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ABSITE > 12 Transplantation > Flashcards

12 Transplantation Flashcards

1
Q

Most important markers in recipient/donor matching?

A

HLA-A, HLA-B, HLA-DR

HLA-DR is most important overall

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2
Q

Cross-match

A

Detects preformed recipient antibodies to the donor organ by mixing recipient serum with donor lymphocytes
If antibiodies are present, it is a positive cross-match - likely for hyperacute rejection to occur

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3
Q

Panel reactive antibody

A

Identical technique to cross-match: detects preformed antibodies
Can get percentage of cells that the recipient serum reacts with
High PRA (>50%) has increased risk of hyperacute rejection

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4
Q

What can increase a PRA?

A

Transfusions
Pregnancy
Previous transplant
Autoimmune disease

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5
Q

Treatment of mild transplant rejection?

A

Pulse steroids

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6
Q

Treatment of severe transplant rejection?

A

Steroids and antibody therapy (ATG or daclizumab)

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7
Q

Number one malignancy following any transplant?

A

Squamous cell skin cancer

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8
Q

Post-transplant lympho-proliferative disorder (PTLD)

A

Second most common malignancy following transplant
Associated with EBV
Tx withdrawal of immunosuppression, may need chemotherapy and XRT for aggressive tumor

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9
Q

Mycophenolate (MFF, CellCept)

A

Inhibits de novo purine synthesis - inhibits growth of T-cells
AE: myelosuppression
Keep WBCs >3
Used as maintenance therapy to prevent rejection
(Similar - Azathioprine)

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10
Q

Steroids

A

Inhibits inflammatory cells (macrophages) and genes for cytokine synthesis (IL-1, IL-6)
Used for induction after transplant, maintenance and acute rejection episodes

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11
Q

Cyclosporin (CSA)

A

Binds cyclophilin protein and inhibits genes for cytokine synthesis (IL-2, IL-4)
Used for maintenance therapy
AE: Nephrotoxicity, Hepatotoxicity, Tremors, Seizures, HUS
Keep trough 200-300
Undergoes hepatic metabolism and biliary excretion (reabsorbed in the gut, entero-hepatic recirculation)

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12
Q

Fk-506 (Prograf, Tacrolimus)

A

Binds FK-binding protein - actions similar to CSA, but more potent
AE: nephrotoxicity, more GI symptoms, more mood changes, less entero-hepatic recirculation
Keep trough 10-15

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13
Q

Sirolimus (Rapamycin)

A

Binds FK-binding protein like FK-506 but inhibits mammalian target of rapamycin (mTOR) - inhibits T and B cell response to IL-2
Maintenance treatment

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14
Q

Anti-thymocyte globulin (ATG)

A

Polyclonal antibodies against T-cell antigen (CD2, CD3, CD4)
Used for induction and acute rejection episodes
Cytolytic (complement dependent)
Keep WBCs >3
AE: Cytokine release syndrome (fever, chills, pulmonary edema, shock); pre-treat with steroids and benadryl

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15
Q

Zenapax (daclizumab)

A

Human monoclonal antibody against IL-2 receptors
Used for induction and acute rejection episodes
Not cytolytic

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16
Q

Hyperacute rejection

A

Occurs within minutes to hours
Preformed antibodies (failure of cross-match)
Complement cascade –> thrombosis
Tx - emergent re-transplant (or removal of the transplanted organ)

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17
Q

Accelerated rejection

A

Occurs within the first week
Sensitized t-cells to donor antigens
Tx - increase immunosuppresion, pulse steroids, possibly antibody tx

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18
Q

Acute rejection

A

Within 1 week to 1 month
T-cells (cytotoxic and helper)
Tx - increase immunosuppression, pulse steroids, possibly antibody tx

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19
Q

Chronic rejection

A

Month to years
Type IV hypersensitivity reactions (sensitized T-cells) and antibody formation
Leads to graft fibrosis
Tx - increase immunosuppression

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20
Q

How long can you store a transplant kidney?

A

48 hours

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21
Q

If a donor has a UTI, can you still use the kidney?

A

Yes

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22
Q

If a donor has an acute increase in Cr, can you still use the kidney?

A

Yes

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23
Q

Primary mortality associated with kidney transplants?

A

Primarily from stroke and MI

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24
Q

Where do you attach the donor kidney?

A

To the iliac vessels

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25
Q

Number one complication from kidney transplant?

A

Urine leak

Tx - drainage and stenting

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26
Q

Renal artery stenosis

A

Dx - ultrasound

Tx - PTA with stent

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27
Q

Lymphocele

A

Most common cause of external ureter compression
Tx:
- Percutaneous drainage
- Peritoneal window

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28
Q

Kidney transplant patient - postop oliguria?

A

ATN (hydrophobic changes)

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29
Q

Kidney transplant patient - post-op diuresis?

A

Due to urea and glucose

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30
Q

Kidney transplant patient - new proteinuria?

A

Suggestive of renal vein thrombosis

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31
Q

Kidney transplant patient - post-op diabetes?

A

Side effect of CSA, FK, steroids

32
Q

Viral infections seen in kidney transplant patients? Treatment?

A

CMV - ganciclovir

HSV - acyclovir

33
Q

Kidney transplant - acute rejection

A

Presents within first six months

Pathology shows tubulitis (severe form of vasculitis)

34
Q

Kidney rejection workup?

A

Performed for an increase in creatinine or poor UOP

  • US with duplex (rule out vascular or ureteral problems)
  • Biopsy
  • Empiric decrease in CSA, FK (can be nephrotoxic)
  • Empiric pulse steroids
35
Q

Kidney transplant - chronic rejection

A

After 1 year

No good treatment

36
Q

Kidney transplant - 5-year graft survival overall?

A

70%

Cadaveric 65%, living donor 75%

37
Q

Most common complication for living kidney donors?

A

Wound infection (1%)

38
Q

Most common cause of death for living kidney donors?

A

Fatal PE

39
Q

How long can you store a transplant liver?

A

24 hours

40
Q

Contraindication to liver transplant?

A

Current ETOH abuse

Acute ulcerative colitis

41
Q

Most common reason for liver transplant in adults?

A

Chronic hep C

42
Q

MELD score?

A

Creatinine, INR, bilirubin (>15 will benefit more from liver transplant than medical management)

43
Q

Criteria for urgent liver transplant?

A

Fulminant hepatic failure (encephalopathy - stupor, coma)

44
Q

Preventing Hep B reinfection after liver transplant?

A

HBIG and lamivudine (protease inhibitor)

Reduces reinfection rate to 20%

45
Q

What disease is most likely to recur in the new liver allograph?

A

Hepatitis C

46
Q

When can you use liver transplantation in liver cancer?

A

No vascular invasion or mets

47
Q

Blood supply for the biliary system?

A

Hepatic artery blood supply

48
Q

Most common arterial anomaly in the liver?

A

Right hepatic coming off SMA

49
Q

Liver transplant - bile leak?

A

Most common complication

Tx - drain, then ERCP with stent across leak

50
Q

Liver transplant - primary nonfunction

A 
First 24 hours:
- Total bilirubin >10
- Bile output <20cc/12hr
- Elevated PT and PTT
After 96 hours:
- Mental status changes
- Increased LFTs
- Renal failure
- Respiratory failure
Tx - Re-transplantation
51
Q

Liver transplant - early hepatic artery thrombosis

A

Most common early vascular complication
Increased LFTs, decreased bile output, fulminant hepatic failure
Tx - emergent re-transplantation (possible stenting of vessel)

52
Q

Liver transplant - late hepatic artery thrombosis

A

Causes biliary structure and abscesses (NOT fulminant hepatic failure)

53
Q

Liver transplant - abscesses

A

Most commonly from late (chronic) hepatic artery thrombosis

54
Q

Liver transplant - IVC stenosis/thrombosis

A

Rare
Edema, ascites, renal insufficiency
Tx - Thrombolytics, IVC stent

55
Q

Liver transplant - Portal vein thrombosis

A

Rare
Early - abdominal pain
Late - UGI bleeding, ascites, poss asymptomatic
Tx: if early - re-op thrombectomy, revise anastomosis

56
Q

Liver transplant - Cholangitis

A

Get PMNs around portal triad

NOT mixed infiltrates

57
Q

Liver transplant - acute rejection

A

T-cells mediated against blood vessels
Clinical - fever, jaundice, decreased bile output
Labs - leukocytosis, eosinophilia, increased LFTs, increased total bili, increased PT
Path - portal triad lymphocytosis, endothelitis, bile duct injury
Occurs within first 2 months

58
Q

Liver transplant - chronic rejection

A

Unusual after liver transplant
Get disappearing bile ducts (antibody and cellular attack on bile ducts)
Get bile duct obstruction, with increased alkaline phosphatase
Portal fibrosis

59
Q

Retransplantation rate in liver transplants

A

20%

60
Q

5-year survival rate in liver transplants

A

70%

61
Q

What do you need for vascular supply in a pancreas transplant?

A

Donor celiac artery and SMA

62
Q

What do you need for venous drainage in a pancreas transplant?

A

Donor portal vein

63
Q

Where do you attach a transplant pancreas?

A

Iliac vessels

64
Q

How do you create enteric drainage for a transplant pancreas?

A

Second portion of duodenum from donor along with ampulla of vater and pancreas
Then perform anastomosis of donor duodenum to recipient bowel

65
Q

Benefits of successful pancreas/kidney transplantation?

A 
Stabilization of retinopathy
Decreased neuropathy
Increased nerve conduction velocity
Decrease autonomic dysfunction (gastroparesis)
Decreased orthostatic hypotention

NO reversal of vascular disease

66
Q

Pancreas transplant - venous thrombosis

A

Most common

Hard to treat

67
Q

Pancreas transplant - rejection

A

Hard to diagnosis if patient does not also have a kidney transplant
Sx: increased glucose or amylase, fever, leukocytosis

68
Q

How long can you store a transplant heart?

A

6 hours

69
Q

Heart transplant - pulmonary hypertension

A

Associated with early mortality

Tx: inhaled NO, ECMO

70
Q

Heart transplant - acute rejection

A

Perivascular lymphocytic infiltrate

Myocyte inflammation and necrosis

71
Q

Heart transplant - Chronic allograft vasculopathy

A

Progressive, diffuse coronary artherosclerosis

MMC of death

72
Q

How long can you store transplant lungs?

A

6 hours

73
Q

Number one cause of early mortality in lung transplantation?

A

Reperfusion injury

Tx - same as ARDS

74
Q

Number one reason for double lung transplant?

A

Cystic fibrosis

75
Q

Exclusion criteria for transplant lungs?

A 
Aspiration
Moderate to large contusions
Infiltrates
Purulent sputum
PO2 < 350 on 100% FiO2 and PEEP 5
76
Q

Lung transplant - acute rejection

A

Perivascular lymphocytosis

77
Q

Lung transplant - chronic rejection

A

Bronchiolitis obliterans

MCC of death

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