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Flashcards in 12 Transplant Deck (166):
1

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

2

what are the fungal causes of opportunistic infections?

fungal: aspergillus, candida, cryptococcus

3

what prophylaxis do you give for opportunistic infection and what does it cover?

bactrim for protozoan

4

what are the protozoan causes of opportunistic infections after lung txp?

protozoan: pneumocystic jiroveci pneumonia

5

what are the viral opportunistic infections after txp?

cmv, hsv, vzv

6

what is the cause of chronic rejection in lung txp patients?

bronchiolitis obliterans

7

what is the mcc of late death and death overall following lung txp?

chronic rejection - bronchiolitis obliterans

8

what are the path findings in lung acute rejection?

perivascular lymphocytosis

9

what is the exclusion criteria for using lungs for donor?

aspiration
moderate to large contusion
infiltrate
purulent sputum
PO2 less than 350 on 100%
FiO2 and PEEP 5

10

what is the indication for double-lung txp?

cystic fibrosis

11

what is the treatment to reperfusion injury after lung tx?

similar to ards

12

what is the mcc cause of early mortality in lung transplant pts?

reperfusion injury

13

what is life expectancy of pts before lung tx?

less than 1 yr

14

what compatibility tests are needed before lung tx?

abo and crossmatch

15

how long can you store a lung before transplant?

6 hrs

16

what is the mcc of late death and death overall following heart txp?

chronic allograft vasculopathy (progressive diffuse coronary atherosclerosis)

17

what is pathology of heart during acute rejection after transplant?

perivascular lyphocytic infiltrate with varying grades of myocyte inflammation and necrosis

18

what is treatment for persistent pulm htn after heart tx?

inhaled NO, ECMO if severe

19

what is a big complication of postop heart transplantation?

pulmonary htn. assoc w early mortality

20

what is the life expectancy of pts before heart transplant?

<1yr

21

what compatibility tests do you need for heart transplant?

compatibility and crossmatch

22

how long can a heart be stored?

6 hours

23

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

24

how do you treat venous thrombosis after pancreas transplant?

hard to treat

25

what are the complications of pancreas transplant?

venous thrombosis (#1) and rejection

26

what diabetic signs/sx are improved after pancreas transplant and what can't be reversed?

stabilization of retinopathy
dec neuropathy
inc nerve conduction velocity
dec autonomy dysfunction (dec gastroparesis)
orthostatic hypotension.
no reversal of vascular dz

27

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

28

what vessel do you attach the pancreas to?

iliac vessels

29

what donor vessel do you need for venous drainage in pancreas transplant?

donor portal vein

30

what donor vessels do you need for arterial supply in pancreas transplant?

donor celiac artery and SMA

31

what is the 5 year survival rate after live transplant?

70%

32

what is the liver retransplantation rate?

20%

33

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
-portal fibrosis

34

what is the cause of disappearing bile ducts during chronic rejection after liver transplant?

antibody and cellular attack on bile ducts

35

when does acute rejection of the liver occur?

usually in 1st 2 months

36

what is pathology of liver biopsy after acute rejection post liver transplant?

portal triad lymphocytosis, endotheliitis (mixed infiltrate), and bile duct injury

37

what labs are abnormal in acute rejection after liver transplant?

leukocytosis, eosinophilia, inc LFTs, inc total bilirubin, inc PT

38

what are the clinical signs of acute rejection?

fever, jaundice, decreased bile output.

39

what is the cause of acute rejection after liver transplant?

T cell mediated against blood vessels

40

what kinds of cells do you find around the portal triad if the pt gets cholangitis after liver transplant?

PMNs (not a mixed infiltrate)

41

what is treatment for portal vein thrombosis after liver transplant?

if early, re-op thrombectomy and revise anastomosis

42

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.

43

what is treatment for IVC stenosis / thrombosis?

thrombolyticcs, IVC stent

44

do abscesses appear from early or late hepatic artery thrombosis after liver transplant?

late (chronic) hepatic artery thrombosis

45

what are the signs of IVC stenosis / thrombosis after liver transplant?

edema, ascites, renal insufficiency. it is rare.

46

what happens during early hepatic artery thrombosis after liver transplant?

inc LFTs, dec bile output, fulminant hepatic failure

47

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)

48

what can late hepatic artery thrombosis after liver transplant result in?

biliary strictures and abscesses

49

can late hepatic artery thrombosis after liver transplant result in fulminant hepatic failure?

no

50

what is the most common early vascular complication of liver transplant?

early hepatic artery thrombosis

51

what is treatment for primary nonfunction after liver transplant?

requires retransplantation

52

what happens during the beginning of primary nonfunction after liver transplant?

total bili >10, bile output <20 cc/12 h, elevated PT and PTT

53

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

54

when is primary nonfunciton of the liver likely to occur after transplant?

first 24 hours

55

what is the treatment for bile leak after liver transplant?

place a drain, then ERCP with stent across leak

56

what is the most common complication of liver transplant?

bile leak

57

what is the most common arterial anatomy in liver transplant?

right hepatic coming off SMA

58

what does the viability of the biliary system (including ducts) depend on?

hepatic artery blood supply

59

where do you place drains after liver transplant?

right subhepatic, right and left subdiaphragmatic drains

60

how is a liver transplant performed in adults and in kids?

adults: duct-to-duct anastomosis
kids: hepaticojejunostomy

61

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

62

what is macrosteatosis?

extracellular fat globules in the liver allograft

63

how likely will an alcoholic start drinking again?

20% (recidivism)

64

is portal vein thrombosis a contraindication to liver transplant?

no

65

can you consider liver transplant if pt has hepatocellular carcinoma?

yes if no vascualr invasion or if mets

66

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.

67

what is the reinfection rate after HBIG and lamivudine?

reduced to 20%

68

how do you treat pts iwth hep B antigenemia?

HBIG (hepatitis B immunoglobulin) and lamivudine (protease inhibitor) after liver transplant to prevent reinfection

69

what is the criteria for an urgent liver transplant?

fulminant hepatic failure (encephalopathy)

70

at what MELD will a pt benefit from liver transplant?

>15

71

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

72

what is the most common reason for liver transplant in adults?

hepatitis C

73

what are the contraindications to liver transplant?

current EtOH abuse, acute ulcerative colitis

74

how long can you store a liver for transplant?

24h

75

what happens to the remaining kidney in living kidney donor?

hypertrophies

76

what is the most common cause of death in living kidney donor?

fatal PE

77

what is the most common complication to living kidney donor and what is the incidence?

wound infection (1%)

78

what is 5 year graft survival in kidney transplant? cadaveric? living donor?

70% (65% cadaveric, 75% living donor)

79

when does acute rejection occur in kidney transplant?

usually occurs in 1st 6 months

80

when does chronic rejection usually happen in kidney transplant?

usually do not see until after 1 year.

81

what do you rule out with u/s with duplex if suspect kidney rejection?

vascular problems and ureteral obstruction

82

why do you empirically decrease CSA or FK when suspect kidney rejection?

they can be nephrotoxic

83

what is the kidney rejection workup?

U/S w duplex and biopsy, empiric dec in CSA or FK, empiric pulse steroids

84

when do you do a kidney rejection workup?

usually for inc in Cr or poor UOP

85

what do you see on pathology after acute rejection?

tubulitis (vasculitis with more severe form)

86

what is the most common viral infection after kidney transplant?

CMV and HSV

87

what is the treatment for CMV and HSV after kidney transplant?

CMV: ganciclovir. HSV: acyclovir

88

what is the most likely cause of postop diabetes after kidney transplant?

side effect of CSA, FK, steroids

89

if the donor has a UTI, can you use the kidney for transplant?

yes

90

if there's an acute increase in creatinine (1.0-3.0) can you use the kidney for transplant?

yes

91

To which vessels do you attach the kidney in transplant?

iliac vessels

92

what is the treatment for urine leak after kidney transplant?

drainage and stenting

93

what is the most common cause of external ureter compression after kidney transplant?

lymphocele

94

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))

95

what is the cause of postop oliguria after kidney transplant? what do you see on pathology?

usually ATN. hydrophobic changes on pathology.

96

what is the cause of postop diuresis after kidney transplant?

usually due to urea and glucose

97

what is the cause of new proteinuria after kidney transplant?

renal vein thrombosis

98

how do you diagnose and treat renal artery stenosis after kidney transplant?

diagnose w ultrasound. treat with PTA with stent

99

what is the number one complication of kidney transplant?

urine leak.

100

what is the most common cause of mortality after kidney transplant?

stroke and MI

101

what is the pre kidney transplant workup?

ABO type compatibility and cross-match

102

how long can a kidney be stored?

48h

103

what is the treatment for chronic rejection?

increase immunosuppression. no really effective treatment

104

what is the result of chronic rejection?

graft fibrosis

105

what is the cause of chronic rejection?

partially a type IV hypersensitivity reaction (sensitized T cells) with antibody formation also.

106

what is the treatment for acute rejection?

increase immunosuppression, pulse steroids, possibly antibody therapy

107

what is the cause of acute rejection?

caused by T cells (cytotoxic and helper T cells)

108

what is the treatment for accelerated rejection?

inc immunosuppression, pulse steroids, possibly antibody therapy

109

what is the cause of accelerated rejection?

sensitized T cells to donor antigens

110

what is treatment for hyperacute rejection?

emergent re-transplant (or just removal of organ if kidney)

111

what happens during hyperacute rejection?

preformed antibodies activates the complement cascade and thrombosis of vessels occurs

112

what is the cause of hyperacute rejection?

preformed antibodies that shoul dhave been picked up by the cross-match

113

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)

114

is zenapax cytolytic?

no

115

when is zenapax used?

induction and acute rejection.

116

what is zenapax?

daclizumab. human monoclonal antibody against IL-2 receptors

117

what is treatment for cytokine release syndrome?

steroids and benadryl given before drug to prevent

118

what are sx of cytokine release syndrome and what causes it?

fever, chills, pulm edema, shock. caused by ATG.

119

what are side effects of giving ATG?

cytokine release syndrome.

120

what should WBCs be when treating with ATG?

>3

121

is ATG cytolytic? what does cytolytic mean?

yes. complement dependent

122

what does cytolytic mean?

complement dependent

123

when is ATG used?

induction and acute rejection episodes

124

what does ATG target?

CD2, CD3, CD4

125

what is another name for rabbit ATG?

thymoglobulin

126

what is another name for equine ATG?

ATGAM

127

how is sirolimus used?

maintenance therapy

128

what happens if mTOR is inhibited?

inhibits T and B cell response to IL-2

129

how does sirolimus work?

binds FK-binding protein like tacrolimus, but inhibits mammalian target of rapamycin (mTOR)

130

what is another name for sirolimus?

rapamycin

131

what is trough level for tacrolimus?

10 to 15

132

compared to CSA, does tacrolimus cause less or more rejection episodes in kidney transplant?

less.

133

what are side effects of tacrolimus?

nephrotoxicity, more GI sx and mood changes than CSA. much less entero-hepatic recirculation compared to CSA

134

is CSA or tacrolimus more potent?

tacrolimus

135

how does tacrolimus work?

binds FK-binding protein. has actions similar to CSA.

136

what are other names for FK-506?

prograf, tacrolimus

137

how is CSA metabolized and excreted?

hepatically metabolised, biliary excretion (reabsorbed into gut, get entero-hepatic recirculation)

138

what is trough for CSA?

200-300

139

what are side effects of CSA?

nephrotoxicity, hepatotoxicity, tremors, sz, hemolytic-uremic syndrome

140

when is cyclosporin used?

maintenance therapy

141

which cytokines do cyclosporin inhibit the genes for?

IL-2, and IL, 4

142

how does cyclosporin work?

binds cyclophilin protein and inhibits genes for cytokine synthesis

143

when are steroids used?

for induction after transplant, for maintenance, and for acute rejection episodes

144

which cytokines are inhibited by steroids?

IL-1, IL-6. their genes are turned off

145

how do steroids work when giving for posttransplant?

inhibits inflammatory cells (macrophages) and genes for cytokine synthesis.

146

what does azathioprine do and what is another name?

imuran. similar action as MMF

147

can mycophenolate be used as maintenance therapy?

yes. prevents rejection

148

what should WBCs be when using mycophenolate?

>3

149

what is the side effect of mycophenolate?

myelosuppression

150

what does mycophenolate do?

inhibits de novo purine synthesis, which inhibits growth of T cells

151

what is treatment for PTLD?

withdrawal of immunosuppression. may need chemo and XRT for aggressive tumor

152

what virus is related to PTLD?

EBV

153

what is the second most common malignancy following transplant?

PTLD.

154

what is PTLD?

post transplant lympho-proliferative disorder.

155

what is the number 1 malignancy following any transplant?

skin cancer (sq cell ca #1)

156

what is treatment for severe rejection?

steroid and antibody therapy (ATG or daclizumab)

157

what is treatment for mild rejection?

pulse steroids

158

what can increase PRA?

transfusions, pregnancy, previous transplant, and autoimmune disease

159

what is a high PRA and what does it mean?

>50%, which is percent of cells that the recipient serum reacts with.

160

what is panel reactive antibody?

technique identical to crossmatch, detects preformed recipient antibodies using a panel of HLA typing cells.

161

what happens if you transplant an organ in pt with a postiive cross-match?

hyperacute rejection

162

how does cross-matching work?

mix recipient serum w donor lymphocytes. if antibodies are present, it is a positive crossmatch

163

what does cross-matching detect?

preformed recipient antibodies to the donor organ

164

which transplants require ABO blood compatibility?

all except liver

165

which HLA is the most important overall?

HLA-DR

166

which HLA types are most important in recipient/donor matching?

HLA-A, -B, and -DR