Transplantation Flashcards
Name three types of transplant
Deceased heart beating
Non-heart beating
Live donations
What investigations do potential recipients have to undergo before they can receive a transplant?
Immunology Virology Cardiorespiratory risk Peripheral vessel assessment Bladder function Mental state Comorbidities
What infections are tested for in potential recipients?
Hepatitis HIV EBV CMV VZV Toxo Syphilis
State the contraindications for transplant
Malignancy Active HCV/HIC Untreated TB Severe IHD Severe airway disease Active vasculitis Severe PVD Hostile bladder
What assessments needs to be done if it is a live donor?
Fit for surgery, enough renal function to remain independent with only one kidney, anatomically normal kidneys, co-mobitities, immunologically and psychologically compatible. No coercion
Describe tissue typing related to blood group
Donor O can give to O, A, B or AB
Donor A can give to A or AB
Donor B can give to B or AB
Donor AB can only give to AB
Why is HLA tested?
HLA molecules bind fragments of protein antigens into a groove for recognition by T cells. T cells recognise self proteins but in an unmatched transplant immune attack can occur
What HLA are specifically looked at?
HLA A
HLA B
HLA DR
What is the significance of sensitising events?
They lead to formation of pre-formed antibodies to non-self antigens - blood transfusion, pregnancy, transplant
Describe desensitisation
Active removal of a blood group/donor specific antibody by plasma exchange or B cell antibody - rituximab. Transplant can be carried out when levels are below acceptable threshold
Where is a kidney transplant inserted?
Iliac fossa and attached onto the external iliac artery and vein
How is the donor ureter connected to the recipient bladder?
With a stent
How long does it take to recover from a kidney transplant?
3 months
What are the complications?
Bleeding Arterial stenosis Venous kinking Ureteric stricture Hydronephrosis Infection Lymphocele
State the three possible outcomes of a transplant
Immediate Graft Function
Delayed Graft Function
Non function
How will a patient with immediate graft function present?
Good urine output, reduced urea/creatinine
What is often required in patients with delayed graft function?
Haemodialysis usually takes 10-30 days - need to do a biopsy to check
State the three types of rejection
Hyperacute
Acute
Chronic
Describe hyperacute rejection
Preformed antibodies, requires transplant nephrectomy
Describe acute rejection
Cellular/antibody mediated, requires increased immunosuppression
Describe chronic rejection
Slow progressive decline, antibody mediated with poor response to treatment
What is the purpose of anti-rejection therapy?
Reduces T cell activation and prevents host vs. transplant immune response
Name the induction immunosuppression
Basiliximab, dacluzimab
What immunosuppressive drug is given during a transplant operation?
IV prednisolone
What are the two combinations of immunosuppression given for maintenance post op?
Prednisolone, tacrolimus, MMF
Prednisolone, ciclosporin, azathiprine
Name some anti-rejection drugs
Methylprednisolone, anti-thymocyte globulin, IV immunoglobulin, plasma exchange, rituximab, bortezimab, eculizumab
What are the side effects of immunosuppression?
Infection and cancers
What are common infections due to immunosuppression?
Bacterial - URTI/UTI (common)
Viral - CMV, HSV, BK
Fungal
Describe the effect of CMV
First 3 months, associated with early graft loss and causes renal/hepatic dysfunction, oesophagitis, pneumonitis, colitis, increased risk of rejection
How is CMV investigated and treated?
IgM and PCR
Prophylactic - valganciclovir
IV ganciclovir if active infection
Where is BK prevalent?
Uroepithelium
What is the effect of BK?
Mimics rejection
How is BK treated?
Reduce immunosuppression and monitor PCR
Other than renal where do transplantation also attend a regular review?
Dermatology
What are the commonest cancers due to immunosuppression?
Non-melanoma skin cancer
Lymphoma
Solid organs
What virus is post transplant lymphoproliferative disease related to?
EBV - causes polyclonal B cell proliferation then monoclonal proliferation and finally lymphoma
How is post transplant lymphoproliferative disease treated?
Reduced Immunosuppression if unresponsive chemotherapy may be required
How do monoclonal antibodies work?
Block IL2 receptor on CD4 T cells and prevent activation
What can calcineurin inhibitors cause?
Renal dysfunction, hypertension, diabetes, tremor
Name two anti-metabolites
Azathioprine and MMF
How do anti-metabolites work?
Block purine synthesis to suppress lymphocyte proliferation
What can anti-metabolites cause?
Leucopenia
GI upset
Anaemia
