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25 Cards in this Set
- Front
- Back
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renal transplantation successes
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-excellent short-term graft survival: >90% at 1 yr
-low acute rejection rates |
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types of renal transplants
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1. Deceased donor: heart beating, non-heart beating
2. living donor: living related, living non-related -historically, deceased donors commonest sources -With long waiting lists and more people requiring transplants, living related and non-related kidney transplants surpass deceased donor transplantation -ABO incompatible transplants are even being performed |
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pretransplant eval of the recipient
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1. full H&P
2. eval of past history particularly cancer 3. careful cardiac eval 4. hepatitis status 5. exposure to viral illnesses particularly: CMV, EBV, HSV |
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PRETRANSPLANT EVALUATION OF THE RECIPIENT
IMMUNOLOGIC CRITERIA |
1. ABO blood group
2. HLA compatibility 3. PRA (panel reactive ABs)- the closer to 0% the better outcome |
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transplant procedure
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-if the donor is living the admission is elective
-With a deceased donor transplant one needs to admit the recipient as soon as possible since the shorter the time from harvest to engraftment, the better the outcome. Beyond 50 hours the outcome is suboptimal -kidney is placed in the R or LLQ -the donor A and V is connected to the hypogastric vessels -the ureter is implanted into the bladder -a ureteral stent is placed -the native kidneys not usually removed |
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immediate post-surgical period
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-the transplanted kidney starts making urine on the operating table
-the engraftement process takes ~3-4 hrs -immunosuppresison is started during surgery -if the transplant is successfull and uneventful, the recipient is discharged by day 4-5 -if the donor is done laparscopically the go home on day 2-3 -F/u recipient 3x/wk for wk 1-2, 2x/wk for wks 3-4, weekly till 6 wks |
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recovery room assessment
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-hemodynamic eval
1. monitor BP -low BP increases risk of post-op ATN or irreversible vascular thrombosis -high BP inc the risk of anastomotic leak -IVF -urine output -early post op bleeding |
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immunological factors contributing to chronic failure of renal allografts
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1. acute rejection
2. inadequate immunosuppression 3. HLA match 4. late rejection |
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nonimmunological factors contributing to chronic failure of renal allografts
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1. delayed graft function
2. donor source 3. donor age 4. gender 5. race 6. HTN 7. hyperlipidemia |
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impact of acute rejection on long-term graft survival
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-occurance of acute rejection sig reduces long-term graft survival
-sig inc risk of biopsy-proven chronic rejeciton -vascular rejeciton within 3mo after transplant was the most impt predicting variable of early and late graft loss |
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immunosuppressive therapies
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1. steroids
2. calcineurin inhibitors: cyclosporine, tacrolimus 3. TOR inhibitors: sirolimus, RAD 4. inhibitors of cel division: azathioprine, mycofenelate 5. Abs against immune proteins |
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common therapeutic regimens
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-multi-drug approach is used in order to interrupt the inflamm response at several sites while min SE
Prednisone/Cyclosporine/Cellcept (or Immuran) Prednisone/Prograf/Cellcept (or Immuran) Prednisone/Prograf/Rapamycin |
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SE of corticosteroids
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1. cushingoid features
2. DM 3. HTN 4. osteoporosis 5. cataracts 6. avascular necrosis of femoral heads 7. skin thinning |
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SE of calcineurin inhibitors
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1. nephrotoxicity
2. DM 3. HTN 4. hyperlipidemia 5. Gum hyperplasia 6. neurotox 7. hyperkalemia 8. hyperuricemia 9. hypomagnesemia 10. hirsuitism/alopecia |
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monitoring drug levels
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-impt!
-Subtherapeutic levels lead to increased chance of rejection -Toxic levels lead to increased chance of nephrotoxicity |
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cyclosporin goal
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Transplanted < 1 year – 150-200
Transplanted > 1 year – 75-125 |
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tacrolimus goal
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Transplanted < 1 year – 9-12
Transplanted > 1 year – 5-10 |
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SE of TOR inhibitors
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1. hyperlipidemia
2. mouth ulceration 3. delayed wound healing 4. anemia 5. granulocytopenia 6. thrombocytopenia |
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SE of cell division inhibitors
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1. diarrhea
2. dyspepsia 3. abdominal bloating 4. anemia 5. granulocytopenia 6. thrombocytopenia |
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complication of renal transplantation
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1. acute and chronic rejection
2. infx 3. HTN 4. DM 5. osteoporosis 6. malignancies |
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slie 25
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slide 25
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mgmt of acute humoral (AB) rejection
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1. plasmapherisis
2. IVIG or CMV hyperimmune globulin 3. Rituximab (anti CD-20) |
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mgmt of acute cellular rejection
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1. high dose steroids- 1st line
2. methylprednisone 1g IV push for 3-5 days 3. murine monoclonal AB, OKT3- 2nd line; 5mg/day for 14 days |
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OKT3
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-has severe SE especially on days 1-3 then tapers off
-thought ot be due to release of cytokines from lymphocytes termed "cytokine release syndrome" 1. pul edema 2. severe diarrhea 3. fever |
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prophylactic treatments
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1. CMV prophylaxis: valgancylovir
2. PCP prophylaxis: TMP-SMZ 3. oral candida prophylaxis: clotrimazole or nystatin - Caution: wean slowly as anti-fungals can affect drug levels of anti-rejection medicines |
