Download (PowerPoint)

Survey
yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Document related concepts

Adherence (medicine) wikipedia, lookup

Transcript
Prior to the start of the program, ensure you have
the following printed program materials:
• Syllabus
– Pre-activity Survey
• Located at the front of your syllabus
– CME Evaluation with Post-activity Survey
•
Located at the back of your syllabus
Disclosures
• The relevant financial relationships reported by faculty that
they or their spouse/partner have with commercial interests
is located on page 5 of your syllabus
• The relevant financial relationships reported by the
steering committee that they or their spouse/partner have
with commercial interests is provided on page 5 of your
syllabus
• The relevant financial relationships reported by the nonfaculty content contributors and/or reviewers that they
or their spouse/partner have with commercial interests is
located on page 5 of your syllabus
Off-label Discussion Disclosure
This educational activity may contain discussion of published
and/or investigational uses of agents that are not indicated
by the Food and Drug Administration. PCME does not
recommend the use of any agent outside of the labeled
indications. Please refer to the official prescribing information
for each product for discussion of approved indications,
contraindications and warnings. The opinions expressed are
those of the presenters and are not to be construed as those
of the publisher or grantors.
Educational Objectives
• Examine the most recent data on kidney disease outcomes
after liver transplantation, and identify criteria that are
currently being investigated to guide patient selection for
liver alone vs dual organ transplant
• Apply an up-to-date understanding of the mechanisms
underlying antibody-mediated rejection to the initiation of
evidence-based approaches to prevent rejection and
minimize immunosuppressant-associated toxicity
• Identify strategies to maximize adherence in patients
undergoing solid organ transplant
Pre-activity Survey
• Please take out the Pre-activity Survey from your packet
• Your answers are important to us and will be used to help
shape future CME activities
• It is important that you fill out the information at the top of
the form:
– Please select the best answer(s) for the questions below:
– Degree: _MD/DO _ Nursing Professional _ PharmD
_Other:_____________________________
– Specialty: _Hepatologist _Transplant Surgeon _ Nephrologist
_Other:_____________________________
Pre-activity Survey Question 1
How often do you think simultaneous liver/kidney (SLK)
transplantation should be performed in non-ESRD patients
needing a liver transplant?
A. >20% of the time
B. 10% to 19% of the time
C. 5% to 9% of the time
D. <5% of the time
Pre-activity Survey Question 2
Which of the following liver failure patients should generally
not be given an SLK transplant?
A.
B.
C.
D.
ESRD
Metabolic kidney disease
No ESRD but receiving hemodialysis for 2 months
Stage 4-5 CKD, with no proteinuria and 25% likelihood of
developing ESRD after liver transplant alone
E. All of the above are good candidates for SLK
F. None of the above should be given a SLK
Pre-activity Survey Question 3
Liver transplant candidates with stage 4-5 chronic kidney
disease (CKD) should be receiving an SLK?
A. Correct
B. Incorrect
C. I don’t know
Pre-activity Survey Question 4
Please rate your level of confidence in your ability to select a
candidate for SLK:
1
Not confident
2
3
4
5
Expert
Pre-activity Survey Question 5
Please rate your level of confidence in recognizing the signs
and symptoms of antibody-mediated rejection (AMR):
1
Not confident
2
3
4
5
Expert
Pre-activity Survey Question 6
In your practice, what percentage of your transplant patients
almost never miss doses of their immunosuppressive
medications one year after transplantation?
A. 75% to 100% of my patients
B. 25% to 74%
C. 10% to 24%
D. <10%
E. I don’t know
Pre-activity Survey Question 7
What strategies have you implemented in your practice to
address patient adherence (select all that apply)?
A. Education
B. Modify/simplify treatment regimen
C. Schedule office visits, even when the patient feels well
D. I have not implemented any strategy yet
Pre-activity Survey Question 8
A 60-year-old male with a history of type 2 diabetes mellitus (5-yr) and
liver disease secondary to NASH is evaluated for liver transplantation.
He has never been told he had kidney disease. Labs: Serum
creatinine: 3.2 mg/dL (up from 1.2 mg/dL a year earlier, and 1.5 mg/dL
4 days ago); Urine output: 690 mL per day (down from 1.2 liters 4 days
ago); Serum Na+ 129 mEq/L; Serum K+ 5.8 mEq/L; Urine: PCR 0.3
mg/g; Na+ 12 mEq/L.
Is this patient a dual liver/kidney transplant candidate?
A. Yes
B. No
C. I don’t know
Pre-activity Survey Question 9
In liver transplant recipients with eGFR >30 mL/min/1.73 m2,
compared to standard tacrolimus dosing, the addition of everolimus to
reduced tacrolimus did which of the following:
A. Prevented kidney function loss but increased the incidence of
acute rejection, graft loss, and death
B. Prevented kidney function loss with similar impact on the
incidence of acute rejection, graft loss, and death
C. Similarly reduced kidney function and the incidence of acute
rejection, graft loss, and death
D. I don’t know
Pre-activity Survey Question 10
The most common cause of AMR is?
A. Viral infection
B. Non-adherence to regimen
C. Age of recipient
Case Report
• 62-year-old male with 5-year history of T2DM
• History of liver disease secondary to NASH
• Presented to local hospital with abdominal pain, nausea,
and coffee ground emesis
• Transferred for liver transplant evaluation
• Work-up revealed decompensated liver failure; ultrasound
showed a cirrhotic liver; EGD esophagitis with varices
Case Report: Laboratory Findings
• Upon transfer, Cr 2.4 mg/dL
– On admission, Cr 1.5 mg/dL
– 1 year earlier, Cr 0.6 mg/dL
• Urine output
– 1.2 L at transfer
– Over 3 days, decreased to 690 mL/day
• Patient became encephalopathic
– Cr 3.2 mg/dL, Na+ 129 mEq/L, K+ 5.8 mEq/L
• Urinalysis bland
– PCR 0.3 g/g, Urine Na+ 12 mEq/L
• Patient placed on active list for a liver transplant
– MELD: 34
Case Report: Renal Ultrasound
Renal ultrasound showed mild echogenicity,
but was otherwise normal
Figure 1A: normal
Photos courtesy of Dr. F. Vincenti.
Figure 1B: case
Polling question
Is this patient a dual liver/kidney transplant candidate?
1. Yes
2. No
3. I need more information
Consequences of MELD Allocation System
• Intended
– Reduced waitlist mortality
• Unintended
– Livers often allocated on basis of kidney disease severity
– Compared to pre-MELD era:
• SLK listings have increased
• SLK transplants increased
Eason JD et al. Am J Transplant. 2008;8:2243-2251.
Davis CL et al. Am J Transplant. 2007;7:1702-1709.
Abnormal Kidney Function is More Common
in Liver Candidates in MELD Era
Pre-OLT creat
(mg/dl)
% pts
pre-MELD
% pts
post-MELD
0-0.99
51.8
46.1
1-1.99
36.6
38.5
≥ 2.0
7.9
10.0
Dialysis
3.7
5.3
P<0.0001
Pre-MELD 1999-2002, n=11010; Post-MELD 2002-2004, n=13163, data from SRTR
Gonwa TA et al. Am J Transplant. 2006;6:2651-2659.
Increasing Number of SLK in USA in
MELD Era
From 2012 Annual Report of OPTN/SRTR.
% SLK
# SLK
MELD introduced
Limited Utility of Estimating Equations in
Candidates with eGFR <40 mL/min
Method
GFR<40 ml/min
GFR>40 ml/min
# pts
GFR
# pts
GFR
Iothalamate*
155
22.6
1218
99.4
Cockcroft-Gault
151
46.1
1213
85.5
Nankivell
148
58.0
1198
99.0
MDRD 4
155
44.5
1218
87.8
MDRD 5
155
43.9
1218
90.5
MDRD 6
155
39.0
1218
82.4
1447 OLT recipients, 1984–2001; *iothalamate GFR used as “gold-standard”
Gonwa TA et al. Liver Transpl. 2004;10:301-309.
Reasons That Centers Consider SLK
• Avoid peri-operative dialysis
• Potential to prevent
– Non-recovery of pre-operative AKI
– Early post-transplant ESRD
– Subsequent ESRD and need for later kidney from another
donor
• May protect center from risk of being exposed to poor
outcomes based on LTA
Wide Variation in Simultaneous Liver-Kidney
Transplants Between Regions
Nadim MK et al. Am J Transplant. 2012;12:3119-3127.
Polling Question
Independent of eGFR, all of the following factors at the time
of LTA have been associated with ESRD except:
1. Older age
2. Diabetes mellitus
3. Duration of dialysis
4. Presence of abnormalities on kidney biopsy
Polling Question
Independent of eGFR, all of the following factors at the time
of LTA have been associated with ESRD except:
1. Older age
2. Diabetes mellitus
3. Duration of dialysis
4. Presence of abnormalities on kidney biopsy
Renal Criteria Used to Determine Need for
SLK vs LTA in Liver Candidates
Results of National Survey of US Transplant Centers
Survey of 88 centers that perform SLK, 65% response
AKI: minimum duration of dialysis for
determining SLK
% of respondents
4 weeks
32%
6 weeks
37%
8 weeks
32%
GFR <40 ml/min
24%
GFR <30 ml/min
76%
CKD (GFR)
Nadim MK et al. Am J Transplant. 2012;12:3119-3127.
Risk of ESRD After LTA in Patients with
Fluctuating eGFR Pre-transplant
Ruebner R et al. Am J Transplant. 2012;12:2958-2965.
ESRD by 6 Months Post-LTA and
Pre-transplant Acute Dialysis Duration
Sharma P et al. Clin J Am Soc Nephrol. 2013;8:1135-1142.
Predictors of Non-recovery of Kidney
Function Post-LTA
Sharma P et al. Clin J Am Soc Nephrol. 2013;8:1135-1142.
Association of Pre-transplant Dialysis
Duration and Survival After SLK
RR of Death
P=0.05, SLK vs LTA
*
Duration of Dialysis (mos)
Cox Proportional Hazard Analysis Comparing SLK and matched-control LTA recipients,
matched for donor age, race, cause of death, recipient MELD and dialysis status
Adapted from Locke JE et al, Transplantation 2008
Proportion of patients surviving
Poor Outcomes in Elderly Patients on
Dialysis at Time of Liver Transplant
>65, on dialysis
Days post-transplantation
≥65, L
<65, D, L
UNOS data, n=9877, MELD era
Dellon ES et al. Am J Transplant. 2006;6:2183-2190.
≥65, D, L
<65, D, L/K
≥65, D, L/K
<65, L
Distribution of LTA Patients Based on
RIFLE Classification
• No AKI:
165
• Risk
34
• Injury
19
• Failure
65
– ATN
30
– HRS
35
Nadim MK et al. Liver Transpl. 2012;18:539-548.
• Retrospective, 283 pts
• ATN based on clinical diagnosis
Recovery of Kidney Function After OLT
Nadim MK et al. Liver Transpl. 2012;18:539-548.
Limitations with Comparing SLK and LTA
Outcomes in MELD Era
• Only retrospective studies
• Lack of:
– Appropriate control groups
– Standardized selection criteria for SLK
– Pre-LTA kidney and/or dialysis data
– Data on pre-txp comorbidity
• Kidney outcomes after LTA not well characterized
• Misclassification with registry data
• Differences in liver disease severity?
Kidney Biopsy in Liver Transplant Candidates
• Pathological abnormalities common
• High risk of bleeding complications
• Not shown to be better than serum creatinine in predicting:
– Post-txp reversibility
– Post-txp kidney function
– Rate of decline of GFR
– Time to ESRD
• Should be considered a research tool for now
McGuire BM et al. Ann Intern Med. 2006;144:735-741.
Wadei HM et al. Am J Transplant. 2008;8:2618-2626.
Tanriover B et al. Transplantation. 2008;86:1548-1553.
OPTN Policy Proposal
Listing Criteria for SLK
a. ESRD
b. CKD with GFR <30 (MDRD-6 or iothalamate) and
proteinuria >3 g/day
c. Sustained AKI requiring dialysis for >6 weeks
d. Sustained AKI (GFR <25) for >6 weeks not on dialysis
e. Sustained AKI: combination of time in (c) and (d) >6 weeks
f. Metabolic disease
OPTN Kidney Transplantation Committee and the Liver and Intestinal Organ Transplantation Committee (OPTN Policy 3.5.10).
OPTN Policy Proposal
Priority local listing for KAL
• If listed for SLK but received LTA
OR
• If required 2 weeks of pre-LTA dialysis and/or eGFR 30-40
mL/min for 4 weeks pre-LTA
AND
a. Continued maintenance dialysis for >90 days post-LTA
b. non-recoverable kidney function
c. between 90-180 days post-LTA
OPTN Kidney Transplantation Committee and the Liver and Intestinal Organ Transplantation Committee (OPTN Policy 3.5.10 and 3.5.10.1).
SLK Allocation in MELD Era
Summary of Issues
• Inadequate characterization of pre-kidney function has
limited the establishment of uniform criteria
• 3 months duration of severe kidney disease is tipping point
for worse outcomes after LTA
• CKD defined by impaired kidney function for >3 months
• Should restrict SLK to patients with stage 4-5 CKD
– No clear benefit for patients not on dialysis
– Selects patients with lowest likelihood of renal recovery
Proposed Algorithm:
SLK vs LTA in Liver Candidates with Kidney Dysfunction
Bloom RD et al. Adv Chronic Kidney Dis. 2009;16:268-277.
Case Report: Liver Transplant
• Transplant nephrology consulted to initiate CRRT
• Decision made that patient did not require kidney transplant
• Patient had a GI bleed requiring multiple transfusions; transferred to ICU
• CRRT initiated
• Urine Na <10 mEq/L; urine output decreased to 200-300 mL
• 6 days later, underwent OLT
• Continued on CVVHD for 48 hours
• Remained oliguric on steroids and mycophenolate mofetil for 5 days, then started
on tacrolimus 2 mg bid
• Discharged, eGFR 20mL/min
Polling Question
In LTA with GFR <25mL/min, which would you NOT
consider?
1. Continue the present immunosuppressive regimen
2. Reduce the dose of tacrolimus
3. Convert tacrolimus to mTor
Polling Question
In LTA with GFR <25mL/min, which would you NOT
consider?
1. Discontinue tacrolimus
2. Reduce the dose of tacrolimus
3. Convert tacrolimus to mTor
Everolimus in Liver Transplant
Saliba F et al. Am J Transplant. 2013;13:1734-1745.
Everolimus in Liver Transplant
Saliba F et al. Am J Transplant. 2013;13:1734-1745.
Case Report: Post-liver Transplantation
• 9 months post-liver transplant, kidneys failed and patient
received a kidney transplant from his 33-year-old son
• T and B cell cytotoxicity crossmatches were negative
• Kidney functioned immediately
• At 1 month, Cr 1.3 mg/dL; on steroids, mycophenolate
mofetil and tacrolimus
Case Report: Post-liver Transplantation
• At 3 months, Cr increased to 2.5 mg/dL
• Biopsy revealed Type Ib Banff acute T cell rejection;
thymoglobulin begun
• Cr remained at 1.8 mg/dL
• Patient did not return for follow-up; compliance concerns
• Presented 9 months later complaining of fatigue and
edema; Cr 2.6 mg/dL, a urine PCR 1.2 mg/g
Case Report: Biopsy
Figure 2A
Figure 2B
Figure 2C
Figure 2D
Photos courtesy of Dr. F. Vincenti.
Case Report
• Blood sample sent for DSA
– Moderate risk antibodies to the donor HLA DQ3 (7000 MFI)
Polling question
What is the most common cause of AMR?
1. Viral infection
2. Non-adherence to regimen
3. Age of recipient
Polling question
What is the most common cause of AMR?
1. Viral infection
2. Non-adherence to regimen
3. Age of recipient
Causes of Kidney Transplant Failure
Antibody-Mediated
Rejection 36 (64%)
BK Virus
4 (7%)
Glomerulonephritis
10 (18%)
Other Causes
6 (11%)
Sellares J et al. Am J Transplant. 2012;12:388-399.
Nonadherent
17 (47%)
Adherent
19 (53%)
Early (<3 Months) vs Late Acute AMR
after Kidney Transplant
Dörje C et al. Transplantation 2013;96:79-84.
C1q Complement-binding Anti-HLA ab
• 1,016 allograft kidney transplants recipients
• Five-year survival of the transplanted kidney:
– 54% in patients with C1q anti-HLA ab
– >93% in those with non-complement binding anti-HLA antibodies
and those without donor-specific anti-HLA antibodies (P<0.001)
• AMR was the cause of rejection in 48% patients with C1q
anti-HLA ab (vs 16% of patients without)
Loupy A et al. N Engl J Med. 2013;369:1215-1226.
KDIGO Guideline Recommendation for
Treatment of Acute AMR
6.4: We suggest treating antibody-mediated acute rejection
with one or more of the following alternatives, with or without
corticosteroids (2C):
• plasma exchange;
• intravenous immunoglobulin;
• anti-CD20 antibody;
• lymphocyte-depleting antibody.
Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of
kidney transplant recipients. Am J Transplant. 2009;9:S21.
Acute AMR Treatment after Kidney
Transplant: A Systematic Review of Controlled Trials
• Searched treatment of AMR with IVIG, monoclonal
antibodies (rituximab or eculizumab), proteasome
inhibitors (bortezomib), and plasmapheresis/exchange
• Studies published 1950 – March 2011
• MEDLINE, EMBASE, Cochrane, and meeting abstracts
• 5 randomized and 7 non-randomized controlled trials
• GRADE quality low or very low
Roberts DM et al. Transplantation. 2012;94:775-783.
Acute AMR Treatment after Kidney
Transplant: Results of 5 RCTs
1st Author
Year
Intervention
Number
Treated/Con
Graft Failure
Treated/Con
Benefit?
Böhmig
2007
Immunoadsorption
5/5
0/4
Yes
Bonomini
1985
Plasmapheresis
23/21
7/17
Yes
Kirubakaran
1981
Plasmapheresis
12/12
6/3
No
Allen
1983
Plasmapheresis
13/14
3/4
No
Blake
1990
Plasmapheresis
19/19
4/6
No
Roberts DM et al. Transplantation. 2012;94:775-783.
Treatment of AMR after Kidney Transplant
Plasmapheresis
n=0
Immunoadsorption
n=700
IVIG
Bortezomib
Corticosteroids
Antithymocyte ab
Eculizumab
Mycophenolate
Rituximab
Cyclophosphamide
Deoxyspergualin
Splenectomy
Tacrolimus
Roberts DM et al. Transplantation. 2012;94:775-783.
Treatment of AMR after Kidney Transplant
Treatment
Plasmapheresis
Immunoadsorption
IVIG
Bortezomib
Corticosteroids
Anti-thymocyte preparations
Eculuzamib
Mycophenolate
Rituximib
Cyclosphosphamide
Deoxyspergualin
Splenectomy
Tacrolimus
Roberts DM et al. Transplantation. 2012;94:775-783.
Evidence
Low, benefit not consistent
Low, seems beneficial
Very low
Very low
Very low
Very low
Very low
Very low
Very low
Very low
Very low
Very low
Very low
Treatment of AMR after
Kidney Transplant
“Data describing the efficacy of treatments for AMR
in renal allografts are of low or very low quality.
Larger randomized controlled trials and doseresponse studies are required.”
Roberts DM et al. Transplantation. 2012;94:775-783.
Conservative Treatment of Early Mixed AMR
Day of Banff ’97
Biopsy Grade
9
6
6
7
10
10
6
8
8
8
5
IIA
IIB
IIB
IIA
IIB
IIA
IIA
IIB
Brdrln
IB
IIB
C4d/ Received CSA
PTC
IL2-RA Before
PMNs Before (ng/mL)
+/+
+/+++
+/++
+/+
+/++
+/+++
+/+
+/++
+/+
+/++
+/+++
Sun Q et al. Kidney Int. 2007;71:24-30.
Dac
--Dac
Bas
Bas
-Bas
----
TAC
Before
(ng/mL)
TAC
After
(ng/mL)
S Cr
Before
(mg/dL)
S Cr
After
(mg/dL)
10.9
10.0
12.5
14.5
10.4
7.1
10.9
9.1
11.2
12.0
9.2
9.5
4.17
CVVH
6.97
6.36
CVVH
CVVH
4.79
9.04
3.26
CVVH
CVVH
0.88
1.00
1.56
0.94
0.91
0.96
1.37
1.74
0.88
1.24
0.79
208
186
NA
160
103
176
12.8
348
5.7
8.3
Conservative Treatment of Early Mixed AMR
Sun Q et al. Kidney Int. 2007;71:24-30.
Potential Treatments of AMR that
Require Additional Study
• Intravenous immunoglobulin
• Rituximab (B-cell antibody)
• Bortezomib (proteasome inhibitor)
• Eculizumab (C5 inhibition)
• C1 Esterase Inhibitor
• BAFF inhibitors
• Plasmapheresis
Early vs Late Acute AMR
Role of Non-adherence
Low drug levels
Low drug levels and
non-adherent
Age (y)
Age (y) of those that
were non-adherent
Early AMR
(n=40)
0/40 (0%)
Late AMR
(n=27)
15/27 (56%)*
0/0 (0%)
10/15 (75%)
50.9±11.6
37.9±12.9*
26.6±9.5
*P<0.001 vs Early AMR
Dörje C et al. Transplantation. 2013;96:79-84.
Addressing Late Graft Loss
• Shift in thinking about the causes of late graft rejection:
insufficient immunosuppression and non-adherence to
immunosuppressive medication are key factors.
• Insufficient immunosuppression may occur during
immunosuppressive minimization (tapering) or
calcineurin-inhibitor-avoidance
• Patients at high risk for non-adherence, specifically
young adults who are in the transition phase from
pediatric to adult renal services, should be identified.
Morath et al. Special Issue: Special Focus – Antibody-Mediated Rejection. Transpl Int. 2012;25:633-645.
Increasing Adherence in Transplant Patients
• Adherence to immunosuppressant regimens is challenging
– Patients commonly take >8 medications/day at multiple specific times
– Weekly clinic appointments for ~1 year post-transplantation
– Laboratory visits between clinic visits
– Significant lifestyle changes to incorporate healthy behaviors
• Physicians and other members of the transplant team can help improve
adherence by providing education on treatment expectations,
management of side effects, and strategies to improve adherence
– Schedule of medication-taking
– Simplified, more convenient medication regimens (reduced dosing, injectable)
– Organizing pills (pill boxes, reminder systems)
– Regularly scheduled visits with a provider, even when the patient feels well
– Individualize regimen to reduce adverse events and side effects
Dosing Frequency, Persistence, and
Adherence in Transplant Recipients
• 219 patients (45% male; 3±2 years post transplantation)
randomized to tacrolimus 145 once daily or 74 twice daily
• Persistence at 6 months: 81.5% of the once-daily group vs
71.9% of the twice-daily group remained with the treatment
(P=0.0824)
• Adherence: 88.2% of the once-daily group and 78.8% of
the twice-daily group (P=0.0009)
• Doses were missed more frequently in the evening than in
in the morning (11.7% vs 14.2%; P=0.0035; twice daily
regimen)
Kuypers DR et al. Transplantation. 2013;95;333-340.
Case Report Management
• Patient was treated with steroid pulse, 3 doses of IVIG 70 g,
and rituximab 1,000 mg X 2 over 2 weeks
• Liver function tests remained normal
Conclusions
• Candidates for SLK transplant include:
– ESRD
– Metabolic kidney diseases cured by liver transplant
– Other?
• AMR is a common cause of death-censored transplant failure
• Currently, management of AMR must include maintenance of
immunosuppression while optimizing patient adherence and
minimizing side effects
– Recognize those at risk for low–adherence
• Future therapies will address underlying pathophysiology of AMR
Participant CME Evaluation
• Please take out the Participant CME Post-activity Survey
and Evaluation from the back of your packet
• If you are not seeking credit, we ask that you still fill out the
information pertaining to your degree and specialty, as well
as the few questions we will read through now measuring
the knowledge and competence you have garnered from
this program.
Post-activity Survey Question 1
After attending this activity, how confident are you in your
ability to select a candidate for simultaneous liver-kidney
transplantation (SLK):
1
Not confident
2
3
4
5
Expert
Post-activity Survey Question 2
After attending this activity, how confident are you in
recognizing the signs and symptoms of antibody-mediated
rejection (AMR):
1
Not confident
2
3
4
5
Expert
Post-activity Survey Question 3
Liver transplant candidates with stage 4-5 chronic kidney
disease (CKD) should be receiving an SLK?
A. Correct
B. Incorrect
C. I don’t know
Post-activity Survey Question 4
A 60-year-old male with a history of type 2 diabetes mellitus (5-yr) and
liver disease secondary to NASH is evaluated for liver transplantation.
He has never been told he had kidney disease. Labs: Serum
creatinine: 3.2 mg/dL (up from 1.2 mg/dL a year earlier, and 1.5 mg/dL
4 days ago); Urine output: 690 mL per day (down from 1.2 liters 4 days
ago); Serum Na+ 129 mEq/L; Serum K+ 5.8 mEq/L; Urine: PCR 0.3
mg/g; Na+ 12 mEq/L.
Is this patient a dual liver/kidney transplant candidate?
A. Yes
B. No
C. I don’t know
Post-activity Survey Question 5
In liver transplant recipients with eGFR >30 mL/min/1.73 m2,
compared to standard tacrolimus dosing, the addition of everolimus to
reduced tacrolimus did which of the following:
A. Prevented kidney function loss but increased the incidence of
acute rejection, graft loss, and death
B. Prevented kidney function loss with similar impact on the
incidence of acute rejection, graft loss, and death
C. Similarly reduced kidney function and the incidence of acute
rejection, graft loss, and death
D. I don’t know
Post-activity Survey Question 6
The most common cause of AMR is?
A. Viral infection
B. Non-adherence to regimen
C. Age of recipient
Thank you for joining us today!
Please remember to turn in your
evaluation form to earn CME credit.
Your participation will help shape future
CME activities.
Backup Slides For
Speaker’s consideration