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Critical Care of Kidney Transplant
Dr yekehfallahphd of nursing
Introduction
Renal transplantation is the preferred treatment
for patients with end-stage renal disease. It offers
better quality of life and confers greater longevity
than long-term dialysis.
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History of Kidney Transplantation
1950’s
First successful kidney transplant
Total body irradiation for immunosuppression
Steroids
1960’s
Azathioprine
1970’s
Polyclonal anitbodies – anti-lymphocyte globulin (now Atgam,
Thymoglobulin)
1980’s
Cyclosporine (Sandimmune ), “triple drug therapy”
Monoclonal antibody, OKT3 (Orthoclone ) in 1985
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Definitions
Allograft : graft between genetically dissimilar
individuals of the same species.
Autograft : graft in which donor and recipient are
the same individual.
Xenograft : Donor and recipient belong to
different species.
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Contraindications To Renal Transplantation
Absolute :



Severe vascular disease.
Infection
Cancer
Relative :






Recent malignancy.
Coronary artery disease.
Active bacterial, fungal, or viral disease.
HIV positivity.
Social conditions.
Others.
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Kidney Donor

Living related.

Living unrelated (emotionally motivated).

Cadaveric (Brain-dead)
Beating and non-beating heart.
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CRITERIA FOR LIVING DONOR
SELECTION
-
Blood relative.
-
Highly motivated.
-
ABO blood group-compatible.
-
HLA-identical or haploidentical with negative
cross-match.
-
Excellent medical condition with normal renal
function.
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CRITERIA FOR CADAVER DONOR
SELECTION
-
-
Irreversible brain damage.
Normal renal function appropriate for age.
No evidence of preexisting renal disease.
No evidence of transmissible diseases.
ABO blood group-compatible.
Negative cross-match.
Best HLA match possible, particularly at the DR
and B loci.
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Matching between Recepient And Donor
A- Tissue typing
Determined by 6 antigens located on cell surface encoded for by
the HLA gen located on the short arm of chromosom 6.
Class I antigens (HLA-A and HLA-B) are expressed on the surface
of most nucleated cells.
Class II antigen (HLA-DR) are expressed on surface of APC and
activated lymphocytes.
These 6 antigens are refered to as major transplant antigens.
The match between donor and recepient can range from 0 to six.
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Matching between Recepient And Donor
B- Cross matching
A laboratory test that determines weather a potential transplant recepient has
preformed antibodies against the HLA antigens of the potential donor. (Donor
Lymphocytest +Recepient Serum)
A Final CM is mandatory
C- Compatible ABO blood group.
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Effect Of HLA Matching On The Graft Outcome
Data from large registries indicate that, the better the HLA-match,
the better the long-term survival of the allograft.
The benefits of matching are particularly notworthy in recipients
of kidneys from donors with zero missmatch.
The benefits of lesser degrees of matching have become less
obvious
with
the
use
of
newer
and
more
potent
immunosuppressive drugs.
Matching for DR antigens are more favorable than others.
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Factors Influencing The Longivity Of Renal
Allograft
Age
HLA matching
Delayed graft function
Ischemia time.
Number of acute rejection episodes.
Native kidney disease.
Ethnicity.
Others
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Major Causes Of Long-Term Allograft Failure
Chronic rejection.
Death with functioning graft.
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Most Common causes Of Death After Kidney
Transplantation

Cardiovascular disease.

Infection.
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GENERAL PRINCIPLES
Renal transplant is the most common solid organ transplant
Improves quality of life and survival compared to dialysis therapy
for patients with chronic kidney disease
Diabetic and hypertensive nephropathy are the most common
causes of chronic kidney disease leading to transplant
Underlying disease and its pathophysiology must be considered
in pretransplant evaluation and postoperative management
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Basics of Transplantation
Kidney transplantation is the most effective
therapy for end-stage renal disease.
The transplanted organ can come from either a
live donor or deceased donor.
Most deceased donor organs come from brain
dead donors.
Non-standard criteria donors:
Expanded criteria donors (ECD).
Donation after cardiac death (DCD).
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Recipient Selection
Very few contraindications.
General medical condition.
Cardiovascular screening.
Age-appropriate routine cancer screening (pap smear,
mammography, colonoscopy, PSA).
Infection (HIV, Hepatitis, TB).
Presence of preformed antibody (PRA).
Pregnancy, prior transplant, blood transfusion
Psychosocial evaluation, including compliance.
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Benefits of Transplantation
Life expectancy
Cardiovascular benefits
Quality of life
Socioeconomic benefits
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Quality of Life
Numerous studies have detailed improved quality
of life.
Life satisfaction, physical and emotional wellbeing and ability to return to work higher in
transplant recipients.
Uremic complications more fully reversed.
Fertility returns.
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Socioeconomic Benefits
Increased rates of return to work.
Cost to society
Mean cumulative costs of dialysis and
transplantation are equal for first 3-4 years, then
lower for transplantation.
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PRETRANSPLANT EVALUATION
Cardiovascular
Assessment:
-History of coronary artery disease
- symptoms of angina or congestive heart failure
-recent change in exercise tolerance
- new ischemic changes on ECG
- Decreased pulse or bruit on peripheral vascular examination
- new murmur on cardiac examination.
Prevention:
- Preoperative and postoperative B²-blocker therapy (atenolol 5 mg
intravenously preoperatively and 50 to 100 mg orally daily for at least the first
postoperative week)
-monitoring for hyperkalemia, bradycardia, and hypotension
- Consider continuing or starting aspirin for patients with multiple risk factors.
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PRETRANSPLANT EVALUATION
Infection
Assessment:
-Signs or symptoms of active infection
-assessment of indwelling hemodialysis or peritoneal dialysis
catheters and hemodialysis access grafts
- Culture and cell count of peritoneal fluid from
Tenckhoff catheter.
Prevention:
-Postpone transplant until active infection has been treated.
-Cephalosporin therapy for perioperative antibacterial prophylaxis
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PRETRANSPLANT EVALUATION
Preoperative dialysis
Assessment :
- hypervolemia
- Determine daily urine output
- hyperkalemia or severe metabolic acidosis.
Acute dialysis treatment to:
- correct electrolyte abnormalities and volume status
- avoiding excessive volume removal
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INTRAOPERATIVE CARE
Careful attention to volume status is critical to
avoid hypovolemia that will impair renal
perfusion and contribute to delayed graft function
(need for dialysis therapy during the first week
after transplant, a risk factor for acute rejection).
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INTRAOPERATIVE CARE
Intravascular volume status should be maintained
at adequate central venous pressure without
predisposing to pulmonary edema. Central venous
pressure monitoring is recommended to maintain
pressure approximately between 5 and 10 cm
H2O
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INTRAOPERATIVE CARE
Consider pulmonary artery catheterization to
assess hemodynamics in patients with
significantly decreased left ventricular function
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Anatomy of Renal Transplantation
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An adult donor kidney transplanted to the left iliac fossa
of an adult recipient
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Graft Prognosis
Directly related to source of donor kidney.
Recipients of cadaveric kidneys have more episodes of
rejection and lower graft survival rates.
Graft survival rates for kidneys from living donor is 95%
1 yr and 76% 5 yrs vs graft survival from a cadaveric
kidney donor is 89% 1 yr and 61% 5 yrs.
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Morbidity
Infection (most common cause of M&M in first year post
transplantation) and graft failure occur.
HT occurs in 75-85% of all renal transplant recipients.
Hyperlipidaemia 60%
CVS disease 15.8 – 23%
DM 16.9 – 19.9% (more likely to be present before transplantation
and new onset DM after transplantation is related to corticosteriod
use.)
Osteoporosis 60%
Malignant neoplasm 14% - related to the degree of
immunosupression
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Mortality
Survival of pts after transplantation from a liver
donor is 98% at 1 yr and 91% 5 yrs.
Survival of pts who receive cadaveric organs is
95% 1 yr and 81% 5 yrs.
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POSTOPERATIVE CARE
Postoperative management is determined by
initial allograft function:
- Chest radiograph
- frequent electrolyte monitoring to assess volume
and metabolic status (sodium, potassium, calcium,
and magnesium levels are essential
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POSTOPERATIVE CARE
Oliguria (urine output <20 mL/h) requires careful
attention to intravascular volume status. If
euvolemic or hypervolemic, then aggressive fluid
resuscitation should be avoided and complications
such as urinary obstruction, vascular thrombosis,
and acute tubular necrosis must be considered.
Hyperkalemia must be identified and treated
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POSTOPERATIVE CARE
With immediate graft function, urine output can
reach 1 L/h. Careful fluid and electrolyte
replacement is required to avoid hypovolemia and
electrolyte depletion
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POSTOPERATIVE
CONSIDERATIONS
Surgical complications
1/Hemorrhage
Risk of occurrence 1.9% to 12%.
Increased risk for patients requiring preoperative reversal of
chronic Coumadin anticoagulation.
Frequently due to vascular anastomotic bleeding, but in half of
cases no obvious source is identified
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POSTOPERATIVE
CONSIDERATIONS
Surgical complications
2/Allograft thrombosis
Risk factors
(1) Hypotension and hypovolemia
(2) Hypercoagulable state (antiphospholipid antibody
syndrome; factors C, S, or antithrombin III deficiency; factor V
Leiden mutation; acute humoral rejection).
(3) Severe peripheral vascular disease (increased risk of intimal
flap and other anastomotic complications).
(4) Multiple small renal arteries
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POSTOPERATIVE
CONSIDERATIONS
Presentation, diagnosis, and treatment
(1) Sudden oligoanuria (arterial thrombosis), gross
hematuria, allograft pain and swelling (venous
thrombosis).
(2) Doppler ultrasound including visualization of
flow in renal artery and vein confirms diagnosis.
(3) Almost always requires allograft nephrectomy
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POSTOPERATIVE
CONSIDERATIONS
Prevention
(1) Maintain adequate blood pressure and intravascular
volume.
(2) Aspirin for severe peripheral vascular disease.
(3) IV heparin for hypercoagulable state. No definitive
evidence-based guidelines are available, but therapeutic
target partial thromboplastin time (PTT) of 1.5 to 1.9
times the upper limit of normal PTT range has been
suggested with low risk of bleeding
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POSTOPERATIVE
CONSIDERATIONS
Surgical complications
3/Urologic
a/Significant hematuria with passage of clots may
require continuous bladder irrigation. Avoid
excessively high intravesical pressures that can
lead to rupture of the ureteroneocystotomy
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POSTOPERATIVE
CONSIDERATIONS
b/Urinary leak
(1) Occurs at the ureteroneocystostomy due to anastomotic
complication or distal ureteral ischemia and necrosis. Patient may
present with sudden oligoanuria or significant increase in wound
drainage.
(2) Ultrasound may identify perigraft fluid collection (urinoma),
nuclear medicine scan may identify extravasation of tracer from
ureter, and increased creatinine level of wound drainage (when
compared to serum creatinine) will confirm urine leak.
(3) In some cases, replacement of Foley catheter with bladder
decompression is sufficient. Surgical reexploration with ureteral
reimplantation and stent placement may be required
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POSTOPERATIVE
CONSIDERATIONS
Surgical complications
4/Wound
a/Infection and dehiscence are infrequent complications
(less than 5%). Risk is increased with obesity (body mass
index >30) and combined use of sirolimus and steroids
for immunosuppression, which both impair wound
healing
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POSTOPERATIVE
CONSIDERATIONS
b/Lymphoceles requiring therapy occur in
approximately 5%. Patients present with ureteral
or venous obstruction of the graft, which are often
associated with ipsilateral lower extremity edema.
Treatment:
laparoscopic internal drainage through a
peritoneal window. External drainage and
sclerotherapy are less effective
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POSTOPERATIVE
CONSIDERATIONS
MEDICAL COMPLICATIONS
1/Cardiovascular
Because of the increased risk of myocardial infarction in
patients with end-stage renal disease (ESRD), a high index of
suspicion is required, especially with prolonged intraoperative
hypotension or postoperative pulmonary edema.
Pericarditis occurs in approximately 2%. Causes include uremia
and infection, especially cytomegalovirus (CMV; unusual in the
immediate postoperative period).
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POSTOPERATIVE
CONSIDERATIONS
MEDICAL COMPLICATIONS
2/Metabolic
Hyperkalemia can occur with delayed graft function. Immediate
therapy is required with calcium chloride, insulin and dextrose, and
bicarbonate. Kayexalate or dialysis is required if diuresis to
eliminate potassium cannot be induced.
Hypokalemia may occur with large-volume diuresis early
postoperatively, requiring frequent monitoring and repletion.
Hypocalcemia, hypophosphatemia, and hypomagnesemia can
occur with large-volume diuresis and early renal tubular
dysfunction. Frequent electrolyte monitoring (at least every 12
hours) and repletion are required
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POSTOPERATIVE
CONSIDERATIONS
MEDICAL COMPLICATIONS
3/Infection
in the early postoperative period is due to
bacterial etiology similar to that for other surgical
patients. Risk is greatest in patients with diabetes
or those over 60 years old. Prophylactic antibiotic
therapy with cephalosporins is required
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POSTOPERATIVE
CONSIDERATIONS
MEDICAL COMPLICATIONS
4/Neurologic
Stroke
is a rare early postoperative complication. Risk is greatest in
patients with any significant vascular disease. Stroke should be
considered in the setting of a postoperatively unexplained altered
level of consciousness or with other neurologic changes.
New onset seizure
is also uncommon. Uremia in the setting of delayed graft function,
stroke, or drug toxicity with OKT-3 is a common cause
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Immunosuppressive Medications
Induction:
Corticosteroids
Anti-thymocyte globulin (ATG)
IL-2 receptor antagonists
Maintenance:
Corticosteroids
Calcineurin inhibitors (CNIs)
mTOR inhibitors
Antimetabolites
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Immunosuppressive Medications
Treatment of Rejection:
Corticosteroids
Anti-thymocyte globulin
Intravenous Immunoglobulin (IVIG)
Rituximab
Plasmapheresis
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Corticosteroids
Used for induction, maintenance and treatment of
rejection.
Mechanism of action:
Inhibit function of dendritic cells.
Inhibit translocation to nucleus of NF-κB.
Suppress production of IL-1, IL-2, IL-3, IL-6, TNF-α,
and γ-IFN.
Adverse effects numerous and well-known.
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Corticosteroids
Component of >80% of transplant protocols.
Given IV at high doses (250-500 mg/day) for
induction or treatment of rejection.
Tapered to maintenance dose of 5-10 mg/day in
early post-transplant phase.
Should NOT be tapered off: increased risk of
rejection and graft loss!
Steroid free regimen: overall some benefits but
graft survival likely worse.
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Anti-thymocyte Globulin (Thymoglobulin)
Used for induction and treatment of rejection.
Prepared by immunization of rabbits with human
lymphoid tissue.
Causes depletion of peripheral blood lymphocytes.
Administered generally via central line for 3-10
days.
Premedication required: acetaminophen,
corticosteroids and antihistamine.
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Anti-thymocyte Globulin: Adverse Effects
Infusion-related reactions: chills, fevers,
arthralgias.
Lymphopenia.
Thrombocytopenia.
Prolonged immunosuppression: increased risk of
opportunistic infections (PCP, CMV, fungal).
Possibly increased risk of BK virus nephropathy.
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IL-2 Receptor Blockers
Basiliximab (Simulect®) and Daclizumab
(Xenapax®).
Block CD25 (IL-2 receptor) on activated T cells.
Used for induction only.
Almost no side effects, but also much less potent.
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Calcineurin Inhibitors
Used for maintenance immunosuppression.
Two agents in clinical practice:
Cyclosporine (Sandimmune, Gengraf, Neoral, generic; CysA)
Tacrolimus (Prograf, generic; FK506).
Generics NOT clinically therapeutically equivalent.
At present are key to maintenance immunosuppression
and a component of the majority of transplant protocols.
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Calcineurin Inhibitors: Dosing and
Monitoring
 Both medications are generally dosed twice per day, 12
hrs apart.
 Trough levels monitored: check approximately 12 hrs
after last dose.
 In some cases C2 levels might be checked 2 hrs after
administration.
 Cyclosporine is 35-40% bioavailable, tacrolimus
approximately 25%.
 Oral to IV conversion 3-4:1.
 Both are metabolized by cytochrome P450 3A4 & 3A5.
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Calcineurin Inhibitors: Interactions
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Calcineurin Inhibitors: Interactions
Drugs to use with caution:
NSAIDs—avoid.
Amphotericin B & Aminoglycosides– worsened
nephrotoxicity.
ACEi & ARBs– use with caution.
Statins– avoid lovastatin, start others at lowest possible
dose.
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Calcineurin Inhibitors: P-Glycoprotein
 P-Glycoprotein (P-gp, also known as MDR1) is an
ABC-transporter found among other places, in the
intestine.
 It is thought to have evolved as a defense mechanism
against harmful substances.
 It acts as an efflux pump for many substances including
drugs (CNIs, colchicine, some cancer chemotherapeutic
agents, digoxin, corticosteroids, antiretrovirals).
 Decreased P-gp expression, such as in diarrhea, leads to
elevated drug levels.
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Calcineurin Inhibitors: Adverse Effects
Nephrotoxicity:
Functional decrease in blood flow from afferent
arteriolar vasoconstriction.
Thrombotic microangiopathy (rare).
Chronic interstitial fibrosis.
Hyperkalemia, hypomagnesemia and type IV renal
tubular acidosis.
Cyclosporine thought to be more nephrotoxic.
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Calcineurin Inhibitors: Adverse Effects
Cyclosporine
Tacrolimus
Hypertension
++
+
Pancreatic islet toxicity
+
++
Neurotoxicity
+
++
Hirsutism
+
-
Hair loss
-
+
Gum hypertrophy
+
-
GI side effects
-
+
Gastric motility
-
+
Dyslipidemia
+
-
Hyperuricemia
++
+
+/↓Mg2+
↑K
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mTOR Inhibitors
Target site is the mammalian target of rapamycin
(mTOR), a key regulatory kinase in cell division.
Sirolimus (Rapamune®) only available mTOR
inhibitor in the US.
Administered once daily, 24-hour trough levels
monitored.
Also metabolized by P450 3A system, with
interactions similar to the CNIs.
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mTOR Inhibitors
Target site is the mammalian target of rapamycin
(mTOR), a key regulatory kinase in cell division.
Sirolimus (Rapamune®) only available mTOR
inhibitor in the US.
Administered once daily, 24-hour trough levels
monitored.
Also metabolized by P450 3A system, with
interactions similar to the CNIs.
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Antimetabolites
Azathioprine (Imuran®, generic) is a purine analogue that
is incorporated into RNA and inhibits cell replication.
A mainstay of transplantation for 30 years, it has largely
been replaced by the below drugs.
Mycophenolate mofetil (Cellcept®) and enteric-coated
mycophenolate sodium (Myfortic®) are prodrugs of
mycophenolic acid (MPA), an inhibitor of inosine
monophosphate dehydrogenase (IMPDH).
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Antimetabolites: Adverse Effects
Azathioprine:
Bone marrow suppression.
Hepatitis.
Azathioprine is inactivated by xanthine oxidase,
therefore should not be used in combination with
allopurinol.
MPA prodrugs:
GI toxicity: diarrhea, nausea, esophagitis.
Leukopenia and anemia.
Not different between
formulations.
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Antimetabolites: Interactions
Azathioprine:
Allopurinol
Other marrow suppressive drugs
MPA prodrugs:
Cyclosporine
Antacids
Cholestyramine
Ferrous sulfate
OK to use with allopurinol
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Antimetabolites: Interactions
Azathioprine:
Allopurinol
Other marrow suppressive drugs
MPA prodrugs:
Cyclosporine
Antacids
Cholestyramine
Ferrous sulfate
OK to use with allopurinol
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Rituximab
 Used in the treatment of antibody-mediated rejection.
 Monoclonal antibody directed at CD20 antigen on B
lymphocytes.
 Causes rapid and sustained depletion of B lymphocytes.
 Does not have direct activity against plasma cells and
memory B cells, which do not express CD20.
 Adverse events: infusion reactions, and increased
susceptibility to infection.
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Other Agents
 OKT3
 Used for induction and treatment of rejection, now largely replaced
by anti-thymocyte globulin.
 Monoclonal antibody against CD3
 Severe infusion reactions (pulmonary edema & capillary leak
syndrome).
 Alemtuzumab (Campath-1H)
 Monoclonal anti-CD52 antibody
 Toxicities include bone marrow suppression and severe infections
 Leflunomide (Arava)
 Dihyroorotate dehydrogenase (DHODH) inhibitor.
 Used in certain clinical settings as an adjunct immunosuppressive.
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Common Complications of Transplantation
 Early complications
 Surgical complications
 Delayed or slow graft function
 Lymphocele
 Acute rejection
 Acute cellular rejection
 Antibody-mediated rejection
 Infectious complications
 Cytomegalovirus
 BK virus
 Others
 Malignancy
5/25/2017
Chronic allograft
dysfunction
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Surgical Complications
 Graft thrombosis:
 Caused by thrombosis of donor renal artery or vein.
 Usually happens in first week.
 Diagnosed by ultrasound with doppler studies.
 Almost always requires explant of kidney.
 Urine leak:
 Elevated creatinine.
 May or may not have abdominal pain.
 Diagnose with nuclear medicine scans (DTPA or MAG3).
 Surgical repair and/or relief of obstruction.
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Lymphocele
Collection of lymph caused by leakage from iliac
lymphatics.
Presents several weeks post-operatively.
Symptoms:
Compression of kidney, ureter, bladder: obstructive uropathy
and ARF.
Compression of iliac vessels: unilateral lower extremity edema
and DVT.
Abdominal mass.
Treatment is surgical.
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Acute Rejection
May present with ARF or proteinuria.
Diagnosis made by biopsy.
Pathology is reported according to Banff
classification.
Acute cellular rejection: treat with steroids or
ATG based on severity
Antibody-mediated rejection: may require
steroids, ATG, rituximab, IVIG or plasmapheresis
based on severity and setting.
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Cytomegalovirus
 Most common viral infection after transplantation.
 Various degrees of severity:
 Asymptomatic CMV viremia
 CMV syndrome (viremia plus constitutional
symptoms)
 CMV end-organ or invasive disease (hepatitis,
gastritis, colitis, pneumonitis)
 Risk factors:
 Use of antibody induction
 Donor seropositive, recipient seronegative status
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Cytomegalovirus
Clinical presentation:
Asymptomatic (detected on screening)
Neutropenia
Malaise & constitutional symptoms
GI CMV: gastritis, colitis, esophagitis
Clinical hepatitis, pneumonitis
Prophylaxis:
All patients at risk (D+/R+, D-/R+ or D+/R-) receive
valganciclovir prophylaxis for 4.5-6 months.
“Preemptive” strategy with CMV PCR monitoring.
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Cytomegalovirus
CMV PCR assays have largely replaced pp65
antigenemia for diagnosis.
Low-level viremia can be treated with full-dose oral
valganciclovir (900 mg bid, dose-adjusted for renal
function).
High-grade viremia or invasive disease requires 2-4 week
course of IV ganciclovir, which may be followed by oral
valganciclovir.
Ganciclovir-resistant cases might require foscarnet or
cidofovir.
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BK Virus Disease
 BK virus is a member of the polyomavirus family.
 An increasingly important cause of allograft failure.
 Latent in genitourinary tract and reactivated by
immunosuppression.
 Usually presents in first year after transplantation.
 Asymptomatic viruria or viremia
 BK-associated interstitial nephritis
 BK virus nephropathy
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BK Virus Disease
Screening is by BK viral PCR in blood or urine.
Presence of BK virus titers >10,000 is suggestive
but not diagnostic of BK nephropathy.
Diagnosis can only be established by biopsy.
Options for therapy:
Judiciously reduce immunosuppression
Use of leflunomide
IVIG (especially in simultaneous rejection & BK
nephropathy).
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BK Virus Monitoring Algorithm
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Other Infections
Transplant patients have increased susceptibility
to all other common infections.
Opportunistic infections can also be seen:
Pneumocystis jirovicii pneumonia
Candida infection
Toxoplasmosis
Nocardiosis
Cryptococcus infections
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Malignancy
 Recipient of organ transplants are at higher risk
of developing malignancy.
 May be related to impaired immune surveillance
as a result of immunosuppression.
 Skin cancer most common: sun protection
mandatory.
 Routine cancer screening.
 Specific malignancies:
 Kaposi sarcoma
 Post-transplant lymphoproliferative disorder (PTLD)
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Chronic Allograft Dysfunction
Persistent rise in serum creatinine and worsening
GFR over weeks to months is termed chronic
allograft dysfunction.
Histological counterpart is chronic allograft
nephropathy (CAN).
Characterized by nonspecific interstitial fibrosis
and tubular atrophy.
Usually irreversible and will lead to allograft
failure and need for dialysis or retransplantation.
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Chronic Allograft Dysfunction: Why Do
Grafts Fail?
Chronic low-grade immune injury
Long-standing hypertension
Recurrent disease (diabetic nephropathy or
glomerulonephritis)
Repeated episodes of acute rejection
Donor disease
Calcineurin inhibitor nephrotoxicity
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Long Term Complications in
Renal Transplantation
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INFECTIONS
MALIGNANCY
BONE DISEASE
CARDIOVASCULAR DISEASE,HYPERTENTION
POST TRANSPLANT D.M
CATARACT
POST TRANSPLANT ERYTHROCYTOSIS
CHRONIC REJECTION
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