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BCTXP > Treatment of Rejection > Flashcards

Treatment of Rejection Flashcards

1
Q

Kidney TCMR Nomenclature

A

Banff IA, IB, IIA, IIB, or III

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2
Q

Liver TCMR Nomenclature

A

Mild, moderate or severe rejection

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3
Q

Heart TCMR Nomenclature

A

Grade 0R (no rejection), 1R (mild), 2R (moderate), 3R (severe)

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4
Q

Lung TCMR Nomenclature

A

A0 (none) through A4 (severe)

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5
Q

Intestine TCMR Nomenclature

A

Grade 1 (mild), Grade 2 (moderate), Grade 3 (severe)

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6
Q

Liver TCMR - When to treat

A

Moderate or severe

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7
Q

Heart TCMR - When to treat

A

2R or 3R unless hemodynamic instability

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8
Q

Lung TCMR - When to treat

A

A2, A3, or A4 unless symptomatic

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9
Q

Kidney ABMR - Requirements for dx

A

(1) Histologic evidence on pathology, (2) C4d staining or microvascular inflammation, (3) DSA

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10
Q

Liver ABMR - Requirements for dx

A

(1) Histologic evidence on pathology, (2) C4d staining, (3) DSA, (4) Exclude other causes

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11
Q

Heart ABMR - Requirements for dx

A

(1) Histologic evidence on pathology, (2) Immunopathologic evidence such as C4d; clinical dysfunction and DSA are optional

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12
Q

Lung ABMR - Requirements for dx

A

Requires symptoms, and 2-4 of the following:(1) Histologic evidence on pathology, (2) C4d staining, (3) DSA, (4) Exclude other causes

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13
Q

Heart ABMR - Nomenclature

A 
pAMR 0 = negative
pAMR 1 (H+) = histologic alone pAMR 1 (I+) = immunopathologic alone
pAMR 2 = pathologic AMR
pAMR 3 = severe pathologic AMR
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14
Q

Lung ABMR - Nomenclature

A

Possible (2), probable (3) or definitive ABMR (4)

Requires symptoms, and 2-4 of the following:(1) Histologic evidence on pathology, (2) C4d staining, (3) DSA, (4) Exclude other causes

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15
Q

CLAD Staging

A 
(Based on FEV1)
CLAD 0: FEV1 >80% baseline
CLAD 1: 65 - 80%
CLAD 2: 50 - 65%
CLAD 3: 35 - 50%
CLAD 4: FEV1 < 35% baseline
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16
Q

CLAD: possible vs probable vs definite

A

Lung allograft dysfxn: >10% decline FEV1 +/- FVC from baseline
Possible CLAD: < 3 weeks; >20% decline
Probable CLAD: 3 weeks - 3 months; >20% decline
Definite CLAD: > months; >20% decline

17
Q

CLAD phenotypes

A
  1. BOS: bronchiolitis obliterans syndrome [obstructive; FEV1/FVC <0.7]
  2. RAS: restrictive allograft syndrome [restrictive; TLC decline >10%]
  3. Mixed
18
Q

BOS Treatment

A
  1. Optimize IS (CsA –> FK)
  2. Azithro 250 mg TIW
  3. Fundoplication if GERD

?Montelukast

19
Q

RAS Treatment

A

Little data indicating effective treatment - antifibrotics, campath, TLI, ECP

20
Q

CAV Nomenclature

A 
CAV0 = no detectable CAV
CAV1 = Mild
CAV2 = Moderate
CAV3 = Severe
21
Q

CAV Risk Factors

A

Rejection, DSA, HTN, HLD, DM, CMV infection, older donor age

22
Q

BOS Risk Factors

A

Rejection, GERD, CMV, respiratory viral infxn, PSA colonization, Aspergillus colonization or fungal PNA, increased BAL neutrophils, PGD

23
Q

RAS Risk Factors

A

Acute rejection, PSA colonization, infection, blood eosinophilia, BAL eosinophilia and neutropenia

24
Q

MOA: Rituximab

A

Anti-CD20 monoclonal antibody where CD20 is expressed on mature B cells (but not plasma cells)

= complement-dependent and antibody-dependent cytotoxicity of B cells

25
Q

Rituximab pre-med, ppx and warnings

A
  1. Pre-med with APAP & Benadryl +/- steroid
  2. PCP prophylaxis x6 months
  3. Boxed warning for HBV reactivation
26
Q

MOA: Proteosome Inhibitors

A

Reversible inhibitor of the 26S proteasome = misfolded proteins apoptosis

27
Q

Proteosome Inhibitors: PPX

A

HSV prophylaxis

28
Q

MOA: Eculizimab

A

Monoclonal antibody that specifically binds to the complement protein C5 with high affinity, thereby inhibiting its cleavage to C5a and C5b and preventing the generation of the terminal complement complex C5b-9

29
Q

Eculizimab: Vaccines

A

Meningococcal vaccines at least 2 weeks prior

If unabl to do so - abx prophy like PCN 500 Q12, azithro 250 daily

30
Q

Tocilizumab

A

Recombinant, humanized IL-6R monoclonal antibody that binds both soluble IL-6R and membrane IL-6R
IL-6 is a pleiotropic pro-inflammatory cytokine produced by a variety of cell types including T- and B-cells, lymphocytes, monocytes and fibroblasts.

31
Q

MOA: IVIG

A

Concentrated IgG antibodies purified from large pools of human plasma (other Ig present in small quantities)

  • Enhances antibody clearance
  • Neutralizing effects and blocks action of the complement & cytokines
  • Inhibition of T cell proliferation
  • B cell apoptosis
  • Inhibition of cytokine synthesis
  • Negative regulatory signals via activation of Fv gamma receptors
32
Q

MOA: Plasmapheresis

A

Remove DSA from the circulation.
Not to be used alone – does not prevent antibody formation and there is rebound of circulating DSA after pheresis
- Alternate day PP may allow for optimal antibody removal by giving adequate time (~48H) for re-equilibration of antibody to intravascular space from interstitium

33
Q

AlloMap: Who are candidates per ISHLT?

A

Heart txp recipients, low-risk patients, 6 months - 5 years post-txp

34
Q

AlloMap cutoff for biopsy

A

2-6 months: 30+
6+ months: 34+
Range: 0-40

35
Q

AlloSure: Who are candidates?

A

Kidney txp 18+, at least 14 days post-txp; not twin or pregnant

36
Q

Allosure Cutoffs

A

Borderline: 0.5
TCMR: 1.0

Serial increase >61%

37
Q

Benefits of DSA monitoring

A
  • Detect DSA earlier and reduce incidence of AMR

- But no diff in rates of patient or graft survival; $$$

BCTXP (11 decks)

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