor blockade
Minimal
13
Q
how does cyclosporine inhibit T-cell activation
A
inhibit calcineurin As primary mechanism secondary effect is IL-2
14
Q
University of Wisconsin solution
A
raffinose
hydroxyethyl starts
lactobionate
15
Q
rejection and start on postoperative day 2
A
accelerated acute rejection
16
Q
Hyperacute rejection
A
minutes to hours
Antibody mediated
Preformed antibiotics to ABO blood blood group or HLA antigens
In the field and necrosis Vascular thromboses Flaccid Cyanotic anuric PMNs packed and peri-capillary
17
Q
Accelerated acute rejection
A
Days
Memory response to prior sensitization
Rare difficult to control
Early graft loss
Cellular and antibody mediated injury
More, and went recipient has been sensitized by previous antigen exposure
Kidney-oliguria
disseminated intravascular coagulation
Thrombocytopenia
Hemolysis
Swollen organ
Tender
Congestive
Arterial necrosis
Perry vasculitis
Glomerular basement membrane CD4 deposition
18
Q
acute rejection
A
days to months
Predominantly cell-mediated:
Lymphocytes
19
Q
Chronic rejection
A
slow progressive of months to years
Immune and nonimmune mechanisms involved
Vascular intimal hyperplasia
Lymphocytic infiltration
Atrophy
Fibrosis
Delayed type hypersensitivity
Chronic ischemia
Antibiotic formation
Causing her inhibitor toxicity is a risk
TGF beta may be a risk
20
Q
the most significant side effect of s sirolimus
A
thrombocytopenia
Other side effects:
Neutropenia
Impaired wound healing
Increased lipids
21
Q
cyclosporine levels are affected by what drugs
A
p450 complication
22
Q
Inducers of the P450 system
A
Phenytoin ramp up p450
23
Q
Inhibitors or competitive ears with the P450 system
A
Inhibitors or competitive ears with the P450 system
Erythromycin
Cimetidine
Ketoconazole
Fluconazole
24
Q
Living donor bowel is removed for transplant
How much length
was blood supply
A
mid ileum to distal ileum-the good part
This is about 200 cm
ileocolic vessels
25
Acceptable cold ischemia time for kidney
36-40 hours
left delayed graft function
26
Acceptable cold ischemia for pancreas
less than 24 hours
left duodenal leaks due to pancreatitis
27
Acceptable cold ischemia for liver
less than 16 hours
Associated with left hepatic dysfunction
Biliary complications
28
The acceptable ischemia time the heart and lung
less than 6 hours! Cold ischemia not an option
29
Most appropriate treatment for lymphocele after renal transplant
Laparoscopic or open peritoneal window
another option is percutaneous catheter with or without sclerotherapy - associated with some risk of recurrence or infection
Not percutaneous aspiration
30
Describe complications associated with lymphocele after renal transplant
Easily over 2 weeks after transplant
Mass effect:
Ureter
Iliac pain
Allograft renal artery
Hypertension
Unilateral leg swelling
Elevated creatinine
Diagnoses:
Ultrasound for confirmation
31
the major cause of death after Renal transplantation
cardiovascular:
Myocardial infarction
Stroke
32
less common causes of death following renal transplantation
sepsis 3%
| Malignancy 2%
33
The leading cause of graft loss following renal transplantation
recipient death-usually cardiovascular
Second most common past chronic allograft nephropathy-slow deterioration of graft function
34
Graft failure due to surgical technique percentage
2%
35
Back table preparation for donor pancreas prior to transplantation includes
Placement of arterial graft to connect the splenic and superior mesenteric arteries
36
the most common cause of liver failure in patient undergoing liver transplantation
hepatitis C United States
| Left commonly hepatitis B
37
Milan criteria
single lesion less than 5
One-3 tumors each less than 30
Absence of vascular or lymphatic invasion
38
indications for liver transplant in acute liver failure
Fulminant hepatic failure different criteria and chronic:
acetaminophen:
PH less than 7.3
INR greater than 6.5
Creatinine greater than 3.4
```
NON--acetaminophen:
INR greater than 6.5
Creatinine greater than 3.4
age less than 10 or greater than 40
non-a non-b hepatitis ( type C)
Duration of jaundice before encephalopathy greater than 7 days
```
39
Defined fulminant hepatic failure
hepatic encephalopathy and profound coagulopathy short after the onset of symptoms such as jaundice and patient's WITHOUT pre-existing liver disease
40
Most common causes of fulminant hepatic failure
```
United States in West acetaminophen
Acute hepatitis B
Hepatic toxins
Wilson's disease
Often idiopathic
```
41
Component of the MELD score
INR
Creatinine
Total bilirubin
42
Most, vascular complication after liver transplantation
Hepatic artery thrombosis
Most common early event
May cause ischemia to common bile duct with diffuse biliary leak or stricture
3-5% adult
5-10% children
Increase with partial transplant
Initial diagnosis Doppler
```
Treatment:
Urgent reexploration
Thrombectomy
REVISION of anastomosis
May require re\re transplant is extensive necrosis
```
Later events:
Stenosis
Pseudoaneurysm
43
posttransplant lymphoproliferative disorder as caused by, Presentation, treatment
Epstein-Barr he
asymptomatic is possible
mononucleosis syndrome
Hepatitis
Posttransplant lymphoproliferative disorder:
may present as localized tumor of the lymph nodes or GI tract or rarely rapidly progressive diffuse fatal lymphomatous infiltration
44
Most common indication for pediatric liver transplantation
Biliary atresia
Others:
Sclerosing cholangitis
Familial cholestasis syndrome
Lack of intrahepatic bile ducts (ALAGILLE syndrome
Metabolic disorder:
Alpha-1 antitrypsin deficiency-most common
Tyrosinemia - hereditary enzyme deficiency so cannot degrade tyrosine-results and cirrhosis with greatly increased risk of hepatocellular carcinoma
Wilson's disease
45
Up for an anti-traction deficiency
Metabolic disorder
Presentation:
Jaundice as a neonate but then resolves often
Subsequent presentation:
Childhood or early less than
Cirrhosis
Portal hypertension
46
Wilson's disease
Autosomal recessive
Proper cannulation in the liver, CNS, kidneys, eyes, other organs
May present form and, supplements, chronic liver failure
47
after transplantation, patient's are at increased risk for which malignancy
```
Kaposi's sarcoma
Skin cancers
Lymphoproliferative disease
Gynecologic cancer
Urologic cancer
```
48
which transplant recipients are at the most increased risk for cancer
kidney 1%
Small bowel and multiple visceral transplants 5-6% of
49
5 year graft survival rate after renal transplantation
75-80%
60-65 cm
50
Main advantage of bladder drainage with pancreaticoduodenal transplant
Direct measure and enzyme activity in urine to follow exocrine function with urine amylase
serum amylase is less sensitive
Urine amylase decreases before hyperglycemia recurrence
Leak rate is the same for enteric anastomosis
51
Disadvantage of bladder drainage with pancreaticoduodenal transplant
Bladder leak is much more severe when compared to bile leak
Dehydration
Acidosis from loss of a clotted pancreatic secretions into the urine
Bladder infection, hematuria, stones, urethritis
10-20% of the bladder drained graft recipient are converted to an enteric drainage
52
Advancement of the enteric drainage for pancreatic transplant
More physiologic
| decreased long-term complications
53
Powders rejection effect simultaneous pancreas and kidney transplant
almost always affects both kidney and pancreas
Therefore creatinine level can be used as a marker for rejection of pancreas
Most centers use enteric drainage for simultaneous pancreas and kidney transplant
His kidney and pancreas are from different donors or if there is pancreas transplant alone bladder drainage is preferred
54
absolute contraindication for orthotopic cardiac transplant
```
severe hypertension
Advanced age over 65
Cardiac trauma
Coronary artery disease
medical noncompliance
renal insufficiency
```
Active infection does not equal uncontrolled infection
55
Contraindications for organ specific donation
```
Medical problems
Malignancy other than primary brain tumor ( or skin cancer which can be treated with excision)
Prolonged cardiac arrest
Uncontrolled infection
HIV?
```
56
And a liver be transplanted with hepatitis B positive
yes
IF kidneys are normal
Recipient appropriate serologic and viral profile to oppose minimal risk
57
Hepatitis C positive liver donation
Yes
normal liver biopsy required
58
Can organ to be donated from patient's with high risk factors
```
no
except an emergency situation
Sexual behavior
Intravenous drug
Correctional institution
```
59
expanded criteria for kidney donation
old and 60 with a history of hypertension, cerebrovascular accident as cause of death
And final procurement creatinine greater than 1.5
mild hypertension may not be a contraindication though severe hypertension is absolute contraindication
60
age as a contraindication for donation
relative
61
contraindications for kidney donation
pre-existing renal disease
62
Contraindication for pancreas donation
diabetes
63
contraindications for heart lung donation
cardiac trauma
Coronary artery disease
Pneumonia
64
age when donor is considered older - and workup needed
35-40
may require a coronary catheterization rule out significant and cardiac disease
65
contraindications for lung donation
pneumonia
Pulmonary trauma
Respiratory compromise
may require bronchoscopy for inspection evaluation
66
heterotopic cardiac transplant
patient's native right heart continues to work against pulmonary hypertension - option sometimes used when patient has pulmonary hypertension
No heart supplies systemic circulation
67
Absolute contraindications for DONATION of heart
prolonged cardiac arrest
Carbon monoxide greater than 20%
Significant smoking history
68
most common cause of renal failure and United States
Diabetes
69
Best test to monitor the development of acute rejection and cardiac transplant
Endomyocardial biopsy
Current indications the patient clinically and for
70
absolute contraindications for renal transplant in a patient with chronic renal failure
chronic active hepatitis
| Recent operation for colon cancer-recommend 5 year disease-free interval
71
Relative contraindications for renal transplant in patient with chronic renal failure
sickle cell disease
HIV?
72
absolute contraindications for kidney donation
age over 70
Chronic renal insufficiency
Intravenous drug use
Severe hypertension
73
which organ is ABO compatibility less important pretransplant
liver
74
criteria for brain death
clinical diagnosis only
No barbiturates
hypothermia not dead until warm and dead
acute metabolic derangement
No spontaneous respiration
Absent pupillary reflex
Absent corneal reflex
Apnea sustained with disconnection ventilator
transplant team is pronounced patient ( not transplant surgeon) the
```
confirmatory tests cannot be used for final diagnoses:
cerebral angiography
electroencephalography
transcranial Doppler
cerebral scintigraphy
```
75
preservation of bone skin dura
cryopreservation
76
Matching required bone skin dura
none ABO not required
77
how is cross-matching done
recipient screened for preformed HLA antibodies
screening:
Donor lymphocytes mixed with recipient serum to evaluate if there are recipient antibodies combined to donor lymphocytes
crossmatch:
Final test
Donor lymphocyte mixed with the patient's serum
78
Absolute contraindication to kidney transplant crossmatch results
a positive T-cell CDC crossmatch
79
Isograft
identical monozygotic twin
Does not require immunosuppression
80
organ besides bone skin dura the does not require immunosuppression
the eyes are in no privileged site
because no lymphatic drainage
or ejection does occur palpable steroid used a
81
Percentage crossmatch and family genetics
each recipient shears one of 2 haplotype with each parent
25% chance assuring both haplo types: " HLA identical"
25% chance of not showing any haplotype
50% chance of sharing one haplotype
82
along the most renal transplant recipients weight before organ is available
3-7 years
less than six-month weight time on dialysis 2 times better graft survival than waiting over 2 years
83
What is arterial inflow most commonly for renal transplant
external iliac
84
Which side is kidney transplant done on
right side external iliac vessels are more superficial
85
what side is preferred to donate kidney from
left to longer vein
86
How do you handle multiple renal vessels
extra artery must be used because of segmental perfusion-use epigastric vessel is extra inflow
Can tie off extra vein
87
most common complication after renal transplant
wound infection
4-7 days
88
Thrombosis of renal vein posttransplant
immediate exploration
Symptoms of decreased urine output
89
and should renal transplant patient received prophylactic antibiotics post transplant
yes:
Bactrim
Antifungal
90
CMV infection
Fever
Weakness
GI bleed
Esophagitis
Treatment
Valganciclovir
91
Artery inflow for pancreatic transplant
splenic
| Superior mesenteric using iliac artery Y graft (iliac artery from the recipient)
92
doses portal enteric drainage for pancreatic transplant increased risk of pancreas thrombosis
no
and no increased risk of infection
urinary tract infections are higher with bladder drainage
93
Liver transplantation for hepatocellular carcinoma
Stage I-2
T1 or T2
No invasion of larger vascular structure
No extrahepatic disease
94
is crossmatch required for liver transplant
no
95
liver transplant in adults which lobe is donated from living donor
right
96
liver transplant in children which lobe was donated from living donor
left - because smaller
97
Specific indications for cardiac transplant
```
cardiomyopathy
Ischemic cardiac disease
Postpartum cardiomyopathy
Terminal cardiac valvular disease
Hypertensive cardiomyopathy
```
98
What can help bridge cardiac failure patient's transplant
ventricular assist device
99
match requirement for an cardiac transplant
ABO
Tissue typing not usually done preoperatively
Under 6 hour preservation time
100
Cancers common after cardiac transplant
skin cancer
Posttransplant lymphoproliferative disorder
Lung cancer
101
heart-lung transplant
| performed when
severe pulmonary hypertension with cardiac disease
associated with congenital heart disease: Eisenmenger's
102
signs of acute and chronic rejection of lung transplant
bronchiolitis
103
one year survival rate for a heart-lung transplant recipients
63%
104
indicators for need of lung transplant
FEV1 less than 25%
PCO2 greater than 55
Increased pulmonary artery pressure
105
can patient with lung cancer a lung transplant
no
106
Does bilateral lung transplant have better survival than single lung
yes
107
what is likely to compromise single lung transplant
emphysema-air trapping in need of long compresses transplant lung
Cystic fibrosis
History of chronic wound infection
108
Contraindications for bowel transplant
uncontrolled infection
Uncontrolled malignancy
109
technical aspects of bowel transplant
heterotopic were orthotopic
anastomosis may be brought up to abdominal wall at ileostomy to allow observation and biopsy monitor rejection or ischemia
venous anastomosis easily to recipient cava but may be due to portal vein
arterial anastomosis to abdominal aorta
110
survival after bowel transplant
80% one year
67% 3 years
54% 5 years
43% 10 years
111
sirolimus most common complications
The most common adverse effects of sirolimus are hyperlipidemia and myelosuppression.
Postmarketing studies have revealed a number of unforeseen adverse effects, including impaired wound healing and possibly proteinuria, edema, pneumonitis, and thrombotic microangiopathy. The incidence of abnormal wound healing with sirolimus is 1% to 12%.
112
CMV infection after solid organ transplantation
one of the most common viral infections,
Presentation of early CMV colitis can be mild and nonspecific, including mild diarrhea, associated fever, and abdominal pain.
A more reliable diagnosis can be made via early and rapid colonoscopy with mucosal biopsies and documentation of the typical colonoscopic and histopathologic findings compatible with CMV colitis.
Although serology is helpful in the diagnosis, sometimes it is inadequate.
Serum CMV IgM and CMV pp65 antigenemia may be negative.
Standard antiviral (ganciclovir, foscarnet) treatment is recommended.
Operation (colectomy) is indicated for life-threatening complications (perforation, bleeding, ischemia) or lack of response to medical management.
113
Organ transplant recipients are at particular risk for what skin cancer
Organ transplant recipients are at particular risk for squamous cell carcinoma (SCC).
Heart transplant patients have a threefold risk of NMSC over renal transplant recipients who have more NMSC than liver recipients. Cancers in other organ systems are also more common in OTRs compared with nonimmunosuppressed age-matched controls; esophagus [RR 4.7], liver [RR 4.8], cervix [RR 4.6], bladder [RR 5.1], and thyroid [RR 4.5].
The incidence of de novo tumor occurrence is 7% after both kidney and liver transplantation. The median elapsed time from transplant to the diagnosis of de novo malignancy was 45 months for kidney and 37 months for liver transplants. Skin cancers were the most common in renal recipients, while gastroenteric cancers were more frequently seen in liver transplants
In renal transplant recipients, the mean incidence per year of NMSC is 8%, comprised equally by SCC and basal cell carcinoma (BCC) and less so by Bowen's disease.
Cancers of the skin and lips comprise 40% of all cancers arising after transplantation.
114
type of cancer more commonly seen with liver transplant
gastroenteric cancers were more frequently seen in liver transplants
115
The definition of organ trafcking
the recruitment, transport, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power, of a position of vulnerability, of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation by the removal of organs, tissues, or cells for transplantation.
116
Transplant tourism a
is a phrase often used interchangeably with organ trafficking but...
some medical tourism that entails the travel of transplant recipients or donors across national borders is not organ trafficking.
Examples of legal and appropriate transplant tourism include travel of a related donor and recipient pair from countries without transplant services to countries where organ transplantation is performed, or persons traveling across borders to donate or receive a transplant via a relative.
The United Network for Organ Sharing (UNOS) recently defined transplant tourism as:
the purchase of a transplant organ abroad that includes access to an organ while bypassing laws, rules, or processes of any or all countries involved.
117
reimbursement for personal expense is allowed for transplant donors
no!
| Including no reimbursement for personal traveled stents, lost wages, housing...
118
followup care for donors is whose responsibility
is the responsibility of the donor
