Renal Transplantation

Question 1

What are the risks of giving immunosuppression to patients having transplants?

Answer 1

Increased risk of infections
Bone marrow suppression
Increased risk of cancer

Question 2

What are the 4 areas involved in working up a patient for a transplant?

Answer 2

Check:

Cardiac
Respiratory
Mitotic lesions
Vascular supply in lower legs

Question 3

How do you check the heart health is suitable for a transplant during work up?

Answer 3

ECG
Myocardial perfusion scan while exercising
Dobutamine stress ECHO

Question 4

How do you check the respiratory health is suitable for a transplant during work up?

Answer 4

CXR
Spirometry
Sats

Question 5

Why is having low mitotic figures extremely important in the work up of a transplant patient?

Answer 5

The immunosuppression given after the transplant can lead to the cancer rapidly progressing

Question 6

How can you check a patient for mitotic lesions when working up for a transplant?

Answer 6

PMH
FHX
SHx for cancer risk
Red flags:
Weight loss
SOB
Bloody stools
Bloody urine

US abdomen

Question 7

Why do you check the vascular supply to the legs is suitable for a transplant during work up?

Answer 7

Transplanted kidney gets inserted into the external iliac artery which then becomes the common femoral which supplies the entire lower limb

If pateitn has claudication before transplant highly likely will develop lower limb ischaemia

Question 8

Who should receive a renal transplant?

Answer 8

Patients with End Stage Renal failure on dialysis.

OR

Patients predicted to enter into end stage renal failure (preemptive transplant)

Question 9

What is dialysis vintage?

Answer 9

Longer a patietn is on dialysis, the higher this value is and the less likely they will be able to have a transplant

Question 10

How are donor kidneys matched to a recipient?

How is it scored?

Answer 10

3 gene loci assessed

DP
DQ
DR

The likelihood of rejection for each of these loci is then scored with a score 0 to 2 for each

Scores of 0 for all 3 means unlikely to mismatch
But scores of 2 for all 3 means its very likely to mismatch and reject

Question 11

What medications are given to induce immunosuppression before and after surgery to prevent acute rejection?

Answer 11

Infusions of:
-Basiliximab
Or
-alentuzumab (Campat)

Question 12

What types of drugs are then used as maintenance to maintain immunosuppression to prevent graft/transplant rejection?

Answer 12

Calcineurin inhibtors
Steroids
Anti-Proliferative agents
mTOR inhibitors

Question 13

What is the best example of a calcineurin inhibitor to maintain immunosuppression following transplantation?

Answer 13

Tacrolimus

Question 14

What is the best example of steroids used to maintain immunosuppression following transplantation?

Answer 14

Prednisolone (aim to taper down ASAP)

Question 15

What are some examples of anti-Proliferative agents used to maintain immunosuppression following transplantation?

Answer 15

Mycophenolate motif
Azathioprine

Question 16

What is an example of an mTOR inhibitor for maintaining immunosuppression following transplantation?

Answer 16

Sirolimus

Question 17

What 3 other types of medications do we give immediately after transplantation?

Answer 17

Antibiotics
Antivirals
Antifungals

Question 18

What antibiotics are typically given post transplant?

Answer 18

Co-trimoxazole

Question 19

What antiviral is typically given post transplantation?

Answer 19

Valgancyclovir

Question 20

What antivfungal is typically given post transplantation?

Answer 20

Fluconazole

Question 21

What virus do you give a longer course of valgancyclovir for if the donor is positive for it but the recipient is negative for it?

Answer 21

CMV

Question 22

Do you give the anti-microbials for long term maintenance?

Answer 22

No eventually stop them

Question 23

What are 5 immediate complications of renal transplantation?

Answer 23

Infections
Acute rejection
Renal vein thrombosis
Acute renal artery occlusion
Hydronephrosis

Question 24

What are the 2 types of rejection for a transplant?

Answer 24

T cell mediated rejection
Or
Antibody mediated rejection

Question 25

What do you do if you suspect acute rejection?

Answer 25

Ultrasound the kidney Then BIOPSY it (Look for inflammatory cells in tubules) to confirm acute rejection Management determined by type of rejection

Question 26

How do you manage an acute T cell mediated rejection?

Answer 26

Increase the dose of the steroids (Prednisolone)

Question 27

How do you manage an acute antibody mediated rejection?

Answer 27

Do plasma exchange to remove all antibodies Then anti B cell agents like RITUXIMAB (anti-CD20)

Question 28

How do you manage immediate complications like renal vein thrombosis, hydronephrosis, acute renal artery stenosis?

Answer 28

Surgical referral

Question 29

What are the 3 types of intermediate complications of renal transplantation?

Answer 29

Infection Rejection Calcineurin inhibitor toxicity

Question 30

Why is infection an intermediate and long term complication of renal transplantation?

Answer 30

Ceased the anti microbials by this point

Question 31

What are some unusual opportunistic infections caused by immunosuppression?

Answer 31

Cytomegalovirus (CMV) Pneumocystis jiroveci TB

Question 32

What are some other potential causes of infection as an intermediate complication of transplantation?

Answer 32

CMV PCP and PCJ TB Pneumonia Sepsis UTI EBV Shingles Cryptosporidium

Question 33

What is the management for a transplant patient that has developed an infection? What is the exception to this?

Answer 33

Need to reduce levels of immunosuppression If infection is CMV, reduce levels of immunosuppression and also give valgancyclovir

Question 34

How do you manage chronic rejection post renal transplantation?

Answer 34

BIOPSY T cell mediated = steroid increase Antibody mediate = plasma exchange if suitable + rituximab

Question 35

How do you assess Calcineurin toxicity?

Answer 35

Measure levels of Tacrolimus (Calcineurin inhibitor) in the blood

Question 36

How does Calcineurin toxicity (Tacrolimus) present?

Answer 36

HTN Tremors Hair loss Gum hypertrophy Neurotoxicity (delirium/myoclonic jerk)

Question 37

How do you manage Calcineurin inhibitor toxicity?

Answer 37

Reduce dose of Tacrolimus or cyclosporin If doesn’t work switch to the mTOR inhibitor Sirolimus

Question 38

What are the long term complications of renal transplantation?

Answer 38

MALIGNANCY Infection Chronic rejection Calcineurin inhibitor toxicity

Question 39

What malignancies are patients at increased risk of developing following Renal transplantation?

Answer 39

Squamous cell carcinomas (Other skin cancers like basal cell carcinoma) Non Hodgkin lymphoma/Post Transplant Lymphoproliferative disorder

Question 40

How do you change your management if a patient develops malignancy following transplantation? Why?

Answer 40

Reduce the dose of anti-Proliferative like Mycophenolate motif To allow the bodies immune cells a chance to fight the malignancy

Question 41

What issues can steroids cause when being used for immunosuppression? How can some of this be mediated?

Answer 41

Cushings symptoms T2DM Peptic ulcers Osteoporosis Wean down ASAP Give PPIs (omeprazole for gastroprotection) Zolendronic acid, Vit D and calcium for bone protection

Question 42

What individuals are at a higher risk of rejection?

Answer 42

Those with: -autoimmune conditions -chronic illness -poor medication complicance -malignancy

Question 43

What timing is considered hyper-acute graft rejection?

Answer 43

Minutes to hours

Question 44

What timing is considered acute graft rejection?

Answer 44

Within 6 months

Question 45

What is considered chronic graft rejection?

Answer 45

After 6 months

Question 46

What medication slows down the progression of Autosomal Dominant Polycystic Kidney disease?

Answer 46

Tolvaptan