Renal transplantation ´ëÀå°æ Á¤¸®
1. ½ÅÀ̽ÄÀÇ Àý´ë ±Ý±â
reversible renal involement, ability of conservative measure,
advanced forms of major extrarenal complication(CVA, coronary disease, neoplasia)
active infection, active GN, previous sensitization of donor tissue
2. Á¶Á÷ÀûÇÕ¼º °Ë»ç
1) hyperacute rejection ¹æÁöÀ§ÇØ => ABO typing, lymphocyte cross-matching
2) long-term survivial => HLA typing
3) ±âŸ: panel reactive antibody(PRA), mixed lymphocyte culture
* PRA: specific HLA lymphocyte panel¿¡¼ recipient serumÀ¸·Î lymphocytotoxicity test¸¦
½ÃÇàÇÏ¿© À̽ÄÀü recipient°¡ donor lymphocyte¿¡ Ç¥ÇöµÇ¾î ÀÖ´Â HLA Ag¿¡ ´ëÇØ
sensitizationµÇ¾î ÀÖ´Â Á¤µµ¸¦ ¾Ë¾Æº¸´Â °Ë»ç
3. T cell warm Ab¾ç¼º½Ã ÀÌ½Ä Àý´ë ±Ý±â
lymphocyte cross-match´Â donor lymphocyte¿Í recipient serumÀ¸·Î
microlymphocytotoxicity test¸¦ ½ÃÇàÇÏ´Â ¹æ¹ýÀ» ÀÌ¿ëÇϴµ¥ T lymphocyte·Î HLA class I
(HLA A & B)À», B lymphocyte·Î HLA class II(HLA DR)¸¦ °Ë»çÇÑ´Ù. T lymphocyte¿¡ ´ëÇÑ
cross-match°¡ ¾ç¼ºÀ̸é À̽ĺҰ¡´ÉÇϰí, B lymphocyte¿¡ ´ëÇØ ¾ç¼ºÀ̸é titer°¡ ³·Àº
°æ¿ì¿¡´Â À̽ĽŠ»ýÁ¸·ü¿¡ ¿µÇâÀÌ ¾øÁö¸¸, titer°¡ ³ôÀº °æ¿ì »ýÁ¸·üÀÌ °¨¼ÒÇÏ¿© À̽ÄÇÏÁö
¾Ê´Â´Ù.
4. Hyperacute rejectionÀ» ÀÏÀ¸Å³¼ö ÀÖ´Â Ç׿ø?
HLA class I, ABO Ag, endothelial Ag
5. recipient¿¡¼ bilateral nephrectomy Ix
uncontrolled hypertension, infection
6. Cadaver donor exclusion criteria
HIV, HBV, HCV (CMV´Â ¾Æ´Ô)
7. Renal transplant graft rejection
1) hyperacute: ¼öºÐ-¼ö½Ã°£
2) accelerated: 5-6Àϳ»
3) acute: 1ÁÖ-3°³¿ù, ±×ÈÄ¿£ ºóµµ°¨¼Ò
4) chronic: multifactorial Ãʱâ-immune mediated, Èıâ-nonimmune
8. ¸é¿ª¾ïÁ¦Á¦
APC(IL-1,6) -> Th cell(IL-2) -> Tc cell proliferation
(glucocorticoid) (cyclosporine)
Azathioprine : DNA, RNAÇÕ¼º¿¡ ÇÊ¿äÇÑ purineÇÕ¼º ¾ïÁ¦
Mycophenolate mofetil(Cellept) azathioprine´ëüÁ¦, °ÅºÎ¹ÝÀÀ ¿¹¹æ ¹× ȸº¹
Sirolimus(rapamycin): fungal macrolide
OKT3: T lymphocyteÀÇ CD3ºÐÀÚ¿Í ¹ÝÀÀ
Tacrolimus(FK-506) : cyclosporine°ú À¯»çÀÛ¿ë, ´ç´¢º´ ¹ß»ý ºóµµ°¡ ´õ ³ô´Ù.
9. Cyclosporine ºÎÀÛ¿ë
nephrotoxicity, hepatotoxicity, hirsutism, gingival hypertrophy
hyperkalemia, hyperuricemia, metabolic acidosis, hypoposphatemia, hypomagnesemia
HUS/TTP, DM, tremor, hypercholesterolemia, palmar & plantar paresthesia
* BM suppressionÀº °ÅÀÇ ¾ø´Ù.
10. cyclosporine¿¡ ÀÇÇÑ ±Þ¼º ½ÅºÎÀüÀÇ ±âÀü
i) afferent arterioles vasoconstriction
ii) ATN
iii) interstitial nephritis(rare)
11-1) CyclosporineÇ÷Á߳󵵸¦ ¿Ã¸®´Â ¾à
-conazole(ketoconazole, fluconazole, itraconazole), Ca channel blocker(diltiazem,
verapamil, nicardipine), cimetidine, metoclopramide, oral contraceptives, EM, ticarcillin
2) Ç÷Á߳󵵸¦ ³·Ãß´Â ¾à
carbamazepine, phenobarbital, phenytoin, ethambutol, rifampin, isoniazid,
nafcillin, primidone, sulfamethoxazole, imipenem
12. Immediate nonfunction of allograft(delayed graft function)ÀÇ ¿øÀÎ
ATN(most common)
obstruction, vascular thrombosis, ureteral compression from hematoma
13. Late allograft dysfunction ¿øÀÎ(3°³¿ù)
i) transplant renal artery stenosis
ii) recurrent primary disease
iii) cyclosporine toxicity
iv) rejection(acute or chronic)
v) urinary tract obstruction
vi) infection
14. Acute rejection Ä¡·á
steroid pulse therapy(ÃÖ´ë 2ȸ) -> Ab treatment 1ȸ(OKT3)
-> CSA¿¡¼ tacrolimus(FK506)·Î ¹Ù²Ù°Å³ª mycophenolate Ãß°¡
refractory rejectionÀÇ ¾à 75%¿¡¼ È¿°ú°¡ ÀÖ´Ù.
15. ½ÅÀÌ½Ä ¿©ÀÚ°¡ ¼º°øÀû ÀÓ½ÅÀ» À§ÇÑ Áöħ
i) ÀÌ½Ä 2³â°£ °ÅºÎ¹ÝÀÀ ¾øÀÌ ¾çÈ£ÇÑ ½Å±â´É »óÅÂ
ii) s-Cr < 2mg/dL
iii) Á¤»óÇ÷¾Ð
iv) ´Ü¹é´¢°¡ ¾ø°Å³ª °æ¹Ì
v) IVP»ó pelvocalyceal distention(-)
vi) ¸é¿ª¾ïÁ¦Á¦¸¦ À¯Áö¿ë·®À¸·Î ÁÙ¿´À» ¶§
16. Bactrim prophylaxis°¡ È¿°ú°¡ ÀÖ´Â °¨¿°
Pneumocystis carini, Norcardia, UTI, Listeria monocytogenes, Toxoplasma gondii
17. CMV(+) donor -> CMV(-) recipient·Î À̽ÄÇÒ ¶§ ¿¹¹æÀû Á¶Ä¡
CMV immunoglobulin Åõ¿©, Ganciclovir Ä¡·á
18. CMV infectionÀÇ Áø´Ü
CMV IgM(+), anti-CMV IgG Ab titer 4¹èÀÌ»ó Áõ°¡,
throat, urineµî¿¡¼ virus µ¿Á¤µÇ¾úÀ»¶§
19. ½ÅÀÌ½Ä ¼º°øÀ» ÀúÇØÇÒ¼ö ÀÖ´Â Áúȯ ȤÀº ÀÎÀÚµé
1) HUS : Àç¹ß ȤÀº graft failure¸¦ ÀÏÀ¸Å³¼ö ÀÖ´Ù. cyclosporineÀÌ Àç¹ßÀ§ÇèÀ» Áõ°¡½ÃŲ´Ù.
2) sickle cell disease: HctÁõ°¡°¡ ¿ÀÈ÷·Á sickle crisis¸¦ Áõ°¡½Ãų¼ö ÀÖ´Ù.
3) scleroderma: long-term vascular & GI problemÀÌ rehabilitationÀ» Á¦ÇÑÇÒ¼ö ÀÖ´Ù.
4) oxalosis: stone diseaseÀÇ Àç¹ßÀÌ ½ÉÇÒ¼ö ÀÖ´Ù.
5) Cystinosis & Fabry's disease: disease activity°¡ Áö¼Ó
6) FSGS: Àç¹ß·Î ÀÎÇÑ graft loss°¡ ÈçÇÏ´Ù.
20. recurrent FSGSÀÇ ¿¹ÃøÀÎÀÚ
i) Áø´ÜÈÄ rapid progression(<3³â)
ii) poor response to therapy
iii) younger age at Dx
iv) mesangial proliferation in initial biopsy
Ä¡·á = plasmapheresis & high-dose cyclosporine therapy
21. ½ÅÀ̽ÄÈÄ °¡Àå Àß Àç¹ßÇÏ´Â »ç±¸Ã¼½Å¿°: MPGN type II
½ÅÀ̽ÄÈÄ °¡Àå ¸¹ÀÌ »õ·Î »ý±â´Â »ç±¸Ã¼½Å¿°(De novo GN): MGN
22. ¸é¿ª¾ïÁ¦Ä¡·á½Ã Àß »ý±â´Â Á¾¾ç
i) lip & skin cancer ii) cervical cancer(CIS) iii) lymphoma(Hodgkins' ds & NHL)
23. ½ÅÀ̽ÄÈÄ °íÇ÷¾Ð ¹ß»ý½Ã ¿øÀÎ
i) cyclosporine Åõ¿©(Ãʱâ)
ii) cronic allograft dysfunction (Èıâ)
iii) native kidney
iv) renal artery stenosis
v) original renal disease recurrence
cf. ½ÅÀ̽ÄÈÄ Ãʱ⿡ ¿À´Â °íÇ÷¾ÐÀÇ °¡Àå ÈçÇÑ ¿øÀÎ? cyclosporine Åõ¿©
½ÅÀ̽ÄÈÄ Èı⿡ ¹ß»ýÇÏ´Â °íÇ÷¾ÐÀÇ °¡Àå ÈçÇÑ ¿øÀÎ? chronic allograft dysfunction
24. ½ÅÀÌ½Ä È¯ÀÚ¿¡¼ Àå±âÃßÀû°Ë»ç¿¡¼ °¡Àå ÈçÇÑ »ç¸Á¿øÀÎ?
atherosclerotic cardiovascular disease
25. »çü ½ÅÀ̽ÄÀÇ °æ¿ì¿¡ À̽ĽÅÀÇ Àå±â»ýÁ¸¿¡ ¹ÌÄ¡´Â ¿µÇâÀÎÀÚ·Î HLA-DRÀÇ ¿µÇâÀÌ °¡Àå
Å©´Ù.
26. cyclosporine¿¡ ÀÇÇÑ °íÇ÷¾Ð¿¡ °¡Àå ÃßõµÇ´Â Ç×°íÇ÷¾ÐÀÇ Á¾·ù? CCB(nifedipine)
27. cyclosporine¿¡ ÀÇÇÑ gum hyperplasiaÀÇ °æ¿ì, CCB°¡ À̸¦ ¾ÇȽÃų¼ö ÀÖ´Ù.
28. CMV esophagitis´Â HSV, candida esophagitisº¸´Ù Áõ»ó¹ßÇöÀÌ ¼¼È÷ ³ªÅ¸³´Ù