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RB Y2 Renal > Renal Transplant > Flashcards

Renal Transplant Flashcards

1
Q

compare the renal function with dialysis and transplant

A
  • dialysis will give a GFR of around 7
  • transplant will give one of 50
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2
Q

age restrictions for transplant?

A

there are none, however co-morbidities accumulate with age that discourage transplantation

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3
Q

altruistic donation

A
  • live donation
  • directed (family/friend/spouse)/undirected
  • paired pool donation
  • financially procured
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4
Q

what is the difference in out comes between DCD and BSD donors

A

there is none

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5
Q

when does the benefit of a transplant begin

A

after around 3 months, before this there are greater risks

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6
Q

outline the patient assessment process

A
  • reasonable life expectance - around 5 years
  • safe to undergo operation
  • Immunology – tissue typing and antibody screening
  • Virology to exclude active infection. Problems can be encountered e.g. if the kidney has been exposed to CMV and the patient hasn’t
  • Assess cardiorespiratory risk:
    • ECG, ECHO ± ETT, coronary angiography
    • CXR ± PFT, CPEX (cardio-pulmonary exercise testing – measure VC, ECG and HR)
  • Assess peripheral vessels
  • Asses bladder function – important
  • Assess mental state
  • Assess any co-morbidities/PMH
  • Independent assessment out-with transplant team
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7
Q

must the patient recieve independent assessment outwith the transplant team

A

yes

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8
Q

patient contraindications to transplant

A
  • malignancy
  • active infection
  • Hep C
  • HIV
  • untreated TB
  • severe CV disease
  • hostile bladder
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9
Q

what effect could IS have on malignancy

A

allow it to grow faster

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10
Q

what is the criteria for malignancy contraindicating transplantation

A
  • known untreated
  • 2-5 years clear of treated cancer
  • watch out for eg breast cancer, which has late recurrence
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11
Q

is IS required when transplanting between monozygotic twins

A

epigenetics means they are slightly genetically different, so yes

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12
Q

what determines ones blood group

A

sugar on red cell surface

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13
Q

what sugars does blood group O have

A
  • none, can donate to anyone
  • can only take from O though
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14
Q

outline which blood groups can donate to which

A
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15
Q

which chromosome is HLA found on

A

chromosome 6

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16
Q

HLA action

A

code for MHC molecules which recognise anything non-self and activate immune system to destroy it

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17
Q

whicih 2 immunological things are importnat to match

A

blood group and HLA

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18
Q

what is the benefit of HLA matching

A
  • critical
  • gives better graft survival even with IS - 10% improvement at 3 years
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19
Q

what are the consequences of a bad HLA match

A
  • person will be more sensitive to subsequent transplants if required
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20
Q

what is a sensitising event

A

periods in a person’s life where they become exposed to foreign antigens which they become immunologically primed to and develop pre-formed antibodies to the non-self antigen e.g.

  • blood cell transfusion
  • pregnancy or miscarriage
  • previous transplant
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21
Q

what is the most common type of sensitising event

A

previous transplant

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22
Q

can a pregnancy and miscarriage both be classed as a sensitising event

A

yes, exposure of maternal blood to foetaa blood via placenta

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23
Q

in what circumstances does a sensitising event often cause problems in donations (maternal blood)

A

eg husband donating to wife if they have a child together

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24
Q

describe the systemi of kidney allocation

A
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25
Q

where do paediatric recipients fit into kidney allocation

A

get first choice irrespective of match

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26
Q

what is required with a eg 100 mismatch

A

additional IS as there is a greater chance of mismatch

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27
Q

what is a good way to overcome Ab.blood group incompatibitlity between donor and recepient

A

paired donation - can be done with multiple matches

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28
Q

Desensitisation

A
  • the active removal of blood group or donsor specific antibody
  • can be done by plasma exchange or B cell antibody (eg rituximab) to kill Ab producing cells
  • Ab levels are monitored until they are low enough to proceed and then the transplant can proceed
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29
Q

outline the transplant procedure

A
  • Transplant is placed extraperitoneally - inserted into iliac fossa and attached to the external iliac artery and vein
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30
Q

renal transplant: wound size, operation length, hospital time, recovery time

A
  • Wound 15-20 cm long
  • Average 2-3 hour operation
  • 7-10 days in hospital
  • Seen regularly after, follow up for life
  • 3 months to get back to full activities
31
Q

what are some surgical complications of a transplant

A
  • Bleed – terminal
  • Arterial stenosis, thrombosis
  • Venous stenosis/kinking
  • Ureteric stricture, hydronephrosis
  • Wound infection
  • Lymphocele - collection of lymphatic fluid in the body not bordered by an epithelial lining
32
Q
A
33
Q

how is the immediate graft function monitored

A

urine ouput, urea and creatinine

34
Q

delayed graft function

A
  • the graft takes 10-30 days to work
  • often need HD in the iterim
  • would biopsy regularly to make sure nothing else is going on
35
Q

primary non function

A

this is where the graft never works

36
Q

hyperacute rejection

A
  • occurs within minutes of transplantation
  • this is due to preformed Ab against HLA type 1 antigens
  • unsalvageable
37
Q

how is a hyperacute rejection managed

A
  • unsalvageable so a transplant nephrectomy is required (removal)
38
Q

how common is hyperacute rejection

A

rarely seen these days due to HLA matching

39
Q

acute rejection

A
  • cellular mediated - cytotoxic T cell mediated with primary activation of T cells
40
Q

time frame of acute rejection

A

under 6 months

41
Q

what virus can cause acute rejection

A

CMV

42
Q

mangement of acute rejection

A

immunosuppression eg steroids

43
Q

how may acute rejection present

A
  • May present with fever, tachycardia, pain and tenderness over kidney, which may be enlarged
  • Hypertension, raised creatinine and urea etc.
44
Q

why does acue rejection usually occur

A

mismatched HLA

45
Q

chronic rejection

A
  • chronic allograft nephropathy
  • this is a slow progressive decline in renal function which is Ab mediated
46
Q

how does chronic rejection usually manifest

A

gradual reduction in renal function associated with proteinuria and exacerbated hypertension

47
Q

induction IS treatment

A
  • Basiliximab/Dacluzimab
48
Q

what type of IS is given during surgery

A

high dose IV steroids eg prednisolone

49
Q

maintenance IS treatment

A
  • Prednisolone, tacrolimus, MMF
  • Prednisolone, ciclosporin, azathioprine
50
Q

how do Basiliximab/Dacluzimab work

A
  • induction treatment - preventative
  • prevent T cells being activated by blocking IL-2 receptors on CD4+ T cells
51
Q

what is the mainstay of IS treatment

A
  • steroids eg prednisolone
  • suppres cytokines and inhibit lymphocyte proliferation, survival and action
52
Q

name 2 calcineurin inhibitors

A
  • Tacrolimus and ciclosporin
53
Q

name 2 anti-metabolite drugs used in IS

A
  • Azathioprine and MMF
54
Q

what is teh most common side effect of IS

A

infection - often UTI, LRT

55
Q

what organism are IC individuals particularly at risk of (causes pneumonia)

A
  • Pneumocystic jirovecii
56
Q

what clinical signs would make you susepct Pneumocystic jirovecii infection

A
  • Fever, dry cough, SOB, weight loss and night sweats
  • absence of chest signs
57
Q

management of increased Pneumocystic jirovecii risk

A

prophylaxis: co-trimixazole

58
Q

which virus is associated with acute rejection and early graft loss

A

CMV - upregulates immune system

59
Q

importance of CMV post transplant

A
  • most common and important
  • cause of morbidity in first 3 months
  • causes higher rates of acute rejection
60
Q

how does CMV infection arise

A
  • reactivation of previous infection due to IS
  • donor kidney exposed to CMV but recipient not
61
Q

clinical features of CMV

A
  • Fever > pneumonitis > colitis > hepatitis > retinitis
  • clinically very similar to glandular fever, lymphadenopathy, arthralgia, fatigue, hepatomegaly, jaundiced sclera
  • atypical pneumonia
  • chorioretinitis – can lead to irreversible blindness
  • congenital infection and foetal damage
62
Q

how is CMV risk managed

A
  • Treat prophylactically with antivirals:
    • PO valganciclovir in high risk patients
    • IV gangciclovir if there is evidence of infection
63
Q

BK nephropathy

A
  • Source of infection:
    • Transmission occurs through donor kidney
    • Reactivation in the recipient renal epithelium after transplantation – over IS
  • can mimic rejection, manifests as renal dysfunction
64
Q

how does BK virus present

A
  • can mimic rejection
  • resp infection - eg cold cough that wont go away
65
Q

management of BK infection

A

there is no effective anti-viral therapy, so treatment is reducing immunotherapy

66
Q

cancer in the IS

A
  • there is a higher risk - accumulative risk and IS
  • have a high index of suspicion
67
Q

what is the most common type of malignancy post transplant

A
  • dermatological -50% have cutaneous lesions by ten years
  • significantly increased risk of SCC (also melanoma)
68
Q

PTLD

A
  • can occur in all forms of transplant
  • there is B cell proliferation due to therapeutic IS after transplant
  • increased risk with increased IS
  • usually occurs 6 months post transplant
69
Q

what are the majority of PTLD cases caused by

A

EBV

70
Q

treatment of PTLD

A
  • decrease IS
  • chemotherapy with B cell antibody
  • good outcomes
71
Q

name 4 complications following transplant

A
  • Atheromatous vascular disease
  • Raised blood pressure
  • Thrombosis
  • Infections due to suppressed T cell immunity
72
Q

graft vs host disease

A
  • caused by engraftment of donor lymphocytes in several IS recipients
  • Can occur with blood transfusions, when it is usually mild unless there is severe immunocompromise, but in its severe form is usually associated with bone marrow transplantation
73
Q

how can graft vs host disease present

A

skin rash and diarrhoea

74
Q

graft survival: cadaveric vs living donor transplant

A

60%:70%

RB Y2 Renal (26 decks)

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