renal transplant immunosuppression

Question 1

intial

Answer 1

ciclosporin/tacrolimus with a monoclonal antibody

Question 2

maintainance

Answer 2

ciclosporin/tacrolimus with MMF or sirolimus

Question 3

when do you add steriods in renal transplant

Answer 3

add steroids if more than one steroid responsive acute rejection episode

Question 4

what does ciclosporin do

Answer 4

inhibits calcineurin, a phosphotase involved in T cell activation

Question 5

what does tacrolimus do

Answer 5

lower incidence of acute rejection compared to ciclosporin
also less hypertension and hyperlipidaemia
however, high incidence of impaired glucose tolerance and diabetes

Question 6

tacrolimus side effects

Answer 6

impaired glucose tolerance and diabetes

Question 7

Mycophenolate mofetil does what

Answer 7

blocks purine synthesis by inhibition of IMPDH
therefore inhibits proliferation of B and T cells

Question 8

side effect of MMF

Answer 8

GI and marrow suppression

Question 9

sirolimus

Answer 9

blocks T cell proliferation by blocking the IL-2 receptor

Question 10

complications of renal transplant

cardiovascular

renal failure

malignancy

Answer 10

Cardiovascular disease - tacrolimus and ciclosporin can cause hypertension and hyperglycaemia.

Tacrolimus can also cause hyperlipidaemia.

Renal failure - due to nephrotoxic effects of tacrolimus and ciclosporin/graft rejection/recurrence of original disease in transplanted kidney

Malignancy - minimising sun exposure to reduce the risk of squamous cell carcinomas and basal cell carcinomas

Question 11

3 types of organ rejection

Answer 11

Types of organ rejection
Hyperacute. This occurs immediately through presence of pre formed antigens (such as ABO incompatibility).
Acute. Occurs during the first 6 months and is usually T cell mediated. Usually tissue infiltrates and vascular lesions.
Chronic. Occurs after the first 6 months. Vascular changes predominate.

Question 12

Patients with end stage renal failure who are dialysis dependent or likely to become so in the immediate future are considered for transplant. Exclusion criteria for renal transplant

Answer 12

active malignancy, old age

A Rutherford-Morrison incision is made on the preferred side. This provides excellent extraperitoneal access to the iliac vessels. The external iliac artery and vein are dissected out and following systemic heparinisation are cross clamped. The vein and artery are anastamosed to the iliacs and the clamps removed. The ureter is then implanted into the bladder and a stent is usually placed to maintain patency. The wounds are then closed and the patient recovered from surgery.

In the immediate phase a common problem encountered in cadaveric kidneys is acute tubular necrosis and this tends to resolve.

Graft survival times from cadaveric donors are typically of the order of 9 years and monozygotic twin transplant (live donor) may survive as long as 25 years.