4: Renal transplantation

Question 1

Apart from dialysis, what can be offered to patients with end-stage CKD?

Answer 1

Kidney transplant

Question 2

What is the best option out of dialysis and renal transplant?

Answer 2

Renal transplant

by far

Question 3

Which type of renal transplant has the best prognosis?

Answer 3

Those from LIVE, RELATED donors

e.g your bro

Question 4

What CKD stage corresponds with end-stage disease?

What is the GFR threshold?

Answer 4

CKD5

GFR < 15

Question 5

What GFR will patients achieve at best

a) on dialysis
b) after a transplant?

Answer 5

a) 7 (so they’ll still feel miserable)

b) 50 (more freedom, better QOL)

Question 6

From which groups of donors can transplants be taken?

Answer 6

Live donors

Cadaveric donors

Question 7

___ is required to prevent organ rejection.

Answer 7

Immunosuppression

Question 8

Which patients are less likely to receive kidney transplants?

Why?

Answer 8

Elderly

Co-morbidities, less likely to achieve good outcomes

Question 9

In which situations are organs taken from cadaveric donors?

Answer 9

Brain stem death (so intubated, HB but no signs of life)

No heart beat (very rapidly after death)

organs taken very rapidly and transported to patient

Question 10

Why are cadaveric organs from brain stem death donors more useful than those from recently dead donors?

Answer 10

Brain stem death - organs still perfused

Recently dead - “ischaemic hit”

Question 11

Donation from living donors is also known as ___ donation.

Answer 11

altruistic

charitable, generous

Question 12

Organ donation involving the exchange of money/services is ___.

Answer 12

illegal

in the UK

Question 13

Patients with CKD5 are only considered for transplant if they are going to live for more than ___ years.

Answer 13

five years

Question 14

What affects a patient’s suitability for surgery?

Answer 14

Age

Co-morbidities - frailty, bleeding, CVD

Response to anaesthetic

Immunosuppressed

Question 15

What must the donor be assessed for before somebody receives their organ?

Answer 15

Infection

stuff like hepatitis, HIV, cytomegalovirus…

Question 16

How is a patient’s CVD and pulmonary risk assessed before they receive a transplant?

Answer 16

ECG

Echocardiogram

Chest X-ray, pulmonary function tests

Question 17

What organ structures must be checked before a patient receives a renal transplant?

Answer 17

Current renal blood supply

Bladder

Question 18

What are conditions are contraindications to renal transplant?

Answer 18

Malignancy

Active infection

why would you immunosuppress these patients

otherwise: severe CVD, respiratory problems

Question 19

What contraindicates someone from donating a kidney?

Answer 19

Not physically fit

Poor renal function - existing renal disease?

Co-morbidities - e.g DM

Kidneys not structurally, immunologically suitable

Donor is being cooerced

Question 20

Donors with blood group ___ can donate to anyone.

Answer 20

O

Question 21

What are the four blood groups?

Answer 21

O

A

B

AB

compatible with what the other person’s got

O covers all

Question 22

How are tissues matched in organ donation?

Answer 22

Blood group

HLA genotype

Question 23

If the donor tissue doesn’t match the recipient’s blood group and HLA genotype, what occurs?

Answer 23

Rejection

Question 24

What events can sensitise patients to antigens and predispose them to organ rejection?

Answer 24

Blood transfusion

Pregnancy

Previous transplant

Question 25

Why may a woman be sensitised to her husband's kidneys?

Answer 25

**Coincidental** **Previous pregnancy**

Question 26

Which patients are given priority on the kidney transplant list?

Answer 26

**Children**

Question 27

How can patients be **desensitised** to donor tissue?

Answer 27

**Plasma exchange** **Biologics** (e.g rituximab - B cell inhibitor)

Question 28

What is the down side of **desensitisation**?

Answer 28

Further immunosuppression so patient is at less risk of rejection but increased risk of all the side effects

Question 29

Where is the incision made in a kidney transplant?

Answer 29

**Iliac fossa**

Question 30

Which artery and vein are transplanted kidneys connected to?

Answer 30

**External iliac artery** **External iliac veins**

Question 31

After transplant, the kidney is (**retroperitoneal / intraperitoneal / extraperitoneal**).

Answer 31

**extraperitoneal** anterior, not within peritoneum at all

Question 32

What are a) vascular b) urological c) other complications of kidney transplant surgery?

Answer 32

**a) Haemorrhage, stenosis** **b) Stenosis** **c) Infection**

Question 33

If the transplanted kidney works immediately, kidney function will \_\_\_.

Answer 33

**improve**

Question 34

If the transplanted kidney **takes time** to function, what occurs acutely?

Answer 34

**Tubular necrosis**

Question 35

What are three types of organ rejection?

Answer 35

**Hyperacute** **Acute** **Chronic**

Question 36

What immune components mediate a) **hyperacute** b) **acute** c) **chronic** organ rejection?

Answer 36

**a) Pre-formed antibodies** **b) Cell/antibody-mediated** **c) Antibody mediated**, slower than acute

Question 37

How is **hyperacute** rejection treated?

Answer 37

**Removal of transplant**

Question 38

How is **acute** rejection treated?

Answer 38

**Increased immunosuppresion**

Question 39

Which drugs are given in **induction immunotherapy**?

Answer 39

**Monoclonal antibodies** (block CD4+ T cells) ## Footnote **Steroids**

Question 40

What type of drug are **tacrolimus** and **ciclosporin**?

Answer 40

**Calcineurin inhibitors** Also inhibit T cells

Question 41

Which drugs can be used in a) induction b) maintenance immunosuppression for transplant?

Answer 41

**a) Monoclonal antibodies, steroids** **b) Tacrolimus, ciclosporin, azathioprine, mycophenolate**

Question 42

What is the major side effect of **excessive** **immunosuppression**?

Answer 42

**Atypical infections**

Question 43

Where do bacterial infections secondary to immunosuppression occur?

Answer 43

**Urinary tract** **Lower respiratory tract**

Question 44

Which **virus** commonly causes death in immunosuppressed transplant patients?

Answer 44

**Cytomegalovirus**

Question 45

How is **immunosuppression-related CMV infection** prevented?

Answer 45

**Viral prophylaxis**

Question 46

Which **virus** classically reactivates and causes kidney disease in excessive immunosuppression? What does this mimic?

Answer 46

**BK virus** **Mimics organ rejection**

Question 47

Which a) bacteria b) viruses clasically reactivate to cause disease in patients who are immunosuppressed?

Answer 47

**a) TB** **b) HIV, Hepatitis, CMV, BK**

Question 48

Apart from infection, what is another major complication of immunosuppression secondary to renal transplant?

Answer 48

**Malignancy**

Question 49

Which type of cancer commonly occurs in renal transplant patients? Why?

Answer 49

**Skin cancer** **Immunosuppression**

Question 50

Which type of skin cancer presents in renal transplant patients?

Answer 50

**Non-melanoma** so BCC or SCC

Question 51

What is the second most common cancer to develop in renal transplant patients?

Answer 51

**Lymphoma**

Question 52

Which virus is related to **lymphoma** secondary to renal transplanation?

Answer 52

**Epstein-Barre virus (EBV)** think of the glange

Question 53

**Renal transplant** patients are followed up for how long?

Answer 53

**Life**

Question 54

What commonly causes death following renal transplant?

Answer 54

**Organ rejection** **CVD, infection and malignancy** (as in dialysis)