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KIDNEY TRANSPLANT

Q.765. What is the prognosis of PTLD? How to improve?

 KIDNEY TRANSPLANT

 

Q.765. What is the prognosis of PTLD? How to improve?

A. Prognosis is poor, but can be improved by:

(1) Technique of monitoring EBV viral  load, to detect risk ptn.                                                        

(2) New therapies: Adoptive immunotherapy, 👈 using EBV-sp.  C.T.L.s. (cytotoxic “T” lymphocytes)

.. So, thorough pre-Tx. evaluation, avoid excessive im/m.+ standard Iry & IIry preventive strategies:   

v Cessation of smoking.  🚭

v Uterine cervix smear.

v If cancer occur ] Reduce im/m. greatly.

Q.766. What is meant by “Adoptive immunotherapy?        👓

 

A.The exquisite specificity of cytotoxic T lymphocytes (CTLs) has led investigators to attempt to isolate cells é significant antitumor activity; infusion of these cells is referred to as adoptive immunotherapy. It has a possible role in refractory Hodgkin lymphoma, based upon the ability to generate clones of cytotoxic T-lymphocytes that’re sp. for Ep.-Barr virus latent Ags [LMP1& LMP2 or Reed-Sternberg cells]. Expanded clones of these cells may have a therapeutic role in Hodgkin lymphoma whose Reed-Sternberg cells express Ep.-Barr viral Ag.

Q.767. What else?     😉

A. I.X. Infectious complications(See also, Q.679), it depends on:

v Intensity of exposure é hospital & community. 

v Overall state of immunosuppression.                                                                                    

    Fishman & Rubin divided it periodically to : 0-1 m.  1-6  m   &  🠉6 m.

Q.768. Which factors can affect the net state of immunosuppression?

A. Net state of immunosuppression could be affected by:

1)   Im/m. dose, duration & type.

2)   Co-morbid dis.:  e.g. [D.M. – U.T.I.]

3)   Integrity of mucocutanous barriers.

4)   Infection with virus affecting the immune system.

Q.769. What is the “spectrum” of PTLD?

A. Spectrum of PTLD:      I. 😃  II. 😑  III. 😌

 I. Early (50 %) [Infectious mononucleosis–like illness, Pth.: Preserved  architec-ture-“Polyclonal”. * ttt: (Reduce im/m. dose+acyclovir), Prognosis is good]. 😃

II. Polymorphic PTLD (30%)[infectious mononucleosis –like illness (+/-)- Wt. loss- Localized Sm.-Pth.: intermediate polyclonal- * ttt.: [Reduce dose of im/m.- + acyclovir-If poor response ttt. like III.] 😑

III. Monoclonal PTLD (20%): [fever- Wt. loss- Localized Sm.– Monoclonal] Pth.: High grade lymphoma + marked atypia - poor prognosis.* ttt. [🠋im/m. to low dose steroid only + Combin. of : Surgery-Chemo./Radiothpy+ Rituximab.]  😌 

Q.770. When can a female recipient allowed to be pregnant?    

A. Certain criteria to be fulfilled:              

ΠGood general health 18 m. before conception.

 Stable allograft fuction, i.e. Pl. cr. £ 0.2 mg/dl.

Ž Minimal “H.T.” & minimal “proteinuria”.

 Immunization at maintenance dose.

 No pelvi-calyceal dilatation at a recent U/S.

N.B.:

-    👆  [H.T., pre-eclampsia, prematurity, low birth wt.] are more common in pregnant recipient.

-      In labor, take care of the ureter, kid. function, to avoid HUS & Ac. Rj.

-      MMF. ] Teratogenic. 👆

-      Aza, CNI & Steroids ] SAFE in Utero.     😃

                             

Q.771. What Lipid abnormalities can be seen after renal transplantation?

A. Abn. lipid profile is a common complication of R.Tx., but a causal association of dyslip. & CVS risk has not been proven. However, due to high incid. of athrsc. dis. events in R.Tx., we consider R.Tx. a coronary heart dis. equivalent risk. So, assessment & ttt of dyslipidemia in R.Tx. ptn. shd be part of routine post-R.Tx. care. Im/m. drugs, esp.👉steroids, CNI & rapamycin