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Flashcards in Transplant Deck (30):
1

Orthotopic vs heterotopic transplant

Orthotopic: transplant graft placed in its anatomic position. Heterotopic: graft placed at different site

2

Brain death declaration criteria for adults

No cerebral function (in coma); no brainstem function (no CN functions, no CN reflexes such as papillary, conreal, cold water calorics, Doll's eyes, or gag); no spontaneous breathing (as shown by apnea test)

3

Brain death criteria for peds

TWO exams/apnea tests/EEGs 12-48 hrs apart (depending on age, younger needs longer time in between exams)

4

What are the MHC alleles?

MHC I: A, B, C. MHC II: DR, DQ, DP

5

Which of the MHC alleles are used for tissue typing?

A, B, and DR. DR is the most important to match

6

Why does matching paradoxically result in worse outcomes in liver transplant?

HLA presents viral peptides to T cells, and compatibility may potentiate the inflammatory phase of viral reinfection after transplant, increasing chance of recurrence of original disease

7

Steroids

Medium dose for maintenance, high dose for rejection

8

Cyclosporine (CsA)

Calcineurin inhibitor, used for maintenance only. P450 metabolism. Side effects include: nephrotoxicity, HTN, hypertricosis, gingival hyperplasia, hepatoxicity

9

Mycophenolate mofetil (MMF)

Aka Cellcept, used for maintenance or rejection. Works by inhibiting purine metabolism. Side effects: diarrhea, nausea.

10

Azathioprine

Inhibits DNA synthesis. Used for maintenance only. Side effects: leukopenia, hepatotoxicity (don't use in liver tx)

11

FK-506, aka tacrolimus

Used for maintenance, *preferred drug in liver transplant*. Calcineurin inhibitor, way more potent than cyclosporine. Side effects: nephrotoxicity, neurotoxicity, diabetogenic

12

Rapamycin

Calcineurin inhibitor. Side effects: hyperTG

13

Antibodies used in transplant management

Antithymocyte globulin (ATG), OKT3 (antibody to CD3). Usually used for rescue in steroid-resistant rejection but also can be used for induction and maintenance.

14

Post-transplant lymphoproliferative disorder

Caused by EBV -> monoclonal B-cell lymphoma. Tx: stop or lower immunosupression, and it can be reversible (not always)

15

Hyperacute rejection

Immediately following graft reperfusion. Caused by pre-existing host antibody binding to donor tissue, initiating complement mediated lysis -> thrombosis of graft. No treatment, graft will be lost. Prevent by ABO typing and negative crossmatch.

16

Delayed vascular rejection

A variant of hyperacute rejection in which the level of host antibodies is too low to be detected by usual assays. Rejection occurs around POD 3

17

Acute rejection

Occurs between POD 5 and 6 months, occurs to some degree in all transplants unless btw identical twins. Due to normal T cell activity. Dx: biopsy. Tx: steroids, immune globulins if refractory. Over 90% of transplants salvaged with treatment.

18

Chronic rejection

Occurs over months to years. Due to cumulative effect of recognition of donor MHC by recipient immune system, likely antibody AND cell mediated.

19

Histology of chronic rejection

Chronic rejection in heart grafts is felt to be manifest by accelerated graft atherosclerosis. Kidneys with chronic rejection have fibrosis (scarring) and damage to the microvasculature. Livers: decreased number of bile ducts on biopsy, "vanishing bile duct syndrome". Transplanted lungs: "bronchiolitis obilterans" a scarring problem in the substance of the lung.

20

Most common causes of ESRD, adults

1. DM
2. HTN
3. Glomerulonephritis

Peds: congenital uro/renal stuff

21

Complications specific to kidney transplant, early

Delayed graft function (must operate), graft thrombosis (must repair), urine leak (usu at VUJ, must repair), bleeding

22

Complications specific to kidney transplant, late

Lymphocele (perinephric fluid collection compressing iliac vein and ureter, may have to drain), ureteral stricture (rising creatinine, balloon dilate or surgery), renal artery stenosis (HTN, fluid retention, angioplasty or surgery)

23

Delayed graft function

Delayed graft function is a form of acute renal failure resulting in post-transplantation oliguria, increased allograft immunogenicity and risk of acute rejection episodes, and decreased long-term survival.

24

Indication for pancreatic transplant

Type I insulini dependent diabetes,

25

Two types of drainage for pancreatic transplant

Bladder (can measure urinary amylase, if decreased it is sign of rejection) or enteric (pro is no need for bicarb replacement). Equal efficacy, mortality, etc.

26

Preferred immunosuppresive drug in liver transplant

Tacrolimus (remember, nephrotoxic). Also, steroids, azathioprine, cyclosporine. May have steroid + 1-2 calcineurin inhibitor(s), or wean down to just 1 calcineuron inhibitor.

27

Small bowel transplant

This is a thing apparently

28

Most common cause of perioperative death in cardiac transplant?

Infection (PNA, mediastinitis, CLABSI, UTI)

29

Calcineurin inhibitors MOA

Ultimately inhibits release of IL-2, which is necessary for stimulating T cell expansion and differentiation

30

OKT3 side effects

Fevers and headaches from cytokine release. Noncardiogenic pulmonary edema, encephalitis, nephrotoxicity, aseptic meningitis