renal transplantation

Question 1

what is the location of a kidney following transplantation?

Answer 1

Transplanted kidney is placed into the iliac fossa and anastomosed to the iliac vessels
Native kidneys usually remain in situ

Question 2

how are donor kidneys preserved?

Answer 2

Cold storage solutions
Minimize oedema
Preserve integrity of tissues
Buffer free radicals

Question 3

what are surgical transplant complications?

Answer 3

Bleeding
Usually anastomotic sites
Perirenal haematoma can be arterial or venous
Areterial thrombosis
Venous thrombosis
Lymphocele
Ureteric
Urine leak
Infections

Question 4

what are available immunosupressive agents?

Answer 4

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 5

what are common side effects of immunosupressive agents?

Answer 5

Question 6

what are induction immunosupression protocols?

Answer 6

Basiliximab

Question 7

what are maintenance immunosupression protocols?

Answer 7

Tacrolimus + Mycophenolate + steroids

Question 8

what are deceased donors?

Answer 8

Donation after brain death/ DBD (heart-beating)
- standard / expanded criteria

Donation after cardiac death/DCD (non-heart-beating)
- standard / expanded criteria

Question 9

what are living donors?

Answer 9

Living Related Donor

Living Unrelated Donors
- spousal
- altruistic
- paired/pooled

Question 10

what is the criteria for brain death?

Answer 10

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 11

how can living kidney donation be carried out?

Answer 11

Live related donor

Live unrelated donor (e.g. spousal)

Live unrelated donor – altruistic, non-directed

Paired / pooled

ABO incompatible / HLA incompatible

Question 12

summarise risks of kidney donation?

Answer 12

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 13

what is acute rejection?

Answer 13

T cell mediated rejection (TCMR)
Tubulointerstitial (Banff I)
Arteritis/endothelialitis (Banff II)
Arterial 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 14

what is hyperacute rejection?

Answer 14

(pre-existing alloreactivity to donor)

Question 15

what are signs of t cell mediated rejection?

Answer 15

Lymphocytic infiltrate

Tubulitis

Endarteritis

Endothelialitis

Question 16

what are signs of antibody mediated rejection?

Answer 16

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

Question 17

what causes new onset diabetes following transplantation?

Answer 17

Question 18

what are common modes of infection following renal transplantation?

Answer 18

Question 19

what is cytomegalovirus?

Answer 19

Most important transplant-related infection
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 20

what is CMV viremia?

Answer 20

Pneumonitis
Hepatitis
Retinitis
Gastroenteritis
Colitis
Nephritis

Question 21

what is polyomadviridae?

Answer 21

BK virus
JC virus

Murine polyoma virus
SV40

Question 22

what are clinical manifestations of BK virus?

Answer 22

Question 23

what are risk factors for BKAN?

Answer 23

Intensity of immunosuppression
- tacrolimus, mycophenolate mofetil, antithymocyte globulin
Patient determinants
- older age, male gender, white ethnicity, DM, negative BKV serostatus (paediatric recipients)
Organ determinants
- graft injury, HLA mismatches, ureteral stents
Viral determinants
- changes in epitopes of viral capsid protein VP-1

Question 24

what is the outcome of BKAN?

Answer 24

Allograft dysfunction

• Loss of graft in 45-80%

Question 25

what is the treatment for BKAN?

Answer 25

• Reduce immunosuppression
• Antiviral therapy
• cidofovir +/- IVIG
  - leflunomide

Question 26

what is the risk of malignancy following renal transplantation?

Answer 26