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ABSITE (EVAN) > Chapter 12: Transplantation > Flashcards

Chapter 12: Transplantation Flashcards

1
Q

Most important in recipient/donor matching

A

HLA-A, -B, and -DR

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2
Q

HLA: most important overall

A

HLA-DR

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3
Q

Generally required for all transplants (except liver)

A

ABO blood compatibility

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4
Q

Detects preformed recipient antibodies to the donor organ by mixing recipient serum with donor lymphocytes

A

Cross-match

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5
Q

What does a positive cross-match mean?

A

If antibodies are present, the cross-match is positive and a hyper acute rejection would likely occur with TXP.

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6
Q

Technique identical to cross-match; detects performed recipient antibodies use a panel of HLA typing cells

A

Panel reactive antibody (PRA)

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7
Q

Panel reactive antibody (PRA) which is a contraindication to transplant

A

> 50% (% of cell that the recipient serum reacts with) - > increased risk of hyper-acute rejection

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8
Q

What can increase the panel reactive antibody (PRA)?

A

Transfusion
Pregnancy
Previous transplant
Autoimmune diseases

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9
Q

Tx: mild rejection

A

Pulse steroids

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10
Q

Tx: severe rejection

A

Steroid and antibody therapy (ATG or daclizumab)

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11
Q

1 malignancy following any transplant

A

Skin cancer (squamous cell CA #1)

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12
Q

2 Next most common malignancy following transplant (Epstein-Barr virus related)

A

Post-transplant lympho-proliferative disorder (PTLD)

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13
Q

Tx: post-transplant lympho-proliferative disorder (PTLD)

A

Withdrawal of immunosuppression; may need chemotherapy and XRT for aggressive tumor

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14
Q
  • Inhibits de novo purine synthesis, which inhibits growth of T cells
  • Side effects: myelosuppression
  • Used as maintenance therapy to prevent rejection
A

Mycophenolate (MMF, CellCept)

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15
Q

WBC: Mycophenolate

A

Need to keep WBC > 3

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16
Q

Inhibit inflammatory cells (macrophages) and genes for cytokine synthesis (IL-1, IL-6); used of induction after TXP, maintenance, and acute rejection episodes

A

Steroids

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17
Q
  • Binds cyclophilin protein and inhibits genes for cytokine synthesis (IL-2, IL-4,etc); used for maintenance therapy
A

Cyclosporin (CSA)

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18
Q

Side effects: cyclosporin

A 
Nephrotoxicity
Hepatotoxicity
Tremors
Seizures
Hemolytic-uremic syndrome
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19
Q

Tough: cyclosporin (CSA)

A

Trough 200-300

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20
Q

Pharm: cyclosporin (CSA)

A

Undergoes hepatic metabolism and biliary excretion (reabsorbed in the gut, get enter-hepatic recirculation)

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21
Q
  • Binds FK-binding protein like FK-506 but inhibits mammalian target of rapamycin (mTOR); result is that it inhibits T and B cell response to IL-2
  • Used as maintenance therapy
A

Sirolimus (Rapamycin)

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22
Q
  • Equine (ATGAM) or rabbit (Thymoglobulin) polyclonal antibodies against T cell antigens (CD2, CD3, CD4)
  • Used for induction and acute rejection episodes
  • Is cytolytic (complement dependent)
A

Anti-thymocyte globulin (ATG)

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23
Q

Side effects: Anti-thymocyte globulin (ATG)

A

Cytokine release syndrome (Fevers, chills, pulmonary edema, shock)

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24
Q

What can prevent cytokine release syndrome from anti-thymocyte globulin (ATG)?

A

Steroids and benadryl

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25
Q

WBCs: anti-thymocyte globulin

A

Need to keep WBCs > 3

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26
Q

Human monoclonal antibody against IL-2 receptors

  • Used for induction and acute rejection episodes
  • Is not cytolytic
A

Zenapax (daclizumab)

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27
Q
  • Occurs within minutes to hours
  • Caused by preformed antibodies that should have been picked up by the cross-match
  • Activates the complement cascade and thrombosis of vessels occurs
A

Hyperacute rejection

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28
Q

Tx: hyperacute rejection

A

Emergent re-transplant (or just removal of organ if kidney)

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29
Q
  • Occurs
A

Accelerated rejection

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30
Q

Tx: accelerated rejection

A

Increase immunosuppression, pulse steroids, and possible antibody treatment

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31
Q
  • Occurs 1 week to 1 month

- Caused by T cells (cytotoxic and helper T cells

A

Acute rejection

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32
Q

Tx: acute rejection

A

Increased immunosuppression, pulse steroids, and possibly antibody treatment

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33
Q
  • Months to years
  • Partially and type 4 hypersensitivity rejection (sensitized T cells)
  • Antibody formation also plays a role
  • Leads to graft fibrosis
A

Chronic rejection

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34
Q

Tx: chronic rejection

A

Increase immunosuppression - no really effective treatment

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35
Q

How long can a kidney be stored?

A

48 hours

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36
Q

Can you still use a kidney with a UTI?

A

Yes

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37
Q

Can you use a kidney with an acute increase in creatinine (1.0-3.0)?

A

Yes

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38
Q

Kidney transplant: what is mortality most likely from?

A

Stroke and MI

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39
Q

What do you attach the kidney to?

A

Attach to iliac vessels

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40
Q

Complications kidney transplant

A

Urine leaks, renal artery stenosis, lymphocele, postop oliguria, postop diuresis, new proteinuria, postop diabetes, viral infection, acute / chronic rejection

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41
Q

1 cause complication with kidney transplant

A

Urine leaks

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42
Q

Tx: urine leaks s/p kidney transplant

A

Drainage and stenting

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43
Q

Dx / Tx: renal artery stenosis s/p kidney transplant

A

Dx: US
Tx: PTA with stent

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44
Q

MCC external ureter compression s/p kidney transplant

A

Lymphocele

45
Q

Tx: lymphocele s/p kidney transplant

A

1st try percutaneous drainage; if that fails, then need peritoneal window (make hole in peritoneum, lymphatic fluid drains into peritoneum and is reabsorbed - 95% successful)

46
Q

Usually due to ATN (pathology shows hydrophobic changes) s/p kidney transplant

A

Postop oliguria

47
Q

Usually due to urea and glucose s/p kidney transplant

A

Postop diuresis

48
Q

Suggestive of renal vein thrombosis s/p kidney transplant

A

New proteinuria

49
Q

Side effect of CSA, FK, steroids s/p kidney transplant

A

Postop diabetes

50
Q

Viral infections s/p kidney transplant

A

CMV - Tx: ganciclovir

HSV - Tx: acyclovir

51
Q

Time / path: acute rejection s/p kidney transplant

A
  • Time: usually occurs in first 6 months

- Path: tubulitis (vasculitis with more severe form)

52
Q

Kidney rejection workup (usually for increase in creatinine or poor urine output)

A
  • US with duplex (r/o vascular problem and ureteral obstruction) and biopsy
  • Empiric decrease in CSA or FK (can be nephrotoxic)
  • Empiric pulse steroids
53
Q

When do you see chronic rejection s/p kidney transplant?

A

Usually do not see until after 1 year; no good treatment

54
Q

5-year graft survival overall: kidney transplant

A

70% (cadaveric 65%, living donors 75%)

55
Q

Living kidney donors: MC complication

A

Wound infection (1%)

56
Q

Living kidney donors: MCC death

A

fatal PE

57
Q

Living kidney donors: outcome remaining kidney

A

Hypertrophy

58
Q

How long can a liver be stored?

A

24 hours

59
Q

Contraindications for liver transplant

A

Current EtOH abuse, acute ulcerative colitis

60
Q

MC reason for liver transplant in adults

A

Chronic hepatitis C

61
Q

Uses creatinine, INR, and bilirubin to predict if patients with cirrhosis will benefit more from liver transplant than from medical therapy

A

MELD score

62
Q

MELD score: benefits from liver transplant

A

MELD score > 15

63
Q

Criteria for urgent liver transplant

A

Fulminant hepatic failure (encephalopathy - stupor coma)

64
Q

Tx: patients with hepatitis B antigenemia after liver transplant to help prevent reinfection

A

HBIG (hepatitis B immunoglobulin) and lamivudine (protease inhibitor)

65
Q

Reinfection rate is reduced to 20% with use of HBIG and lamivudine s/p liver transplant

A

Hepatitis B

66
Q

Disease most likely to recur in the new liver allograft; reinfects essentially all grafts s/p liver transplant

A

Hepatitis C

67
Q

Liver TXP: if no vascular invasion or metastases can still consider transplant

A

Hepatocellular CA

68
Q

Not a contraindication to liver transplant

A

Portal vein thrombosis

69
Q

Definition: recidivism

A

20% will start drinking again s/p liver transplant

70
Q

Extracellular fat globules in the liver allograft

A

Macrosteatosis

71
Q

Macrosteatosis: risk-factor for primary non-function

A

If 50% of cross-section is macrosteatatic in potential donor liver, there is a 50% chance of primary non-function.

72
Q

Surgery: liver transplant

A

Duct to duct anastomosis is performed. Hepaticojejunostomy in kids. Right sub hepatic, right, and left sub diaphragmatic drains are placed.

73
Q

Liver transplant: depends on hepatic artery blood supply

A

Biliary system (ducts, etc)

74
Q

Liver transplant: MC arterial anomaly

A

Right hepatic coming off SMA

75
Q

Complications liver transplant

A

Bile leak, Primary nonfunction, early / late hepatic artery thrombosis, abscesses, IVC stenosis/thrombosis, portal vein thrombosis, cholangitis, acute rejection

76
Q

1 complication liver transplant

A

Bile leak

- Tx: place drain, then ERCP with stent across leak

77
Q

DX: s/p Liver transplant:

- 1st 24 hours: total bili > 10, bile output

A

DX: Primary non-function

78
Q

Tx: primary non-function s/p liver transplant

A

Re-transplantation

79
Q

MC early vascular complication s/p liver transplant

A

Early hepatic artery thrombosis

80
Q

Dx: s/p liver transplant:

- Increased LFTs, decreased bile output, fulminant hepatic failure

A

Dx: early hepatic artery thrombosis

81
Q

Tx: early hepatic artery thrombosis

A

MC will need emergent re-transplantation for ensuing fulminant hepatic failure (can try to stent or revise anastomosis)

82
Q

Complication s/p liver TXP: results in biliary strictures and abscesses (not fulminant hepatic failure)

A

late hepatic artery thrombosis

83
Q

MC’y from late (chronic) hepatic artery thrombosis s/p liver transplant

A

Abscesses

84
Q

Dx: s/p liver transplant

  • (rare) edema, ascites, renal insufficiency
  • Tx: thrombolytics, IVC stent
A

IVC stenosis / thrombosis

85
Q

Dx: s/p liver transplant

  • (rare) Early - abdominal pain. Late - UGIB, ascites, may be asymptomatic
  • Tx: if early, re-op thrombectomy and revise anastomosis
A

Portal vein thrombosis (rare)

86
Q

Dx: s/p liver transplant - get PMNs around portal triad (not mixed infiltrate)

A

Cholangitis

87
Q

Dx: s/p liver transplant - T cell mediated against blood vessels.

  • Clinical: fever, jaundice, decreased bile output
  • Labs: leukocytosis, eosinophilia, increased LFTs, increased total bilirubin, and increasedPT
  • usually occurs in 1st 2 months.
A

Acute rejection s/p liver transplant

88
Q

Pathology: acute rejection liver transplants

A

Shows portal triad lymphocytosis, endotheliitis (mixed infiltrate) and bile duct injury

89
Q

Unusual after liver transplant; get disappearing bile ducts (antibody and cellular attack on bile ducts); gradually get bile duct obstruction with increase in alkaline phosphatase, portal fibrosis

A

Chronic rejection

90
Q

Liver TXP: Retransplantation rate

A

20%

91
Q

Liver TXP: 5-year survival rate

A

70%

92
Q

Pancreas TXP: donor arterial supply

A

Need both donor celiac artery and SMA for arterial supply

93
Q

Pancreas TXP: donor venous drainage

A

Need donor portal vein for venous drainage

94
Q

Where do you attach pancreas TXP?

A

Attach to iliac vessels

95
Q

How do you drain pancreatic duct s/p pancreas TXP?

A

Most use enteric drainage for pancreatic duct. Take 2nd portion of duodenum from donor along with ampulla of Vater and pancreas, then perform anastomosis of donor duodenum to recipient bowel.

96
Q

Successful pancreas/kidney TXP results in..

A

Stabilization of retinopathy, decreased neuropathy, increased nerve conduction velocity, decreased autonomic dysfunction (gastroparesis), decreased orthostatic hypotension. No reversal of vascular disease.

97
Q

Complications: pancreas TXP

A
  • Venous thrombosis (#1) - hard to treat
  • Rejection - hard to diagnosis if pt does not also have a kidney transplant. (Can see increased glucose or amylase; fever, leukocytosis)
98
Q

How long can a heart store for TXP?

A

Can store for 6 hours

99
Q

s/p heart transplant

  • Associated with early mortality after heart TXP
  • Tx: inhaled nitric oxide, ECMO if severe
A

Persistent pulmonary hypertension after heart transplantation

100
Q

s/p heart transplant

- Shows perivascular lymphocytic infiltrate with varying grades of myocyte inflammation and necrosis

A

Acute rejection

101
Q

s/p heart TXP

- MCC of late death and death overall following heart TXP

A

Chronic allograft vasculopathy (progressive diffuse coronary atherosclerosis)

102
Q

How long can you store a lung?

A

Can store for 6 hours

103
Q

Lung TXP:

- #1 cause of early mortality

A

Reperfusion injury (Tx: similar to ARDS)

104
Q

Indication for double-lung TXP

A

Cystic fibrosis

105
Q

Lung TXP: exclusion criteria for using lungs

A

Aspiration, moderate to large contusion, infiltrate, purulent sputum, PO2

106
Q

Lung transplant: perivascular lymphocytosis

A

Acute rejection

107
Q

Lung TXP: bronchiolitis obliterans. MCC of late death and death overall following lung TXP

A

Chronic rejection

108
Q

Opportunistic infections:

  • Viral?
  • Protozoan?
  • Fungal?
A
  • Viral: CMV, HSV, VZV
  • Protozoan: Pneumocystis jiroveci pneumonia (reason for Bactrim prophylaxis)
  • Fungal: Aspergillus, Candida, Cryptococcus
109
Q

Hierarchy for Permission for Organ Donation from Next of Kin

A

1) Spouse
2) Adult son or daughter
3) Either parent
4) Adult brother or sister
5) Guardian
6) Any other person authorized to dispose of the body

ABSITE (EVAN) (35 decks)

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