338.2 🩺 國考版

338.2.1 高頻考點

338.2.1.1 Donor Types

  • LD (living donor) > DD (deceased)
  • DBD vs DCD (expanding)
  • ECD (expanded criteria)
  • Paired exchange + altruistic

338.2.1.2 HLA Matching

  • Class I: A, B, C
  • Class II: DR, DQ, DP
  • Importance: DR > B > A

338.2.1.3 Crossmatch

  • T-cell crossmatch (Class I, II)
  • B-cell crossmatch (Class II)
  • Positive = contraindication (pre-formed antibodies)

338.2.1.4 Induction

  • Basiliximab (IL-2 receptor antagonist) — low-risk
  • rATG (Thymoglobulin) — high-risk, sensitized, DCD
  • Alemtuzumab — selected

338.2.1.5 Maintenance Triple

  • Tacrolimus + MMF + prednisone (standard)
  • mTOR inhibitor alternative
  • Belatacept for select

338.2.1.6 Tacrolimus

  • CYP3A4 metabolism
  • Drug interactions: azoles, macrolides, grapefruit
  • Trough 5-10 ng/mL early, 4-7 long-term
  • Nephrotoxicity (chronic), neurotoxicity, NODAT, HTN, K+

338.2.1.7 Acute Rejection

  • ACR: cellular; pulse steroids 500-1000 mg × 3 d
  • AMR: antibody-mediated; plasmapheresis + IVIG + rituximab + bortezomib
  • Hyperacute: pre-formed antibodies (rare now)

338.2.1.8 Chronic Allograft Issues

  • IFTA (interstitial fibrosis, tubular atrophy)
  • Chronic active T-cell rejection
  • Chronic active AMR
  • Recurrence of original disease

338.2.1.9 Infections Post-Transplant

  • CMV (most common viral): valganciclovir prophylaxis 6-12 mo
  • BK virus nephropathy: PCR monitoring; reduce IS
  • PCP: TMP-SMX prophylaxis
  • Fungal: candida, aspergillus
  • PTLD: EBV-driven; reduce IS + rituximab

338.2.1.10 Malignancy Post-Transplant

  • Skin: SCC > BCC
  • PTLD: B-cell lymphoma (EBV)
  • Kaposi sarcoma (HHV-8)
  • Solid organ
  • RCC in native kidneys

338.2.1.11 CV Risk

  • HTN, HLD, DM (NODAT)
  • ↑ Events vs general population
  • Top cause of death

338.2.1.12 Disease Recurrence

  • FSGS (especially primary): 20-30%
  • MN (anti-PLA2R)
  • MPGN/C3G
  • IgA (mild typically)
  • aHUS (eculizumab)

338.2.1.13 Belatacept

  • CTLA-4 + IgG Fc
  • IV monthly
  • EBV+ only (PTLD risk in EBV-)
  • BENEFIT trials

338.2.2 易混淆比范

Rejection Type Mechanism Diagnosis Treatment
Hyperacute Pre-formed Ab Within hours Graft loss; rare now
Acute cellular T-cell mediated Cr ↑, Banff 1A-3 Pulse steroids; rATG refractory
Acute AMR DSA mediated C4d on biopsy, DSA Plasmapheresis + IVIG + rituximab + bortezomib
Chronic ACR T-cell tubulitis Subclinical biopsy IS optimization
Chronic AMR DSA + microvascular Glomerulopathy Difficult; IS optimization
IFTA Multifactorial Histology Address underlying

338.2.3 Special Topics

338.2.3.1 NODAT (New-Onset Diabetes After Transplant)

  • 10-30% of recipients
  • CNI (tacrolimus) + steroids contribute
  • Metformin first; minimize steroids
  • Same DM management

338.2.3.2 Donor Procurement

  • Cold ischemia time
  • Pulsatile perfusion vs static cold storage
  • Ex vivo normothermic perfusion (emerging)