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Clinical 2.0 > Renal Transplant > Flashcards

Renal Transplant Flashcards

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1
Q

benefits of transplant

A

longer survival
health care cost savings
improved quality of life
not life saving - renal replacement therapy

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2
Q

3 things considered for kidney allocation

A

medical need
utility
justice

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3
Q

types of living kidney donors

A

direct donation
kidney paired exchange
altruistic

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4
Q

types of decreased kidney donors

A

neurological determination death
donation after cardiac death
medical assistance in dying

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5
Q

who are highly sensitized kidney transplant recipients

A

PRA >95%

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6
Q

what are human leukocyte antigens

A

markers on most cells that identify self from foreign

match between A, B, DR, DQ types

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7
Q

degree of HLA difference = ______________

A

degree of immunologic risk

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8
Q

what are some sensitizing events that can lead to antiHLA antibody

A

pregnancy
blood transfusions
previous transplant

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9
Q

what is panel reactive antibody screening

A

degree of transplatability

ex 95% incompatible for transplant with 95 out of 100 potential donors

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10
Q

what is cross matching, whats a positive result

A

a test between donor and recipient

positive is bad means the recipients cells can recognize and attack donor cells, increased risk of rejection

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11
Q

what is a common cause of someone developing antibodies to the donor after the transplant

A

often result of non compliance

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12
Q

what is used in induction therapy

A

intense immunosuppressive therapy at time of transplant to reduce risk of acute rejection

  1. deplete antibodies with thymoglobulin
  2. non depleteing antibodies : basiliximab
  3. corticosteroids: prednisone
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13
Q

ex calcineurin inhibitors

A

cyclosporine

tacrolimus

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14
Q

ex corticosteroids

A

prednisone

methylprednisilone

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15
Q

ex antiproliferatives

A

azathioprine

mycopehnolate

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16
Q

ex rapamycins

A

sirolimus

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17
Q

what is the standard therapy for adult kidney transplant

A

tacrolimus: inhibits early in tcell activation
mycopehnolate mofetil: decrease t cell proliferation
prednisone: inhibits lymphocytes

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18
Q

calcineurin inhibitor AE

A 
increase BG - TAC
increase BP, K, uric acid 
increase lipids (CSA)
decrease Mg, P 
tremor 
nephro and hepato toxicity 
gingival hyperplasia 
hair growth CSA
hair loss TAC
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19
Q

calcineurin inhibitor are substrates and inhibitors for

A

cyp3A4 and pgp

CSA > inhibitor

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20
Q

what can cause loss of pgp

A

diarrhea can cause sloughing of intestinal endothelium

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21
Q

inhibitors of cyp 3A4 that increase CSA and TAC

A 
azoles
macrolides
non DHP CCB
grapefruit juice
protease inhibitors
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22
Q

inducers of cyp 3A4 that increase CSA and TAC

A 
rifampin 
phenytoin 
carbamazepine 
phenobarbital 
stjohns wort
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23
Q

minoxidil + csa

A

hirsutism

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24
Q

phenytoin, nifedipine + CSA

A

gum hyperplasia

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25
statins, dig , capsofungin _ CSA
decreased clearance
26
colchicine + CSA
increased myopathy and hepatotoxicity
27
glyburide + CSA
increase CSA level
28
repaglinide + CSA
increased repaglinide exposure
29
warfarin + CSA
decrease INR and CSA levels
30
potassium sparing diuretics + CSA
hyperkalemia
31
which statins might be ok to use with CSA
pravastatin and fluvastatin
32
tecrolimus DI
potassium sparing diuretics cause hyperkalemia metoclopramide increase tacrolimus - not a worry statins - atorv low dose ok
33
NOACs and CI
dabigatran not recommended rivaroxiban unknown apixaban likely safe
34
which drugs have additive nephrotoxicity with CI
``` nsaids ACei aminoglycosides amphotericin B renal sparin = CCB ```
35
sirolimusAE
increased lipids, proteinuria, delayed wound healing, anemia, hypertension caution in liver and lung transplant - hepatic artery stenosis, bronchial anastomotic dehiscence
36
spacing of cyclosporin and sirolimus
give CSA 4 hours before or will get increase concentrations of sirolimus
37
sirolimus DI
cyp 3A4 substrate | same as CI
38
azathioprine AE
bone marrow suppression hepatotoxicity use TPMT phenotype to guide dosin (enzymes that metabolizes azathioprine)
39
mycopehnolate AE
leukopenia | GI intolerance
40
azathioprine DI
allopurinol - increase AZA ACEi - increased neutropenia warfarin - decreased INR
41
mycophenolate DI
antibiotics - may change enterohepatic recirculation cholestyramine - prevents reabsorption via enterohepatic recirculation PPIs - decreases myco levels antacids - separate by 2 hours iron preps
42
prednisone AE
``` increase lipids, BG, BP sleep disturbance increased appetite and weight mood swings, osteoporosis acne fluid retention ```
43
general drugs to avoid
immmune stimulants duh decongestants - increase BP PPIs - use lowest dose NSAIDs, aminoglycosides, amphotericin B
44
blood concentration must correlate with
exposure | clinical outcomes - therapeutic and toxic
45
trough level within 30 min pre dose target CSA
50-150mcg/L | depends on time since transplant and individual patient
46
trough level target in tacrolimus
correlated well with AUC | 6-8mcg/L
47
sirolimus trough level target
correlates well with drug exposure | 6-10mcg/L depends on time since transplant and patient
48
mycophenolate trough level targets
wide individual variability no time point accurately reflects exposure dont measure levels
49
what else do you want to know if get dyslipidemia on therapy
``` BMI diet and exercise smoking CVD history renal function ```
50
effects of statins and immunisuppressants
lipids and CV disease is common myopathy with CSA increased statin exposure atorva, prava, fluva, simv safe at lose dose esp tacrolimus
51
what do you recommend for dyslipidemia after transpalnt
diet exercise smoking cessation start low dose statin and monitor for side effects
52
fibrates?
no outcome data
53
ezetimibe?
no data in renal transplant
54
resin?
drug binding, absorption interference
55
niacin?
glucose issues | increased uric acid
56
fish oil?
no benefit but not harmful
57
how long do we prophylactically treat pcp
3 months | co-trimoxazole
58
treatment for pcp
septrafor 3 weeks
59
when and what prophylaxis do you give for cmv
give valganciclovir for 6 months in people with mismatched CMV status to their donor or with use of induction agents (donor +, and recipient - biggest risk)
60
pre emptive treatment for cmv
routine screening using PCR | treatment until 2 negative PCR
61
treatment of cmv in invasive tissue disease
severe leukopenia can occur | ganciclovir IV, valganciclovir po
62
why is routine screen screening for BK viraemia and graft dysfunction important
BK virus common in general pop may be reactivated in immunosuppressed state leading to nephropathy and graft failure
63
treatment of BK virus
no good treatment reduce baseline immunosuppression switch to cyclosporin
64
EBV is associated with devellpment of post transplant lymphoproliferative disorder when should routine screening occur
if EBV mismatch at time of transplant
65
treatment for EBV
lower immunosuppressive therapy
66
most common infection post transplant
UTI
67
complications of pyelonephritis
sepsis | graft dysfunction and failure
68
UTI prophylaxis
in first 3 months TMPSMX
69
vaccines in renal transplant
avoid live | can get flu shot after 3 months and vaccines after 6
70
the "ABCDEs" we should know
``` anemia - lots of blood work, takes time for kidney to start epo production analgesia bone density - decrease due to steroids and renal bone disease blood pressure - increase cholesterol - increase cancer risk BG - increased depression - steroid use eyes- cataracts from steroids exercise ```
71
mycophenolate and fertility
teratogenic in females unknown for sure effects in males switch to azathioprine if planning for pregnancy, wait at least 1 year post transplant
72
goals of transplant
prolong graft survival prevent rejection episodes min long term complication s

Clinical 2.0 (24 decks)

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