Chapter 73 / Transplant Surgery 677
How does it work? Inhibitor of inosine monophosphate dehydrogenase required for de novo purine synthesis which expanding T and B cells depend on; also inhibits adhesion molecule and antibody production
OVERVIEW OF IMMUNOSUPPRESSION MECHANISMS
What drug acts at the following sites:
Mφ |
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A? |
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IL-1 |
TNF-α |
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IL-1 |
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IL-6 |
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Lymphocyte |
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IL-2 |
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B? |
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B |
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Tn |
Tc |
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T-B cell |
C? |
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interaction |
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Clonal |
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expansion |
D?
A? |
Corticosteroids |
B? |
CSA/tacrolimus |
C? |
AZA/MMF |
D? |
OKT3/ATGAM |
678 Section III / Subspecialty Surgery
MATCHING OF DONOR AND RECIPIENT
How is ABO crossmatching |
Same procedure as in blood typing |
performed? |
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What is the purpose of |
Tests for HLA antibodies in serum; |
lymphocytotoxic |
most important in kidney and pancreas |
cross-matching? |
transplants |
How is the test performed? |
Mix recipient serum with donor |
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lymphocyte and rabbit complement |
Is HLA crossmatching |
Yes, for kidney and pancreas transplants |
important? |
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REJECTION |
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How many methods of |
Two: humoral and cell-mediated |
rejection are there? |
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Name the four types of |
1. Hyperacute—immediate in O.R. |
rejection and their associated |
2. Accelerated acute—7 to 10 days |
time courses. |
post-transplant |
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3. Acute—weeks to months post-transplant |
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4. Chronic—months to years |
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post-transplant |
What happens in hyperacute |
Antigraft antibodies in recipient |
rejection? |
recognize foreign antigen immediately |
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after blood perfuses transplanted organ |
What happens in acute |
T cell–mediated rejection |
rejection? |
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What type of rejection is |
Cellular, antibody (humoral), or both |
responsible for chronic |
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rejection? |
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What is the treatment of |
Remove transplanted organ |
hyperacute rejection? |
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680 Section III / Subspecialty Surgery |
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What are the indications for |
Irreversible renal failure from: |
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kidney transplant? |
1. |
Glomerulonephritis (leading cause) |
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2. |
Pyelonephritis |
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3. |
Polycystic kidney disease |
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4. |
Malignant HTN |
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5. |
Reflux pyelonephritis |
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6. |
Goodpasture’s syndrome |
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(antibasement membrane) |
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7. |
Congenital renal hyperplasia |
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8. |
Fabry’s disease |
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9. |
Alport’s syndrome |
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10. |
Renal cortical necrosis |
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11. |
Damage caused by type 1 |
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diabetes mellitus |
Define renal failure. |
GFR 20% to 25% of normal; as GFR |
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drops to 5% to 10% of normal, uremic |
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symptoms begin (e.g., lethargy, seizures, |
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neuropathy, electrolyte disorders) |
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What is the most common |
Diabetes (25%) |
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cause for kidney transplant? |
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STATISTICS |
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What are the sources of |
Deceased donor (70%) |
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donor kidneys? |
Living related donor (LRD; 30%) |
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What survival rate is |
90% at 1 year if HLA matched; 80% at |
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associated with deceased |
1 year if not HLA matched; 75% graft |
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donor source? |
survival at 3 years |
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What survival rate is |
95% patient survival at 1 year; 75% to |
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associated with LRD? |
85% graft survival at 3 years |
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What are the tests for |
ABO, HLA typing |
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compatibility? |
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If a choice of left or right |
Left—longer renal vein allows for easier |
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donor kidney is available, |
anastomosis |
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which is preferred? |
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Should the placement of |
Heterotopic—retroperitoneal in the RLQ |
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the kidney be heteroor |
or LLQ above the inguinal ligament |
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orthotopic? |
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