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Fiser's ABSITE Ryan > Chapter 12 - Transplant > Flashcards

Chapter 12 - Transplant Flashcards

1
Q

Which HLA antigens are most important in recipient/donor matching?

A

HLA -A, -B, -DR (-DR most important overall)

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2
Q

ABO blood compatibility is not required for which transplant?

A

Liver

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3
Q

How is a crossmatch performed?

A

By mixing recipient serum with donor lymphocytes

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4
Q

What does a crossmatch detect?

A

Detects preformed antibodies; would generally cause hyperacute rejection

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5
Q

What is a panel reactive antibody (PRA)?

A

Technique identical to crossmatch; detects preformed recipient antibodies using a panel of typing cells

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6
Q

What can increase PRA?

A

Transfusions, pregnancy, previous transplant, autoimmune diseases

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7
Q

Treatment for mild rejection?

A

Pulse steroids

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8
Q

Treatment for severe or secondary rejection?

A

OKT3 or other drugs

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9
Q

1 malignancy following any transplant?

A

Skin cancer (squamous cell CA #1)

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10
Q

2 most common malignancy following transplant?

A

Posttransplant lymphoproliferative disorder (EBV-related)

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11
Q

Treatment for PTLD?

A

Withdrawal of immunosuppression; may need chemo/XRT for aggressive tumor

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12
Q

Mechanism of action of Azathioprine (Imuran)?

A

Inhibits de novo purine synthesis (which inhibits T cells); active metabolite is 6-mercaptopurine

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13
Q

Side effects of Azathioprine?

A

Myelosuppression; keeps WBC >3

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14
Q

Mechanism of action of steroids in anti-rejection?

A

Inhibit genes for cytokine synthesis (IL-1, IL-6) and macrophages

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15
Q

Mechanism of cyclosporin (CSA)?

A

Binds cyclophilin protein and inhibits genes for cytokine synthesis (IL-2, IL-3, IL-4, INF-gamma)

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16
Q

Side effects of CSA?

A

Nephrotoxicity, hepatotoxicity, HUS, tremors, seizures

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17
Q

Mechanism of action of FK-506 (Prograf)?

A

Binds FK-binding protein; similar to CSA but 10-100x more potent

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18
Q

Side effects of Prograf?

A

Nephrotoxicity, mood changes, more GI and neurological side effects than CSA

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19
Q

Mechanism of action of ATGAM?

A

Equine polyclonal antibodies directed against antigens on T cells (CD2, CD3, CD4, CD8, CD11/18)

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20
Q

What is ATGAM used for?

A

Induction therapy

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21
Q

ATGAM is dependent on what to work?

A

Complement dependent

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22
Q

Mechanism of action of thymoglobulin?

A

Rabbit polyclonal antibody; similary action as ATGAM

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23
Q

Mechanism of action of OKT3?

A

Monoclonal abs that block antigen recognition function of T cells by binding CD3, inhibiting T cell receptor complex; causes CD3 opsonization that is complement dependent

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24
Q

What is OKT3 used for?

A

Severe rejection

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25
Q

Side effects of OKT3?

A

Fever, chills, pulmonary edema, shock

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26
Q

Mechanism of action of Zenapax?

A

Human monoclonal ab againsst IL-2 receptors

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27
Q

When is Zenapax used?

A

Used with induction and to treat rejection

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28
Q

What is hyperacute rejection?

A

Within minutes to hours; caused by preformed antibodies that should have been picked up by the crossmatch; activates complement cascade and thrombosis of vessels occurs

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29
Q

Treatment of hyperacute rejection?

A

Emergent retransplant

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30
Q

What is accelerated rejection?

A

(<1 wk) Caused by sensitized T cells to donor antigens; produces secondary immune response

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31
Q

Treatment for accelerated rejection?

A

Increased immunosuppression, pulse steroids, possibly OKT3

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32
Q

What is acute rejection?

A

(1wk to 1month) Caused by T cells (cytotoxic and helper T cells)

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33
Q

Treatment of acute rejection?

A

Increased immunosuppression, pulse steroids, possibly OKT3

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34
Q

What is chrnoic rejection?

A

(months to years) Type IV hypersensitivity reaction (sensitized T cells); Ab formation also plays a role, leads to graft fibrosis and vascular damage

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35
Q

Treatment of chronic rejection?

A

Increased immunosuppression, OKT3 - no really effective treatment

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36
Q

How long can a kidney be stored?

A

48 hours

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37
Q

What is the mortality following kidney transplant from?

A

Stroke and MI

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38
Q

Can a kidney from a patient with a UTI or acute increase in Cr (1.0-3.0) still be used?

A

YES

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39
Q

Transplanted kidney is attached to what?

A

Iliac vessels

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40
Q

1 complication following kidney transplant?

A

Urine leak

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41
Q

Treatment for urine leaks following kidney transplant?

A

Drainage and stenting usually first; may need reoperation

42
Q

Other complications of kidney transplant?

A

Renal arthery stenosis, lymphocele, postop oliguria, postop diuresis, new proteinuria, postop diabetes, viral infections

43
Q

How is the diagnosis of renal artery stenosis made? Treatment?

A

Ultrasound; PTA with stent

44
Q

What is the most common cause of external compression following kidney transplant? Treatment?

A

Lymphocele; perc drainage, then intraperitoneal marsupialization

45
Q

What is postop oliguria caused by after kidney transplant?

A

ATN; path shows hydrophobic changes

46
Q

What is post-op diuresis caused by following a kidney transplant?

A

Urea and glucose

47
Q

What is new proteinuria caused by following a kidney transplant?

A

Renal vein thrombosis

48
Q

What causes postop diabetes following kidney transplant?

A

Side effect of CSA, FK, steroids

49
Q

What makes up a kidney rejection workup?

A

Usually done for increase in Cr; US with duplex and biopsy; empiric decrease in CSA or FK; pulse steroids

50
Q

What is the most common complication for living kidney donors?

A

Wound infection

51
Q

What is the most common cause of death in living kidney donors?

A

Fatal PE

52
Q

What happens to the remaining kidney in living kidney donors?

A

Hypertrophies

53
Q

How long can a liver be stored?

A

24 hours

54
Q

What are contraindications to liver transplant?

A

Current EtOH abuse, acute UC

55
Q

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

A

Chronic hepatitis

56
Q

What are the criteria for emergent transplant?

A

Stage III (stupor), stage IV (coma)

57
Q

What is the best predictor of 1-yr survival following liver transplant?

A

APACHE score

58
Q

How can patients with hepatitis B angigenemia be treated following liver transplant?

A

HBIG and lamivudine (protease inhibitor)

59
Q

Is portal vein thrombosis a contraindication to transplant?

A

NO

60
Q

Is hepatocellular CA a contraindication to transplant?

A

NO: if single tumor <3cm

61
Q

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

A

Hepatitis C; reinfects essentially all grafts

62
Q

What is the reinfection rate of Hepatitis B?

A

20% with use of HBIG

63
Q

What % will start using EtOH again?

A

20% (recidivism)

64
Q

What is the #1 predictor of primary nonfunction of liver transplant?

A

Macrosteatosis; extracellular fat globules in the liver allograft

65
Q

Where are drains placed following liver transplant?

A

Right subhepatic, right and left subdiaphragmatic

66
Q

Biliary system depends on what blood supply?

A

Hepatic artery

67
Q

What is the most common arterial anomaly in liver transplant?

A

Right hepatic off of SMA

68
Q

1 complication following liver transplant?

A

Bile leak

69
Q

Treatment for bile leak?

A

PTC tube and stent

70
Q

What are indications of primary nonfunction of liver transplant?

A

Total bili >10, bile output <20cc/hr, PT and PTT 1.5x normal; after 96 hours: hyperkalemia, mental status changes, inc. LFTs, renal failure, repsiratory failure

71
Q

Treatment for primary nonfunction of liver transplant?

A

Retransplantation

72
Q

Treatment for hepatic artery thrombosis?

A

Angio (balloon dilation, +/- stent), surgery, retransplantation

73
Q

What are signsof IVC stenosis following liver transplant?

A

Edema, ascites, renal insufficiency

74
Q

Signs of cholangitis on pathology?

A

PMNs around portal triad, NOT a mixed infiltrate

75
Q

Signs of acute rejection of liver transplant?

A

Fever, jaundice, dec. bile output, change in bile consistency; leukocytosis, eosinophilia, inc. LFTs, inc. total bili, inc. PT

76
Q

Pathology findings in acute rejection of liver transplant?

A

Portal lympocytosis, endothliitis (mixed infiltrate) and bile duct injury

77
Q

Most common predictor of chronic rejection?

A

Acute rejection

78
Q

Signs of chronic rejection of liver transplant?

A

Disappearing bile ducts (Ab and cellular attack on bile ducts), gradually get bile duct obstruction in inc. in alk phos, portal fibrosis

79
Q

Liver retransplantation rate?

A

20%

80
Q

5-yr survival rate following liver transplant?

A

70%

81
Q

What is the arterial supply for pancreas transplant?

A

Donor celiac and SMA

82
Q

What is the venous supply for pancreas transplant?

A

Donor portal vein

83
Q

What is the donor pancreas attached to?

A

Recipient iliac vessels

84
Q

How is the pancreatic duct drained in pancreas transplant?

A

Enteric drainage; 2nd portion of duodenum from donor along with ampulla of Vater and pancreas, then perform anastomosis of donor duodenum to recipient bowel

85
Q

Successful kidney/pancreas transplant results?

A

Stabilization of retinopathy, dec. neuropathy, inc. nerve conduction velocity, dec. autonomic dysfunction (gastroparesis), inc. orthostatic hypotension

86
Q

1 complication of pancreas transplant?

A

Thrombosis - hard to treat

87
Q

How is rejection of pancreas transplant diagnosed?

A

Difficulty if pt does not also have a kidney transplant; inc. glucose, amylase or trypsinogen; fever, leukocytosis

88
Q

How long can a heart be stored?

A

6 hours

89
Q

Complications following heart transplantation?

A

Persistent pulmonary hypertension

90
Q

Treatment of persistent pulmonary hypertension following heart transplant?

A

Flolan (PGI2); inhaled NO, ECMO if severe; associated with inc. morbidity and mortality after transplant

91
Q

Pathologic findings of acute rejection following heart transplant?

A

Perivascular infiltrate with inc. grades of myocyte inflammation and necrosis

92
Q

Pathologic findings of chronic rejection following heart transplant?

A

Progressive diffuse coronary atherosclerosis

93
Q

How long can lungs be stored for?

A

6 hours

94
Q

1 cause of early mortality following lung transplant?

A

Reperfusion injury

95
Q

Indication for double lung tranplant?

A

Cystic fibrosis

96
Q

Exclusion criteria for using lungs?

A

Aspiration, moderate to large contusion, infiltrate, purulent sputum, PO2 <350 on 100% FiO2, PEEP 5

97
Q

Pathologic findings of acute rejection following lung transplant?

A

Perivascular lymphocytosis

98
Q

Pathologic findings of chrnoic rejection after lung transplant?

A

Bronchiolitis obliterans

99
Q

What is the hierarchy for permission for organ donation from next of kin?

A

Spouse –> adult son or daughter –> either parent –> adult brother or sister –> guardian –> any other person authorized to dispse of the body

100
Q

What is bactrim prophylaxis used against?

A

Pneumocystis jiroveci pneumonia

Fiser's ABSITE Ryan (50 decks)

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