Transplant Chapter NHBR

Question 1

What is C4d negative ABMR?

Answer 1

C4d negative AMR is characterized by the presence of microvascular injury in the presence of DSAbut without
PTC C4d staining.

Question 2

What are the RF for PTDM?

Answer 2

• AA
• ≥40 years
• Male
• HLA mismatch
• PKD
• Hep C / CMV
• HypoMg2+
• Proteinuria
• CNI / mTORi /steroid
• Obesity

Question 3

What is the treatment of dn anti-GBM disease post-transplant in Alport’s?

Answer 3

• Plasmapheresis

- CYC

Question 4

What treatment measures can be employed in ABMR?

Answer 4

• TPE
• IVIg
• Rituximab
• Bortezomib
• Eculizumab
• rATG
• Steroids

Question 5

What drugs may potentiate CNI toxicity?

Answer 5

• NSAIDs
• mTORi
• Tenofovir
• Amphortericin
• Foscarnet
• Cidofovir

Question 6

What drugs and foods increase absorption of CNIs?

Answer 6

• Metoclopramide

- Grapefruit juice

Question 7

What is the recurrence rate of membranous GN post transplant?

Answer 7

10-30%

Question 8

What is the recurrence rate of lupus nephritis post transplant?

Answer 8

3-10%

Question 9

What is optimal timing for transplant in anti-GBM disease?

Answer 9

> 6 months after antibody disappearance

Question 10

What is the recurrence rate for ANCA?

Answer 10

10-20%

Question 11

What is the recurrence rate for aHUS?

Answer 11

• 20-25%, but 80% graft loss

- at least 1 year of queiescence is recommended

Question 12

Why do X-linked Alport’s females not develop anti-GBM post-transplant?

Answer 12

• They carry a normal copy of the affected gene

Question 13

When would you use rATG in ACMR?

Answer 13

• refractory to steroids

- Banff IIA rejection

Question 14

When would they perform a DGF transplant biopsy in the highly sensitised patient at Brigham?

Answer 14

• Day 3-5

- Rebiopsy again if no rejection on initial but DGF persists by day 5-7

Question 15

When would you biopsy the low-risk DGF patient? (at Brigham)

Answer 15

• Day 7-10

Question 16

What cold-ischaemia and warm ischaemia times increase the risk for DGF?

Answer 16

• Cold ischaemia >15 hrs

- Warm ischaemia >45 minutes

Question 17

What KDPI is most associated with DGF?

Answer 17

> 85%

Question 18

What is the effect of diarrhoea on CNI levels?

Answer 18

• Diarrhoea causes an increase in CNI levels

Question 19

What statin should be avoided in patients on CNI?

Answer 19

• Simvastatin carries a FDA black box warning for co-administration with FK

Question 20

What statins are safe to use with FK506?

Answer 20

• Fluvastatin
• Atorvastatin (lower risk of interaction)
• Rosuvastatin, but Atorvastatin favoured on basis of PLANET trial.

Question 21

What is the most common cause of DGF?

Answer 21

ATN

Question 22

Whom does KDIGO recommend depletion therapy for at induction?

Answer 22

• 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

Question 23

How does hypertension effect CV mortality in transplant recipients?

Answer 23

• Each 20mmHg leads to a 32% increase in CVD risk, and a

- 13% increased risk of mortality.

Question 24

What are the available strategies for DSA removal?

Answer 24

• Plasmapheresis
• Immunoadsorption
• Rituximab
• Bortezomib

Question 25

Give an example of a desensitisation protocol.

Answer 25

- 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

Question 26

How do you manage AMR?

Answer 26

- TPE and IVIg (first line) - TPE, IVIg, Ritux and bortezomib (second line) - Eculizumab (third line)

Question 27

What features confer a greater risk of HCC in a kidney transplant candidate?

Answer 27

- HBV viral load - HBeAg positive - HBsAg positive - Asian or African ethnicity

Question 28

What are the conditions for performing a kidney transplant in a person with HIV?

Answer 28

- HIV viral load <50 copies/mL - CD4 count >200/mm3 - No opportunistic infections in the past year

Question 29

What single parameter is associated with the highest risk for allograft loss in a transplant patient wishing to become pregnant?

Answer 29

- pre-pregnancy creatinine, ideally <1.5mg/dL

Question 30

Birth defects are more common in babies fathered by transplant recipients. true/false

Answer 30

- true

Question 31

What is the incidence of ESRD among kidney donors?

Answer 31

<0.5% at 15 years

Question 32

What is the Banff Classification for ACR?

Answer 32

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

Question 33

What are the 2013 Banff Criteria for AMR?

Answer 33

1. Serological evidence of DSAs against HLA or other antigen 2. Histological evidence of tissue injury in the absence of another cause 3. 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

Question 34

What is the pathogenesis for chronic rejection?

Answer 34

- 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

Question 35

What is the most common type of peritransplant fluid collection?

Answer 35

- Lymphocoele | - Incidence is higher with sirolimus

Question 36

What is the treatment for transplant erythrocytosis? Hb >17, HCT >52%

Answer 36

- ACEi/ARB | - Phlebotomy