Renal Transplantation

Question 1

What are the mechanisms for HLA sensitisation?

Answer 1

previous transplant, pregnancy, blood transfusions

Question 2

Why do ABO incompatible transplants have similar long term outcomes to ABO compatible transplants?

Answer 2

because you can remove the antibodies to acceptable titres prior to transplantation via plasma exchange

Question 3

Why are older living donors at a decreased risk of ESKD post donation compared to younger donors?

Answer 3

because ESKD takes time to develop

Question 4

Is there an age cutoff for renal transplantation?

Answer 4

no

Question 5

What are the two main agents for induction?

Answer 5

basiliximab and anti-thymocyte globulin

Question 6

What are the side effects of calcineurin inhibitors?

Answer 6

nephrotoxicity, hypertension, hyperlipidaemia

Question 7

Do calcineurin inhibitors cause bone marrow suppression?

Answer 7

no

Question 8

Are calcineurin inhibitors safe in pregnancy?

Answer 8

yes

Question 9

What are the benefits of tacrolimus compared to cyclosporin?

Answer 9

less acute rejection, less de novo DSA, less gum hypertrophy, less hirsuitism, less drug interaction

Question 10

What are the benefits of cyclosporin compared to tacrolimus?

Answer 10

Less diabetes, less hypo Mg/PO4, less tremor/neurotoxicity, less hair loss

Question 11

How is mycophenolate affected by cyclosporin?

Answer 11

cyclosporin lowers mycophenolate levels

Question 12

What is the mechanism of action of mycophenolate?

Answer 12

inhibits IMPDH involved in purine synthesis

Question 13

At what time period does mycophenolate cause bone marrow suppression/cytopaenia?

Answer 13

2-6 months

Question 14

Is mycophenolate safe in pregnancy?

Answer 14

no - need to change to azathioprine

Question 15

Which causes less acute rejection - mycophenolate or azathioprine?

Answer 15

mycophenolate

Question 16

Which causes more diarrhoea - mycophenolate or azathioprine?

Answer 16

mycophenolate

Question 17

What are the benefits of mTOR inhibitors?

Answer 17

less cancer risk, less CMV infection

Question 18

What are the side effects of mTOR inhibitors?

Answer 18

wound complications, proteinuria, cytopaenias, hyperlipidaemia, mouth ulcers, oedema, interstitial pneumonitis, contraindicated in pregnancy

Question 19

How is it best to use mTOR inhibitors?

Answer 19

in combination with calcineurin inhibitors at a lower dose

Question 20

What are the benefits of using an mTOR inhibitor with calcineurin inhibitor?

Answer 20

less CMV, less skin malignancy, less neutropaenia, less diarrhoea

Question 21

What is the most common cause of overall graft loss?

Answer 21

death with graft function

Question 22

What is the most common cause of death with graft function in the first year?

Answer 22

cardiovascular

Question 23

What is the most common cause of death with graft function?

Answer 23

cancer

Question 24

What is the most common cause of graft loss without death in the first year?

Answer 24

graft thrombosis

Question 25

What is the most common cause of graft loss without death after the first year?

Answer 25

chronic allograft nehpropathy

Question 26

What are the causes of chronic allograft nephropathy?

Answer 26

chronic antibody mediated rejection (under immunosuppression and poor HLA matching) and CNI toxicity

Question 27

What causes delayed graft function?

Answer 27

usually post ischaemic ATN, but can also be graft thrombosis, obstruction/urine leak, rejection or early recurrences of FSGS/TMA/oxalosis

Question 28

What are the risk factors for post ischaemic ATN?

Answer 28

deceased donor, donor AKI, donor age, DCD, cold ischaemic time

Question 29

What are the causes of early worsening graft function?

Answer 29

acute rejection, CNI toxicity, renal artery stenosis, obstruction/leak/collection, BK nephropathy, recurrent disease

Question 30

What are the different types of acute rejection?

Answer 30

T cell mediated, antibody mediated or mixed

Question 31

What is the treatment for T cell mediated rejection?

Answer 31

pulse methyld pred, optomise immunosuppression, if steroid resistant give anti thymoglobulin

Question 32

What is the treatment for antibody mediated rejection?

Answer 32

plasma exchange, IVIG

Question 33

What prophylaxis is required in transplant patients?

Answer 33

PJP, CMV

Question 34

How do you prevent BK nephropathy?

Answer 34

screening by serum PCR in first 12 months

Question 35

What is the treatment for BK nephropathy?

Answer 35

reduce immunosuppression

Question 36

What are the risk factors for CMV?

Answer 36

D+R- status and higher level immunosuppression

Question 37

Which patients need CMV prophylaxis?

Answer 37

D+R- or D-R+ or D+R+

Question 38

What limits duration of prophylaxis for CMV?

Answer 38

neutropaenia

Question 39

What is the treatment for CMV?

Answer 39

oral valganciclovir and cautious immunosuppression reduction

Question 40

What cancers are more common in renal transplant paients?

Answer 40

NHL, kidney, melanoma, skin cancer