Transplantation Flashcards
Most important HLA’s for recipient/donor matching. Which is the most important overall?
HLA-A, B, DR
HLA-DR
ABO blood compatibility is not required for which type of transplant
Liver
Universal donor blood type
O
Universal recipient blood type
AB
What is a cross match?
It detects preformed recipient antibodies to the donor by mixing RECIPIENT serum with DONOR lymphocytes
* If positive cross-match –> hyperacute rejection
What is Panel Reactive Antibody
Similar to cross-match: detects preformed recipient antibodies using a panel of HLA typing cells. A high PRA means highly sensitized
What increases panel reactive antibody?
Transfusion, pregnancy, previous transplant, autoimmune disease
Treatment for mild –> severe rejection
Mild: pulse steroids
Severe: steroids and antibody therapy (ATG, thymo)
Number one @ two malignancy following any transplant
- Squamous cell skin cancer
2. PTLD / related to EBV
Signs/symptoms of PTLD
SBO, mass, adenopathy
RF: Cytolytic drugs
Treatment: Withdrawal IS, ritux (anti-CD20), CTX/RT
Risks of long-term immunosupression
Cancer, cardiovascular disease, infection, osteopenia
Myocphenolate/MMF/CellCept
- Mechanism
- AE
Inhibits de novo purine synthesis (which inhibits growth of T cells)
AE: GI intolerance (N/v/d), myelosuppression – need to keep WBC > 3; used as maintenace therapy; Azathioprine (Imuran) has similar MOA
Steroids
- Mechanism
Inhibit inflammatory cells (macrophages) and genes for cytokine synthesis (IL-2 most important)
Cyclosporin MOA
Binds cyclophilin protein; complex inhibits calcinuerin; decreased cytokine synthesisof IL-2, 4).
AE: nephrotoxicity, hepatotoxicity, tremor, seizure, HUS (trough 200-300); hepatic metabolism, biliary excretion
FK-506, Prograf, Tacrolimus
Binds FK-binding protein; more potent than CsA
AE: Nephro, GI sx, mood changes, DM
Trough 10-15
Sirolimus/Rapamycin
Inhibits mTOR, inhibits T and B cell response to IL-2
ATG (anti-thymocyte globulin)
Equine or rabbit (Thymo) polyclonal antibodies against T cell antigens (CD2, 3, 4)
- Induction, acute rejection, cytolytic
- Depends on complement
AE: cytokine release syndrome – give steroids and benadryl (fever, chills, pulmonary edema, shock); also PTLD, myelosuppression
Hyperacute rejection
Caused by pre-formed antibodies that should have been picked up by cross-match (T2 hypersensitivity); MCC-ABO incompatibility
- Activates compliment cascade and thrombosis of vessesls
- Emergent re-txp or explant
Accelerated rejection
Sensitized T cells to donor HLA (IS, pulse steroids, possible Antibody treatment)
Acute rejection
Occurs 1 week to 1 month
- Caused by T cells (cytotoxic and helper T cells) to HLA antigens
Chronic rejection
Type IV hypersensitivity (sensitized T cells); antibody formation; graft fibrosis
RF: increased acute rejection episodes
How long can a kidney be stored cold?
48 hours
Major cause of mortality in kidney transplant recipients
Stroke, MI
Number one complication of kidney transplant operation
Urine leak; drain/stent
How to diagnose/treat renal artery stenosis in a kidney recipient
Flow acceleration at level of stenosis on duplex; PTA with stent
Most common cause of external ureter compression in a post-txp patient
Lymphocele; 3 weeks after TXP (late decreased urine output with hydro adn fluid collection)
- Try perc drainage; peritoneal window (hole into peritoneum, lymph fluid is re-absorbed)
Kidney txp post-op oliguria is usually 2/2
ATN (hydropic changes; dilation and loss of tubules)
Post-op diuresis in a kidney recipient is 2/2
Urea and glucose
New proteinuria in a kidney recipient is 22
Renal vein thrombosis
Post-op diabetes in a kidney recipient is 2/2
CSA, FK, steroids
Treatment CMV, HSV
CMV: ganciclogir
HSV: acyclovir
S/Sx kidney rejection
Increased Cr, decreased U/O
Work-up kidney txp rejection
Duplex: r/o vascular, ureteral obstruction
- Empiric decrease in CSA/FK (nephrotoxic)
- Empiric pulse steroids
- Fluid/Lasix challenge
MCC mortality in a kidney txp recipient
Myocardial infarction
How many hours can a liver be stored?
24 hours
MCC complication in kidney donor
Wound infection
Most common cause of death in a living kidney donor
Fatal PE
To help prevent re-infection from HBV in a liver recipient
HBIF, lamivudine
Is portal vein thrombosis a contraindication to transplantation?
No
What percentage of patients will start to drink again after txp?
20%
Macrosteatosis is a risk factor for primary non-function
Yes; 50% = 50% primary non-function
Number one post-op complication, liver transplant
Bile leak – ERCP/stent
Primary non-function of liver txp
TB >10; bile output < 20 cc/12 hr, elevated INR, renal failure, pulmonary failure; require re-txp
For hepatic artery stenosis…
Place a stent
MCC early hepatic artery thrombosis
Early vascular complication; increase LFT, decreased bile output, fulminant liver failure; emergent re-transplantation
Late hepatic artery thrombosis
Biliary stricture & abscess; not fulminant liver failure
IVC stenosis/thrombosis
Edema, ascites, renal failure; thrombolytics and IVC stent
PV thrombosis
Early: abdominal pain
Late: UGI bleed, ascites, asymptomatic
Live donor liver for an adult vs child
Adult: take R lobe
Child: L lateral
MC indication for pancreas transplant
DM with renal failure
What arteries/veins are needed for pancreas txp
Donor celiac and SMA; and donor portal vein
Do most panc txps use enteric drainage?
Yes; take second portion of duodenum from donor along with ampulla of Vater and pancreas; anastamosis of donor duodenum to recipient bowel
Number one complication of pancreas txp
Venous thrombosis
For how long can a heart be stored
6 hours
T/F persistent pulmonary hypertension after heart transplantation is a/q early mortality after heart txp
True; Tx: iNOS, ECMO
MCC early cardiac graft mortality
Infection
MCC of late death heart txp
Chronic allograft vasculopathy
Acute rejection, heart txp
Perivascular lymphocytic infiltrate with myocyte inflammation and necrosis
Number one cause of early mortality in lung txp
Reperfusion injury (similar to ARDS)
Indication for double lung-txp
Cystic fibrosis
MCC chronic rejection, lung txp
Bronciolotis obliterans
Viral, protozoan, fungal infections in txp recipients
CMV, HSV, VZV
PCP
Aspergillus, Candida, Cryptococcus
Exclusion criteria for lung txp
Aspiration, moderate to large contusion, infiltrate, purulent sputum, PO2 < 350 on 100% FiO2, PEEP 5
Graft vs. Host disease is mediated by T cells
True
Hyperacute rejection is due to …
Preformed recipient antibodiesokt3
Number one virus post transplant
CMV
Azathioprine (Imuran)
6-MP derivative, purine analog, anti-metabolite, decreases DNA synthesis
T/F Prednisone blocks IL-1 from macrophages
True
Liver transplant 1 year graft survival
70%
