Renal transplantation

Question 1

By how much will renal transplant improve GFR?

Answer 1

50

Question 2

By how much will renal haemodialysis or peritoneal dialysis improve GFR?

Answer 2

7

Question 3

What are the different types of transplant?

Answer 3

Deceased heart beating donors (brain stem death)
Non-heart beating donors (DCD)
Live donation: directed and undirected, paired donation

Question 4

How should potential recipients be screened?

Answer 4

Patients with reasonable life expectancy (>5 years)

Patient is safe to undergo the operation: GA, procedure, immunosuppression, fluid (heart failure etc)

Question 5

What specifically is assessed once someone is eligible for an operation?

Answer 5

Immunology: tissue typing, antibody screening 
Virology: HBV, HCV, HIV, EBV, CMV, VSV, Toxo, Syphilis 
Cardioresp risk: ECG, echo, angio, CXR 
Assesses peripheral vessels
Assess bladder function
Assess mental state
Assess any co-morbidity/ PMHx 
Independent assessment

Question 6

What are contraindications to transplant?

Answer 6

Malignancy - solid tumor in last 2-5 years 
Active HCV/ HIV infection 
Untreated TB
Severe IHD
Severe airways disease
Active vasculitis 
Severe PVD
Hostile bladder

Question 7

What does tissue typing involve?

Answer 7

Blood group: O can only get from O
AB can get from everyone
HLA

Question 8

What are common sensitising events?

Answer 8

Blood transfusion
Pregnancy or miscarriage
Previous transplant
Leads to formation of preformed antibodies to non-self antigens

Question 9

Where are transplant kidneys grafted?

Answer 9

Onto the iliac vessels (vein and artery) and they graft the ureter to the bladder

Question 10

What are common surgical complications to kidney transplant?

Answer 10

Bleeding
Arterial stenosis
Venous stenosis/ kinking
Ureteric stricture and hydronephrosis 
Wound infection 
Lymphocele

Question 11

What is an indication of immediate graft function?

Answer 11

Good urine output

Falling urea and creatinine

Question 12

What is an indication of delayed graft function?

Answer 12

Post-transplant ATN
Often need HD in interim
Usually works within 10-30 days
Usually need biopsy

Question 13

What is hyperacute rejection?

Answer 13

Due to preformed antibodies
Unsalvageable
Transplant nephrectomy required

Question 14

What is acute rejection?

Answer 14

Cellular or antibody mediated

Can be treated with increased immunosuppression

Question 15

What is chronic rejection?

Answer 15

Antibody mediated slowly progressive decline in renal function
Poorly responsive to treatment

Question 16

What do anti-rejection therapy aim to do?

Answer 16

Reduce the activation of T cells

Aim is to prevent host V transplant mediated immune response

Question 17

What is the induction immunosuppressive therapy?

Answer 17

Basiliximab or daclizumab

Question 18

What immunosuppression is given during the transplant surgery?

Answer 18

IV prednisolone

Question 19

What immunosuppressive maintenance treatment is used post transplant?

Answer 19

Prednisone, tacrolimus, MMf
OR
Prednisolone, ciclosporin, azathioprine

Question 20

What are the different anti-rejection treatments?

Answer 20

Pulsed IV methylprednisolone
Anti-thymocyte globulin
IV immunoglobulin
Plasma exchange
Rituximab, bortezomib, eculizumab

Question 21

What is the main aim of immunosuppressive therapy?

Answer 21

Stops IL-2 release

Question 22

What are common complications of immunosuppression?

Answer 22

Bacterial infection: UTI, LRIT
Prophylaxis for PJP
Viral: CMV, HSV, BK
Fungal infections

Question 23

What is the prophylaxis for PJP?

Answer 23

Co-trimoxazole

Question 24

What is CMV disease associated with post transplant?

Answer 24

Most important cause of morbidity in immunosuppressed patients in first 3 months of transplant
Associated with early graft loss

Question 25

What will CMV disease cause?

Answer 25

Renal and hepatic dysfunction Oesophagitis, pneumonitis and colitis Increased risk of rejection

Question 26

What treatment is given in CMV disease for post-transplant patients?

Answer 26

Prophylactic PO valganciclovir | IV ganciclovir is evidence of infections

Question 27

How can CMV disease be diagnosed?

Answer 27

IgM | PCR

Question 28

What cancers are most common in immunosuppressed patients?

Answer 28

Non-melanoma skin cancers Lymphoma (EBV mediated PTLD) Solid organs

Question 29

Describe the pathogenesis of post-transplant lymphoproliferative disease?

Answer 29

EBV infection Polyclonal B cell proliferation Monoclonal proliferation Lymphoma

Question 30

What is the long term follow up of kidney transplant?

Answer 30

``` Rejection Hypertension and assessment of CVS Chronic allograft nephropathy UTI Recurrent primary renal disease Surveillance for malignancy Viral mediated graft dysfunction Management of CKD ```

Question 31

What do induction monoclonal antibodies do?

Answer 31

Basiliximab or daclizumab Block IL-2 receptors on CD4 T cells Prevent activation of these cells and therefore prevent rejection

Question 32

What is the action of steroids?

Answer 32

Inhibit lymphocyte proliferation, survival and activation | Suppress cytokines

Question 33

What are the common side effects of steroids?

Answer 33

Weight gain Diabetes Osteoporosis

Question 34

What is the mode of action of calcineurin inhibitors?

Answer 34

Tacrolimus and ciclosporin Act by inhibiting activation of T cells Prevent cytokine release

Question 35

What are the side effects of calcineurin inhibitors?

Answer 35

Renal dysfunction Hypertension Diabetes Tremor

Question 36

What is the mode of action of anti-metabolites?

Answer 36

Azathioprine and MMF | Blocks purine synthesis causing the suppression of proliferation of lymphocytes

Question 37

What are the side effects of anti-metabolites?

Answer 37

Leucopenia GI upset Anaemia