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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¦ ¾ÇÈ­½Ãų¼ö ÀÖ´Ù.

28. CMV esophagitis´Â HSV, candida esophagitisº¸´Ù Áõ»ó¹ßÇöÀÌ ¼­¼­È÷ ³ªÅ¸³­´Ù