Transplant Chapter NHBR Flashcards
What is C4d negative ABMR?
C4d negative AMR is characterized by the presence of microvascular injury in the presence of DSAbut without
PTC C4d staining.
What are the RF for PTDM?
- AA
- ≥40 years
- Male
- HLA mismatch
- PKD
- Hep C / CMV
- HypoMg2+
- Proteinuria
- CNI / mTORi /steroid
- Obesity
What is the treatment of dn anti-GBM disease post-transplant in Alport’s?
- Plasmapheresis
- CYC
What treatment measures can be employed in ABMR?
- TPE
- IVIg
- Rituximab
- Bortezomib
- Eculizumab
- rATG
- Steroids
What drugs may potentiate CNI toxicity?
- NSAIDs
- mTORi
- Tenofovir
- Amphortericin
- Foscarnet
- Cidofovir
What drugs and foods increase absorption of CNIs?
- Metoclopramide
- Grapefruit juice
What is the recurrence rate of membranous GN post transplant?
10-30%
What is the recurrence rate of lupus nephritis post transplant?
3-10%
What is optimal timing for transplant in anti-GBM disease?
> 6 months after antibody disappearance
What is the recurrence rate for ANCA?
10-20%
What is the recurrence rate for aHUS?
- 20-25%, but 80% graft loss
- at least 1 year of queiescence is recommended
Why do X-linked Alport’s females not develop anti-GBM post-transplant?
- They carry a normal copy of the affected gene
When would you use rATG in ACMR?
- refractory to steroids
- Banff IIA rejection
When would they perform a DGF transplant biopsy in the highly sensitised patient at Brigham?
- Day 3-5
- Rebiopsy again if no rejection on initial but DGF persists by day 5-7
When would you biopsy the low-risk DGF patient? (at Brigham)
- Day 7-10
What cold-ischaemia and warm ischaemia times increase the risk for DGF?
- Cold ischaemia >15 hrs
- Warm ischaemia >45 minutes
What KDPI is most associated with DGF?
> 85%
What is the effect of diarrhoea on CNI levels?
- Diarrhoea causes an increase in CNI levels
What statin should be avoided in patients on CNI?
- Simvastatin carries a FDA black box warning for co-administration with FK
What statins are safe to use with FK506?
- Fluvastatin
- Atorvastatin (lower risk of interaction)
- Rosuvastatin, but Atorvastatin favoured on basis of PLANET trial.
What is the most common cause of DGF?
ATN
Whom does KDIGO recommend depletion therapy for at induction?
- increased number of HLA mismatches
- Younger recipient and older donor
- AA people
- PRA higher
- Presence of DSA
- ABO incompatibility
- Delayed onset graft function
- Cold ischaemia time >24 hours
How does hypertension effect CV mortality in transplant recipients?
- Each 20mmHg leads to a 32% increase in CVD risk, and a
- 13% increased risk of mortality.
What are the available strategies for DSA removal?
- Plasmapheresis
- Immunoadsorption
- Rituximab
- Bortezomib
Give an example of a desensitisation protocol.
- TPE, 2-3 sessions for low DSA titre, 6-10 sessions for high titres followed by IVIg
- Tacrolimus and MMF, commence 2-3 weeks before the transplant
How do you manage AMR?
- TPE and IVIg (first line)
- TPE, IVIg, Ritux and bortezomib (second line)
- Eculizumab (third line)
What features confer a greater risk of HCC in a kidney transplant candidate?
- HBV viral load
- HBeAg positive
- HBsAg positive
- Asian or African ethnicity
What are the conditions for performing a kidney transplant in a person with HIV?
- HIV viral load <50 copies/mL
- CD4 count >200/mm3
- No opportunistic infections in the past year
What single parameter is associated with the highest risk for allograft loss in a transplant patient wishing to become pregnant?
- pre-pregnancy creatinine, ideally <1.5mg/dL
Birth defects are more common in babies fathered by transplant recipients. true/false
- true
What is the incidence of ESRD among kidney donors?
<0.5% at 15 years
What is the Banff Classification for ACR?
1:
1A: Tubulitis, focal (>4 lymph)
1B: Tubulitis, severe (>10 lymph)
2A: Arteritis, <25% of luminal area
2B: Arteritis, >25% of luminal area
3: Transmural inflammation and necrosis of the media
What are the 2013 Banff Criteria for AMR?
- Serological evidence of DSAs against HLA or other antigen
- Histological evidence of tissue injury in the absence of another cause
- Evidence of current/recent interaction of an antibody with the vascular endothelium.
- C4d staining
- Increased expression of gene transcripts in the the biopsy indicative of endothelial injury
What is the pathogenesis for chronic rejection?
- Alloantigen dependent
1. Acute rejection episodes
2. Ab mediated immune response
3. Poor HLA matching
4. Inadequate immunosuppression - Alloantigen independent
1. CNI toxicity
2. BK nephropathy
3. CMV infection
What is the most common type of peritransplant fluid collection?
- Lymphocoele
- Incidence is higher with sirolimus
What is the treatment for transplant erythrocytosis? Hb >17, HCT >52%
- ACEi/ARB
- Phlebotomy
