Post on 10-Feb-2016
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ASSESSMENT AND MANAGEMENT OF THE KIDNEY TRANSPLANT PATIENT
THE FIRST THREE MONTHS
UTI PROPHYLAXIS
UTI in 40 to 70% of transplant patients within first 3 months
Increased risk of Klebsiella, enterococcus, pseudomonas
Gram positive organisms up to 40% Prophylaxis of little benefit 15% of transplant recipients have reflux Increased risk of pyelonephritis with or without
reflux Aggressive monitoring of U/A, C&S Minimum 2 week course of treatment
POST DISCHARGE OFFICE VISIT SCHEDULE
Hospital outpatient POD 2-4 Weekly clinic visit for 6 weeks Biweekly clinic visit for 6 weeks
Routine visit labs: CBC, CMP, Mg, PO4, Prograf level, U/A
POST DISCHARGE OFFICE VISITS
Assessment of renal function Assessment of patient understanding of medical regimen Assessment of drug level Assessment of drug toxicity Assessment of UTI Assessment of transplant site Assessment of volume status Assessment of blood glucose Assessment of Mg, PO4 Assessment of serum K Assessment of blood pressure Assessment of everything else
ASSESSMENT OF RENAL FUNCTION/ELEVATED Cr
Volume depletion ( approx. 10% with Na wasting) Calcineurin inhibitor toxicity Acute cellular mediated rejection (highest risk within first 3
months) 3-7% incidence Delayed appearing antibody mediated rejection Acute tubular necrosis Urine leak/urinoma (with or without obstruction) Obstruction (hematoma, distal ureteral stricture. Prostate dz.) Neurogenic bladder Thrombotic microangiopathy related to calcineurin inhibitor Drugs (NSAID’s, ACEI, ARB, contrast, AIN) Recurrence of original disease Post transplant lymphoproliferative disease (we actually had
one at 2 months
EVALUATION OF ELEVATED Cr
Calcineurin inhibitor history (drug level may be artificially low if not a true trough)
Drug intake history Ultrasound Renal Scan Polyoma virus titers Biopsy
ASSESSMENT OF ELEVATED CALCINEURIN INHIBITOR LEVELS
Make sure a true trough Drugs that increase levels Calcium channel blockers Ketoconazole, fluconazole, itraconazole Erythromycin HAART drugs Metoclopramide Grapefruit juice
Make sure patient taking right dose
CALCINEURIN INHIBITOR LEVELS DECREASE FROM BASELINE
Rifampin, rifabutin Barbiturates Phenytoin Carbamazepine
Not a true trough Quit taking fluconazole Severe gastroparesis
ASSESSMENT OF DRUG TOXICITY/CNI
Hair loss Headache Memory changes Tremors Nausea Elevated Cr Type IV RTA Hypomagnesemia Hypophosphatemia
ASSESSMENT OF DRUG TOXICITY/ MMF
Neutropenia Anemia Thrombocytopenia Nausea, vomiting Diarrhea
ASSESSMENT OF DRUG TOXICITY/PREDNISONEh
Hyperglycemia Myopathy Weight gain Hypertension Avascular necrosis
HYPERKALEMIA
Calcineurin inhibitor Type IV RTA (obstruction, CNI, post transplant
tubulopathy) Renal insufficiency TMP/SMX Diet Other meds
HYPERTENSION
40-60% of post transplant patients with HTN (seems like 90% in our population)
Steroids Calcineurin inhibitor ( Na retention, renal and
peripheral vasoconstriction) Improved diet, increased Na intake Renal insufficiency
NEUTROPENIA
Mycophenelate mofetil Azathioprine CMV disease TMP/SMX Other viral infections Valcyte
ANEMIA
Renal insufficiency Gastrointestinal blood loss Menorrhagia Mycophenelate mofetil B12 deficiency Hypothyroidism Folate deficiency Iron deficiency Parvovirus B19 Thrombotic microangiopathy
ABNORMAL LIVER FUNCTION TESTS
Exacerbation of Hepatitis C CMV Drugs (fluconazole, MMF,Valcyte, other) Proton pump inhibitors Angiotensin receptor blockers
THREE MONLTH FOLLOWUP VISIT Routine labs CMV PCR BK PCR EBV PCR Lipid panel Parathyroid hormone Vitamin D studies D/C Valcyte if CMV D+/- R+ D/C Acyclovir if CMV D-/R- D/C fluconazole Adjust CNI upwards
INDUCTION THERAPY
PAN T CELL DEPLETING ANTIBODIES Alemtuzumab Thymoglobulin
B CELL DEPLETING ANTIBODIES Rituximab
NON DEPLETING ANTIBODIES Basiliximab Daclizumab
COSTIMULATION BLOCKADE Belatacept
METHODIST TRANSPLANT INSTITUTE INDUCTION PROTOCOL
Solumedrol 500mg IV in OR 250mg IV POD 1 100 mgIV POD2 Prednisone 50 mg po POD3 20mg po POD4 – 7
Thymoglobulin 1.5mg/kg IV in OR before revascularization
1.5 mg/kg IV POD 1-6 depending on graft function ( 3 doses for IGF, 5 doses for SGF, 7 doses for DGF)
Mycophenelate mofetil 500mg po bid (target 1000mg bid)
POST INDUCTION IMMUNOSUPPRESSION
Prednisone 15 mg po POD 7-14 10 mg po POD14-30 5mg po POD 31, thereafter
Tacrolimus 0.05 mg/kg every 12 hours starting POD3 or when Thymoglobulin complete. Target blood level 8-10.
Mycophenelate mofetil 1000mg po every 12 hours.
DELAYED GRAFT FUNCTION
Renal dysfunction requiring dialysis Differential Diagnosis Acute tubular necrosis Technical issues (urine leak, vascular
thromboses from anastamotic misadventures, etc…)
Antibody mediated rejection, cellular rejection (rare)
Cortical necrosis
EVALUATION OF DELAYED GRAFT FUNCTION
Transplant ultrasound with doppler interrogation Exclude obstruction, assess for urine leak Doppler’s assess flow, resistive indices
Renal Scan Assess radioisotope uptake and excretion Good uptake, no excretion….ATN Delayed uptake, no excretion…Rejection, Severe ATN
Percutaneous transplant renal biopsy
SLOW GRAFT FUNCTION
<30% decline of Cr over 3 days
Differential diagnosis and evaluation basically the same as delayed graft function
INFECTION PROPHYLAXIS
Mid 1990’s, infections exceeded rejection as leading cause for hospital readmission.
Transplant recipients at increased risk for post-operative bacterial infections
Lymphocyte depleting induction regimens increased dramatically risk of CMV
Though uncommon, pneumocystis, other fungal infections potentially catastrophic
CMV PROPHYLAXIS
30-60% risk of infection/disease within first 3 months if no prophylaxis
Valcyte 450mg qod to daily for D+/R- for 6 months Valcyte 450mg qod to daily for D+/- to R+ for 3
months Acyclovir 400mg tid for D-/R- for 3 months
If R+ gets infected, 30% comes from recipient, 70% comes from donor
Valcyte qod dosing for GFR <30, daily dosing for GFR>30
BENEFITS OF CMV PROPHYLAXIS
58%Reduction in CMV disease 39% Reduction in CMV infection 37% Reduction in all cause mortality Decreased risk of herpes simplex, herpes zoster,
bacterial infection and protozoal infections RR 1.6 for acute rejection with CMV infection RR2.5 for acute rejection with CMV disease OR 1.5 for arrythmia, CHF, coronary occlusion
with CMV disease OR 4.0 for post transplant diabetes with CMV
infection
FUNGAL PROPHYLAXIS
Low risk of fungal infection within first 3 months Candida, Histoplasmosis, Aspergillosis,
Toxoplasmosis most common in this area
Fluconazole 100mg daily until GFR>30, then 200mg daily
Give for 3 months Adjust calcineurin inhibitor with discontinuation
Some centers do not provide
PNEUMOCYSTIS PROPHYLAXIS
Low risk TMP/SMX SS daily for 6 months, then Tu/Th until
1 year Dapsone 25mg daily for one year if sulfa allergic