Transplant (renal replacement therapy 2) Flashcards by J Murray

where is the transplanted kidney placed

into the iliac fossa

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onto what is the transplanted kidney attached

anastomosed to the iliac vessels

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what happens to the native kidneys

usually stay in situ - however some situations call for a kidney to be removed

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what are indications for native nephrectomy

size - polycystic kidneys

infection - chronic pyelonephritis

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how can a donor kidney be preserved

cold storage solutions - minimise oedema - preserve integrity of tissues - buff free radicals

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what is cold ischaemia time

the time a donor kidney is without blood supply

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why is cold ischaemia time important

the longer the cold ischaemia time - the poorer the outcome of the transplant is going to be

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what are the three types of complications in transplantation

vascular
ureteric
infections

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what are vascular complications of transplantation

bleeding
arterial thrombosis
venous thrombosis
lymphocele

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what are the most common types of bleeding complications

usually anastomotic sites

2. perirenal haematoma - can be arterial or venous

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what is a ureteric complication of transplantation

urine leak - medical emergency - need to go back to surgery

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what is used to minimise risk of rejection

immunosuppressive agents

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what is the immunesuppression protocols

induction - basiliximab

maintenance - tacrolimus + mycophenolate + steroids*

**steroid free when possible - e.g. paediatric patients can often cope without

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what can be used instead if a patient is intolerant to tacrolimus

belatacept

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what are some of the side effects of corticosteroids

hypertension, hyperglycaemia, infections, bone loss, GI bleeding

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what are some of the side effects of tacrolimus

hyperglycaemia, AKI (acute kidney injury), tremor

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what are some of the side effects of mycophenolate

cytopenia, GI upset

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what are some of the side effects of belatacept

infections, malignancy

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what are 2 types of kidney donors

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deceased donors

living donors

what are the different types of deceased donors

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donation after brain death (DBD)

2. donation after cardiac death (DCD)

what are the different types of living donors

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living related

2. living unrelated - spousal, altruistic, paired/pooled

what are the two sets of criteria for deceased donors

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standard and extended

what is the different implications between standard and extended criteria transplants

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standard criteria donor transplants are more successful than organs from extended criteria donors

what is the standard brain death criteria

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coma, unresponsive to stimuli
apnoea off ventilator despite build up of CO2
absence of cephalic reflexes
body temp > 34C
absence of drug intoxication

what is the extended criteria for deceased donors

1. donor aged >60yrs | 2. donor aged 50-59yrs + history of HBP, death from cerebrovascular accident or terminal certain of >132 micro mol/L

are older patients more or less likely to get a transplant

less likely - as they are less likely to a) survive procedure b) accept kidney and c) more prone to complications

what does an ABO incompatible transplant mean

donor organ is from someone with a different blood type to recipient - can be done but recipient must be on immunosuppressants before and after treatment to minimise chance of rejection

what does a HLA incompatible transplant mean

recipient has antibodies that are incompatible with donor organ (HLA = human leukocyte antigens)

which type of incompatible transplant is more successful - ABO or HLA

ABO

what is a paired donation

If donor A cannot give to recipient A, they can instead give to recipient B while donor B gives to recipient A ``` e.g. mother (A) not a match for son (a) and husband (B) not a match for wife (b) BUT A is a match for b B is a match for a ``` so these sets of people can cross over donors

what is pooled donation

knock on domino effect of donations - can include multiple people e.g. starts with altruistic donor giving to A - A's brother gives to B - B's husband gives C etc etc

what are the risks of kidney donation

1. similar patient survival to general population 2. lower rate of ESRD compared to general population 3. compensatory increase in GFR of remaining kidney to 70% of premonition value

what are longer term complications of renal transplantation

1. rejection 2. infection 3. cardiovascular 4. malignancy 5. new onset diabetes mellitus

what are the different types of acute rejection

1. T cell mediated rejection 2. acute antibody mediated rejection (ABMR) **ABMR causes more damage and is more difficult to control than T cell mediated rejection

what occurs at the three levels of T cell mediated rejection

Banff 1 - tubulointerstitial Banff 2 - arteritis/endothelialitis Banff 3 - arterial fibrinoud necrosis

what occurs at the three levels of acute AMBR

Banff 1 - ATN-like Banff 2 - capillaries or glomerular inflammation Banff 3 - arterial inflammation

what are the most common infections straight after transplant

wound infection and UTI

what is the most common (and important) infection after 6 months and why

cytomegalovirus - patient put on prophylaxis therapy for CMV for first 6 months post transplant - after this at risk of CMV infection **high mortality and morbidity if untreated

what two common ways can a patient receive CMV

1. transmission from donor tissue | 2. reactivation of latent virus

what are the two types of CMV

1. viraemia | 2. tissue invasive - pneumonitis, hepatitis, retinitis, gastroenteritis, colitis, nephritis

what virus is common after transplant

BK virus (BKAN)

what are risk factors for BKAN

1. intensity of immunosuppression 2. patient determinants - older age, male, white, -ve BKV aerostats (paed patients) 3. organ determinants - graft injury, HLA mismatch, ureteral stents 4. viral determinants - changes in epitopes of viral capsid protein VP-1

what is the treatment for BKAN

1. reduce immunosuppression | 2. antiviral therapy - cidofovir +/- IVIG leflunomide

what is the outcome of BKAN infection on graft

allograft dysfunction and loss of graft in 45-80%

what are the relative risks of different malignancies after renal transplantation

colon, lung, breast - 2 testicular, bladder - 3 melanoma, leukaemia, cervical - 5 renal - 15 non-melanoma skin, kaposi sarcoma, non-hodgkin lymphoma - 20

what is the relationship between supply and demand of renal transplants

demand MUCH HIGHER than supply

Transplant (renal replacement therapy 2) Flashcards

(46 cards)