Flashcards in 12 Transplant Deck (166):
what is the hierarchy for permission for organ donation from next of kin?
spouse, adult son or daughter, either parent, adult brother or sister, guardian, any other person authorized to dispose of body
what are the fungal causes of opportunistic infections?
fungal: aspergillus, candida, cryptococcus
what prophylaxis do you give for opportunistic infection and what does it cover?
bactrim for protozoan
what are the protozoan causes of opportunistic infections after lung txp?
protozoan: pneumocystic jiroveci pneumonia
what are the viral opportunistic infections after txp?
cmv, hsv, vzv
what is the cause of chronic rejection in lung txp patients?
what is the mcc of late death and death overall following lung txp?
chronic rejection - bronchiolitis obliterans
what are the path findings in lung acute rejection?
what is the exclusion criteria for using lungs for donor?
moderate to large contusion
PO2 less than 350 on 100%
FiO2 and PEEP 5
what is the indication for double-lung txp?
what is the treatment to reperfusion injury after lung tx?
similar to ards
what is the mcc cause of early mortality in lung transplant pts?
what is life expectancy of pts before lung tx?
less than 1 yr
what compatibility tests are needed before lung tx?
abo and crossmatch
how long can you store a lung before transplant?
what is the mcc of late death and death overall following heart txp?
chronic allograft vasculopathy (progressive diffuse coronary atherosclerosis)
what is pathology of heart during acute rejection after transplant?
perivascular lyphocytic infiltrate with varying grades of myocyte inflammation and necrosis
what is treatment for persistent pulm htn after heart tx?
inhaled NO, ECMO if severe
what is a big complication of postop heart transplantation?
pulmonary htn. assoc w early mortality
what is the life expectancy of pts before heart transplant?
what compatibility tests do you need for heart transplant?
compatibility and crossmatch
how long can a heart be stored?
how do you diagnosis pancreas rejection?
hard to diagnose if they don't also have kidney transplant
can see inc glucose or amylase. fever, leukocytosis
how do you treat venous thrombosis after pancreas transplant?
hard to treat
what are the complications of pancreas transplant?
venous thrombosis (#1) and rejection
what diabetic signs/sx are improved after pancreas transplant and what can't be reversed?
stabilization of retinopathy
inc nerve conduction velocity
dec autonomy dysfunction (dec gastroparesis)
no reversal of vascular dz
how do you drain pancreas enterically after transplant? what do you need from the donor?
take second portion of duodenum from donor + ampulla of Vater and pancreas.
perform anastomosis of donor duodenum to recipient bowel
what vessel do you attach the pancreas to?
what donor vessel do you need for venous drainage in pancreas transplant?
donor portal vein
what donor vessels do you need for arterial supply in pancreas transplant?
donor celiac artery and SMA
what is the 5 year survival rate after live transplant?
what is the liver retransplantation rate?
what do you find with chronic rejection of the liver? is it common?
-unusual. get disappearing bile ducts
-gradually obstruction of bile ducts w inc in alk phos
what is the cause of disappearing bile ducts during chronic rejection after liver transplant?
antibody and cellular attack on bile ducts
when does acute rejection of the liver occur?
usually in 1st 2 months
what is pathology of liver biopsy after acute rejection post liver transplant?
portal triad lymphocytosis, endotheliitis (mixed infiltrate), and bile duct injury
what labs are abnormal in acute rejection after liver transplant?
leukocytosis, eosinophilia, inc LFTs, inc total bilirubin, inc PT
what are the clinical signs of acute rejection?
fever, jaundice, decreased bile output.
what is the cause of acute rejection after liver transplant?
T cell mediated against blood vessels
what kinds of cells do you find around the portal triad if the pt gets cholangitis after liver transplant?
PMNs (not a mixed infiltrate)
what is treatment for portal vein thrombosis after liver transplant?
if early, re-op thrombectomy and revise anastomosis
what are the manifestations of portal vein thrombosis after liver transplant? is it common?
rare. early signs: abdominal pain.
late signs: UGI bleed, ascites, may be asymptomatic.
what is treatment for IVC stenosis / thrombosis?
thrombolyticcs, IVC stent
do abscesses appear from early or late hepatic artery thrombosis after liver transplant?
late (chronic) hepatic artery thrombosis
what are the signs of IVC stenosis / thrombosis after liver transplant?
edema, ascites, renal insufficiency. it is rare.
what happens during early hepatic artery thrombosis after liver transplant?
inc LFTs, dec bile output, fulminant hepatic failure
what is the treatment for early hepatic artery thrombosis after liver transplant?
will likely need emergent retransplantation for ensuing fulminant hepatic failure (can try to stent or revise anastomosis)
what can late hepatic artery thrombosis after liver transplant result in?
biliary strictures and abscesses
can late hepatic artery thrombosis after liver transplant result in fulminant hepatic failure?
what is the most common early vascular complication of liver transplant?
early hepatic artery thrombosis
what is treatment for primary nonfunction after liver transplant?
what happens during the beginning of primary nonfunction after liver transplant?
total bili >10, bile output <20 cc/12 h, elevated PT and PTT
what happens later during primary nonfunction after liver transplant and when does it happen?
after 96h. mental status changes, inc LFTs, renal failure, resp failure
when is primary nonfunciton of the liver likely to occur after transplant?
first 24 hours
what is the treatment for bile leak after liver transplant?
place a drain, then ERCP with stent across leak
what is the most common complication of liver transplant?
what is the most common arterial anatomy in liver transplant?
right hepatic coming off SMA
what does the viability of the biliary system (including ducts) depend on?
hepatic artery blood supply
where do you place drains after liver transplant?
right subhepatic, right and left subdiaphragmatic drains
how is a liver transplant performed in adults and in kids?
adults: duct-to-duct anastomosis
how likely will a donor liver suffer primary non function if it has macrosteatosis?
if 50% of cross-section is macrosteatatic in potential donor liver, 50% chance of primary non function
what is macrosteatosis?
extracellular fat globules in the liver allograft
how likely will an alcoholic start drinking again?
is portal vein thrombosis a contraindication to liver transplant?
can you consider liver transplant if pt has hepatocellular carcinoma?
yes if no vascualr invasion or if mets
what is the rate of reinfection of hep C after liver transplant? where does it recur?
most likely recurs in new liver allograft. reinfects essentially all grafts.
what is the reinfection rate after HBIG and lamivudine?
reduced to 20%
how do you treat pts iwth hep B antigenemia?
HBIG (hepatitis B immunoglobulin) and lamivudine (protease inhibitor) after liver transplant to prevent reinfection
what is the criteria for an urgent liver transplant?
fulminant hepatic failure (encephalopathy)
at what MELD will a pt benefit from liver transplant?
what is included in the MELD score? what does it tell you?
creatinine, INR, bilirubin. predicts if pts with cirrhosis will benefit more from liver transplant than from medical therapy
what is the most common reason for liver transplant in adults?
what are the contraindications to liver transplant?
current EtOH abuse, acute ulcerative colitis
how long can you store a liver for transplant?
what happens to the remaining kidney in living kidney donor?
what is the most common cause of death in living kidney donor?
what is the most common complication to living kidney donor and what is the incidence?
wound infection (1%)
what is 5 year graft survival in kidney transplant? cadaveric? living donor?
70% (65% cadaveric, 75% living donor)
when does acute rejection occur in kidney transplant?
usually occurs in 1st 6 months
when does chronic rejection usually happen in kidney transplant?
usually do not see until after 1 year.
what do you rule out with u/s with duplex if suspect kidney rejection?
vascular problems and ureteral obstruction
why do you empirically decrease CSA or FK when suspect kidney rejection?
they can be nephrotoxic
what is the kidney rejection workup?
U/S w duplex and biopsy, empiric dec in CSA or FK, empiric pulse steroids
when do you do a kidney rejection workup?
usually for inc in Cr or poor UOP
what do you see on pathology after acute rejection?
tubulitis (vasculitis with more severe form)
what is the most common viral infection after kidney transplant?
CMV and HSV
what is the treatment for CMV and HSV after kidney transplant?
CMV: ganciclovir. HSV: acyclovir
what is the most likely cause of postop diabetes after kidney transplant?
side effect of CSA, FK, steroids
if the donor has a UTI, can you use the kidney for transplant?
if there's an acute increase in creatinine (1.0-3.0) can you use the kidney for transplant?
To which vessels do you attach the kidney in transplant?
what is the treatment for urine leak after kidney transplant?
drainage and stenting
what is the most common cause of external ureter compression after kidney transplant?
what is the treatment for lymphocele after kidney transplant?
1st try percutaneous drainage. if fails, then need peritoneal window (make hole in peritoneum, lymphatic fluid drains into peritoneum and is absorbed (90% successful))
what is the cause of postop oliguria after kidney transplant? what do you see on pathology?
usually ATN. hydrophobic changes on pathology.
what is the cause of postop diuresis after kidney transplant?
usually due to urea and glucose
what is the cause of new proteinuria after kidney transplant?
renal vein thrombosis
how do you diagnose and treat renal artery stenosis after kidney transplant?
diagnose w ultrasound. treat with PTA with stent
what is the number one complication of kidney transplant?
what is the most common cause of mortality after kidney transplant?
stroke and MI
what is the pre kidney transplant workup?
ABO type compatibility and cross-match
how long can a kidney be stored?
what is the treatment for chronic rejection?
increase immunosuppression. no really effective treatment
what is the result of chronic rejection?
what is the cause of chronic rejection?
partially a type IV hypersensitivity reaction (sensitized T cells) with antibody formation also.
what is the treatment for acute rejection?
increase immunosuppression, pulse steroids, possibly antibody therapy
what is the cause of acute rejection?
caused by T cells (cytotoxic and helper T cells)
what is the treatment for accelerated rejection?
inc immunosuppression, pulse steroids, possibly antibody therapy
what is the cause of accelerated rejection?
sensitized T cells to donor antigens
what is treatment for hyperacute rejection?
emergent re-transplant (or just removal of organ if kidney)
what happens during hyperacute rejection?
preformed antibodies activates the complement cascade and thrombosis of vessels occurs
what is the cause of hyperacute rejection?
preformed antibodies that shoul dhave been picked up by the cross-match
what are the types of rejection and when do they occur?
hyperacute (min to hrs)
accelerated (<1 week)
acute (1 week to 1 mo)
chronic (months to yrs)
is zenapax cytolytic?
when is zenapax used?
induction and acute rejection.
what is zenapax?
daclizumab. human monoclonal antibody against IL-2 receptors
what is treatment for cytokine release syndrome?
steroids and benadryl given before drug to prevent
what are sx of cytokine release syndrome and what causes it?
fever, chills, pulm edema, shock. caused by ATG.
what are side effects of giving ATG?
cytokine release syndrome.
what should WBCs be when treating with ATG?
is ATG cytolytic? what does cytolytic mean?
yes. complement dependent
what does cytolytic mean?
when is ATG used?
induction and acute rejection episodes
what does ATG target?
CD2, CD3, CD4
what is another name for rabbit ATG?
what is another name for equine ATG?
how is sirolimus used?
what happens if mTOR is inhibited?
inhibits T and B cell response to IL-2
how does sirolimus work?
binds FK-binding protein like tacrolimus, but inhibits mammalian target of rapamycin (mTOR)
what is another name for sirolimus?
what is trough level for tacrolimus?
10 to 15
compared to CSA, does tacrolimus cause less or more rejection episodes in kidney transplant?
what are side effects of tacrolimus?
nephrotoxicity, more GI sx and mood changes than CSA. much less entero-hepatic recirculation compared to CSA
is CSA or tacrolimus more potent?
how does tacrolimus work?
binds FK-binding protein. has actions similar to CSA.
what are other names for FK-506?
how is CSA metabolized and excreted?
hepatically metabolised, biliary excretion (reabsorbed into gut, get entero-hepatic recirculation)
what is trough for CSA?
what are side effects of CSA?
nephrotoxicity, hepatotoxicity, tremors, sz, hemolytic-uremic syndrome
when is cyclosporin used?
which cytokines do cyclosporin inhibit the genes for?
IL-2, and IL, 4
how does cyclosporin work?
binds cyclophilin protein and inhibits genes for cytokine synthesis
when are steroids used?
for induction after transplant, for maintenance, and for acute rejection episodes
which cytokines are inhibited by steroids?
IL-1, IL-6. their genes are turned off
how do steroids work when giving for posttransplant?
inhibits inflammatory cells (macrophages) and genes for cytokine synthesis.
what does azathioprine do and what is another name?
imuran. similar action as MMF
can mycophenolate be used as maintenance therapy?
yes. prevents rejection
what should WBCs be when using mycophenolate?
what is the side effect of mycophenolate?
what does mycophenolate do?
inhibits de novo purine synthesis, which inhibits growth of T cells
what is treatment for PTLD?
withdrawal of immunosuppression. may need chemo and XRT for aggressive tumor
what virus is related to PTLD?
what is the second most common malignancy following transplant?
what is PTLD?
post transplant lympho-proliferative disorder.
what is the number 1 malignancy following any transplant?
skin cancer (sq cell ca #1)
what is treatment for severe rejection?
steroid and antibody therapy (ATG or daclizumab)
what is treatment for mild rejection?
what can increase PRA?
transfusions, pregnancy, previous transplant, and autoimmune disease
what is a high PRA and what does it mean?
>50%, which is percent of cells that the recipient serum reacts with.
what is panel reactive antibody?
technique identical to crossmatch, detects preformed recipient antibodies using a panel of HLA typing cells.
what happens if you transplant an organ in pt with a postiive cross-match?
how does cross-matching work?
mix recipient serum w donor lymphocytes. if antibodies are present, it is a positive crossmatch
what does cross-matching detect?
preformed recipient antibodies to the donor organ
which transplants require ABO blood compatibility?
all except liver
which HLA is the most important overall?