ASN QBank Pearls - Renal Transplant Flashcards
(137 cards)
1
Q
what are HLA class 1?
A
- A, B, C
- all nucleated cells
2
Q
what are HLA class 2?
A
- DP, PQ, DR
- on Ag presenting cells (APCs)
3
Q
sensitization of immune system occurs from
A
- blood transfusions
- pregnancy
- prior transplants
4
Q
panel reactive antibodies (PRA)
A
- tells how sensitized a patient is to HLAs in general population
- 0-100%
5
Q
donor specific antibodies (DSA)
A
- tests presence of Abs to DONOR’S HLA types only
- semiquantitative
6
Q
crossmatch
A
- combines donor cells w/ recipient serum
7
Q
positive crossmatch predicts what?
A
HYPERacute rejection
8
Q
blood groups between donor and recipient must be
A
compatible (like blood transfusion)
9
Q
crossmatch between donor and recipient must be
A
negative
10
Q
HLA typing of donor and recipient determines
A
- matching compatibility
- range from 0/6 to 6/6
11
Q
HLA matching has better outcomes if
A
match is 6/6
12
Q
can rejection still occur if HLA match is 6/6? and, if yes, why?
A
- yes!
- non-HLA incompatibilities
13
Q
contraindications to kidney transplantation
A
- poor cardiac function
- morbid obesity
- psychosocial issues which can affect compliance
- active infection
- recent, unresolved cancer
- ANY serious comorbidity which reduces life expectancy
14
Q
infections that need to be tested for in a transplant recipient
A
- HBV
- HCV
- EBV
- CMV
- syphilis
- HIV
- latent TB
15
Q
what cancer screening needs to done for transplant recipients?
A
- mammogram
- PAP smear
- PSA
- colonoscopy
16
Q
waiting time after cancer treatment for most cancers before proceeding w/ transplant?
A
2 years
17
Q
waiting time after cancer treatment for metastatic breast, colorectal, and melanoma before proceeding w/ transplant?
A
5 years
18
Q
waiting time after cancer treatment for non-melanoma skin cancer and some in situ malignancies before proceeding w/ transplant?
A
none, considered low risk
19
Q
contraindications to living donation
A
- age < 18
- GFR < 80 ml/min
- hematuria
- proteinuria
- HTN
- DM
- obesity
- h/o cancer
- infectious disease
- significant, unresolved medical issues
- psychosocial factors
- inability to give informed consent
20
Q
long term risk of ESRD over 15 years for kidney donor
A
6 fold increase
21
Q
donor evaluation
A
- H&P
- CMP
- FLP
- GFR; 24 hour urine
- UA, C+S
- serum hCG
- EKG
- CXR
- TTE
- age-appropriate cancer screening
- CT a/p
- SW evaluation
22
Q
minimum criteria for listing for kidney transplant
A
- initiation of dialysis (time is backlogged from start time)
- GFR < 20 ml/min (time starts at time of eval and consent given to list)
23
Q
what is a nonstand kidney?
A
- higher kidney donor profile index (KDPI) score (higher = worse)
- cardiac death donor (longer CIT)
- “higher-risk” donors
- HBV and/or HCV donors
24
Q
thymoglobulin MOA
A
depletes T cells
25
basiliximab MOA
blocks IL-2 receptors in T cells
26
thymoglobulin adverse effects
- leukopenia
- thrombocytopenia
- fever
- flu-like symptoms
27
CNI MOA
binds FK-binding protein thus inhibiting response to IL-2
28
CNI adverse effects
- Afferent arteriole vasoconstriction
- hyperkalemia
- metabolic acidosis
- hypomagnesemia
- hyperglycemia and HLD by blocking beta cells in pancreas
- renal fibrosis (long-term)
29
azathioprine and MMF adverse effects
- leukopenia
| - MMF can cause diarrhea
30
do levels of azathioprine and MMF correlate well with toxicity?
no
31
use of azathioprine and allopurinol is
contraindicated
32
sirolimus MOA
mTOR inhibitor; blocks FK-binding protein thus inhibiting IL-2 response
33
adverse effect of sirolimus
- poor wound healing
| - proteinuria
34
belatacept MOA
blocks accessory pathway of T cell stimulation
35
advantage of using belatacept
avoid CNI nephrotoxicity
36
perioperative complications
- wound infection
- bleeding
- lymphocele
- urine leak
- transplant RAS
37
delayed graft function (DGF) histology
ATN
38
delayed graft function (DGF) risk factors
- quality of donor kidney
- kidney from after cardiac death donor
- prolonged CIT
- perioperative hypotension
39
how long to wait before renal transplant biopsy if DGF?
4 weeks
40
opportunistic infections
| - first month
bacterial, perioperative
41
opportunistic infections
| - 2-6 months
viral;
- CMV
- BK (polyoma) virus
42
opportunistic infections
| - > 6 months
mostly bacterial
43
infection ppx
| - antifungal
- fluconazole or nystatin x 1 month
44
infection ppx
| - PJP
- SMX/TMP or dapsone (if sulfa allergy) x 12 months
45
infection ppx
| - CMV
depends on IgG serology
46
infection ppx
- CMV positive donor
- CMV negative recipient
valganciclovir x 6 months
47
infection ppx
- CMV positive donor
- CMV positive recipient
valganciclovir x 3 months
48
infection ppx
- CMV negative donor
- CMV negative recipient
low risk
49
CMV clinical manifestations
- flu-like symptoms
- leukopenia
- diarrhea
- colitis
- rare; hepatitis, pneumonitis, ophthalmitis
50
BK virus normally dormant in
urinary tract
51
subacute or chronic loss of allograft function d/t over IS
BK nephropathy
52
treatment for BK nephropathy
taper down IS
53
uncommon clinical features of BK virus
- hematuria
| - ureteral stricture
54
ddx of AKI in setting of transplant
- same ddx as native kidneys (prerenal, renal, postrenal)
- acute rejection
- CNI toxicity
- surgical complications (if soon after surgery) (urine leak, ureteral stenosis, transplant RAS)
55
acute cellular rejection (ACR) histological findings
(in order of worsening severity)
- T cell infiltrates
- tubulitis
- cellular involvement of larger blood vessels
- hemorrhage
56
antibody mediated rejection (AMR) histological findings
(in order of worsening severity)
- PERItubular capillaritis
- staining for C4d
- duplication of endothelial BMs
- positive DSA
57
ACR treatment
- pulse steroids
| - thymoglobulin if more severe
58
AMR treatment
- plasmapheresis
- IVIG
- rituximab
59
treatment response to ACR
aggressive presentation, but may respond well
60
treatment response to AMR
often insidious onset and poor response if caught late
61
preformed DSA, although very rare, can lead to
hyperacute rejection
62
which type of rejection has better outcome?
ACR
63
MC type of cancer post-transplant
squamous cell skin cancer
64
rare cancer caused by EBV post-transplant
post-transplant lymphoproliferative disorder (PTLD)
65
post-transplant lymphoproliferative disorder (PTLD) risk factors
- EBV negative recipients
| - greater intensity and duration IS
66
treatment for post-transplant lymphoproliferative disorder (PTLD)
- taper IS as tolerated
| - heme/onc
67
MCC of death w/ functional graft
CVD
68
CNIs inhibit metabolism of statins which leads to increased risk of
rhabdomyolysis
69
vaccines to AVOID post-transplant
- avoid LIVE vaccines
- varicella
- INHALED influenza
- MMR
- meningococcal
70
vaccines that should be received post-transplant
- INJECTABLE influenza
| - pneumococcal
71
recurrence uncommon, but can be severe immediately post-transplant
FSGS
72
treatment for FSGS that occurs post-transplant
plasmapheresis
73
does HPT improve after transplant?
yes, partially
74
does fracture risk improve after transplant?
no
75
does fracture risk improve post-transplant if steroids are tapered off?
no, they are still at increased risk compared to general population
76
is infertility reversed after kidney transplant?
yes; should use contraception if not planning on conceiving
77
risks to mother in pregnancy after transplantation
- rejection
| - preeclampsia
78
risks to fetus in post-transplant mother
- fetal loss
- low birth weight
- teratogens (MMF and sirolimus; must be stopped before pregnancy)
- infection; CMV
79
indication for pancreas transplant
hypoglycemic transplant
80
- usually occurs after rapid d/c'ing of IS
- fatigue
- fever
- gross hematuria
- allograft tenderness
graft intolerance syndrome
81
treatment of graft intolerance syndrome
restart IS w/ higher dose steroids
82
patients with bladder-drained pancreata develop
metabolic acidosis (loss of bicarb into bladder)
83
immunohistochemistry positive for SV40 (looks brown)
BK nephropathy
84
second line treatment for BK nephropathy after reduction of IS
- IVIG
| - or leflunomide or cidofovir
85
treatment for post-transplant erythrocytosis (PTE) (hb > 17 g/dl, hct > 51%)
ACEI
86
which medication group can improve nephrotoxic effects of cyclosporine?
CCBs
87
biggest risk factor for post-transplant lymphoproliferative d/o with belatacept
EBV negative recipient
88
sirolimus induced proteinuria will likely show up on biopsy as
podocytopathy causing FSGS
89
ABO incompatible transplant is a/w
significantly higher risk of infection and hemorrhagic complications
90
highest rate of recurrence post-transplant
diabetic nephropathy (40%)
91
second highest rate of recurrence post-transplant
FSGS (20-30%)
92
- one of the MCC of allograft failure in early post-transplant period
- sudden anuria
- tenderness around allograft
early graft thrombosis
93
HF before surgery with UF > 1.5-2 kg may be a strong predictor of
intraoperative hypotension
94
- progressively worsening HTN
- unresponsive to meds
- worsening renal function
- recurrent flash pulmonary edema
transplant renal artery stenosis (TRAS)
95
transplant renal artery stenosis (TRAS) treatment
angiographic stenting
96
IS medication that causes alopecia
tacrolimus
97
IS medication that causes hair growth and hirsutism
cyclosporine
98
how to diagnose CMV in a post-transplant patient with symptoms
serum CMV PCR
99
does SLK have lower immunological risk for kidney rejection?
yes
100
medication used in treatment of resistant hypomagnesemia
amiloride
101
treatment for lymphocele
laparoscopic peritoneal window creation
102
brown crap on immunohistochemistry in setting of AMR
C4D positivity
103
management of major surgery in post-transplant patient on sirolimus for IS
- hold sirolimus x 5-10 days before surgery (wound healing)
| - add steroids if not already on any
104
on histology, BK nephropathy mimics
ACR
105
difference in nephrotoxicity between tacrolimus and cyclosporine
same, but tacrolimus is less nephrotoxic at lower doses
106
what solution is infused during plasmapheresis? and is a possible adverse effect?
- citrate for AC
| - hypocalcemia
107
expected post transplant survival (EPTS) score is based on which 4 factors?
- age
- DM
- time on dialysis
- previous solid organ transplant status
108
what factors are a/w increased risk of PTLD?
- recipient EBV negative
| - number of HLA mismatches (especially HLA-B or HLA-DR)
109
is BK shedding in urine (BK viruria) common?
yes, about 30%
110
donor risk of ESRD post-nephrectomy
8-10 fold increase
111
compensatory hypertrophy post-nephrectomy returns GFR to
75% of baseline at long-term f/u
112
BK nephropathy initial test for diagnosis
serum BK PCR
113
is weight or body fat composition different at 1 year in patients on steroids vs steroid-avoidance protocols?
no
114
acute cellular rejection types
| - 4 cells infiltrated per tubule AND TUBULITIS
type 1
115
acute cellular rejection types
| - > 10 cells infiltrated per tubule AND ENDOTHELIALITIS
type 2
116
acute cellular rejection types
- lymphocytic cell infiltration AND interstitial hemorrhage
- vasculitis
- fibrinoid changes
type 3
117
T cell activation cascade signals
| - which medications block signal 1?
- thymoglobulin
- alemtuzumab
- tacrolimus
- cyclosporine
118
T cell activation cascade signals
| - which medications block signal 2?
belatacept
119
T cell activation cascade signals
| - which medications block signal 3?
- basiliximab
- sirolimus
- everolimus
- MMF
- azathioprine
- leflunomide
120
treatment of ACR typically involves increasing which T cell activation cascade signal blockers?
signal 1 and 3
121
medications that increase CSA levels (cyclosporine toxicity)
```
# abx
- macrolides
# CCB
- verapamil
- diltiazem
# mTOR inhibitors
- sirolimus
- everolimus
#antifungals
- ketoconazole
- fluconazole
```
122
what is the MOST appropriate INDUCTION IS?
| - Caucasian recipients of two-haplotype-identical, living, related allograft
no induction required (low risk for rejection)
123
what is the MOST appropriate INDUCTION IS?
- second transplant
- sensitized recipients
- transplant across ABO blood type
antithymocyte globulin (ATG)
124
what is the MOST appropriate INDUCTION IS?
| - first line agent
basiliximab
125
MMF MOA
inhibits inosine monophosphate dehydrogenase (IMPD), a key enzyme in purine synthesis
126
azathioprine MOA
- inhibits both DNA and RNA synthesis
- also suppresses purine synthesis
- action on cell cycle is not precisely defined
127
which IS in a KTR should be avoided to prevent lowering sperm count?
mTOR inhibitors
128
MCC of anemia is a post-renal transplant patient
poor graft function
129
histopathological finding that is an independent risk factor for anemia in a post-renal transplant patient
IFTA from prolonged CIT
130
MOST strongly a/w new onset DM after kidney transplantation (NODAT)?
advanced recipient age
131
relative risk of malignancy post-renal transplant
| - NHL
40-50%
132
relative risk of malignancy post-renal transplant
| - Kaposi's sarcoma
400-500%
133
relative risk of malignancy post-renal transplant
| - SCC
15-20%
134
relative risk of malignancy post-renal transplant
| - melanoma
8-10%
135
relative risk of malignancy post-renal transplant
| - Ca of vulva/anus
100%
136
highest ABSOLUTE risk of malignancy post-renal transplant
SCC
137
BK polyoma viral infection progression is characterized by what stages?
urinary decoy cells --> viruria --> viremia --> BK nephropathy
