Complications

Question 1

Risk factors for AIH recurrence following LT

Answer 1

1. Increasing time post-tx
2. DC of steroids
3. Poorly controlled AIH pre-txp
4. Concomitant autoimmune diseases

Question 2

Islet Cell Txp Complications

Answer 2

1. Bleeding
2. PVT (2/2 txp procedure via protal vein; consider ppx)
3. Pain
4. Mild AST/ALT elevations (engraftment in liver; should resolve)
5. Sensitization (risk inc with # of donors)

Question 3

Panc Txp vs Islet Cell Txp

• Insulin Independence
• Adverse events
• Duration hospitalization

Answer 3

• Insulin Independence: Panc wins
• Adverse events: Islet cell wins (panc has more thrombosis, relap, CMV reactivation)
• Duration hospitalization: Islet cell wins

Question 4

Risk factors for FSGS recurrence

Answer 4

• 1st txp failed dt recurrence
• Rapid progression to ESRD
• Young age at time of diagnosis

Question 5

Indications for kidney bx per KDIGO

Answer 5

9.1: We recommend kidney allograft biopsy when there is a persistent, unexplained increase in serum creatinine. (1C)
9.2: We suggest kidney allograft biopsy when serum creatinine has not returned to baseline after treatment of acute rejection. (2D)
9.3: We suggest kidney allograft biopsy every 7–10 days during delayed function. (2C)
9.4: We suggest kidney allograft biopsy if expected kidney function is not achieved within the first 1–2 months after transplantation. (2D)
9.5: We suggest kidney allograft biopsy when there is:
• new onset of proteinuria (2C);
• unexplained proteinuria ≥3.0 g/g creatinine or ≥3.0 g per 24 hours. (2C)

Question 6

KDIGO recs for FSGS recurrence screening

Answer 6

Screen for proteinuria
• daily for 1 week (2D);
• weekly for 4 weeks (2D);
• every 3 months, for the first year (2D);
• every year, thereafter. (2D)

Question 7

KDIGO recs for IgA/MPGN/anti-GBM/ANCA recurrence screening

Answer 7

Screen for proteinuria, microhematuria:
• once in the first month to determine a baseline (2D);
• every 3 months during the first year (2D);
• annually, thereafter. (2D)

Question 8

Treatment of recurrent FSGS

Answer 8

We suggest plasma exchange if a biopsy shows minimal change disease or FSGS
in those with primary FSGS as their primary kidney disease.

Question 9

Treatment of recurrent anti-GBM/ANCA

Answer 9

We suggest high-dose corticosteroids and cyclophosphamide in patients with recurrent ANCA-associated vasculitis or anti-GBM disease

Question 10

Cause of pre-kidney txp secondary hyperparathyroidism? Implications on phos, Ca, Vit D?

Answer 10

Renal function declines –> reduction in phosphate reabsorption in the nephrons via FGF23 –> PTH increases to maintain phosphate balance

Phos: Elevated
Ca: Dec (dt inc PTH, bone resorption)
Vit D: Dec (dt dec 1a hydroxylase in kidney to conver to active vit D)

Question 11

Treatment of secondary hyperparathyroidism post-txp

Answer 11

• Calcimimetics if elevated PTH
• Vit D or calcitriol pending 25HD level
• Surgical parathyroidectomy PRN

Question 12

Monitoring of secondary hyperparathyroidism post-txp

Answer 12

Immediately post-txp: Monitor Ca and Phos at least weekly

Then, monitor PTH, Ca, Phos with frequency depending on abnormalities

Question 13

Requirements to be within Milan Critera

Answer 13

- Solitary tumor <5 CM 
OR
- Up to 3 tumor nodules (each < 3CM)
AND
No extra hepatic or vascular invasion

Question 14

Which type of pancreas txp has the highest risk of rejection?

Answer 14

PTA

Question 15

Islet allograft survival: donor and recipient factors

Answer 15

• Induction
• Calcineurin inhibitor maintenance
• > 500 000 islet equivalents infused
• Recipient age >35
• Donor BMI >30 with A1c <6.5%
• <43 units/day pretransplant insulin requirements

Question 16

Recommended volume for islet cell txp

Answer 16

Preferred: >7k IE/kg from single donor
Acceptable: >5k IE/kg

Question 17

Anti-inflammatory medications that improve islet cell engraftment & insulin independence

Answer 17

Block inflammatory reaction:

1. Anti-TNF (Etanercept)
2. IL-1 receptor antagonist (Anakinra)

Question 18

Non-Anti-inflammatory medications that improve islet cell engraftment and/or insulin independence

Answer 18

1. Heparin (UFH or LMWH to target aPTT): counteract thromobogenic effects of islets
2. Insulin to target normoglycemia: anti-inflammatory properties
3. GLP-1 Receptor Agonists: augment insulin production by islets

Question 19

Risk for bacteremia post-intestinal txp

Answer 19

• Liver graft
• Pre-op bili >5
• Pediatrics
  Note: G+ > G- > fungal

Question 20

Foods that cause dumping syndrome

Answer 20

• Insoluble cellulose

- Simple carbohydrates

Question 21

Risk factors for PTLD post-intestinal txp

Answer 21

• ITx
• Primary EBV infxn
• Depleting induction
• Young recipient age

Question 22

Risk factors for poor outcomes post-heart txp (donor & recip & surgical)

Answer 22

Donor

• Older age (>50)
• Gender mismatch
• Size mismatch
• LV thickness >1.4 cm

Recipient

• Pre-txp amio use
• The usual: older age, DM, HTN, obesity, vascular dz, frailty

Surgical
- Ischemic tima (ideal <4 hr; max 6 hr)

Question 23

Ideal vasoactives post-heart txp

Answer 23

1. Something with minimal vasodilation (likely vasoplegic after OR) - NOT isoproterenol
2. Chronotropy - Anything with beta/milrinone
3. Increased contractility (stunted from cold time) - Anything with beta/milrinone
4. Decreased arrhythmia risk - NOT isoproterenol, epi

Question 24

What decrease in FEV1 is considered significant for lung dysfunction?

Answer 24

10%+