RRT - Transplant Flashcards

1
Q

Where is a kidney transplant placed?

A

Right iliac fossa and anastomosed to the iliac vessels

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2
Q

What happens to the native kidney?

A

Usually left in.
Removed if:
- Oversized e.g. polycystic kidney disease
- Infected e.g. Chronic Pyelonephritis

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3
Q

List the medications used for immunosuppression in transplantees?

A

1) CCS
2) Calcineurin inhibitors (Tacrolimus or Cyclosporin)
3) Anti-proliferative (Azathioprine or Mycophenolate)
4) mTOR inhibitors (Sirolimus)
5) Costimulatory signal blockers (Belatacept)
6) Depleting agenets (Rituximab or basiliximab)

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4
Q

Explain how we go about immunosuppressing patients?

A

Induction with basiliximab (depleting agent)

Maintenance with Tacrolimus (CNI), mycophenolate (Anti-proliferative) and steroids

Steroid free treatments can be used
CNI-free treatments replace tacrolimus with Belatacept

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5
Q

what are the types of kidney donor?

A

Living:

  • Related
  • Spouse
  • Altruistic
  • Pooled/paired

Dead:

  • DBD (post brain death)
  • DCD (post cardiac death)
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6
Q

What are the criteria for brain death?

A
Coma
Apnoea despite CO2 build up
Absent cephalic reflexes e.g. pupillary
Body temp >34
No drug intoxication
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7
Q

What are the risks to the kidney donator?

A

Having one kidney puts you at higher risk of renal disease.
But the one compensates by increasing GFR up to 70%

Being older or having a high BMI is associated with ending up with a low GFR

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8
Q

List the complications with transplant?

A

Vascular:

  • Anastomotic bleed
  • Perirenal Haematoma
  • Arterial/venous thrombosis
  • Lymphocele
Uterine: Urine leak
Infection
CVS problems 
Rejection 
Malignancy
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9
Q

What kind of CV problems can arise post=transplant?

A
Chronic renal failure 
Underlying renal disease 
Hypertension
Hyperlipidaemia
Post transplant Diabetes!
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10
Q

What kind of cancers does a renal transplant predispose to?

A
Desc. order:
1) Non-melanoma skin cancer
2) Renal
3)Melanoma
Leukaemia
Cervical
4) Testicular/bladder
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11
Q

What are the major post-transplant infections?

A

CMV- Cytomegalovirus

Polyomaviridae (specifically BK or JC virus)

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12
Q

How do you get a CMV infection?

A

Either reactivation of latent virus or transmission from donor tissue.
It affects 8% of transplants despite prophylaxis

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13
Q

What can CMV infection cause?

A

CMV viraemia –> Tissue invasive disease

Affects many tissues e.g. hepatitis, nephritis, pneumonitis, colitis etc.

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14
Q

What can BK associated nephropathy cause?

A

Ureteral Stenosis
Interstitial Nephritis
ESRF

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15
Q

What are the risk factors for a BK associated nephropathy post-transplant?

A

Intense immunosuppression
Patient factors - Old, male, white, DM
Organ factors - HLA mismatch, graft injury or ureteral stent
Viral factors - Changes in viral capsid protein (VP-1)

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16
Q

How do you treat BK infection?

A

Reduce the immunosuppression
Anti-virals:
- Cidofovir +/- IVIG
- OR Leflunomide

17
Q

What is hyperacute rejection?

A

When theres a pre-existing alloreactivity to the donor

18
Q

What are the modes of Acute Rejection?

A
T cell mediated (TCMR)
Antibody Mediated (ABMR)
19
Q

Explain the banff categorisation of TCMR?

A

Banff 1 - Tubulointerstitial
Banff 2 - Arteritis/Endothelialitis
Banff 3 - Arterial Fibrinoid Necrosis

20
Q

Explain the Banff Categorisation of ABMR?

A

Banff 1 - ATN-like
Banff 2 - Capillary and/or glomerular inflammation
Banff 3 - Arteritis

21
Q

What are the Extended criteria in donors for brain death?

A

o Donor aged over 60
o Donor between 50-59 with a history of hyprtension, death from cerebrovascular accident, terminal creatinine of over 132

22
Q

Which is the most effective drug and why is it used so little?

A

belatacept

Too expensive

23
Q

How does the rejection pathway work?

A

1- Antigen on donor organ presented to T-cell
2- Three different molecules needed to stimulate a T-cell response: signal 1 activates, signal 2 co-stimulates, signal 3: proliferates
3- T-cell activated moves back to kidney and rejects