URINARY Section 7: Transplant

Question 1

the best treatment for end stage renal disease

Answer 1

tansplant

Question 2

Where the transplanted kidney is most commonly placed

Answer 2

extraperitoneal iliac fossa so that the allograft can be anastomosed with the iliac vasculature and urinary bladder.

Question 3

two major points to know first when thinking about resistance indices (RI)

Answer 3

1. Kidney has an unforgiving capsule
2. A sick kidney is a swollen kidney

Question 4

RI =

Answer 4

Question 5

If the meat (parenchyma) of the kidney is sick and swollen, but can’t expand because it is wrapped in a tight unforgiving capsule you can imagine the
blood vessels going through that kidney are going

Answer 5

going to get the squeeze!!

You can also probably imagine that the passive diastolic flow would be more impaired (compared to the active systolic flow) by this squeeze.

Question 6

If the meat of the kidney becomes “sick” from whatever the cause might be {rejection, infection, inflammation, etc…) it swells =

Answer 6

Increasing resistance

Question 7

RI should stay below?

Answer 7

Below 0.7

Question 8

For the purpose of multiple choice, you should never use elevated RIs

Answer 8

to exclude pathology (unless the answer is normal)

Question 9

3 flavors of Transplant Complications

Answer 9

a. Urologic
b. Vascular
c. Cancer

Question 10

why do tranplanted kidneys have some mild hydro?

Answer 10

denervation of the transplant

loppy tone to the ureter.

If there is a true obstruction it is usually at the site of ureteral implantation to the bladder.

Question 11

Common causes of tranplant obstruction?

Answer 11

post operative edema
scarring
technical errors leading to kinking

Question 12

Hematoma in transplant

Answer 12

Common immediately post op
Spontenous resolution

Question 13

Large post transplant hematoma can produe

Answer 13

hydronephrosis

Question 14

Acute hematoma vs chronic

Answer 14

ACute = echogenic

chronic = anechoic + septated

Question 15

Urinoma is usually found __ weeks post op

Answer 15

2 weeks

Question 16

Urinoma on USD

Answer 16

anechoic fluid collection with no septations, that is rapidly increasing in size.

Question 17

Where do most leaks (urine extravasation) go?

Answer 17

Ureterovesical anastomosis

Question 18

How do you demosntrate urinoma?

Answer 18

MAG 3 nuc med

or

USD (cheaper)

Question 19

When do lymphoceles start post op?

Answer 19

1-2 months

Question 20

Cause of lymphocele

Answer 20

leakage of lymph from surgical disruption of lymphatics or leaking lymphatics in the setting of inflammation

Question 21

most common fluid collection to cause transplant hydronephrosis.

Answer 21

LYmphocele

Question 22

Ipsilateral lower extremity edema from femoral vein compression.

Answer 22

Lymphocele

Question 23

Think Complex Collection + Heterogenous, Septa,

Answer 23

Hematoma

Question 24

Simple Collection between the bladder and the kidney

Answer 24

Urinoma

Question 25

Complex Hyperemic Collection

Answer 25

Abscess

Question 26

Simple Collection (may have tiny septa).

Answer 26

Lymphocele

Question 27

CT appearance of Hematoma

Answer 27

Appearance will depend on how acute it is. Acute = more dense.

Question 28

CT appearance of Urinoma

Answer 28

Ifyoudoadelayed phase you can see leakage of contrast

Question 29

CT appearance of Abscess

Answer 29

Peripheral Enhancement

Question 30

CT appearance of Lymphocele

Answer 30

If you do a delayed phase you will NOT see leakage of contrast

Question 31

Urinoma causes

Answer 31

These things happen from ischemia to the ureter or obstruction (usually)

Question 32

an immediate failure of the graft - and you rarely see this imaged. It is basically a dead on arrival transplant.

Answer 32

Hyperacute Rejection

Question 33

Acute rejection happens between -

Answer 33

Week 1-3

Question 34

Acute Tubular Necrosis (ATN)

Answer 34

The mechanism is ischemia in the kidney after they carve it out of the Hobo (presuming the transplant is from the usual donor - Hobo found floating in the river). So in the time it takes to carve it out of the Hobo and sew it into an affluent celebrity (Selena Gomez, Tracy Morgan, etc..) there is going to be some ischemia - and therefore ATN.

Question 35

transplant requiring dialysis in the first week

Answer 35

“Delayed Graft Function (DGF) ”

Question 36

Immunosuppressive therapy necessary to keep the body from rejecting the graft can ironically end up poisoning the graft.

Answer 36

Cyclosporin

Question 37

Cyclosporin Toxicity (Calcineurin Inhibitor) timing

Answer 37

Latera than ATN (around a month)

Question 38

Cellular Immune. (T-Cell) Mediated rejection

Answer 38

Chronic rejection

Question 39

Antibody / Cell Mediated rejection

Answer 39

Acute rejection

Question 40

Ischemia During “Harvesting”

Answer 40

ATN

Question 41

Nephrotoxic Reaction to Immunosuppressive

Answer 41

Cyclosporin Toxicity

Question 42

Renal artery thrombosis happens when?

Answer 42

first month (usually minutes to hours post op)

Question 43

Technical factors of Renal artery Thrombosis?

Answer 43

Kinking or torsion

Question 44

Renal artery stenosis happens when?

Answer 44

first year

Question 45

Easily the most common vascular complication of transplant.

Answer 45

Renal Artery Stenosis

Question 46

Where does renal artery stenosis happen?

Answer 46

Anastomosis (end-to-end tpyeS)

Question 47

Risk factore for renal artery stenosis?

Answer 47

CMV

Question 48

"refractory hypertension"

Answer 48

REnal artery stenosis * PSV > 200-300 cm/s. (some people say 340-400 cm/s) * PSV ratio > 1.8-2.5x (Stenotic Part vs Non Stenotic Part) * Tardus Parvus: Measured at the Main Renal Artery Hilum (NOT at the arcuates) * Anastomotic Jetting

Question 49

Renal Vein Thrombosis happens when?

Answer 49

First week

Question 50

Swollen kidney 1 week post op + reversed diasolic flow =

Answer 50

Renal Vein Thrombosis

Question 51

Reverse M sign

Answer 51

Renal Vein Thrombosis

Question 52

Biopsy + "tissue vibration artifact" =

Answer 52

Arteriovenous Fistula (AVF) (perivascular, mosaic color assignment due to tissue vibration), with high arterial velocity, and pulsatile flow in the vein.

Question 53

Biopsy + graft infection/anastomotic dehiscence + Yin-yang

Answer 53

Pseudoaneurysm

Question 54

Answer 54

Pseudoaneurysm Doppler with biphasic flow at the neck of the pseudoaneurysm.

Question 54

Renal transplant + Immunusuppresion therapy =

Answer 54

100x increased risk of developing CA In particular, they get more nonmelanomatous skin cancer, lymphoma, and colon cancer

Question 55

recommendation for all renal transplant patients

Answer 55

annual skin exams

Question 56

RCC subtype in renal transplant?

Answer 56

Papillary

Question 57

This is an uncommon comphcation of organ transplant, associated with B-Cell prohferation.

Answer 57

Post Transplant Lymphoproliferative Disorder (PTLD)

Question 58

is a risk factor and that is one of the main reasons they screen for it

Answer 58

EBV

Question 59

When is Post Transplant Lymphoproliferative Disorder (PTLD) common?

Answer 59

It is most common in the first year post transplant, and often involves multiple organs.

Question 60

Answer 60

Post Transplant Lymphoproliferative Disorder (PTLD) mass lesion encasing / replacing the hilum

Question 61

Renal Transplant +BK Virus =

Answer 61

Urothelial Malignancy