Transplant (renal replacement therapy 2) Flashcards
where is the transplanted kidney placed
into the iliac fossa
onto what is the transplanted kidney attached
anastomosed to the iliac vessels
what happens to the native kidneys
usually stay in situ - however some situations call for a kidney to be removed
what are indications for native nephrectomy
size - polycystic kidneys
infection - chronic pyelonephritis
how can a donor kidney be preserved
cold storage solutions - minimise oedema - preserve integrity of tissues - buff free radicals
what is cold ischaemia time
the time a donor kidney is without blood supply
why is cold ischaemia time important
the longer the cold ischaemia time - the poorer the outcome of the transplant is going to be
what are the three types of complications in transplantation
- vascular
- ureteric
- infections
what are vascular complications of transplantation
- bleeding
- arterial thrombosis
- venous thrombosis
- lymphocele
what are the most common types of bleeding complications
- usually anastomotic sites
2. perirenal haematoma - can be arterial or venous
what is a ureteric complication of transplantation
urine leak - medical emergency - need to go back to surgery
what is used to minimise risk of rejection
immunosuppressive agents
what is the immunesuppression protocols
induction - basiliximab
maintenance - tacrolimus + mycophenolate + steroids*
**steroid free when possible - e.g. paediatric patients can often cope without
what can be used instead if a patient is intolerant to tacrolimus
belatacept
what are some of the side effects of corticosteroids
hypertension, hyperglycaemia, infections, bone loss, GI bleeding
what are some of the side effects of tacrolimus
hyperglycaemia, AKI (acute kidney injury), tremor
what are some of the side effects of mycophenolate
cytopenia, GI upset
what are some of the side effects of belatacept
infections, malignancy
what are 2 types of kidney donors
deceased donors
living donors
what are the different types of deceased donors
- donation after brain death (DBD)
2. donation after cardiac death (DCD)
what are the different types of living donors
- living related
2. living unrelated - spousal, altruistic, paired/pooled
what are the two sets of criteria for deceased donors
standard and extended
what is the different implications between standard and extended criteria transplants
standard criteria donor transplants are more successful than organs from extended criteria donors
what is the standard brain death criteria
- coma, unresponsive to stimuli
- apnoea off ventilator despite build up of CO2
- absence of cephalic reflexes
- body temp > 34C
- absence of drug intoxication
what is the extended criteria for deceased donors
- donor aged >60yrs
2. donor aged 50-59yrs + history of HBP, death from cerebrovascular accident or terminal certain of >132 micro mol/L
are older patients more or less likely to get a transplant
less likely - as they are less likely to a) survive procedure b) accept kidney and c) more prone to complications
what does an ABO incompatible transplant mean
donor organ is from someone with a different blood type to recipient - can be done but recipient must be on immunosuppressants before and after treatment to minimise chance of rejection
what does a HLA incompatible transplant mean
recipient has antibodies that are incompatible with donor organ (HLA = human leukocyte antigens)
which type of incompatible transplant is more successful - ABO or HLA
ABO
what is a paired donation
If donor A cannot give to recipient A, they can instead give to recipient B while donor B gives to recipient A
e.g. mother (A) not a match for son (a) and husband (B) not a match for wife (b) BUT A is a match for b B is a match for a
so these sets of people can cross over donors
what is pooled donation
knock on domino effect of donations - can include multiple people
e.g. starts with altruistic donor giving to A - A’s brother gives to B - B’s husband gives C etc etc
what are the risks of kidney donation
- similar patient survival to general population
- lower rate of ESRD compared to general population
- compensatory increase in GFR of remaining kidney to 70% of premonition value
what are longer term complications of renal transplantation
- rejection
- infection
- cardiovascular
- malignancy
- new onset diabetes mellitus
what are the different types of acute rejection
- T cell mediated rejection
- acute antibody mediated rejection (ABMR)
**ABMR causes more damage and is more difficult to control than T cell mediated rejection
what occurs at the three levels of T cell mediated rejection
Banff 1 - tubulointerstitial
Banff 2 - arteritis/endothelialitis
Banff 3 - arterial fibrinoud necrosis
what occurs at the three levels of acute AMBR
Banff 1 - ATN-like
Banff 2 - capillaries or glomerular inflammation
Banff 3 - arterial inflammation
what are the most common infections straight after transplant
wound infection and UTI
what is the most common (and important) infection after 6 months and why
cytomegalovirus - patient put on prophylaxis therapy for CMV for first 6 months post transplant - after this at risk of CMV infection
**high mortality and morbidity if untreated
what two common ways can a patient receive CMV
- transmission from donor tissue
2. reactivation of latent virus
what are the two types of CMV
- viraemia
2. tissue invasive - pneumonitis, hepatitis, retinitis, gastroenteritis, colitis, nephritis
what virus is common after transplant
BK virus (BKAN)
what are risk factors for BKAN
- intensity of immunosuppression
- patient determinants - older age, male, white, -ve BKV aerostats (paed patients)
- organ determinants - graft injury, HLA mismatch, ureteral stents
- viral determinants - changes in epitopes of viral capsid protein VP-1
what is the treatment for BKAN
- reduce immunosuppression
2. antiviral therapy - cidofovir +/- IVIG leflunomide
what is the outcome of BKAN infection on graft
allograft dysfunction and loss of graft in 45-80%
what are the relative risks of different malignancies after renal transplantation
colon, lung, breast - 2
testicular, bladder - 3
melanoma, leukaemia,
cervical - 5
renal - 15
non-melanoma skin, kaposi sarcoma, non-hodgkin lymphoma - 20
what is the relationship between supply and demand of renal transplants
demand MUCH HIGHER than supply
