Transplantation

Question 1

What are the main types of HLA

Answer 1

class 1 - HLA A and HLA B
class 2 - HLA DR

Question 2

how may a person typicaly form HLA antibodies throughout life

Answer 2

blood transfusions

pregnancy

Question 3

what infections are kidney transplant patients most at risk of

Answer 3

CMV

BK virus
pneumocytis jirovecci

Question 4

what malignancies are kidney transplant patients at risk of

Answer 4

non melanoma skin cancer

lymphoma - usually due to post transplant exposure to EBV

Question 5

what steps are taken to prevent these infections in kidney transplant patients

Answer 5

CMV status of donar and recient established and antiviral treatment given pre transplant if there is a mismatch

cotrimoxazole is given for prophylaxis of PCP

Question 6

how are malignancies monitored for in these patients

Answer 6

yearly check up with dermatologist - most likely squamous cell cancer

Question 7

give the types of rejection in kidney transplant

Answer 7

hyperacute - due to PREFORMED antibodies i.e. ABO mismatch, nothing you can do, must remove kidney
acute - T or B cell mediated, can be treated with increased immunosuppression
chronic - “slow rejection”

Question 8

describe the process of immunosuppression in kidney transplant

Answer 8

induction - steroids, MMF, CyA, tacrolimus and antibodies
consolidation - steroids, MMF, CyA, tacrolimus
maintainence (on for life) - steroids, MMF, CyA, tacrolimus

Question 9

name the calcineurin inhibitors

Answer 9

tacrolimus

cyclophosphamide

Question 10

how does tacrolimus work

Answer 10

works on T helper cells

• prevent NK cell production
• reduce cytotoxic T cell activation
• reduce B cell proliferation and antibody production

Question 11

side effects of tacrolimus

Answer 11

kidney dysfunction
hypertension
diabetes
tremors

Question 12

what is important to remember about tacrolimus

Answer 12

metabolised in CP450 so lots of drug interactions

Question 13

name the drugs used which block purine synthesis

Answer 13

azathioprine and mycophenalate

Question 14

how does mycophenalate work

Answer 14

works on B cells

-prevents proliferation of lymphocytes and B cells

Question 15

side effects of mycophenalate

Answer 15

leucopenia
anaemia
GI side effects

Question 16

what is the bad interaction with azathioprine

Answer 16

allopurinol

increases azathioprine activity by 40 percent

Question 17

names types of donors

Answer 17

Deceased brain dead
deceased cardiac death
live donor kidney - close family or friend
kidney pancreas duel transplant - type 1 diabetics with kidney disease

Question 18

who is suitable for transplant

Answer 18

more than 5 year life expectancy
should have been on HD for more than 6 months
then given based on tissue type, then time on waiting list

Question 19

how are kidney transplant patients assessed prior to transplant

Answer 19

assess cardiovascular risk - ECG, angiogram, echo
full virology - note HIV is NOT a contraindication to transplant if treated
chest x ray
bladder assessment
investigate any comorbidity e.g. need to be cancer free for 2 years if previous malignancy (5 if breast or colorectal)

Question 20

absolute contraindication to transplant

Answer 20

untreated TB
current malignancy - need to be cancer free for 2 years if previous malignancy (5 if breast or colorectal)
severe ischaemic heart disease
severe airways disease e.g. COPD on oxygen therapy
current vasculitis
severe peripheral vascular disease (as translating on to external iliac)

Question 21

what does the live donor have to be assessed for

Answer 21

proper GFR
CXR
ECG
virology 
protein in urine
blood pressure
angiogram
crossmatch against recipient

Question 22

what can happen after transplant

Answer 22

immediate graft function - good urine output etc
delayed graft function - bit like having a AKI, will take 10-30 days to work, HD in meantime
some grafts never work :(

Question 23

most common cause of death in transplant patients

Answer 23

cardiovascular disease or malignancy

also disease recurrence