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Section III Subspecialty Surgery P517 > Transplant Surgery, C73 P671-690 > Flashcards

Transplant Surgery, C73 P671-690 Flashcards

1
Q

Define the following terms:
Autograft
P671

A

Same individual is both donor and

recipient

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2
Q

Define the following terms:
Isograft
P671

A

Donor and recipient are genetically

identical (identical twins)

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3
Q

Define the following terms:
Allograft
P672

A

Donor and recipient are genetically

dissimilar, but of the same species

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4
Q

Define the following terms:
Xenograft
P672

A

Donor and recipient belong to different

species

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5
Q

Define the following terms:
Orthotopic
P672

A 
Donor organ is placed in normal
anatomic position (liver, heart)
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6
Q

Define the following terms:
Heterotopic
P672

A

Donor organ is placed in a different site
than the normal anatomic position
(kidney, pancreas)

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7
Q

Define the following terms:
Paratopic
P672

A

Donor organ is placed close to original

organ

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8
Q

Define the following terms:
Chimerism
P672

A

Sharing cells between the graft and donor

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9
Q

BASIC IMMUNOLOGY
What are histocompatibility
antigens?
P672

A

Distinct (genetically inherited) cell
surface proteins of the human leukocyte
antigen system (HLA)

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10
Q

BASIC IMMUNOLOGY
Why are they important?
P672

A 
They are targets (class I antigens) and
initiators (class II antigens) of immune
response to donor tissue (i.e.,
distinguishing self from nonself)
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11
Q

BASIC IMMUNOLOGY
Which cells have class I
antigens?
P672

A 
All nucleated cells (Think: class 1 = ALL
cells and thus “ONE for ALL”)
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12
Q

BASIC IMMUNOLOGY
Which cells have class II
antigens?
P672

A

Macrophages, monocytes, B cells,

activated T cells, endothelial cells

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13
Q

BASIC IMMUNOLOGY
What are the gene products
of MHC called in humans?
P672

A

HLA (Human Leukocyte Antigen)

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14
Q

BASIC IMMUNOLOGY
What is the location of the
MHC complex?
P672

A

Short arm of chromosome 6

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15
Q

BASIC IMMUNOLOGY
What is a haplotype?
P672

A

Combination of HLA genes on a
chromosome inherited from one parent;
therefore, two siblings have a 25%
chance of being “haploidentical”

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16
Q

BASIC IMMUNOLOGY
Does HLA matching matter
in organ transplantation?
P673

A

With recent improvements in
immunosuppression (i.e., cyclosporine),
the effect is largely obscured, but it still
does matter; the most important ones to
match in order to improve renal allograft
survival are HAL-B and HLA-DR

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17
Q

CELLS
T CELLS
What is the source?
P673

A

Thymus

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18
Q

CELLS
T CELLS
What is the function?
P673

A

Cell-mediated immunity/rejection

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19
Q

CELLS
T CELLS
What are the types?
P673

A 
Th (CD4): helper T—help B cells
    become plasma cells
Ts (CD8): suppressor T—regulate
    immune response
Tc (CD8): cytotoxic T—kill cell by direct
    contact
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20
Q

B CELLS
What is the function?
P673

A

Humoral immunity

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21
Q

B CELLS
What is the cell type that
produces antibodies?
P673

A

B cells differentiate into plasma cells

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22
Q

MACROPHAGE
What is it?
P673

A

Monocyte in parenchymal tissue

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23
Q

MACROPHAGE
What is its function?
P673

A

Processes foreign protein and presents it

to lymphocytes

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24
Q

MACROPHAGE
What is it also known as?
P673

A

Antigen-Presenting Cell (APC)

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25
Q 
MACROPHAGE
Briefly describe the events
leading to antibody
production.
P673
A 
1. Macrophage engulfs antigen and
    presents it to Th cells; the
    macrophage produces IL-1
2. Th cells then produce IL-2, and the
    Th cells proliferate
3. Th cells then activate (via IL-4) B cells
    that differentiate into plasma cells,
    which produce antibodies against the
    antigen presented
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26
Q

IMMUNOSUPPRESSION
Who needs to be
immunosuppressed?
P674

A

All recipients (except autograft or isograft)

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27
Q

IMMUNOSUPPRESSION
What are the major drugs
used for immunosuppression?
P674

A

Triple therapy: corticosteroids,

azathioprine, cyclosporine/tacrolimus

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28
Q

IMMUNOSUPPRESSION
What are the other drugs?
P674

A

OKT3, ATGAM, mycophenolate

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29
Q

IMMUNOSUPPRESSION
What is the advantage of
“triple therapy”?
P674

A

Employs three immunosuppressive drugs;
therefore, a lower dose of each can be used,
decreasing the toxic side effects of each

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30
Q

IMMUNOSUPPRESSION
What is “induction therapy”?
P674

A

High doses of immunosuppressive drugs

to “induce” immunosuppression

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31
Q 
IMMUNOSUPPRESSION
CORTICOSTEROIDS
Which is most commonly
used in transplants?
P674
A

Prednisone

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32
Q

IMMUNOSUPPRESSION
CORTICOSTEROIDS
How does it function?
P674

A

Primarily blocks production of IL-1 by
macrophage and stabilizes lysosomal
membrane of macrophage

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33
Q 
IMMUNOSUPPRESSION
CORTICOSTEROIDS
What is the associated
toxicity?
P674
A

“Cushingoid,” alopecia, striae, HTN,
diabetes, pancreatitis, ulcer disease,
osteomalacia, aseptic necrosis (especially
of the femoral head)

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34
Q 
IMMUNOSUPPRESSION
CORTICOSTEROIDS
What is the relative
potency of the following
corticosteroids:
Cortisol?
P674
A

1

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35
Q 
IMMUNOSUPPRESSION
CORTICOSTEROIDS
What is the relative
potency of the following
corticosteroids:
Prednisone?
P674
A

4

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36
Q 
IMMUNOSUPPRESSION
CORTICOSTEROIDS
What is the relative
potency of the following
corticosteroids:
Methylprednisolone?
P674
A

5

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37
Q 
IMMUNOSUPPRESSION
CORTICOSTEROIDS
What is the relative
potency of the following
corticosteroids:
Dexamethasone?
P674
A

25

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38
Q

IMMUNOSUPPRESSION
AZATHIOPRINE (AZA [IMURAN®])
How does it function?
P674

A

Prodrug that is cleaved into
mercaptopurine; inhibits synthesis of DNA
and RNA, leading to decreased cellular
(T/B cells) production

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39
Q 
IMMUNOSUPPRESSION
AZATHIOPRINE (AZA [IMURAN®])
What is the associated
toxicity?
P675
A

Toxic to bone marrow (leukopenia
thrombocytopenia), hepatotoxic,
associated with pancreatitis

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40
Q 
IMMUNOSUPPRESSION
AZATHIOPRINE (AZA [IMURAN®])
When should a lower dose
of AZA be administered?
P675
A

When WBC is <4

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41
Q 
IMMUNOSUPPRESSION
AZATHIOPRINE (AZA [IMURAN®])
What is the associated drug
interaction?
P675
A 
Decrease dose if patient is also on
allopurinol, because allopurinol inhibits
the enzyme xanthine oxidase, which
is necessary for the breakdown of
azathioprine
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42
Q

IMMUNOSUPPRESSION
CYCLOSPORINE (CSA)
What is its function?
P675

A

“Calcineurin inhibitor” inhibits

production of IL-2 by Th cells

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43
Q 
IMMUNOSUPPRESSION
CYCLOSPORINE (CSA)
What is the associated
toxicity?
P675
A 
Toxicity for cyclosporine includes the
11 “H’s” and three “N’s”: Hepatitis,
    Hypertrichosis, gingival Hyperplasia,
    Hyperlipidemia (worse than FK),
    Hyperglycemia, Hypertension (worse
    than FK), Hemolytic uremic syndrome,
    Hyperkalemia, Hypercalcemia,
    Hypomagnesemia, Hyperuricemia,
    Nephrotoxicity, Neurotoxicity (headache,
    tremor), Neoplasia (lymphoma, KS,
    squamous cell skin cancers)
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44
Q 
IMMUNOSUPPRESSION
CYCLOSPORINE (CSA)
What drugs increase CSA
levels?
P675
A

Diltiazem
Ketoconazole
Erythromycin, fluconazole, ranitidine

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45
Q 
IMMUNOSUPPRESSION
CYCLOSPORINE (CSA)
What drugs decrease CSA
levels?
P675
A

By inducing the p450 system: dilantin,

Tegretol®, rifampin, isoniazid, barbiturates

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46
Q 
IMMUNOSUPPRESSION
CYCLOSPORINE (CSA)
What are the drugs of
choice for HTN from CSA?
P675
A

Clonidine, calcium channel blockers

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47
Q 
IMMUNOSUPPRESSION
CYCLOSPORINE (CSA)
ATGAM/ANTITHYMOCYTE GLOBULIN
How does it function?
P675
A

Antibody against thymocytes,

lymphocytes (polyclonal)

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48
Q

IMMUNOSUPPRESSION
ATGAM/ANTITHYMOCYTE GLOBULIN
When is it typically used?
P675

A

For induction

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49
Q 
IMMUNOSUPPRESSION
ATGAM/ANTITHYMOCYTE GLOBULIN
What is the associated
toxicity?
P676
A

Thrombocytopenia, leukopenia, serum
sickness, rigors, fever, anaphylaxis,
increased risk of viral infection, arthralgia

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50
Q

IMMUNOSUPPRESSION
OKT3
How does it work?
P676

A

MONOclonal antibody that binds CD3

receptor (on T cells)

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51
Q 
IMMUNOSUPPRESSION
OKT3
What is a major problem
with multiple doses?
P676
A

Blocking antibodies develop, and OKT3

is less effective each time it is used

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52
Q 
IMMUNOSUPPRESSION
OKT3
What are basiliximab and
daclizumab?
P676
A

Anti-CD25 monoclonal antibodies

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53
Q 
IMMUNOSUPPRESSION
TACROLIMUS
What is tacrolimus also
known as?
P676
A

Prograf®(FK506)

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54
Q

IMMUNOSUPPRESSION
TACROLIMUS
How does it work?
P676

A

Similar to CSA—“calcineurin inhibitor,”
blocks IL-2 receptor expression, inhibits
T cells

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55
Q 
IMMUNOSUPPRESSION
TACROLIMUS
What is its potency
compared to CSA?
P676
A

100x more potent than CSA

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56
Q

IMMUNOSUPPRESSION
TACROLIMUS
What are its side effects?
P676

A

Nephrotoxicity and CNS toxicity
(tremor, seizure, parasthesia, coma),
hyperkalemia, alopecia, diabetes

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57
Q 
IMMUNOSUPPRESSION
SIROLIMUS
What is sirolimus also
known as?
P676
A

Rapamycin, Rapamune®

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58
Q

IMMUNOSUPPRESSION
SIROLIMUS
How does it work?
P676

A

Like CSA and tacrolimus, it does not
bind to and inhibit calcineurin; rather, it
blocks T-cell signaling

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59
Q

IMMUNOSUPPRESSION
SIROLIMUS
Toxicity?
P676

A

Hypertriglyceridemia, thrombocytopenia,
wound/healing problems, anemia, oral
ulcers

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60
Q

IMMUNOSUPPRESSION
MYCOPHENOLATE MOFETIL (MMF)
What is MMF also known as?
P676

A

CellCept®

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61
Q

IMMUNOSUPPRESSION
MYCOPHENOLATE MOFETIL (MMF)
How does it work?
P677

A 
Inhibitor of inosine monophosphate
dehydrogenase required for de novo
purine synthesis which expanding T and
B cells depend on; also inhibits adhesion
molecule and antibody production
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62
Q 
OVERVIEW OF IMMUNOSUPPRESSION MECHANISMS
What drug acts at the
following sites:
A?
P677 (picture)
A

Corticosteroids

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63
Q 
OVERVIEW OF IMMUNOSUPPRESSION MECHANISMS
What drug acts at the
following sites:
B?
P677 (picture)
A

CSA/tacrolimus

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64
Q 
OVERVIEW OF IMMUNOSUPPRESSION MECHANISMS
What drug acts at the
following sites:
C?
P677 (picture)
A

AZA/MMF

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65
Q 
OVERVIEW OF IMMUNOSUPPRESSION MECHANISMS
What drug acts at the
following sites:
D?
P677 (picture)
A

OKT3/ATGAM

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66
Q

MATCHING OF DONOR AND RECIPIENT
How is ABO crossmatching
performed?
P678

A

Same procedure as in blood typing

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67
Q 
MATCHING OF DONOR AND RECIPIENT
What is the purpose of
lymphocytotoxic
cross-matching?
P678
A

Tests for HLA antibodies in serum;
most important in kidney and pancreas
transplants

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68
Q

MATCHING OF DONOR AND RECIPIENT
How is the test performed?
P678

A

Mix recipient serum with donor

lymphocyte and rabbit complement

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69
Q

MATCHING OF DONOR AND RECIPIENT
Is HLA crossmatching
important?
P678

A

Yes, for kidney and pancreas transplants

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70
Q

REJECTION
How many methods of
rejection are there?
P678

A

Two: humoral and cell-mediated

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71
Q 
REJECTION
Name the four types of
rejection and their associated
time courses.
P678
A
  1. Hyperacute—immediate in O.R.
  2. Accelerated acute—7 to 10 days
    post-transplant
  3. Acute—weeks to months post-transplant
  4. Chronic—months to years
    post-transplant
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72
Q

REJECTION
What happens in hyperacute
rejection?
P678

A

Antigraft antibodies in recipient
recognize foreign antigen immediately
after blood perfuses transplanted organ

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73
Q

REJECTION
What happens in acute
rejection?
P678

A

T cell–mediated rejection

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74
Q 
REJECTION
What type of rejection is
responsible for chronic
rejection?
P678
A

Cellular, antibody (humoral), or both

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75
Q

REJECTION
What is the treatment of
hyperacute rejection?
P678

A

Remove transplanted organ

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76
Q

REJECTION
What is the treatment of
acute rejection?
P679

A

High-dose steroids/OKT3

77
Q

REJECTION
What is the treatment of
chronic rejection?
P679

A

Not much (irreversible) or retransplant

78
Q

ORGAN PRESERVATION
What is the optimal storage
temperature of an organ?
P679

A

4° C—keep on ice in a cooler

79
Q

ORGAN PRESERVATION
Why should it be kept cold?
P679

A

Cold decreases the rate of chemical
reactions; decreased energy use
minimizes effects of hypoxia and ischemia

80
Q

ORGAN PRESERVATION
What is U-W solution?
P679

A

University of Wisconsin solution; used to
perfuse an organ prior to removal from
the donor

81
Q

ORGAN PRESERVATION
What is in it?
P679

A

Potassium phosphate, buffers, starch,

steroids, insulin, electrolytes, adenosine

82
Q

ORGAN PRESERVATION
Why should it be used?
P679

A

Lengthens organ preservation time

83
Q

MAXIMUM TIME BETWEEN HARVEST
AND TRANSPLANT OF ORGAN
Heart?
P679

84
Q

MAXIMUM TIME BETWEEN HARVEST
AND TRANSPLANT OF ORGAN
Lungs?
P679

85
Q

MAXIMUM TIME BETWEEN HARVEST
AND TRANSPLANT OF ORGAN
Pancreas?
P679

86
Q

MAXIMUM TIME BETWEEN HARVEST
AND TRANSPLANT OF ORGAN
Liver?
P679

87
Q

MAXIMUM TIME BETWEEN HARVEST
AND TRANSPLANT OF ORGAN
Kidney?
P679

A

Up to 72 hours

88
Q 
MAXIMUM TIME BETWEEN HARVEST
KIDNEY TRANSPLANT
In what year was the first
transplant performed in man?
P679
89
Q

MAXIMUM TIME BETWEEN HARVEST
KIDNEY TRANSPLANT
By whom?
P679

A

Joseph E. Murray—1990 Nobel Prize

winner in Medicine

90
Q 
MAXIMUM TIME BETWEEN HARVEST
KIDNEY TRANSPLANT
What are the indications for
kidney transplant?
P680
A 
Irreversible renal failure from:
1. Glomerulonephritis (leading cause)
2. Pyelonephritis
3. Polycystic kidney disease
4. Malignant HTN
5. Reflux pyelonephritis
6. Goodpasture’s syndrome
    (antibasement membrane)
7. Congenital renal hyperplasia
8. Fabry’s disease
9. Alport’s syndrome
10. Renal cortical necrosis
11. Damage caused by type 1
    diabetes mellitus
91
Q

MAXIMUM TIME BETWEEN HARVEST
KIDNEY TRANSPLANT
Define renal failure.
P680

A

GFR <20% to 25% of normal; as GFR
drops to 5% to 10% of normal, uremic
symptoms begin (e.g., lethargy, seizures,
neuropathy, electrolyte disorders)

92
Q 
MAXIMUM TIME BETWEEN HARVEST
KIDNEY TRANSPLANT
What is the most common
cause for kidney transplant?
P680
A

Diabetes (25%)

93
Q 
MAXIMUM TIME BETWEEN HARVEST
STATISTICS
What are the sources of
donor kidneys?
P680
A 
Deceased donor (70%)
Living related donor (LRD; 30%)
94
Q 
MAXIMUM TIME BETWEEN HARVEST
STATISTICS
What survival rate is
associated with deceased
donor source?
P680
A

90% at 1 year if HLA matched; 80% at
1 year if not HLA matched; 75% graft
survival at 3 years

95
Q 
MAXIMUM TIME BETWEEN HARVEST
STATISTICS
What survival rate is
associated with LRD?
P680
A

95% patient survival at 1 year; 75% to

85% graft survival at 3 years

96
Q 
MAXIMUM TIME BETWEEN HARVEST
STATISTICS
What are the tests for
compatibility?
P680
A

ABO, HLA typing

97
Q 
MAXIMUM TIME BETWEEN HARVEST
STATISTICS
If a choice of left or right
donor kidney is available,
which is preferred?
P680
A

Left—longer renal vein allows for easier

anastomosis

98
Q 
MAXIMUM TIME BETWEEN HARVEST
STATISTICS
Should the placement of
the kidney be hetero- or
orthotopic?
P680
A

Heterotopic—retroperitoneal in the RLQ

or LLQ above the inguinal ligament

99
Q

MAXIMUM TIME BETWEEN HARVEST
STATISTICS
Why?
P681

A

Preserves native kidneys, allows easy
access to iliac vessels, places ureter close
to the bladder, easy to biopsy kidney

100
Q 
MAXIMUM TIME BETWEEN HARVEST
STATISTICS
Define anastomoses of
a heterotopic kidney
transplant.
P681 (picture)
A
  1. Renal artery to iliac artery
  2. Renal vein to iliac vein
  3. Ureter to bladder
101
Q 
MAXIMUM TIME BETWEEN HARVEST
STATISTICS
What is the correct
placement of the ureter?
P681
A

Submucosally through the bladder

wall—decreases reflux

102
Q 
MAXIMUM TIME BETWEEN HARVEST
STATISTICS
What is the differential
diagnosis of post–renal
transplant fluid collection?
P681
A 
“HAUL”:
    Hematoma
    Abscess
    Urinoma
    Lymphocele
103
Q

MAXIMUM TIME BETWEEN HARVEST
STATISTICS
Why keep native kidneys?
P681

A

Increased morbidity if they are removed

104
Q 
MAXIMUM TIME BETWEEN HARVEST
STATISTICS
What is the indication for
removal of native kidneys?
P681
A

Uncontrollable HTN, ongoing renal sepsis

105
Q 
MAXIMUM TIME BETWEEN HARVEST
REJECTION
What is the red flag that
indicates rejection?
P681
A

↑ creatinine

106
Q 
MAXIMUM TIME BETWEEN HARVEST
REJECTION
What is the differential
diagnosis of increased
creatinine?
P682
A

(Remember: “-TION”) obstrucTION,
dehydraTION, infecTION, intoxicaTION
(CSA); plus lymphocele, ATN

107
Q 
MAXIMUM TIME BETWEEN HARVEST
REJECTION
What are the signs/
symptoms?
P682
A

Fever, malaise, HTN, ipsilateral leg

edema, pain at transplant site, oliguria

108
Q 
MAXIMUM TIME BETWEEN HARVEST
REJECTION
What is the workup for the
following tests:
U/S with Doppler?
P682
A

Look for fluid collection around the

kidney, hydronephrosis, flow in vessels

109
Q 
MAXIMUM TIME BETWEEN HARVEST
REJECTION
What is the workup for the
following tests:
Radionuclide scan?
P682
A

Look at flow and function

110
Q 
MAXIMUM TIME BETWEEN HARVEST
REJECTION
What is the workup for the
following tests:
Biopsy?
P682
A

Distinguish between rejection and

cyclosporine toxicity

111
Q 
MAXIMUM TIME BETWEEN HARVEST
REJECTION
What is the time course for
return of normal renal
function after transplant?
P682
A

LRD—3 to 5 days

Deceased donor—7 to 15 days

112
Q

LIVER TRANSPLANT
Who performed the first
liver transplant?
P682

A

Thomas Starzl (1963)

113
Q

LIVER TRANSPLANT
What are the indications?
P682

A 
Liver failure from:
    1. Cirrhosis (leading indication in
       adults)
    2. Budd-Chiari
    3. Biliary atresia (leading indication
       in children)
    4. Neonatal hepatitis
    5. Chronic active hepatitis
    6. Fulminant hepatitis with drug
       toxicity—acetaminophen
    7. Sclerosing cholangitis
    8. Caroli’s disease
    9. Subacute hepatic necrosis
    10. Congenital hepatic fibrosis
    11. Inborn errors of metabolism
    12. Fibrolamellar hepatocellular
       carcinoma
114
Q

LIVER TRANSPLANT
What is the MELD score?
P683

A 
“Model for End Stage Liver Disease” is
the formula currently used to assign
points for prioritizing position on the
waiting list for deceased donor liver
transplant; based on INR, bilirubin, and
creatinine with extra points given for the
presence of liver cancer
115
Q

LIVER TRANSPLANT
What is the test for
compatibility?
P683

A

ABO typing

116
Q

LIVER TRANSPLANT
What is the placement?
P683

A

Orthotopic

117
Q

LIVER TRANSPLANT
What are the options for
biliary drainage?
P683

A
  1. Donor common bile to recipient
    common bile duct end to end
  2. Roux-en-Y choledochojejunostomy
118
Q

LIVER TRANSPLANT
What is the “piggyback
technique”?
P683

A 
Recipient vena cava is left in place; the
donor infrahepatic IVC is oversewn; the
donor superior IVC is anastomosed onto
a cuff made from the recipient hepatic
veins (allows for greater hemodynamic
stability of the recipient during OLT)
119
Q 
LIVER TRANSPLANT
How does Living Donor
Liver Transplantation
(LDLT) work?
P683
A

Adult donates a left lateral segment to a
child or an adult donates a right lobe to
another adult

120
Q

LIVER TRANSPLANT
What is a split liver
transplant?
P683

A

Deceased donor liver is harvested
and divided into two “halves” for two
recipients

121
Q

LIVER TRANSPLANT
What is chronic liver
rejection called?
P683

A

“Vanishing bile duct syndrome”

122
Q 
LIVER TRANSPLANT
REJECTION
What are the red flags
indicating rejection?
P683
A

Decreased bile drainage, increased

serum bilirubin, increased LFTs

123
Q

LIVER TRANSPLANT
REJECTION
What is the site of rejection?
P683

A

Rejection involves the biliary epithelium

first, and later, the vascular endothelium

124
Q 
LIVER TRANSPLANT
REJECTION
What is the workup with the
following tests:
U/S with Doppler?
P684
A

Look at flow in portal vein, hepatic
artery; rule out thrombosis, leaky
anastomosis, infection (abscess)

125
Q 
LIVER TRANSPLANT
REJECTION
What is the workup with the
following tests:
Cholangiogram?
P684
A

Look at bile ducts (easy to do; patients
usually have a T-tube if they have
primary biliary anastomosis)

126
Q 
LIVER TRANSPLANT
REJECTION
What is the workup with the
following tests:
Biopsy?
P684
A

Especially important 3 to 6 weeks
postoperatively, when CMV is of
greatest concern

127
Q 
LIVER TRANSPLANT
REJECTION
Does hepatorenal syndrome
renal function improve after
liver transplant?
P684
128
Q 
LIVER TRANSPLANT
SURVIVAL STATISTICS
What is the 1-year survival
rate?
P684
A

≈80% to 85%

129
Q 
LIVER TRANSPLANT
SURVIVAL STATISTICS
What percentage of patients
requires retransplant?
P684
130
Q

LIVER TRANSPLANT
SURVIVAL STATISTICS
Why?
P684

A

Usually primary graft dysfunction,
rejection, infection, vascular thrombosis,
or recurrence of primary disease

131
Q

PANCREAS TRANSPLANT
Who performed the first
pancreas transplant?
P684

A

Richard C. Lillehei and William D. Kelly

1966

132
Q

PANCREAS TRANSPLANT
What are the indications?
P684

A

Type I (juvenile) diabetes mellitus
associated with severe complications
(renal failure, blindness, neuropathy) or
very poor glucose control

133
Q

PANCREAS TRANSPLANT
What are the tests for
compatibility?
P684

A

ABO, DR matching (class II)

134
Q

PANCREAS TRANSPLANT
What is the placement?
P684

A

Heterotopic, in iliac fossa or paratopic

135
Q 
PANCREAS TRANSPLANT
Where is anastomosis of the
exocrine duct in heterotopic
placement?
P685 (picture)
A

To the bladder

136
Q

PANCREAS TRANSPLANT
Why?
P685

A

Measures the amount of amylase in
urine, gives an indication of pancreatic
function (i.e., high urine amylase
indicates good pancreatic function)

137
Q

PANCREAS TRANSPLANT
What is the associated
electrolyte complication?
P685

A

Loss of bicarbonate

138
Q 
PANCREAS TRANSPLANT
Where is anastomosis of the
exocrine duct in paratopic
placement?
P685
A

To the jejunum

139
Q

PANCREAS TRANSPLANT
Why?
P685

A

It is close by and physiologic

140
Q

PANCREAS TRANSPLANT
What is the advantage of
paratopic placement?
P685

A

Endocrine function drains to the portal
vein directly to the liver, and pancreatic
contents stay within the GI tract (no
need to replace bicarbonate)

141
Q

PANCREAS TRANSPLANT
What are the red flags
indicating rejection?
P685

A

Hyperamylasemia, hyperglycemia,

hypoamylasuria, graft tenderness

142
Q 
PANCREAS TRANSPLANT
Why should the kidney and
pancreas be transplanted
together?
P685
A

Kidney function is a better indicator of
rejection; also better survival of graft is
associated with kidney-pancreas
transplant than pancreas alone

143
Q 
PANCREAS TRANSPLANT
Why is hyperglycemia not a
good indicator for rejection
surveillance?
P685
A

Hyperglycemia appears relatively late

with pancreatic rejection

144
Q

HEART TRANSPLANT
Who performed the first
heart transplant?
P686

A

Christiaan Barnard (1967)

145
Q

HEART TRANSPLANT
What are the indications?
P686

A 
Age birth to 65 years with terminal
acquired heart disease—class IV of
New York Heart Association classification
(inability to do any physical activity
without discomfort = 10% chance of
surviving 6 months)
146
Q

HEART TRANSPLANT
What are the
contraindications?
P686

A

Active infection
Poor pulmonary function
Increased pulmonary artery resistance

147
Q

HEART TRANSPLANT
What are the tests for
compatibility?
P686

148
Q

HEART TRANSPLANT
What is the placement?
P686

A

Orthotopic anastomosis of atria, aorta,

pulmonary artery

149
Q

HEART TRANSPLANT
What is sewn together in a
heart transplant?
P686 (picture)

A

Donor heart atriums, pulmonary artery,
and aorta are sewn to the recipient
heart atriums, pulmonary artery, and
aorta

150
Q

HEART TRANSPLANT
What are the red flags of
rejection?
P686

A

Fever, hypotension or hypertension,

increased T4/T8 ratio

151
Q

HEART TRANSPLANT
What is coronary artery
vasculopathy?
P686

A

Small vessel occlusion from chronic

rejection—often requires retransplant

152
Q

HEART TRANSPLANT
What are the tests for
rejection?
P687

A

Endomyocardial biopsy—much more
important than clinical signs/symptoms;
patient undergoes routine biopsy

153
Q 
HEART TRANSPLANT
What are survival statistics
for:
1 year?
P687
154
Q 
HEART TRANSPLANT
What are survival statistics
for:
5 year?
P687
155
Q

INTESTINAL TRANSPLANTATION
What is it?
P687

A

Transplantation of the small bowel

156
Q

INTESTINAL TRANSPLANTATION
What types of donors are
there?
P687

A

Living donor, deceased donor

157
Q

INTESTINAL TRANSPLANTATION
Anastomosis:
Living donor?
P687

A

Ileocolic artery and vein

158
Q

INTESTINAL TRANSPLANTATION
Anastomosis:
Deceased donor?
P687

159
Q

INTESTINAL TRANSPLANTATION
What are indications?
P687

A

Short gut syndrome, motility disorders,
and inability to sustain TPN (liver failure,
lack of venous access, etc.)

160
Q 
INTESTINAL TRANSPLANTATION
What is a common
postoperative problem
other than rejection?
P687
A

GVHD (Graft-Versus-Host Disease) from
large lymphoid tissue in transplanted
intestines

161
Q

INTESTINAL TRANSPLANTATION
CMV status of donor?
P687

A

Must be CMV negative if recipient is

CMV negative

162
Q 
INTESTINAL TRANSPLANTATION
What is the most
common cause of death
postoperatively?
P687
163
Q

INTESTINAL TRANSPLANTATION
How is rejection surveillance
conducted?
P687

A

Endoscopic biopsies

164
Q

INTESTINAL TRANSPLANTATION
What is the clinical clue to
rejection?
P687

A

Watery diarrhea

165
Q

LUNG TRANSPLANT
Who performed the first
lung transplant?
P688

A

James Hardy (1963)

166
Q

LUNG TRANSPLANT
What are the indications?
P688

A 
Generally, a disease that substantially
limits activities of daily living and is likely
to result in death within 12 to 18 months:
    Pulmonary fibrosis
    COPD
    Eosinophilic granuloma
    Primary pulmonary HTN
    Eisenmenger’s syndrome
    Cystic fibrosis
167
Q

LUNG TRANSPLANT
What are the
contraindications?
P688

A

Current smoking

Active infection

168
Q 
LUNG TRANSPLANT
What tests comprise the
pretransplant assessment of
the recipient?
P688
A
  1. Pulmonary—PFTs, V/Q scan
  2. Cardiac—Echo, cath, angiogram
  3. Exercise tolerance test
169
Q

LUNG TRANSPLANT
What are the donor
requirements?
P688

A
  1. 55 years of age or younger
  2. Clear chest film
  3. PA oxygen tension of 300 on 100%
    oxygen and 5 cm PEEP
  4. No purulent secretions on
    bronchoscopy
170
Q

LUNG TRANSPLANT
What are necessary
anastomoses?
P688

A

Bronchi, PA, pulmonary veins

Bronchial artery is not necessary

171
Q

LUNG TRANSPLANT
What are the postop
complications?
P688

A

Bronchial necrosis/stricture, reperfusion,

pulmonary edema, rejection

172
Q

LUNG TRANSPLANT
What are the red flags of
rejection (4)?
P688

A
  1. Decreased arterial O2 tension
  2. Fever
  3. Increased fatigability
  4. Infiltrate on x-ray
173
Q

LUNG TRANSPLANT
What is chronic lung
rejection called?
P688

A

Obliterative Bronchiolitis (OB)

174
Q

LUNG TRANSPLANT
What are the survival rates:
1 year?
P689

175
Q

LUNG TRANSPLANT
What are the survival rates:
3 yrs?
P689

176
Q

TRANSPLANT COMPLICATIONS
What are four major
complications?
P689

A
  1. Infection
  2. Rejection
  3. Post-transplant lymphoproliferative
    disease
  4. Complications of steroids
177
Q

TRANSPLANT COMPLICATIONS
INFECTION
What are the usual agents?
P689

A

DNA viruses, especially CMV, HSV, VZV

178
Q 
TRANSPLANT COMPLICATIONS
INFECTION
When should CMV infection
be suspected?
P689
A

>21 days post-transplant

179
Q 
TRANSPLANT COMPLICATIONS
INFECTION
What is the time of peak
incidence of CMV infections?
P689
A

4 to 6 weeks post-transplant

180
Q 
TRANSPLANT COMPLICATIONS
INFECTION
What are the signs/
symptoms of CMV?
P689
A

Fever, neutropenia, signs of rejection
of transplant; also can present as viral
pneumonitis, hepatitis, colitis

181
Q

TRANSPLANT COMPLICATIONS
INFECTION
How is CMV diagnosed?
P689

A

Biopsy of transplant to differentiate

rejection, cultures of blood, urine

182
Q 
TRANSPLANT COMPLICATIONS
INFECTION
What is the treatment of
CMV?
P689
A

Ganciclovir, with or without

immunoglobin; foscarnet

183
Q 
TRANSPLANT COMPLICATIONS
INFECTION
What are the complications
of ganciclovir?
P689
A

Bone marrow suppression

184
Q 
TRANSPLANT COMPLICATIONS
INFECTION
What are the signs/
symptoms of HSV?
P689
A

Herpetic lesions, shingles, fever,

neutropenia, rejection of transplant

185
Q

TRANSPLANT COMPLICATIONS
INFECTION
What is the treatment of HSV?
P689

A

Acyclovir until patient is asymptomatic

186
Q 
TRANSPLANT COMPLICATIONS
MALIGNANCY
What are the most common
types?
P689
A

Skin/lip cancer (40%), B-cell cancer,
cervical cancer in women, T-cell
lymphoma, Kaposi’s sarcoma

187
Q 
TRANSPLANT COMPLICATIONS
MALIGNANCY
Which epithelial cancers are
important after transplant?
P690
A

Skin/lip cancer, especially basal cell and

squamous cell

188
Q 
TRANSPLANT COMPLICATIONS
MALIGNANCY
What is post-transplant
lymphoma associated with?
P690
A

Multiple doses of OKT3
EBV
Young > elderly

189
Q 
TRANSPLANT COMPLICATIONS
MALIGNANCY
What is the treatment for
post-transplant lymphoproliferative
disease (PTLD)?
P690
A
  1. Drastically reduce immunosuppression
  2. ± Radiation
  3. ± Chemotherapy

Section III Subspecialty Surgery P517 (11 decks)

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