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53 Cards in this Set
- Front
- Back
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What type of rejection?
Foreign MHC Ag's on graft cells stimulate cytotoxic + helper T cells |
Acute rejection:
-2/2 foreign MHC antigens of graft cells (mediated by cytotoxic and helper T cells) -Bx: lymphocytic infiltrate -Tx: OKT3, increase immunosupression, pulse steroids (1 week-1 month p/ transplant) |
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_-type rejection is 2/2 ongoing production of Ab against donor Ag
Occurs @ timepoint _ |
ANTIBODY-MEDIATED rejection is 2/2 ongoing production of Ab against donor Ag
Occurs anytime (depends on pt's amnestic response) Highly presensitized cases can be treated c/ plasmapheresis, IV Ig |
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_-type rejection of kidney allograft ->
margination of neutrophils, diffuse CD4 staining in peritubular capillaries |
ANTIBODY-MEDIATED rejection of kidney allograft ->
margination of neutrophils, diffuse CD4 staining in peritubular capillaries |
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Drug is metabolized in liver to 6-mercaptopurine -> inhibits purine synthesis -> inhibits T cells
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Azathioprine = Imuran = purine analog that acts as antimetabolite
-Inhibits de novo PURINE synthesis -> inhibits T CELLS -6-MERCAPTOPURINE = active metabolite formed in liver -SE: myelosupression -Keep WBCs > 3 |
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After liver tx, delayed hepatic artery thrombosis can cause _
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After liver tx, delayed hepatic artery thrombosis can cause BILE DUCT NECROSIS
-Biliary anastomosis receives its blood supply from hepatic artery |
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Pt presents c/ biliary stricture p/ liver transplant:
-Check __ b/c may be 2/2 __ |
Biliary stricture p/ liver transplant:
-check hepatic artery flow b/c may be 2/2 ischemia |
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RARELY s/p liver tx, hepatic vein thrombosis + IVC stenosis can cause _
-Tx = _ |
RARELY s/p liver tx, hepatic vein thrombosis + IVC stenosis can cause BUDD CHIARI
-Tx = surgery (IVC stenosis may be dilated + stented sometimes) |
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what kinds of cells lack mycophenolic acid?
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Cellcept = myfortic:
-active metabolite = MPA -inhibits purine synthesis -all cells have MPA except WBC |
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2 wks after transplant, pt develops resp insufficiency.
CXR: diffuse infiltrates Bronchial washings: cells c/ inclusion bodies What is the diagnosis, tx? |
CMV Pneumonia
CXR: diffuse infiltrates Bronchial washings: ALVEOLAR MACROPHAGES (c/ inclusion bodies) Tx: GANCYCLOVIR |
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What is a postive cross-match?
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Cross match;
-Mix donor lymphocytes + recipient serum -Postive cross-match = recipient has preformed Ab's against donor Ag's -Hyperacute rejection likely |
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Cross match is performed by mixing _ from donor with _ from recipient
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Cross match;
-Mix donor lymphocytes + recipient serum -Postive cross-match = recipient has preformed Ab's against donor Ag's -Hyperacute rejection likely |
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Mechanism of drug _ =
binding to cyclophilin protein -> inhibit genes for synthesis of cytokines IL-2, IL-3, IL-4, INF-gamma |
Cyclopsporin (CSA)
-Binds cyclophilin protein -> inhibits genes for synthesis of IL-2 (also IL-3, IL-4, INF-gamma) -Rotamase inhibitor -SE: NEPHROTOXIC, hepatotoxic, HUS, tremors, seizures -Trough level 200-300 -Hepatic metabolism, Biliary excretion |
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Cyclopsporin (CSA)
Metabolized by the _ Excreted by the _ |
Cyclopsporin (CSA)
-Binds cyclophilin protein -> inhibits genes for synthesis of IL-2 (also IL-3, IL-4, INF-gamma) -Rotamase inhibitor -SE: NEPHROTOXIC, hepatotoxic, HUS, tremors, seizures -Trough level 200-300 -Hepatic metabolism, Biliary excretion |
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55 year-old male with history of an orthotopic kidney transplant 5 years ago develops cholangitis due to choledocholithiasis and requires a common bile duct exploration. Seven days post-op the patient develops acute rejection. The most likely cause is:
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Cyclopsporin (Hepatic metabolism, Biliary excretion) being secreted via T tube
Recall that cyclosporin is excreted in its active form into the bowel. If you have a T-tube after any choledochotomy you will be draining out all the cyclosporin, thus causing rejection. |
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what types of drugs require revison of Prograf, Cya, or Rapamycin dosing 2/2 cytochrome p450
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interact c/ antifungals, abx, Ca channel blockers
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what is the mechanism of FK-506
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FK-506 = Prograf:
-binds FK-binding protein -> blocks IL-2 production/expression from T cells -SE: nephrotoxic (Mg, K, BP problems) mood changes, more GI and neuro changes (e.g. tremor) than cytosporine -Keep trough 10-15 -10% of heart tx, liver tx pts develop renal failure |
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Graft vs. Host disease:
-mediated by _ type lymphocytes |
Graft vs. Host Disease:
T cell mediated |
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Heart transplant => _% 1-yr survival
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Heart transplant:
-84% 1-yr survival. Candidates for transplant have life expectancy < 1 yr. -if persistant pulm HTN p/ transplant => Flolan (PGI2). ECMO if severe. -Acute rejection: perivasc. infiltrate, myocyte inflamm and necrosis -Chronic rejection: progressive diffuse coronary atherosclerosis |
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Fulminant hepatic failure POD2 s/p orthotopic liver tx.
Most likely cause = _ |
HEPATIC ARTERY THROMBOSIS
= most likely cause of fulminant hepatic failure POD2 s/p orthotopic liver tx. Tx = angiography + nalloon dilatation +- stent -> retransplantation |
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_-type rejection is 2/2 preformed donor-specific Ab's
Occurs @ timepoint _ Tx = _ |
HYPERACUTE rejection: type 2 hypersensitivity
-2/2 preformed donor-specific Ab's Occurs @ reperfusion Tx = graft removal (avoid by not transplanting when crossmatch is positive) |
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_-type rejection of kidney allograft ->
widespread glomerular capillary thrombosis, necrosis, +/- areas of interstitial hemorrhage |
HYPERACUTE rejection of kidney allograft -> donor-specific Ab's -> widespread glomerular capillary thrombosis, necrosis, +/- areas of interstitial hemorrhage
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What rejection type:
Pre-formed recipient Ab's to donor Ag's -> complement cascade = a type _ hypersensitivity rxn Most commonly due to _ Tx = _ |
Hyperacute rejection:
Type 2 hypersensitivity Pre-formed recipient Ab's to donor Ag's -> complement cascade -> vascular thrombosis Most commonly due to ABO incompatibility (postiive crossmatch) Tx = remove organ |
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Pt 1 wk s/p renal tx has increased Cr. US shows flow acceleration, narrowing @ arterial anastomosis
-Tx =_ |
Tight arterial anastomosis following kidney tx:
-Increase in Cr soon after surgery US: flow acceleration, narrowing @ arterial anastomosis -Tx: angiogram c/ angioplasty + stent |
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how are monoclonal Ab's used in transplant?
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Induction: high immuo risk => ned for potent induction, e.g. c/ anti-T cell agents
-esp in 2nd transplant, Af Am, high PRA -less effect in pts c/ low immuno risk |
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_ = #1 cause of oliguria p/ renal tx
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ATN = #1 cause of oliguria p/ renal tx
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#1 complication after renal tx = _
Tx = _ |
URINE LEAK = #1 complication s/p renal tx
-Tx: percutaneous drainage of fluid collection, place ureteral stent across anastomosis -Redo the anastomosis if it totally fell apart on POD 1 |
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New proteinuria in pt s/p renal tx.
Suspect _ |
Renal vein thrombosis:
-New proteinutia in pt s/p renal transplant |
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#1 cause of death in living related kidney donor = _
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PE = #1 cause of death in living related kidney donor
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#1 cause of death following kidney transplant = _
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MI = #1 cause of death following kidney transplant
(some say stroke) |
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Liver tx => _% 1 yr survival
best predictor = __ |
Liver tx:
-70% 1-yr survival (APACHE score = best predictor). 20% retransplantation rate. -Indications: chronic hepatitis #1 (emergent if stage 3=stupor or stage 4 =coma), hepatocellular ca if single tumor <5cm or up to 3 tumors <3cm -Contraindications: current EtOH, active UC -HepC ~100% reinfection; use HBIG (+ lamivudine = protease inhibitor) to reduce HepB reinfection to ~20%. -Macrosteatosis = #1 predictor of primary graft nonfunction -Duct-to-duct anastomosis. Hepatico-jej in kids. -Hepatic artery feeds bilary system. -Complications: bile leal #1 , primary nonfunction, hep artery thrombosis +/- abscess following, IVC stenosis, cholangitis |
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#1 complication of liver tx = __
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LIver tx complications:
-Bile leak #1 => PTC tube + stent -Primary nonfunction => usually needs re-tx -Hepatic artery thrombosis => angio + balloon dilation +/- stent (hepatic vein thrombosis rare) -Abscess (usually 2/2 hepatic artery thrombosis) -IVC stenosis (have edema, ascites, renal insuff) -Cholangitis (PMNs around portal triad - not mixed infiltrate) |
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Liver tz:
-#1 cause of early mortality = _ -exclusion criteria for donating lungs |
Lung t:
-Candidates have life expectancy <1 yr -Reperfusion injury = #1 cause of early mortality -Exlusion criteria for lungs: PO2 <350 on FiO2 1 and PEEP 5, aspiration, mod-large contusion, infiltrate, purulent sputum -Acute rejection: perivascular lymphocytosis -Chronic rejection: bronchiolitis obliterans |
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mechanism of mycophenolate
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Mycophenolate = Cellcept:
-blocks purine synthesis-> decreases T and B cell proliferation (similar mechanism to azathioprine) |
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What drug? -
Bind CD3 molecule on lymphocytes -> inhibits formation of T-cell receptor complex -> opsonization of T cell -Can be used to treat rejection resistant to pulse steroids |
OKT3: -
Monoclonal Ab's block CD3 molecule on lymphocytes -> inhibits formation of T-cell receptor complex = block T cell Ag recognition-> complement-dependent CD3 opsonization of T cell -Interferes c/ MHC class I, II -Treats ACUTE REJECTION resistant to pulse steroids |
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what drug is used to treat acute rejection that is resistant to pulse steroids?
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OKT3 = monoclonal Ab
-Blocks CD3 molecule on lymphocytes -> inhibits formation of T-cell receptor complex = block T cell Ag recognition -> complement-dependent CD3 opsonization of T cell -Interferes c/ MHC class I, II -Treats ACUTE REJECTION resistant to pulse steroids |
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Portal vein thrombosis s/p liver tx (much less common than hepatic artery thrombosis)
-Early PVT causes _, Tx is _ Late PVT causes _, Tx is _ |
Portal vein thrombosis s/p liver tx
-Early thrombosis: -> liver dysfx, Tx = re-op + thrombectomy -Late thrombosis/stenosis: -> portal venous HTN (ascites, variceal bleeding, splenomegaly), Tx surgery for thrombosis, angioplasty for stenosis |
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#1 virus post-transplant = _
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CMV = #1 virus post-transplant (others: HSV, VZV)
-Since immunosupression is mostly cellular, not humoral, viral infections > bacterial |
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#1 protozoal infection post-transplant = _
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Pneumocystis carinii (AKA jeroveci) pneumonia => need Bactrim ppx
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#1 malignancy following transplant = _
(3 other common malignancies are...) |
SKIN CANCER = #1 malignancy following transplant
-Others: leukemia, lymphoma, cervical -b/c immunosupression is mostly cellular, not humoral. |
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Post-transplant lymphoproliferative disorder:
-Main RF = _ Tx: _ -> _ if that does not work |
Post-transplant lymphoproliferative disorder:
-Most commonly ass'd c/ EBV Tx: decrease immunosupression -> chemo-XRT if tumor does not regress |
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2 major targets of Ab-mediated graft rejection
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3 major targets of Ab-mediated graft rejection =
HLA class 1 Ag's endothelium-ass'd donor Ag's |
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Principal cells in acute rejection are _
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Acute rejection
-1 week to 1 month post-op -T cell mediated (cytotoxic, helper T cells ) -Tx: increase immunosupression, pulse steroids, +/- OKT3 |
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Pt 1 wk s/p renal tx has increased Cr. US is normal.
Next step = _ |
Pt 1 wk s/p renal tx has increased Cr. US is normal.
Next step = renal bx to r/o acute rejection |
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Pt 1 wk s/p renal tx has increased Cr -> US normal -> Bx shows acute tubulitis +/- vasculitis
Next step = _ |
Acute rejection of renal allograft:
Increased Cr 1 week s/p tx, US normal, Bx (+) for acute tubulitis (+ vasculitis if severe) -PULSE STEROIDS -Follow Cr, re-Bx kidney in 5-7 days |
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_ = #1 cause of urinary obstruction 2/2 ureter compression
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Lymphocele = #1 cause of urinary obstruction 2/2 ureter compression
-Forms in retroperitoneal space @ iliac fossa developed for implantation of the allograft (disrupts the tiny lymphatics that surround the recipeint's eternal iliac artery + vein) Lymph collects post-op in perinephric space -> mashes the ureter -> low UOP. US shows hypoechoic mass, hydronephrosis. May have temporary decrease in Cr if pressure in renal pelvis overcomes pressure in the ureter -Tx: percutaneous drainage -> laparoscopic peritoneal window if not successful |
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What is wrong?
Months-years s/p renal tx, pt has oliguria, hypertension, rising Cr |
Renal artery stenosis s/p renal tx:
-usually occurs months-years after tx -presents c/ oliguria, hypertension, rising serum Cr |
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3 causes of vascular compromise of graft s/p renal tx
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Vascular compromise:
Occurs w/in hrs-days of renal tx -Brought on bt renal artery/vein thrombosis, arterial dissection, pseudoaneurysm formation |
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New proteinuria in pt s/p renal tx.
Suspect _ |
New proteinuria in pt s/p renal tx.
Suspect renal vein thrombosis |
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what immunosupression drug?
-blocks IL-2 R's @ nuclear level. -same transport binding protein as Prograf but different mechanism -bad for wound healing |
Sirolimus (rapamycin):
-blocks IL-2 R's @ nuclear level -same transport binding protein as Prograf but different mechanism -bad for wound healing -increases cholesterol and triglycerides |
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Drug that inhibits IL-1 production by macrophages
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Steroids:
-inhibit genes for synthesis of cytokies (IL-1, IL-6) form macrophages |
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what 3 HLAs are most important in recipient/donor matching?
which is most important overall? |
Tissue types: HLA-A, B, C, DP, DQ, DR
HLA-A, B, DR most important in matching HLA-DR most important overall |
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When does ureteroneocystostomy stenosis occur in post-op course following renal tx?
-Amything that can be done to prevent it? |
Ureteroneocystosomy stenosis = stenosis @ ureterovesical anastomosis
Occus EARLY in post-op course -May be prevented c/ intraop stent placement through anastomosis |
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What drug?
Human monoclonal Ab against IL-2 receptors |
Zenepax:
-Human monoclonal Ab against IL-2 receptors -Uses: induction, rejection tx |
