Transplantation PDF

BASIC SURGERY A (BASIC??? BASIC IBAGSAK! HUYY MAG-ARAL TAYO GUYS!!) LECTURER: Dr. Carl Evans Y. De Castro, si doc daw savior natin ngayong finals (weh) bacteria, and fungi, but it also acts to reject trans...

BASIC SURGERY A (BASIC??? BASIC IBAGSAK! HUYY MAG-ARAL TAYO GUYS!!) LECTURER: Dr. Carl Evans Y. De Castro, si doc daw savior natin ngayong finals (weh) bacteria, and fungi, but it also acts to reject transplanted cells, tissues, and organs, recognizing them as foreign DEFINITION OF TERMS Process of transferring an organ, HOST DEFENSES TRANSPLANTATION tissue, or cell from one place or First line of defense another ○ Chemical and physical barriers (skin) that line the parts of the body that are exposed to the outside Surgical procedure in which a ORGAN world failing organ is replaced by a TRANSPLANTATION ○ Prevent functioning one ○ When transplant is done, no matter what type of Implanted in the SAME anatomic agent, the immune system recognizes it as foreign location in the recipient as it was and triggers a strong response that is designed to in the donor either to eradicate pathogenic organisms or reject ORTHOTOPIC Requires REMOVAL OF DISEASED foreign cells or tissue ORGAN Example: Heart, Lungs, Liver or Intestine ENTRY OF FOREIGN BODY Second line of defense Implanted in ANOTHER anatomic ○ Internal cellular defenses location HETEROTOPIC ○ Attack Diseased organ KEPT IN PLACE Example: Kidney, Pancreas Third line of defense ○ Immune response system ○ Destroy TRANSPLANTATION BY DEGREE OF IMMUNOLOGIC SIMILARITY BETWEEN DONOR AND RECIPIENT Transfer of cells, tissue, or an organ from one part of the body to another part in the SAME Transplants between genetically nonidentical persons person lead to recognition and rejection of the organ by the AUTOTRANSPLANT No immunosuppression is recipient’s immune system, if no intervention is taken required Main antigens responsible for this process are part of the Example: skin, artery or vein, major histocompatibility complex (MHC) bone, cartilage, nerve, and islet In humans, these antigens make up the human leukocyte cell transplants antigen (HLA) system Transfer of cells, tissue, or an organ from one person to MAJOR HISTOCOMPATIBILITY COMPLEX ANOTHER of the SAME species (HUMAN LEUKOCYTE ANTIGEN) Immunosuppression is required The antigen encoding genes are located on ALLOTRANSPLANT since the immune system of the chromosome 6 recipient recognizes the donated HUMAN LEUKOCYTE ANTIGEN SYSTEM CLASSES organ as a foreign body HLA-A, HLA-B, HLA-C Exception: Identical Twins CLASS I Expressed by ALL NUCLEATED Transfer of cells, tissue, or an CELLS organ from one organism to HLA-DR, HLA-DP, HLA-DQ XENOTRANSPLANT ANOTHER of a DIFFERENT species Expressed by antigen presenting Animal to human cells (APCs) such as B Still experimental CLASS II lymphocytes, dendritic cells, macrophages, and other phagocytic cells The function of HLA antigens is to present the fragment proteins to T lymphocytes, leading to the recognition and elimination of the foreign antigen with great specificity The outcomes of early transplants were less than satisfactory MECHANISMS OF GRAFT REJECTION The limiting factor was the lack of understanding of immunologic processes, and irreversible rejection was Most common the reason for graft loss in the vast majority of recipients Damage by activated T CELLULAR The immune system is designed as a defense system to lymphocytes REJECTION protect the body from foreign pathogens, such as viruses, Process of activation and proliferation is triggered by KUMUNOY’S IMPROPERTY 1 1  BASIC SURGERY A (BASIC??? BASIC IBAGSAK! HUYY MAG-ARAL TAYO GUYS!!) LECTURER: Dr. Carl Evans Y. De Castro, si doc daw savior natin ngayong finals (weh) exposure of T lymphocytes to the donor’s HLA molecules Damage by circulating antibodies against the donor’s HLA molecules The donor-specific antibodies can be present either pretransplant, due to previous HUMORAL exposure (because of a previous REJECTION transplant, pregnancy, blood transfusion, or immunization), posttransplant After antibody binding to the donor’s HLA molecules, the complement cascade is activated, leading to cellular lysis The end result for both types is the same – graft damage caused by inflammatory injury LAW OF TRANSPLANTATION HOST VS GRAFT GRAFT VS HOST ImmunoCOMPROMISED host ImmunoCOMPETENT host grafted with foreign recognizes foreign immunocompetent antigens lymphoid cells TYPES OF CLINICAL REJECTION ↓ ↓ Irreversible damage and graft Mounts an immune Immunoreactive T-cells in the loss within minutes to hours after response graft recognize the foreign organ reperfusion; very rapid ↓ antigens on the host tissue Caused by Preformed Antibodies REJECTION ↓ against Donor’s HLA or ABO DAMAGE OF HOST TISSUE (HUMORAL REJECTION) DIC causing Ischemic necrosis of Graft rejection is due to a complex interaction of different HYPERACUTE graft components of the immune system, including B and T Prevented by Pretransplant Blood lymphocytes, APCs, and cytokines Typing and Cross matching (in Reaction of the host against allo-antigens of the graft which the donor’s cells are mixed (Host vs. Graft) results in its rejection with the recipient’s serum, and Major obstacle in organ transplantation then the cells are observed for Warning signs (general) any destruction) ○ Fever, flu-like symptoms, hypertension, edema or MOST COMMON sudden weight gain, changes in heart rate, shortness Within days to weeks post of breath, and pain over the graft site transplant Most importantly graft dysfunction is observed Caused by CELLULAR OR HUMORAL REJECTION OR BOTH T cell or Antibody mediated, Inflammatory injury to donor organ ACUTE Diagnosis through Biopsy transplanted organ, IHS (special immunologic stains), Laboratory tests (elevated creatinine levels in kidney transplant recipients, elevated liver test values in liver transplant recipients, and elevated levels of KUMUNOY’S IMPROPERTY 2 1  BASIC SURGERY A (BASIC??? BASIC IBAGSAK! HUYY MAG-ARAL TAYO GUYS!!) LECTURER: Dr. Carl Evans Y. De Castro, si doc daw savior natin ngayong finals (weh) glucose, amylase, and lipase in MHC identity with the recipient pancreas transplant recipients) ○ An identical twin is the ideal donor Slowly and progressive ○ Grafts from an HLA matched sibling have 95-100% Manifest within FIRST YEAR of chance of success transplant but most often takes The major histocompatibility complex is a large locus in place gradually over several our DNA and it contains a set of closely linked years polymorphic chains that encodes on the surface Cause is not well understood but HLA matching: if two people share the same HLA type, the pathologic changes they are considered a match eventually lead to Tissue fibrosis CHRONIC and loss of graft function A close match between a donor’s and patient’s HLA Becoming more common as markers is essential for a successful transplant advances in immunosuppression HLA matching promotes the growth and development of have diminished the incidence of new healthy blood cells (engraftment); it reduces acute rejection posttransplant complications Can be prevented by For optimal graft outcome compatibility at 3 HLA Loci immunosuppressants, which is (HLA-A, HLA-B, and HLA-DR) is most desirable why it is given lifetime One haplotype-identical parent or sibling must match at the HLA-D region GRAFT VS HOST REACTION ○ Half is inherited from the mother and half is inherited ACUTE GVHD CHRONIC GVHD from the father /100* days after ○ Each brother and sister who share the same parents ONSET have a 1 out 4 or 25% chance to match after transplant transplant Recipient age Acute GVHD ○ Extended family members are NOT LIKELY to be close RISK Recipient age HLA matches but about 70% of patients who need a FACTORS Female-to-male transplant won’t have a fully matched donor in their sex mismatch family Skin (skin Multisystem: skin An ABO compatibility is essential rashes, (hyperpigmented erythema) skin), liver, GI RECIPIENT PREPARATION Liver tract, eyes, bone Infection free TARGET GI tract marrow, immune Cancer screening ORGANS system, mucus ○ If there is any lymphomatous or hematogenous membranes spread of cancer, it would likely transfer the cancer (buccal erosions, cells to the graft exophytic masses Optimal cardiac function over the tongue) Current Diseases is not active Prophylaxis: Prophylaxis (anti- Immunosuppression (drugs) methotrexate infective) Prophylaxis Corticosteroids TREATMENT (anti-infective) Supportive care Corticosteroids Supportive care *Mode; acute GVHD may occur as early as 7-10 days; classical A successful transplant hinges upon a balance between onset of chronic GVHD is 50-70 days but may be greater than 12 the extent of the recipient’s immune response, the health months and viability of the donor allograft, and pharmacologic immunosuppression Common clinical manifestations of Graft vs. Host reaction ○ Diarrhea (changes in the lining of GIT), erythema, IMMUNOSUPPRESSANTS weight loss (loss of appetite in general), body malaise, Presently, immunosuppressants are used in multidrug fever, joint pain, death regimens aimed at increasing efficacy by targeting multiple pathways to lower the immune response and to decrease the toxicity of individual agents Certain regimens may involve withdrawal, avoidance, or minimization of certain classes of drugs Transplant centers generally institute their immunosuppressive protocols based on experience, risk DONOR SELECTION profiles, cost considerations, and outcomes. KUMUNOY’S IMPROPERTY 3 1  BASIC SURGERY A (BASIC??? BASIC IBAGSAK! HUYY MAG-ARAL TAYO GUYS!!) LECTURER: Dr. Carl Evans Y. De Castro, si doc daw savior natin ngayong finals (weh) Delivered in two phases ○ Induction – starting immediately posttransplant when DECEASED DONORS the risk of rejection is highest; Anti-T lymphocyte- Most transplants today utilize organs from deceased depleting or non-depleting antibodies donors ○ Maintenance – usually starting within days Formerly, death was determined by the cessation of both posttransplant and usually continuing for the life cardiac and respiratory function (lifetime) of the graft and the recipient; calcineurin Brain Death – irreversible cessation of brain function, inhibitors, antiproliferative agents, and corticosteroids including the brainstem A conventional immunosuppressive protocol might Medical conditions that mimic brain death (drug include overdose, medication side effects, severe hypothermia, ○ Induction with anti-T-lymphocyte–depleting or hypoglycemia, induced coma, and chronic vegetative nondepleting antibodies state) NEED TO BE EXCLUDED ○ Maintenance with calcineurin inhibitors, antiproliferative agents, and corticosteroids STEPS ON CLINICAL DIAGNOSIS OF BRAIN DEATH Prophylaxis for bacteria, viral, and fungal elements are Establishment of the proximate cause of the neurologic given during the first 3 to 6 months because the degree of insult immunosuppression is highest in the first 3 to 6 months Clinical examinations to determine coma, absence of (immune system is very weak) brainstem reflexes, and apnea Utilization of ancillary tests, such as IMMUNOSUPPRESSIVE DRUGS BY GROUPING electroencephalography (EEG), cerebral Calcineurin inhibitors angiography, or nuclear scans, in patients who do not Immunophilin (Cyclosporine, Tacrolimus) meet clinical criteria Binders Noninhibitors of calcineurin Appropriate documentation (Sirolimus) Inhibitors of de novo purine The medical history and social history are obtained from Antimetabolites synthesis (Azathioprine, the available family members Mycophenolate mofetil) A battery of tests, including serologic or molecular Polyclonal antibodies (Atgam, detection of human immunodeficiency virus (HIV) and Antithymocyte viral hepatitis are performed immunoglobulin) Biologic Monoclonal antibodies LIVING DONORS Immunosuppression (Muromonab-CD3, Basiliximab, The maxim of medical ethics is “primum non nocere” (first, Belatacept, Alemtuzumab, do no harm), and for that reason, living organ donation Rituximab, Bortezomib, presents unique ethical and legal challenges Eculizumab) Performing potentially harmful operations to remove Other Corticosteroids organs from healthy individuals seems to contradict that maxim but the ethical framework of living organ donation rests on three guiding principles respected in all discussions of medical practice: ○ Beneficence to the recipient ○ Nonmaleficence to the donor ○ Donor’s right to autonomy Organ procurement is a key element in organ In order to achieve optimal outcomes (the common transplantation good), transplant professionals should focus on Organ procurement organizations (OPOs) maximizing the benefits for the recipient and minimizing ○ Responsible for evaluating and procuring deceased the damage to the donor donor organs for transplantation in a specific A shorter waiting time generally implies a healthier geographic region recipient – one whose body has not been ravaged by ○ Determines the medical suitability of the deceased prolonged end-stage organ failure for organ donation ○ Requests consent for donation from family members With the use of living donors, transplants are planned ○ If consent is given, contacts the OPTN to analyze and (rather than emergency) procedures, allowing for better identify potential recipients whose HLA antigens most preoperative preparation of the recipient closely match those of the donor Receiving an organ from a closely matched relative may ○ Arranges for the recovery and transport of any also have immunologic benefits donated organs Long-term results may be superior with the use of living ○ Preserve organ function and optimize peripheral donors as is certainly the case with kidney transplants oxygen delivery until the organ procurement commences KUMUNOY’S IMPROPERTY 4 1  BASIC SURGERY A (BASIC??? BASIC IBAGSAK! HUYY MAG-ARAL TAYO GUYS!!) LECTURER: Dr. Carl Evans Y. De Castro, si doc daw savior natin ngayong finals (weh) is an important part of the pretransplant evaluation. Ullman reported the first attempted human kidney Malignancies transplant in 1902 ○ Because of the long-term use of immunosuppressive medications, transplant For the next 50 years, sporadic attempts all resulted in recipients are at increased risk for either technical failure or in graft failure from rejection. development of malignancies. Joseph Murray Infections ○ Performed the first successful kidney transplant in Kidney Disease 1954, an epochal history of organ transplantation. ○ The third most common cause of graft loss in Today, a kidney transplant remains the most definitive kidney transplant recipients is recurrence of and durable renal replacement therapy for patients with glomerular diseases such as focal segmental ESRD. It offers better survival and improved quality of life glomerulosclerosis (FSGS), immunoglobulin A and is considerably more cost-effective than dialysis (IgA) nephropathy, hemolytic uremic syndrome, systemic lupus erythematosus, LIVING DONOR KIDNEY TRANSPLANT and membranoproliferative Better posttransplant glomerulonephritis. outcomes Hypercoagulopathy ADVANTAGE Avoidance of prolonged ○ In recipients at risk for hypercoagulopathy, waiting time and dialysis pediatric kidney grafts and any kidney Recipient desensitization allografts with a complex vascular anatomy Supply and demand should be avoided. CHALLENGES Rejection ○ A perioperative anticoagulation protocol is Active infection recommended in this population. Presence of malignancy Surgical Evaluation CONTRAINDICATIONS Active substance abuse Urologic Evaluation Poorly controlled psychiatric ○ Kidney transplant candidates (pediatric illness patients, in particular) with chronic kidney Medical Evaluation (CVD, disease as a result of congenital or Infection, Malignancy, genitourinary abnormalities should undergo Kidney Disease, a thorough urologic evaluation. PRETRANSPLANT Hypercoagulability) ○ A voiding cystourethrogram and a complete EVALUATION Surgical Evaluation (Urologic, lower urinary tract evaluation to rule out Vascular, Immunologic, outlet obstruction are essential. Psychosocial) Vascular Evaluation ○ The potential implant sites for a kidney graft Pretransplant Evaluation include the recipient’s iliac vessels and, less Active infection or the presence of a malignancy, commonly, the aorta and vena cava. active substance abuse, and poorly controlled Immunologic Evaluation psychiatric illness are the few absolute ○ ABO blood typing and HLA typing (HLA-A, -B, contraindications to a kidney transplant and -DR) are required before a kidney To achieve optimal transplant outcomes, the many transplant risks (such as the surgical stress to the cardiovascular Psychosocial Evaluation system, the development of infections or ○ Patients with uncontrolled psychiatric malignancies with long-term immunosuppression, disorders are at high risk for noncompliance and the psychosocial and financial impacts on with drug treatment, impaired cognitive compliance) must be carefully balanced. function, and the development of substance Any problems detected during the evaluation of abuse. transplant candidates are communicated to their referring physician and/or to a specialist if advanced evaluation and treatment are needed, ultimately improving overall care. Medical Evaluation Cardiovascular DIsease ○ Diabetes and hypertension are the leading causes of chronic renal disease. Concomitant cardiovascular disease (CVD) is a common finding in this population. ○ Therefore, assessment of the potential kidney transplant candidate’s cardiovascular status KUMUNOY’S IMPROPERTY 5 1  BASIC SURGERY A (BASIC??? BASIC IBAGSAK! HUYY MAG-ARAL TAYO GUYS!!) LECTURER: Dr. Carl Evans Y. De Castro, si doc daw savior natin ngayong finals (weh) RECIPIENT OPERATION Offering transplants to alcoholic patients has always Kidney Allografts are transplanted drawn some opposition because of the perception of heterotrophically (can transplant in another it being a self-inflicted illness, as well as concerns location without removing the diseased organ) about recidivism and the recipient’s possible inability Ideal position: Iliac Fossa to maintain postoperative immunosuppression and care. Patients who drink 4 to 8 ounces of liquor daily for 10 to 15 years have an increased risk of developing cirrhosis, the general requirement for acceptance as a transplant candidate is 6 months of abstinence. Furthermore, most transplant centers recommend rehabilitation and Alcoholics Anonymous programs. Hepatitis C Virus (HCV) ○ Yielded worse outcomes than transplants for other diseases because. ○ The reason is the universal recurrence of the virus post transplant. Viral levels reach Figure 11-6. Incision and exposure for kidney transplant. pretransplant levels as early as 72 hours post 1. Mark for the skin incision. transplant 2. Anterior rectus sheath incised obliquely. The ○ The course of the viral infection is often abdominal muscle transected lateral to the rectus accelerated posttransplant: 10% to 20% of muscle. recipients develop cirrhosis after just 5 years. 3. External iliac artery and vein dissected. Hepatocellular carcinoma (HCC) ○ A complication of cirrhosis, is the most common type of hepatic malignancy ○ Resection is the first line of treatment if possible, but often, cirrhosis is too advanced. ○ If the tumor meets the Milan criteria, a liver transplant can be performed. Figure 11-7. Vascular anastomoses of kidney transplant Contraindications A. Arterial anastomosis: donor renal artery with Carrel In general terms, contraindications to a liver patch to recipient external iliac artery, end-to- transplant include insufficient cardiopulmonary side. reserve, uncontrolled malignancy or infection, and B. Venous anastomosis: donor renal vein with caval refractory noncompliance extension conduit to recipient external iliac vein, Older age is only a relative contraindication: carefully end-to-side. selected recipients over the age of 70 years can achieve satisfactory outcomes. Surgical procedure A liver transplant is among the most extensive operations performed, and it can be associated with The first attempts at liver transplants in the late 1960s considerable blood loss through the 1980s were largely experimental endeavors, with a 1-year survival rate of only 30%. LIVER TRANSPLANTATION But breakthroughs in immunosuppression, surgical ANY FORM OF IRREVERSIBLE technique, organ preservation, anesthesia, and LIVER DISEASE critical care have improved that rate to INDICATIONS ○ Chronic alcohol disease approximately 85% today. ○ HCV Liver transplants remain daunting, especially in the ○ HCC face of an organ shortage that results in sicker Insufficient Pulmonary potential candidates. Reserve The perioperative mortality rate and the 1-year Uncontrolled Malignancy mortality rate are among the highest of any surgical CONTRAINDICATIONS and Infection operation currently performed. Refractory Noncomp;icance Indications Relative Contraindication: In general, any form of irreversible liver disease is an Older age indication for a liver transplant. Chronic alcoholic disease and HCV are the most common indications in the United States. KUMUNOY’S IMPROPERTY 6 1  BASIC SURGERY A (BASIC??? BASIC IBAGSAK! HUYY MAG-ARAL TAYO GUYS!!) LECTURER: Dr. Carl Evans Y. De Castro, si doc daw savior natin ngayong finals (weh) Main indication is progressive complication despite medical care ○ Neuropathy, retinopathy, nephropathy Brittle DM: frequent hypoglycemia, DKA History of Diabetes Mellitus Type 1 Previous Pancreatic CONTRAINDICATIONS procedure Chronic Pancreatitis Intraductal Papillary Mucinous Neoplasm RECIPIENT OPERATION Ideal position: Right Iliac Fossa Anastomosed to External Iliac Vessels RECIPIENT OPERATION Bilateral subcostal incision with midline extension Ligamentous attachments, vascular structures, bile duct, portal structures, and vena cava are divided, completing the hepatectomy An intestine transplant is indicated for patients with Suprahepatic, Infrahepatic vena caval, CHA irreversible intestine failure in combination with TPN anastomosis failure. The definition of intestine failure does not specify the exact length of the remaining intestine. Intestine failure is typically multifactorial. SMALL BOWEL TRANSPLANTATION Short bowel syndrome with complication in TPN Jejunum: Lactose intolerance INDICATIONS Irreversible intestinal failure Congenital mucosal disorders Adults: Ischemia (22%) Pedia: Gastroschisis (27%) A successful pancreas transplant currently is the only Small bowel from duodenum to ileum — 600 cm definitive long-term treatment for patients with insulin- You need at least 180 cm to be able to digest and absorb. dependent diabetes mellitus (IDDM) that (a) restores ○ If less than that, you have Short Bowel Syndrome. normal glucose homeostasis without exposing patients to the risk of severe hypoglycemia and (b) prevents, halts, or, in some cases, reverses the development or progression of secondary complications of diabetes PANCREAS TRANSPLANTATION Very important option for type I DM ○ Hyperglycemia is the INDICATIONS most important factor influencing complications KUMUNOY’S IMPROPERTY 7 1  BASIC SURGERY A (BASIC??? BASIC IBAGSAK! HUYY MAG-ARAL TAYO GUYS!!) LECTURER: Dr. Carl Evans Y. De Castro, si doc daw savior natin ngayong finals (weh) FACTORS AFFECTING TRANSPLANT OUTCOME Early graft dysfunction and early graft ischemia Previous graft rejection Presence of preformed anti HLA antibodies in serum of recipient Early rejection episodes Increased cold-ischemia time of graft (>48 hours) ANTIGEN INDEPENDENT FACTORS - Ischemia - Hypothermia - Reperfusion Injury SMALL BOWEL TRANSPLANTATION Overall survival is 45% ○ 70% in 1 year ○ Full graft function 80% Recovery ○ Tube feeding on 2nd week (low osmolality isotonic dipeptide) Mortality The three most common causes of death after ○ Sepsis is main cause of mortality (49%) transplantation: 90% acute rejection ○ Cardiovascular disease ○ Lymphoma ○ Infectious disease ○ Acute Rejection occurs in 90% ○ Malignancy Two most common causes of graft loss: ○ Death with a functioning graft ○ Chronic rejection INFECTION: ○ Urinary tract infection is quite common ○ Cytomegalovirus (CMV) ○ Pneumocystis carinii ○ HSV ○ Toxoplasma ○ Hepatitis C Virus ○ Pneumococcal Infection KUMUNOY’S IMPROPERTY 8 1  BASIC SURGERY A (BASIC??? BASIC IBAGSAK! HUYY MAG-ARAL TAYO GUYS!!) LECTURER: Dr. Carl Evans Y. De Castro, si doc daw savior natin ngayong finals (weh) ○ EBV What is the most common mechanism in cellular rejection TRANSPLANT ASSOCIATED MALIGNANCY: a. Humoral Cellular b. Cellular ○ Overall incidence of malignancy: 6% c. Hyperacute ○ Lymphomas: 1-2% d. Chronic ○ Kaposi’s sarcoma and genital neoplasms What is the warning sign for kidney ○ Posttransplant lymphoproliferative disease transplant rejection? (PTLD) are abnormalities driven by Epstein- a. Hypertension Hypertension Barr virus (EBV) b. Increased urine output c. Sudden weight loss d. All of the choices are correct How long should maintenance immunosuppressants be given for post- Xenotransplants (i.e., cross-species transplants of transplant patients? Lifetime organs, tissues, or cells) have immense, yet untapped, a. 1 year potential to solve the critical shortage of available b. 5 years c. 10 years grafts. d. Lifetime A primary hurdle is the formidable immunologic Which of the following refers to barrier between species, especially with vascularized transplantation of a donated human whole organs kidney in the iliac fossa without removing Other problems include the potential risk of the damaged kidney? transmitting infections (known as zoonoses or a. Orthotopic Heterotopic xenoses) and the ethical problems of using animals b. Heterotopic for widespread human transplants, even though c. Xenotransplantation great progress has been made in the past few years d. Autotransplantation in efforts to overcome these problems. Which of the following categories of transplantation requires Pigs are generally accepted as the most likely donor immunosuppression? Identical twins species for xenotransplants into human beings a. Identical twins transplantation transplantation ○ Pigs would also be easier to raise on a large- b. Autotransplantation of islet cells scale basis. c. Xenotransplantation of islet cells At a recent symposium organized by the International d. All of the choices requires Xenotransplantation Association, data presented immunosuppression demonstrated extended survival time of porcine solid Which of the following correctly describes The immune system organs in nonhuman primates: from about 30 days to allotransplantation? of the recipient an average of 60 days and even up to 250 days a. Still experimental recognizes the b. Transfer of tissue from one part of donated organ as (depending on the model). the body to another part in the a foreign body However, clinical application is still limited by same person thrombotic microangiopathy and consumptive c. No immunosuppression required coagulopathy; novel methods to prevent those d. The immune system of the complications will be required for further progress recipient recognizes the donated organ as a foreign body Which class of Human Leukocyte Antigen are expressed by nucleated cells? HLA - A a. A b. DR c. DP d. DQ Which of the following is NOT true for Class MIDYEAR FINALS MAJOR EXAM- May 25, 2024 III MHC? Which of the following refers to a. Expressed by antigen presenting cells Presents transplantation of a donated human liver b. Presents fragments of foreign body to fragments of after removing the diseased liver? Orthotopic T Lymphocytes foreign body to a. Orthotopic c. Originates from nucleated cells b. Heterotopic d. Example include HLA-DR T lymphocytes c. Xenotransplantation d. Autotransplantation Which of the following correctly describes autotransplantation? a. Transfer of organ from one person to another of the same species b. Immunosuppression is not required Immunosuppression c. Still experimental is not required d. Requires ABO and HLA crossmatching KUMUNOY’S IMPROPERTY 9 1  BASIC SURGERY A (BASIC??? BASIC IBAGSAK! HUYY MAG-ARAL TAYO GUYS!!) LECTURER: Dr. Carl Evans Y. De Castro, si doc daw savior natin ngayong finals (weh) What is the mechanism of damage for Which of the following is a humoral rejection? contraindication for kidney transplant? a. Activated lymphocytes proliferates Circulating a. Active infection Active and attacks donor’s HLA molecules antibodies b. DM infection b. Inactivated lymphocytes activates c. Controlled psychiatric illness and attacks donor’s HLA molecules attacks donor’s d. Peripheral occlusive disease c. Exposure of T lymphocytes to donor’s HLA molecules What is the ideal recipient position of HLA molecules kidney transplant? d. Circulating antibodies attacks a. Retroperitoneal Iliac fossa donor’s HLA molecules b. Sacral area c. Iliac fossa d. infra-hepatic Which of the following is NOT a warning Which of the following irreversible liver sign of liver transplant rejection? diseases is NOT an indication for liver a. Jaundice Diarrhea transplant? Hepatitis C b. Pruritus a. Hepatocellular carcinoma c. Diarrhea b. HCV Virus d. Tea colored Urine c. Chronic alcohol disease Which of the following clinical rejection is d. Uncontrolled hepatic metastasis caused by preformed antibodies against Which of the following is a the donor's HLA? contraindication for pancreatic a. Hyperacute b. Acute Hyperacute transplant? Intraductal Papillary a. DM nephropathy despite medical Mucinous Neoplasm c. Chronic care progression despite d. All of the choices are correct b. DM neuropathy despite medical medical care What is TRUE for chronic clinical rejection? care a. Cause is not well understood c. DM Type 1 with hyperglycemic b. Manifest within first month of episodes despite medical care transplant Cause is not well d. Intraductal Papillary Mucinous c. Leads to Disseminated Intravascular understood Neoplasm progression despite Coagulation medical care d. Prevented by pre transplant blood What is the leading cause of intestinal typing failure leading to small bowel What is the time of clinical rejection transplantation in adults? Visceral preparation in hyperacute rejection? a. Seconds to minutes Minutes to a. Gastroschisis ischemia b. Crohn's disease b. Minutes to hours secondary to c. Days to week hours c. Visceral ischemia secondary to SMA SMa thrombosis thrombosis d. Within first year d. Massive resection secondary to Which of the following is NOT TRUE for tumors chronic e graft versus host reaction? What is the main cause of mortality in a. Onset is more than 100 days after Usually small bowel transplantation? transplant b. Usually manifest with skin rashes and manifest with a. Sepsis Sepsis b. Lymphoma erythema skin rashes c. Acute rejection c. Treated by Prophylactic antibiotics, Corticosteroids and supportive care and d. Malabsorption d. Risk factor include female to male erythema sex mismatch Long term complications of graft loss Which of the following is NOT TRUE for includes which of the following MOST transplant donor selection? COMMON causes of graft loss? Death with a a. Grafts from HLA matched sibling has Grafts from HLA a. Death with a functioning graft and functioning graft 25% chance of success matched chronic rejection and chronic b. An identical twin is the ideal donor b. Cardiovascular disease and chronic rejection c. One haplotype identical sibling must during sibling rejection match at the HLA-D region has 25% c. Acute rejection and d. ABO compatibility is essential chance immunosuppression d. Presence of multiple comorbidities success Small bowel transplantation is being When should antibacterial prophylaxis be performed since 1985. Which of the given while ongoing immunosuppression following are included in the regimen? INDICATIONS of small bowel a. First week b. First 6 months First 6 months transplantation in adults? Ischemia a. Gastroschisis c. First year b. Volvulus d. Not necessarily given c. Necrotizing enterocolitis KUMUNOY’S IMPROPERTY 10 1  BASIC SURGERY A (BASIC??? BASIC IBAGSAK! HUYY MAG-ARAL TAYO GUYS!!) LECTURER: Dr. Carl Evans Y. De Castro, si doc daw savior natin ngayong finals (weh) d. Ischemia members of the same species genetically What is the most common transplanted b. Allogeneic - genetically identical organ in the world? strain identical strain a. Liver Kidney c. Syngeneic - genetically different b. Kidney members of the same species c. Pancreas d. Syngeneic - genetically identical d. Small bowel strain Which of the following are the most Which of the following is included in the common causes of death after factors affecting transplant outcome in general? Early rejection transplantation? a. Iatrogenic injury, cardiovascular Cardiovascular a. Late graft dysfunction episodes are diseases, malignancy diseases, b. Absence of preformed anti HLA strongly b. Cardiovascular diseases, infectious antibodies in serum of patient correlated with hypersensitivity reaction, iatrogenic c. Decreased cold ischemia time of degree of HLA injury diseases, graft