Renal Replacement Therapy 2 (Transplantation)

Question 1

where is the transplanted kidney placed and what vessels is it connected to?

Answer 1

Transplanted kidney is placed into the iliac fossa and anastomosed to the iliac vessels

Question 2

Are the old kidneys removed in a kidney transplant?

Answer 2

Native kidneys usually remain in situ

Question 3

What are some indicstions to remove the original kidneys?

Answer 3

Indications for native nephrectomy include size (polycystic kidneys) and infection (chronic pyelonephritis)

Question 4

how is preservation of doner kidney done?

Answer 4

Cold storage solutions

Minimize oedema

Preserve integrity of tissues

Buffer free radicals

Question 5

what are some transplant surgical complications?

Answer 5

Vascular complications:

• Bleeding: Usually anastomotic sites, Perirenal haematoma can be arterial or venous
• Areterial thrombosis
• Venous thrombosis
• Lymphocele (a collection of lymphatic fluid within the body not bordered by epithelial lining)

Ureteric - Urine leak

Infections

Question 6

Why is immunosuppression needed in a kidney transplant?

Answer 6

As the body of the person receiving the kidney will reject it and the persons body cells will attack it

Can interfere with these 3 signals is how you do immune suppression

Question 7

what are examples of immunosuppressive agents? and what are osme of their side effects?

Answer 7

Corticosteroids

Calcineurin inhibitors - Tacrolimus, Cyclosporine

Anti-proliefratives - Mycophenolate mofetil, Azathioprine

mTOR inhibitors - Sirolimus

Costimulatory signal blockers - Belatacept

Depleting agents - Basiliximab ( anti-CD25), Anti-thymocyte globulin (ATG), Rituximab (anti-CD20)

Question 8

What is the immunesuppression protocol?

Answer 8

Induction: Basiliximab

Maintenance: Tacrolimus + Mycophenolate + steroids - tripple agent

Steroid free is possible

Others: CNI-free using Belatacept

Question 9

what are the different type of donors?

Answer 9

Deceased Donors

Living Donors

Question 10

what are the types of Deceased Donors?

Answer 10

Donation after brain death/DBD - standard / extended criteria

Donation after cardiac death/DCD - standard / extended criteria

Question 11

what are the types of living donors?

Answer 11

Living Related Donor

Living Unrelated Donors:

• spousal
• altruistic
• paired/pooled

Question 12

what is the brain death criteria?

(bulk of donations are from these people)

Answer 12

Coma, unresponsive to stimuli

Apnoea off ventilator (with oxygenation) despite build up of CO2

Absence of cephalic reflexes:

▪ pupillary

▪ oculocephalic

▪ oculovestibular (caloric)

▪ corneal

▪ gag

▪ purely spinal reflexes may be present

Body temperature above 34 C

Absence of drug intoxication

Question 13

What is SCD and ECD?

Answer 13

Standard criteria, not ECD

Extended criteria (ECD):

• Donor aged > 60y
• Donor aged 50-59 + history of hypertension, death from cerbrovascular accident or terminal creatinine of >132µmol/L

Go for standard criteria as it is a better kidney but you can still take the risk and take the extended criteria donor kidney

Question 14

is there a gap between demand and donation?

Answer 14

Question 15

WHat type of transplant has the best survival rates?

Answer 15

All better survival if you have a living kidney donation

Question 16

What is the Frequency of donor type-Scotland 1960-2013?

Answer 16

Question 17

What is the post-listing outcome of transplant like?

Answer 17

If on transplant list should have a long chance of survival of around 5 years

Some do die while waiting

Some removed if they become more ill

Question 18

what is the waiting time for a transplant?

Answer 18

Question 19

what tends to be the gae of transplantation?

Answer 19

Dialysis is a treatment that filters and purifies the blood using a machine. This helps keep your fluids and electrolytes in balance when the kidneys can’t do their job

In medicine, dialysis is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally. This is referred to as renal replacement therapy

Question 20

living kidney donation may be done by who?

Answer 20

Live related donor

Live unrelated donor (eg spousal)

Live unrelated donor – altruistic, non-directed

Paired / pooled

ABO incompatible / HLA incompatible

Question 21

What is pooled donation?

Answer 21

Create a chain and the number of transplants you did is much greater and utilise the altruistic to start the chain

Question 22

what things need to be thought about in relation to kidney donation saftey?

Answer 22

Is it safe to donate a kidney?

What are short and long-term risks?

Is there a risk of end stage kidney disease?

Question 23

How does GFR and urinary albumin excretion change after donation?

Answer 23

Glomerular Filtration Rate (GFR) and Urinary Albumin Excretion According to Time since Donation

Question 24

what are the risks of kidney donation?

Answer 24

Similar patient survival to general population

Lower rate of ESRD compared to general population reduced

Compensatory increase in GFR of remaining kidney to 70% of pre-donation values

Compensatory increase greater in younger donors

Older age and high BMI were associated with GFR of <60

Relatively short follow up time (12 years)

Question 25

what are the different types of complications that may happen after renal transplant?

Answer 25

rejection infective - Infection increases when you offer immunosuppression to deal with rejection cardiovascular malignancy

Question 26

what are types of rejection complications after a renal transplant?

Answer 26

Cell mediated Humoral (Ab mediated)

Question 27

what are types of infective complications after a renal transplant?

Answer 27

Bacterial Viral Fungal

Question 28

what are types of cardiovascular complications after a renal transplant?

Answer 28

Underlying renal disease CRF Hypertension Hyperlipidaemia PT Diabetes

Question 29

what are types of malignancy complications after a renal transplant?

Answer 29

Skin Lymphoma Solid Cancers

Question 30

what are the types of acute rejection?

Answer 30

Hyperacute rejection (pre-existing alloreactivity to donor) Acute rejection: - T cell mediated rejection (TCMR) Tubulointerstitial (Banff I) - Banff 1 not as bad as Banff 3 Arteritis/endothelialitis (Banff II) Areterial fibrinoid necrosis (Banff III) - Acute antibody mediated rejection (ABMR) ATN-like (Banff I) Capillaries and or glomerular inflammation (Banff II) Arterial inflammation (Banff III)

Question 31

What are the types of T cell mediated rejections?

Answer 31

top picture: Lymphocytic infiltrate Tubulitis (inflammation of a tubule) bottom picture: Endarteritis (inflammation of the inner lining of an artery) Endothelialitis (inflammation of the endothelium)

Question 32

What are the 3 ways to check for antibody mediated rejection?

Answer 32

**Microvascular inflammation:** - Neutrophil infiltration - Glomeruli - Peritubular capillaries **Donor specific antibodies** **Positive C4d** - peritubular capillaries

Question 33

What may someone dveelop after transplantation?

Answer 33

New onset diabetes mellitus after transplantation Diabetes risk high in the first year then comes down

Question 34

Infection after renal transplantation What is the most important transplant-related infection?

Answer 34

Cytomegalovirus Affects around 8% of trasnplant recipients, despite prophylaxis therapy High mortality and morbidity if untreated Recipient affected via: - Transmission from donor tissue - Reactivation of latent virus

Question 35

CMV viremia is said to be a tissue _________ disease

Answer 35

Tissue invasive disease - Pneumonitis - Hepatitis - Retinitis - Gastroenteritis - Colitis - Nephritis

Question 36

Does prophylaxis help CMV

Answer 36

Avoid it by prophylaxis in the first place

Question 37

What are the clinical manifestations of the BK virus?

Answer 37

Can have it in other transplants and settings

Question 38

How do you check to see if someone has BK virus?

Answer 38

Urine and Allograft-Biopsy Specimens from a Patient with BK Virus Nephropathy Check it in blood to see if someone has it

Question 39

Higher immunosuppression then higher risk of \_\_

Answer 39

BK

Question 40

WHat are the outcomes and management of BKAN?

Answer 40

Outcome: - Allograft dysfunction - Loss of graft in 45-80% Treatment: - Reduce immunosuppression - Antiviral therapy (Antiviral therapy doesn’t really work) - cidofovir +/- IVIG, leflunomide

Question 41

what is the risk of different malignancies after transplant?

Answer 41

When tumour occurs you are forced to come down on immunosuppression as that is the priority

Question 42

Summary: Kidney Transplantation is the best way to treat \_\_\_\_\_ Demand is much higher than \_\_\_\_\_\_ Expanding living and cadaveric donor pool is possible Transplantation is not right for everyone and is not ____ free

Answer 42

Summary: Kidney Transplantation is the best way to treat **_ESRD_** Demand is much higher than **_supply_** Expanding living and cadaveric donor pool is possible Transplantation is not right for everyone and is not **_risk_** free