Renal Replacement Therapy 2

Question 1

Where is the transplanted kidney usually located in the body?

Answer 1

Iliac fossa

Question 2

What vessels is the transplanted kidney anastomosed to?

Answer 2

Iliac vessels

Question 3

What happens to the native kidney when a kidney is transplanted?

Answer 3

Is usually left in situ

Question 4

What are indicates for native nephrectomy?

Answer 4

Size (polycystic kidneys)

Infection (chronic pyelonephritis)

Question 5

How is preservation of the donor kidney achieved?

Answer 5

• Cold storage solutions
• Minimise oedema
• Preserve integrity of tissues
• Buffer free radicals

Question 6

What are some complications with kidney transplants?

Answer 6

• Vascular complications
  
  • Bleeding
    
    • Usually anastomotic sites
    • Perirenal haematoma can be arterial or venous
  • Arterial thrombosis
  • Venous thrombosis
  • Lymphocele
• Ureteric
  
  • Urine leak
• Infections

Question 7

How is immunosuppression achieved after a kidney transplant?

Answer 7

• Corticosteroids
• Calcineurin inhibitors
  
  • Tacrolimus, cyclosporine
• Anti-proliefratives
  
  • Mycophenolate mofetil, azathioprine
• mTOR inhibitors
  
  • Sirolimus
• Costimulatory signal blockers
  
  • Belatacept
• Deleting agents
  
  • Basiliximab ( anti-CD25), Anti-thymocyte globulin (ATG), Rituximab (anti-CD20)

Question 8

What are side effects of corticosteroids?

Answer 8

Question 9

What are side effects of tacrolimus?

Answer 9

Question 10

What are side effects of cyclosporin?

Answer 10

Question 11

What are side effects of mycophenolate mofetil?

Answer 11

Question 12

What are side effects of sirolimus?

Answer 12

Question 13

What are side effects of belatacept?

Answer 13

Question 14

What are side effects of ATG?

Answer 14

Question 15

Explain the typical immunosuppression protocol?

Answer 15

• Induction
  
  • Basiliximab
• Maintenance
  
  • Tacrolimus and mycophenolate and steroids
• Steroid free is possible
• Others
  
  • CNI-free using belatacept

Question 16

What are some different types of donors?

Answer 16

• Decreased donors
  
  • Donation after brain death/DBD
    
    • Standard/extended criteria
  • Donation after cardiac death/DCD
    
    • Standard/extended criteria
• Living donors
  
  • Living related donor
  • Living unrelated donor
    
    • Spousal
    • Altruistic
    • Paired/pooled

Question 17

What does DBD stand for?

Answer 17

Donation after brain death

Question 18

What does DCD stand for?

Answer 18

Donation are cardiac death

Question 19

What is the criteria to be considered a donor after brain death?

Answer 19

• Coma, unresponsive to stimuli
• Apnoea off ventilator (with oxygenation) despite build-up of CO₂
• Absence of cephalic reflexes
  
  • Pupillary
  • Oculocephalic
  • Oculovestibular
  • Corneal
  • Gag
  • Purely spinal reflexes may be present
• Body temperature above 34^oC
• Absence of drug intoxication

Question 20

What are the 2 kinds of donor criteria?

Answer 20

• Standard criteria (SCD)
• Extended criteria (ECD)
  
  • Donor aged over 60
  • Donor aged 50-59 with history of hypertension, death from cerebrovascular accident or terminal creatinine of over 123umol/L

Question 21

What does SCD stand for?

Answer 21

Standard criteria donor

Question 22

What does ECD stand for?

Answer 22

Extended criteria donor

Question 23

When is somone considered to be an extended criteria donor?

Answer 23

• Donor aged 50-59 with history of hypertension, death from cerebrovascular accident or terminal creatinine of over 123umol/L

Question 24

Is there a gap between supply and demand for kidney transplants?

Answer 24

There is way more demand than supply

Question 25

Does whether the donor is living or deceased impact the survival time of the person recieving the transplant?

Answer 25

Yes, donations from living donors are better

Question 26

Are most kidney donations from living or deceased donors?

Answer 26

Deceased donors

Question 27

What is the average waiting time for a kidney donation for adults and children?

Answer 27

Adults - 845 to 883 days Children - 205 to 327 days

Question 28

Does the amount of people on dialysis or with a transplant change depending on age?

Answer 28

Yes, more older people are on dialysis and younger people get transplants

Question 29

Who could living kidney donations come from?

Answer 29

* Liver related donor * Liver unrelated donor (such as spousal) * Liver unrelated donor (altruistic, non-directed) * Paired/pooled * ABO incompatible/HLA incompatible

Question 30

What is paired pool and pooled donation?

Answer 30

The pair may be matched to another couple in a similar situation so that both people in need of a transplant receive a matched organ or part organ. Pooled donation is where more than two pairs of donors and recipients are involved in the swap.

Question 31

Are the long term consequences for kidney donors severe?

Answer 31

No, they appear to be minor

Question 32

Summarise the risk of kidney donation for the donor?

Answer 32

* Similar patient survival to general population * Lower rate of ESRD compared to general population * Compensatory increase in GFR remaining kidney to 70% of pre-donation values * Older age and high BMI associated with GFR \<60

Question 33

What are some possible complications after renal transplantation?

Answer 33

* Rejection * Cell mediated * Humoral (ab mediated) * Cardiovascular * Underlying renal disease * CRF * Hypertension * Hyperlipidaemia * PT diabetes * Infective * Bacterial * Viral * Fungal * Malignancy * Skin * Lymphoma * Solid cancers

Question 34

What are the 2 different kinds of acute renal rejection?

Answer 34

* T cell mediated rejection (TCMR) * Tubulointersitial (Banff I) * Arteritis/endothelilitis (Banff II) * Arterial fibrinoid necrosis (Banff III) * Acute antibody mediated rejection (ABMR) * ATN-like (Banff I) * Caillaries and or glomerular inflammation (Banff II) * Arterial inflammation (Banff III)

Question 35

What does TCMR stand for?

Answer 35

T cell mediated rejection

Question 36

What does ABMR stand for?

Answer 36

Acute antibody mediated rejection

Question 37

What is used to classify the biopsies from solid organ translants?

Answer 37

The Banff Classification of Allograft Pathology

Question 38

What is the most important transplant related infection?

Answer 38

Cytomegalovirus

Question 39

How are transplant patients infected with cytomegalovirus?

Answer 39

* Transmission from donor tissue * Reactivation of latent virus

Question 40

How is the likelihood of cytomegalovirus infection destroying the graft reduced?

Answer 40

Prophylaxis treatment

Question 41

What are tissue invasive disease that can affect a patient after receiving a kidney transplant?

Answer 41

* Pneumonitis * Hepatitis * Retinitis * Gastroenteritis * Colitis * Nephritis

Question 42

Other than cytomegalovirus, what other virus often affects patients after a kidney transplant?

Answer 42

Polyomaviridae

Question 43

What are the different kinds of polyomaviridae?

Answer 43

* BK virus * JC virus * Murine polyoma virus * SV40

Question 44

What is the clinical presentation of the BK polyomaviridae virus?

Answer 44

Question 45

What does BKAN stand for?

Answer 45

BK virus nephropathy

Question 46

What are risk factors for BK virus nephropathy (BKVN)?

Answer 46

* Intensity of immunosuppression * Patient determinants * Older age, male gender, whte ethnicity, DM * Organ determinants * Graft injury, HLA mismatches, ureteral stents * Viral determinants * Changes in epitopes of viral capsid protein VP-1

Question 47

What are BKAN outcomes?

Answer 47

* Allograft dysfunction * Loss of graft in 45-80%

Question 48

What is the treatment of BKAN?

Answer 48

* Reduce immunosuppression * Antiviral therapy * Cidofovir with or without IVIG * Leflunomide

Question 49

What are the most common malignancies that occur after renal transplant?

Answer 49