Renal Transplantation

Question 1

What are some contra-indications to renal transplant?

Answer 1

Active metastatic malignancy

Relative- Active infection, HIV with viral replication, unstable CVD

Question 2

List the different types of kidney donors

Answer 2

Living
Cardiac Death
Brain Death (Kidney still perfused)
Extended criteria donors

Question 3

Give four classes of immunosuppressive drugs used for post-transplant immunosuppression

Answer 3

Monoclonal Antibodies
Calcineurin Inhibitors
Anti-metabolites
Steroids

Question 4

Give an examples of a monoclonal antibody used for post-transplant immunosuppression, when is this agent used?

Answer 4

Basiliximab (IL-2 Ab that blocks T cell proliferation)

Recommended as an induction agent that also includes a calcineurin inhibitor

Question 5

Give two examples of calcineurin inhibitors

Answer 5

Tacrolimus (more effective)

Ciclosporin (hardly used for post-transplant immunosupression)

Question 6

How do calcineurin inhibitors work?

Answer 6

They prevent the intra-cellular signalling that leads to T cell proliferation. Recommended to be given with basiliximab as an induction regime

Question 7

What are some side effects of tacrolimus? What class is it?

Answer 7

Tremor
Nephrotoxicity
Diabetes (new onset)
Neurotoxicity
CV Risk Factors- (inc new onset diabetes, cholesterol, increase BP)

Question 8

What class of antibiotics might tacrolimus interact with?

Answer 8

Macrolide ABx (also anti-fungals)

Examples- Azithromycin, Erythromycin, Clarithromycin

Because clearance is dependent on p450 enzymes

Question 9

Give an example of an anti-metabolite used for post-transplant immunosuppression

Answer 9

Mycophenolate Mofetil

also Azathioprine

Question 10

What is a serious risk of mycophenolate mofetil?

Answer 10

It is teratogenic

Also causes bone marrow suppression (anaemia and leukopenia)

Question 11

How does sirolimus work?

Answer 11

It is an anti-proliferative that blocks mTOR. Can be used for induction or maintenance

Question 12

How do steroids work for immunosuppression?

Answer 12

Reduce transcription of pro-inflammatory cytokines

They’re the first line treatment for acute rejection and may be used for induction and as low dose maintenance

Question 13

What are some complications of renal transplantation?

Answer 13

Delayed graft function
Acute rejection
Chronic rejection
Infection due to immunosuppression (e.g. opportunistic fungal or PJP)
Immunosuppression increases risk of malignancy- esp. skin cancers, Kaposi sarcoma, cervical cancer