assessment and management of the kidney transplant patient

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