Anatomy
Name the structures and their relation in hepato-duodenal ligament
CBD-lateral
Common hepatic artery-medial
Portal vein-posterior
What is the mechanism of action of tacrolimus (Prograf)
Calcineurin inhibitor
FK506 binding protein that inhibits calcineurin
What is the requirement for brain death in Tennessee?
A physician must determine it
"Irreversible cessation of all functions of the entire brain, including the brain stem is dead. A determination of death must be made in accordance with accepted medical standards." Uniform Determination of Death Act (UDDA)
Name of the two most common organ preservation solutions
University of Wisconsin solution and histidine-tryptophan-ketoglutarate (HTK) solution
What is Dr. Grandas's middle name?
Henry
What is the typical location of the left renal vein as it crosses the aorta and what can be an anatomical variant that predisposes it to devastating injury?
between SMA and aorta. Variant can be a retro-aortic left renal vein
What is the mechanism of action of mycophenolate (Cellcept)?
Antimetabolite.
Inhibits purine synthesis to suppress T cell proliferation and adhesion
Inhibits inosine-5'-monophosphate dehydrogenase
How long should paralytics and sedatives be held before a brain death exam? How can you test for residual paralytic?
6 hours minimum (or 3 drug half lives)
Electrical stimulation (train of 4)
What do the terms "warm ischemia" and "cold ischemia" refer to?
warm ischemia: time from interruption of circulation (i.e. cardiac arrest) to the time organ is flushed w/ hypothermic solution
cold ischemic time: time from organ becoming hypothermic to time of donation
Ideal time of CIT: 4-6 hrs for heart, <12 hrs for liver and pancreas, and <24 hrs for kidney
What is Dr. Grandas's preferred saying when doing med management rounds?
"Ok, no changes"
Name the most common aberrant anatomy of the left and right hepatic arteries (1 for each)
Right hepatic artery: replaced right off of SMA
Left hepatic artery: accessor left off of left gastric
Others you may encounter: replaced CHA from SMA, right and left hepatic arteries arising seperately from celiac, right hepatic artery that crosses anterior to CHD, accessory LHA from RHA
Target trough level for Prograf (tacrolimus) after recent kidney transplant?
5-15 ng/mL for first 2-4 months post-transplant
*based on Kidney Disease: Improving Global Outcomes guidelines*
What labs should you check before a brain death exam?
Indications and contraindications for liver transplant?
Indications: chronic hepatitis, alcoholis cirrhosis, PSC, autoimmune disease, NASH, HCC (milan criteria), hepatoblastoma, cholangiocarcinoma
Contraindications: inability to tolerate surgery, Active malignancies or extra-hepatic malignancies, ongoing substance abuse, active infection
What year did Dr. Grandas complete residency? (must be exact)
1997
When do you know you have fully Kocherized the duodenum?
Exposure of left renal vein
What are drugs that can affect tacrolimus trough levels?
Carbamazepine, metamizole, isoniazid, high dose steroids, anti-fungals
Any CYP450 inhibiting drugs
Diseases that can mimic brain death? (Name 2 of 3)
Locked-in syndrome, hypothermia, and drug intoxication
Arterial supply to ureters and technique to avoid devascularizing ureter?
renal artery, gonadal artery, aorta, and direct branches from iliac.
Preserve peri-adventitial tissue along ureter
Does Dr. Grandas require sleep?
Trick question, no one knows
What structures should you isolate prior to cannulation?
Supra-celiac aortic control, IMV, distal aortic control, supra-hepatic IVC
What main cytokine is inhibited by sirolimus and tacrolimus?
IL-2
Reflexes to test during brain death exam (Name all 6)
Ideal Kidney Donor Profile Index number? (KPDI)
0-20%, average 11.5 years function
Others:
Standard donor with KDPI 21% to 85%: average 9 years function
Marginal donor with KDPI 86% to 100%: average 5.6 years function
Donor factors include age, height, weight, cause of death, creatinine, diabetes
What is the main diet of a transplant surgeon when in the hospital? (2 parts)
Nespresso and white bread