Renal Transplantation

Front 1

1-year patient and renal graft survival rates

Back 1

1-year patient and graft survival rates exceed 90% in most transplant centers.

Front 2

indications for renal trans

Back 2

1-ESRD

2-kidney tumors

Front 3

the most common cause of chronic renal failure ??

Back 3

1-Diabetes

Front 4

the 2nd most common cause of chronic renal failure ??

Back 4

HTN

Front 5

the 3rd most common cause of chronic renal failure ??

Back 5

Glomerular nephritis

Front 6

the 4th most common cause of chronic renal failure ??

Back 6

cystic kidney

Front 7

conditions may recur in the transplanted kidney,

Back 7

1- (IgA) nephropathy

2-certain glomerulonephritides

3-oxalosis

4-diabetes

Front 8

can you do transplant for pts with conditions may recur in the transplanted kidney,

Back 8

yes !

still risk is low that justify transplantation

Front 9

combined transplantation

Back 9

kidney-pancrease combined transplant

(( the treatment of choice for patients who havetype 1 diabetes and ESRD))

ombined liver-kidney transplantation

((in oxalosis))

Front 10

kidney-pancrease combined transplant

indications /

Back 10

DM 1 + ESRD , who are :

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1-younger than 50 years

2-do not have significant coronary artery disease (CAD).

Front 11

which is better simultaneous kidney-pancreas transplants or pancrease after kidney

Back 11

simultaneous kidney-pancreas transplants

Front 12

options to treat oxalosis with ESRD

Back 12

1-combined liver-kidney transplantation

2-renal transplantation in conjunction with pyridoxine

Front 13

how to manage pt with H.oxalosis before transplantation

Back 13

intensive preoperative dialysis to reduce the oxalate burden

Front 14

contraindications for transplantation

Back 14

*
*
* cured cancers بعد فترة زمنيه لكل واحد

Poor social support

substance abuse,

intractable financial problems .

Front 15

when HIV pt can have renal transplant

Back 15

1- CD4 count > 200/µL for at least 6 months

2-HIV-I RNA is undetectable,

3- stable on antiretroviral therapy for at least 3 months, and there are no major infectious or neoplastic complications

Front 16

the most common cause of death in renal-transplant

Back 16

death from cardiac causes due to accelerated disease due to immunosup. effect on lipid / coronaries / B.sugar

Front 17

waiting time for transplantation in diff. cancers

Back 17

most : 5 years

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breast

prostate

colorectal

melanoma

diffuse bladder

ovarian cancer

Front 18

shorter waiting periods in some tumors

Back 18

2 years : skin cancer , wilms tumor

1 yr : isolated prostate nodule / bladder focal

Front 19

most likely diseases to recure after renal transplantation

Back 19

1- mesangiocapillary glomerulonephritis type 1

2-IgA nephropathy

3-Hereditary oxalosis

Front 20

diabetic nephropathy recurrence after transplantation

Back 20

nearly all demonestrat histo evidence of diabetic nephro within 4 yrs

Front 21

factors affecting outcom

Back 21

-type of donor = live related = best

-kidney preservation time

-donor age

-delayed graft function after transplantation

-early rejection episodes

-comorbid. pt

Front 22

which type of donation is the best

Back 22

living related donors

Complete-mismatch living-donor transplants = zero-mismatch deceased-donor transplants.

Front 23

kidney preservation time

Back 23

Prolonged cold ischemia can result in delayed graft function immediately after transplantation and may result in a somewhat shorter lifespan for the transplant

Front 24

pre-operative evaluation

goals

Back 24

1-potential contraindications

2-baseline immunologic studies

3-likelihood of success with transplantation.

Front 25

Basic pretransplant studies

Back 25

1-Cr clearance < 20 ml/min or need for dialysis

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Echo + stress study

CXR

basic cancer screen : Colonoscopy , PAP smear , Mammography, (PSA) test, (depending on patient age)

Noninvasive vascular studies

Abdominal and renal ultrasonography

Serologic tests infections

Studies of bladder capacity and function (potentially indicated)

Front 26

Serologic tests mustbe done for pts befor trans

Back 26

HIV infection

hepatitis B

hepatitis C

(CMV)

Front 27

Immunologic studies

Back 27

1- (HLA) typing

2- the panel-reactive antibody (PRA) titer.

Front 28

2- the panel-reactive antibody (PRA) titer.

Back 28

The panel-reactive antibody titer approximates the likelihood that a randomly chosen kidney donor has a positive cytotoxic lymphocyte crossmatch with the potential recipient, thereby ruling out that particular donor-recipient combination.

Screening for donor-specific antibodies in the potential recipient by using HLA-coated beads is currently becoming routine at many transplant centers.

Front 29

Evaluation of potential living donors

Back 29

1-assessment of renal function

2-evaluation of general health

3-imaging of the renal vasculatur / spiral computed tomography (CT)

4-HLA typing,

5-crossmatching

6-(GFR) of at least 80 mL/min.

7 no DM or HTN

Front 30

Postoperative management

goals

Back 30

1-manage the dynamic fluid balance

2-administration of immunosuppression.

Front 31

dynamic fluid balance

Back 31

the new kidney is capable of responding to the high urea nitrogen load with an osmotic diuresis

but is less capable of concentrating urine or reabsorbing sodium.

HTN/Electrolytes Rx

Front 32

immunosuppressive therapy

types

Back 32

1-induction

2-maintinance

Front 33

induction regimens

Back 33

1-Ab's based

2-non-Ab's based

Front 34

antibody-based induction immunosuppression

Back 34

1-monoclonal Abs

2-polyclonal Abs

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directed toward T-cells

Front 35

maintinance / medication categories

Back 35

1-calcineurin inhibitor

2-antiproliferative agent

3-prednisone.

Front 36

when Ab's based induction is seems to be better

Back 36

*

Front 37

the mainstay of clinical immunosuppression

Back 37

Calcineurin inhibitors

Front 38

Calcineurin inhibitors target ?

Back 38

target proliferating T cells by blocking the elaboration of cytokines (eg, interleukin [IL]–2) essential for proliferation

Front 39

Calcineurin inhibitors

examples

Back 39

cyclosporine = neural

tacrolimus = prograf

Front 40

Calcineurin inhibitors

specific toxicity important for renal trans

Back 40

nephrotoxicity

Front 41

Calcineurin inhibitors

what type of nephrotoxicity

Back 41

dose-related nephrotoxicity

Front 42

drug level monitoring

Back 42

follow drug trough levels

Front 43

cyclosporine and tacrolimus metabolism

Back 43

in the liver by the cytochrome P-450 (CYP-450)

Front 44

drugs that can cause tacrolimus=prograf or cyclo=neural toxicity

Back 44

fluconazole or verapamil

Front 45

drugs that can cause tacrolimus=prograf or cyclo=neural subtherauetic levels

Back 45

rifampin or phenytoin)

Front 46

Mycophenolate mechanism of action

Back 46

reversibly inhibits de novo synthesis of purines during the S phase.

Front 47

what is the main difference betw azathioprin and mycophenolate

Back 47

mycophenolate inhibits the de novo synthesis pathway of purines , where is lymphocytes are more dependent on this pathway than other body cells so it's more affected than other cells

so mycophenolate is more selective than azathioprin

Front 48

mycophenolate main side effect

Back 48

Gi side effect

nausea

diarrhea

Front 49

what are the transplant complications

Back 49

1-complication of surgery

2-complications of organ transplant/medical

3-complications of medicationssu

Front 50

surgical complications

Back 50

Delayed graft function

Vascular thrombosis and stenosis

Ureteral obstruction

Urinary leakage

Front 51

Delayed graft function

definition

Back 51

as defined by the need for dialysis after transplantation

Front 52

Delayed graft function

mian cause

Back 52

related to :

cold ischemia time

most related to deceased donor kidneys

Front 53

Delayed graft function

Back 53

most eventually function,but somewhat diminished lifespan compared with kidneys that function immediately

Front 54

Vascular thrombosis %

Back 54

1%

Front 55

Vascular thrombosis

the main cause

Back 55

small caliber art's

Front 56

Vascular thrombosis

Rx

Back 56

1-thrombectomy

2-if failed : nephrectomy

Front 57

renal Arterial stenosis %

Back 57

2-10 %

Front 58

renal Arterial stenosis

when it happens

Back 58

months - years

Front 59

renal Arterial stenosis

clinical presentation

Back 59

abrupt HTN

Front 60

renal Arterial stenosis

Dx : methods

Back 60

Doppler ultrasonography : suggestive

angiography : contrast risk

CO2 angio : no contrast risk

Front 61

Venous thrombosis %

dx

ttt

Back 61

0.5 - 4 %

usually delayed dx

thrombolytic agrnts

Front 62

graft infarct

causes

manegment

Back 62

can be with patent renal a+vein

nephrectomy is mandatory bcoz of high risk of infection / death

Front 63

Ureteral obstruction

types

Back 63

common

1-early

2-delayed

Front 64

Early uretral obstruction

causes

Back 64

1- clot

2-edema,

3-technical problems associated with the ureteroneocystostom

Front 65

Early uretral obstruction

Rx

Back 65

1-Foley catheter placement and expectant management

2-if failed , revision over a stent

Front 66

Late obstruction

causes

Back 66

1-external compression ( lymphocele or pregnancy)

2-fibrosis

3- nephrolithiasis.

Front 67

Late obstruction

Rx

Back 67

1- radiologic or cystoscopic stent placement and stricture dilatation.

Front 68

Urinary leakage

when it happens

site

Back 68

usually wihin 1 month

any level of the urinary tract, from the renal pelvis to the urethra.

Front 69

when to suspect a urinary leak

Back 69

good or improving graft function develops a fluid leak from the wound or abdominal pain or perineal swelling

Front 70

urinary leak

how to dx / confirm

Back 70

1-Fluid leaking from the wound can be collected and assayed for creatinine.

2-Nuclear renal scanning is probably the most sensitive test for urinary leakage.

Front 71

urinary leak

Rx

Back 71

1- Small bladder leaks often can be managed by means of bladder decompression with a Foley catheter.

2-Larger and more proximal leaks typically call for exploration and repair.

Front 72

pt presented with swelling at site of surgery with pain and impaired function

possible causes

Back 72

-hematoma

-leak

-lymphocele

Front 73

Lymphocele

definition

Back 73

Leakage from perivascular lymphatic vessels can lead to significant collections of lymph between the lower pole of the transplanted kidney and the bladder.

Front 74

Lymphocele

time of presentation

Back 74

1st year

Front 75

Lymphocele

clinical presentation

Back 75

manifest as swelling, pain, and impaired renal function

Front 76

Lymphocele

dx

Back 76

Ultrasonography

computed tomography (CT)

Front 77

Lymphocele

Rx

Back 77

1-Aspiration occasionally (( significant risk of infection)))

2-Sclerotherapy with 10% povidone-iodine solution (( in small nonloculated collections, but the lymphocele is highly likely to recur))

3- instilling fibrin glue that contains gentamicin and iodine solution.

4- current standard of care is internal drainage of the lymphocele into the abdominal cavity.

(( laparoscopically ))

Front 78

most important pathogens to cause infection in renal transplant

Back 78

1-CMV = cytomegalovirus

2-BK virus

3-fungi

4-Pneumocystis (carinii) jiroveci,

5-Legionellaspecies.

Front 79

Chronic rejection

causes

Back 79

immunologic and nonimmunologic components.

Front 80

Risk factors for Chronic rejection

Back 80

1- initial poor function of the graft

2- history of acute rejection episodes.

Front 81

Chronic rejection Rx

Back 81

Chronic rejection is not treatable.

Front 82

acute rejection %

Back 82

15 - 25 %

Front 83

acute rejection

clinical presentation

Back 83

1- usually asymptomatic , as an unexplained rise in serum creatinine levels

2- sometimes associated with fever and pain at the graft site.

Front 84

acute rejection

confirmation

Back 84

confirmed with biopsy

Front 85

acute rejection

biopsy findings

Back 85

- lymphoplasmacytic infiltration of the renal interstitial areas with occasional penetration of the tubular epithelium by these cells.

Front 86

acute rejection

Back 86

1- short course of increased steroid doses is usually effective

2- Failure to respond to steroid therapy use other like antilymphocyte antibody agents

Front 87

maintinance chemo

categories

Back 87

1-steroids

2-antimetabolites,

3-other immunosuppressants

Front 88

cyclosporin

brand name

Back 88

neural