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67 Cards in this Set

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IgG
2nd in immune response
Most common
crosses placenta
IgA
Lines mucous membranes and protects body surfaces
IgM
First in immune response
Forms antibodies to ABO blood antigens
IgD
Present in lymphocyte surface
Assists in differentiation of B lymphocytes
IgE
Causes symptoms of allergic reactions
Fixes to mast cells and basophils
Assists in defense against parasitic infections
Type I reaction
- IgE mediated reaction
- Anaphylactic reactions
- immediate, humoral

First exposure: IgE--> attaches to masts cells and basophils

2nd exposure: allergen --> links to IgE bound to mast cells --> release of chemical mediators/degranulation (histamine, serotonin, leukotrienes, eosinophil chemotactic factor of anaphylaxis, kinins, bradykinins)--> target tissues/organs--> allergy symptoms-->manifestation depend on if remains local or systemic --> smooth muscle contraction, increased vascular permeability, vasodilation, hypotension, increased mucus, and itching--> mediators are short acting and are reversible
Histamine
- within mast cells and basophils
- increases vascular permeability
- constricts smooth muscle
- stimulates irritant receptors

-->
- airway and larynx edema
- bronchial constriction
- urticaria
- angioedema
- pruritis
- N/V
- diarrhea
- shock
Leukotrienes
- constrict bronchial smooth muscles
- increase vascular permeability

-->
- bronchial constriction
- enhanced effect of histamine on smooth muscles
Prostaglandins
- vasodilation
- constrict smooth muscle

-->
- wheal and flare reaction on skin
- hypotension
- bronchospasm
Platelet-activating factor
- in mast cells
- aggregates platelets
- stimulates vasodilation

-->
- increased pulmonary artery pressure
- hypotension
Kinins
- stimulate slow, sustained smooth muscle contraction
- increased vascular permeability
- stimulate mucus secretion
- stimulate pain receptors

-->
- angioedema with painful swelling
- bronchial constriction
Serotonin
- from platelets
- increases vascular permeability
- stimulates smooth muscle contraction

-->
- mucosal edema
- bronchial constriction
Anaphylatoxins
- from compliment activation
- stimulate histamine release

-->
- same as histamine
Type I Reaction examples
Anaphylaxis
Atopic reactions (rhinitis, asthma, atopic dermatitis, angioedema)
IgE
Type II Reaction
IgG and IgM

antibodies--> antigen--> comeplemtn system --> cytolysis or enhanced phagocytosis of cells (rapid tissue damage)

common target cells include erythrocytes, platelets, and leukocytes
Type II Reaction examples
hemolytic transfusion reactions (AVO, Rh, autoimmune and drug hemolytic anemias)
Good pasture syndrome
Type III Reaction
secondary to antibody/antigen complex

Complex formed IgG or IgM --> deposit in tissue or small blood vessel --> fixation of complement and release of chemotactic factors--> inflammation and tissue destruction of area
Type III Examples
- kidneys, skin, joints, blood vessels, lungs
- SLE, RA, some acute golmerulonephritis
Type IV Reactions
no immunoglobulins
- T lymphocytes --> attack antigens and release cytokines--> some attract macrophages --> enzymes release--> tissue destruction

Also called a mediated immune response

* delayed reactions, takes 24-28h
Type IV Reaction examples
- Contact dermatitis
- hypersens to bacterial, fungal, viral infections (antigentic material released from TB--> reaction with T lymphocytes --> causing lung necrosis)
- transplant rejections
- some drug reactions
Cellular immunodeficiency =
less than 1200 /ug or 1.2 x10^9 /L
Good test for determining various allergic reactions to foods and anaphylaxis
RAST (radioallergosorbent) test
Skin tests can not be performed on who?
Pts that can't be removed from meds that suppress immune response

Otherwise they are good to determine specific allergies that are causing symptoms
Positive skin test response
wheal and flare
- size of reaction does not correlate with severity of allergy symptoms

*this test has increased chance of anaphylactic reaction
**Observe for itching and edema!!
*Should not be left alone!
Cardinal principles for anaphylaxis treatment
Speed in:
1. recognition of S/S
2. maintenance of patent airway
3. prevention of spread of allergen by using a tourniquet
4. Admin of drugs
5. treatment for shock
Tx for mild anaphylaxis symptoms
- 0.2-0.5 mL of epinephrine q 10-15 min
- IV infusion 0.5mL/kg IV every 2-5 min (for hypotension)
- Diphenhydramine (benadryl) for urticaria/angioedema- can also be given preventatively
Tx for severe symptoms of anaphylaxis
- IV epi, followed by adminstration of high-flow oxygen 100% via non-rebreather
- volume expanders, inotropes (Dopamine)- to maintain BP
Latex-food syndrome
- banana
- avocado
- chestnut
- kiwi
- tomato
- water chestnuts
- guava
- hazelnuts
- potatoes
- peaches
- grapes
- apricots
High risk for latex allergy
- long term exposure (healthcare workes, multiple surgeries, rubber manufaturers)
- asthma, hay fever, allergies
- latex-food syndrome
Atopic reactions
Type 1- sensitivity to environmental allergens
- allergic rhinitis
- asthma
-Atopic dermatitis (eczema)
- urticaria (hives)
- Angioedema
Allergic rhinitis
- year round or seasonal
- airbornse substances (pollens, dust, molds)
- target areas are conjuntivae, mucosa of upper respiratory tract

S/S- nasal discharge, sneezing, lacrimation, mucosal swelling of the airway, obstruction, pruritis around eyes, nose, throat, mouth
Asthma
Manifested with dyspnea, wheezing, coughing, chest tightness, thick sputum
Atopic dermatitis
Chronic inherited skin disorder
- caused by several environmental allergens
- skin lesions are generalized and involve vasodilation of blood vessels resulting in interstitital edema with vesicle formation
Urticaria
- characterized by transient wheals
- develops rapidly after exposure to allergen and may take minutes or hours
- Histamine--> vasodilation (erythema)--> transudation of fluid (wheal) and flaring
- Histamine is responsible for itching
Angioedema
- Localized cutaneous lesion involving deeper layers of skin and submucosa
- eyelids, lips, tongue, larynx, hands, feet, GI tract, genitalia
- swelling usually begins in the face then progresses to airways
- dilation and engorgement of capillaries secondary to release of histamine--> diffuse swelling
- lesions may burn, sting, itch, abdominal pain if in GI tract
CBC with differential and allergies
lymphocyte count < 1200 uL = cellular immunodeficiency

Eosinophils are increased with type 1 hypersens with IgE immunoglobulins
RAST test
Radioallergosorbent test

- invitro diagnostic test for IgE antibodies to specific allergens
- good for pts with history of severe anaphylactic reactions
- sputum, nasal, and bronchial secretions tested for eosinophils
Skin tests
- used to confirm specific pt with atropic disease after hx is suggestive of allergy
**CANNOT be performed on pts who cannot be removed from medications that suppress the histamine response or pts with food allergies

-cutaneous scratch or prick
- intracutaneous injection
- wheal and flare would be a positive
- a negative doesn't always mean negative

- increased risk of developing anaphylactic reaction--> observe site for itching and edema
**should not be left alone
Plasmapheresis
removal of plasma containing components causing or though to be causing disease

- used to treat SLE, CBS, myasthenia gravis, good pasture syndrome, RA, glomerulonephritis, and thrombocytopenic purpura

- plasma is removed and replaced by substitute fluids (salin, frash frozen plasma, albumin)
- removed immunomediators (such as IgG and can also remove inflammatory mediators)
Human Leukocyte Antigen
HLA
- major histocompatibility antigens
- primarily used in matching organs and tissues for transplants
- highly variable, different alleles, with many combinations
Organs that can be transplanted together
kidney and pancreas
kidney and liver
kidney and heart
Cadaver transplant
the longer it is cold the harder it is to get it to work
Living transplant
better cause it still has blood going through it
- want to maintain good perfusion
- live donors must meet certain criteria also
how matching is one
ABO and HLA, medical urgency, time on waiting list, geography

higher on list if under 19
Crossmatch
A positive crossmatch is an absolute contraindication to transplant!

- a positive match means that the recipient has cytotoxic antibodies to to the donor!

- you WANT A NEG!
Hyperacute transplant rejection
- antibody mediated humoral
- minutes to hours after transplant due to blood vessel destruction
- person had preexisting antibodies against transplanted tissue or organ
- remove organ ASAP
- kidney is most susceptible
Acute transplant rejection
- days to months after transplant, within the first 6 months
- mediated by recipients lymphocytes which have been activated against the donor tissue or organ
- another type occurs when anti0donor antibodies develop after transplantation
- requires long term use of immunosuppressants (higher doses at first which increases infection risk!)
Chronic transplant rejection
- occurs over months or to yers and is IRreversible
- unknow reasons or from repeated episodes of acute rejection
- transplanted organ is infiltrated with large numbers of T and B cells characteristic of an on-going, low-grade immune-mediated injury

--> results in fibrosis and scarring
Transplant rejection manifestation in liover
- loss of bile ducts
Rejection manifestations in kidney
fibrosis and glomerulopathy
rejection manifestation in heart
accelerated CAD
rejection manifestations in lung
bronchiolitis
- supportive therapy, retransplanted
Immunosuppressive therapy concerns
- Increased risk of infection
- Increased risk of malignancies
- Increased risk of toxicity
- side effects
- need suppression to prevent rejection but need immune response to prevent massive infection and malignancies
Cyclosporine, tacrolimus
- most effective immunosupressant
- need for life!
- do not cause bone marrow suppression or alterations in inflammatory response
- potentially nephrotoxic and don't mix with grapefruit juice
Initial immunosupression
triple therapy, one being a steroid so want to wean them off steroid as as soon as possible
Monoclonal antobidies
---mab

a flu-like syndrome may develop during the first few days of tx from cytokine release (fever, rigors, HA, myalgias, various GI disturbances)
Graft versus Host disease (GVHD)
- when immunocompentent pt is trasfused or transplanted with immuno-competent cells
- blood prducts from fetal thymust or fetal liver or bone
- graft rejects recipient
- 7-30 days onset
- little can be done to modify
- skin, GI liver ar target organs
- donor T cells attacking host cells
- palms of hands and soles of feet--> generalized erythema, pruritus, rash, desquamation
- liver-->jaundice to hepatic coma
S/S of GVHD
- rash
- jaundice
- hepatic coma
- watery diarrhea
- mild pruritus
- pain on pressure
- palms/soles
- N/V
- abdominal pain
- dark yellow urine

* be cautious if a pt receiving bone marrow transplant is experiencing a rash--> could be this!

tx is steroids and immunosuppressive agents (most effective in prevention!)
- radiate blood products before adminsitration
Advantages of a live donor
- better pt and graft survival rate regardles of HLA match
- immediate organ availaility
- immediate function (minimal cold time)
- opportunity to have recipient in best condition (elective surgery)
Deceased donors
- donors must be regularly healthy and declared brain dead
- brain dead donor must have effective cardiovascular function to preserve organs (dopamine to keep BP up, mech vet, etc.)
- age most suitable is 2-70
Preop nursing teaching
- educate on procedure and expected outcome
- including dialysis may be needed immediately after (kidney transplant)
- need for immunosuppressant drugs and infection prevention
Postop nursing management of live donor
Live Donor
- similar to post op laproscopic procedures
- monitor for renal function
- acknowledge "gift"
Postop nursing management of kidney recipient
- maintenance of fluid and electrolyte balance
- in ICU for 12-24 hours post transplant
- large volumes of urine may be produced soon after blood supply established (due to new kidney ability to filter BUN, surgical fluids, inhibition of concentration)
- watch venous pressure--> don't want a lot of BP fluctuation
- may have trouble concentrating urine
- avoid dehydration
* a sudden decrease in urine output is a cause for concern (could be dehydration, rejection, urine leack, obstruction)
- common obstruction is blood clot in catheter
- patency must be maintained (remains in bladder for 3-5 days to allow for anastomosis healing)
Post operative teaching of kidney recipient
- prevention and treatment of rejection, infection, complications of surgery, purpose and side effects of immunosuppression
- frequent blood tests and clinic visits to detect early rejection signs
- immunosuppressive therapy
Chronic rejection...
should be put back on transplant list
Immunosuppressants and cardiovascular disease
- increased incidence of atherosclerotic vascular disease
- immunosuppressants can worsen HTN and dyslipidemia
most common secondary malignancies
basal cell carcinoma of skin and lymphoma (nutrition, antioxidants)