Transcript Evaluation and Management of Allograft Dysfunction

Monitoring Renal Transplants
Planning follow up based on risks
& cost
Early outpatient visits
• Timing
– First month: 2 – 3 visits/wk
– 1 – 3 months: weekly visit
– 4 – 12 months: monthly
• Risks (immediate)
– Acute rejection
– Infection (months 1 – 6)
– Drug monitoring
Adverse distant outcomes
• Long term risks include:
– Cardiovascular disease
– Hyperlipidemia
– Hypertension
– Cancer
• Chronic allograft nephropathy
• Non-adherence (non-compliance)
Importance of early visits
• Frequent visits early on
– Reassure patient
– Emphasize importance of monitoring
• May increase compliance
• Some data suggest that patients dislike
long intervals between visits
Monitoring function
• In stable patient, check creatinine
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Twice weekly first month
Weekly in the second month
Biweekly months three and four
Monthly from month five to end of year
Bimonthly during second year
Quarterly thereafter
• Educate patients on importance of Cr
• Calculate GFR at baseline
• May periodically measure 24 hour clearance
Monitoring function
• “Sudden” changes suggest
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Acute rejection
Infection
Volume depletion
Obstruction
• Creatinine “creep”
– Chronic transplant nephropathy
– Drug toxicity
– Other causes (see above)
Proteinuria
• Transient (rejection issues)
• Persistent
– > 0.5 to 1.0 gm / 24 hours for >3-6 mo
– Occurs in 10 – 25%
– Associates with glomerular lesions
• Chronic allograft nephropathy
• Recurrent glomerular disease
Proteinuria -- screening
• Check baseline at 2 wks post KT
• Screen urine at least every 3 – 6 mo for
year one
• After year one, screen every 6 – 12 mo
• Screen every 2 wks for 2 months if pt with
FSGS
• Protein/creatinine ratio is OK, but can start
with dipstick (>1+ pushes test)
Protocol biopsies
• Clinically silent rejection is seen in 15 – 30%
of patients with “DGF”
• Silent rejection is seen in 4 – 27% at three
months
• Borderline acute rejection in 21 – 71% at
three months
• Borderline and subclinical rejection each
seen in a quarter at 6 months
• At two years subclinical rejection seen in 2%
Protocol biopsies
• Chronic allograft nephropathy in
– 3 to 38% at three months
– 50 to 70% at two years
• Those who do protocol biopsies treat
based on results
• The impact of this activity on outcome is
not established
Cyclosporin
• Nephrotoxicity
– Decreased RBF and GFR
• Other
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HTN 41 – 82 %
Hypercholesterolemia 37%
Hyperuricemia 35 – 52%
Hyperkalemia 55%
Tremor 12 – 43 %
DM 2 – 13%
Gingival hyperplasia 7 – 43%
Hirstutism 29 – 44%
Cyclosporin
• Low trough levels “may” be associated
with more rejection
• High trough levels “may” be associated
with more side effects
• Relationships are imprecise
• Pharmacokinetic studies are better than
trough levels….
Tacrolimus
• Graft survival similar to cyclosporin
• Fewer acute rejections
• Side effects
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Decreased renal function (35 –42%0
Diarrhea (22 – 44%)
Constipation (31 – 35%)
Vomiting (13 – 29%)
Hypertension (37 – 50%)
Infections (72 – 76%)
CMV (14 – 20%)
CyA vs Tac
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CMV about the same
Tremor about the same
Gingival hyperplasia more in CyA
Hirstutism more in CyA
CyA and Tac
• Monitor with
– Periodic history
– Check BP, renal function, glucose
– Follow blood levels
• Frequent early
• Measure after changes
• Measure after new drugs
Sirolimus
• The data used by Kassiske are so
limited as to be useless
• He does, however, recommend periodic
monitoring of glucose, K, and lipids
MMF
• Consider MMF toxicity when taking
history and doing physical
• CBC – weekly for first two months,
biweekly the next two months, monthly
for the rest of year one, and then
quarterly to semi annually
Azathioprine
• Check for toxicity with H&P
• CBC as for MMF
• LFTs monthly for the first 3 months, then
q 3 months for one year, then yearly
Steroids
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Check for toxicity with H&P
Follow growth in children
Measure BP, glucose, lipoproteins
Annual eye exams
Spine and hip bone densities (how
often?)
CVD
• At 15 years:
– CAD in 23%
– Cerebrovascular in 15%
– PVD in 15%
• Follow risk in regular exams
• No evidence for utility of EKG, ETT, or
carotid Dopplers
• Consider aspirin
Hyperlipidemia
• Screen once in first six months and at
one year
• Annually thereafter
PTDM
• Weekly FBS for first three months,
biweekly for next three months, monthly
for rest of first year
• After year one, at least yearly FBS and
A1C
Erythrocytosis
• 10 to 20% of cases
• Detect with scheduled CBC’s
Anemia
• Probably >10%
• Follow CBC
Osteoporosis
• Up to 60%
• Bone densitometry at KT, 6 months, and
then q year if abnormal
Secondary hyperpara
• 10 – 20% hypercalcemia
• Monthly serum calcium for 6 months,
bimonthly for rest of year
• Correct for albumin
• PTH at 6 and 12 months, then yearly
Hypophosphatemia
• More than 50%
• Check monthly for 6 months, then
bimonthly for rest of year, then annually
Hypomagnesemia
• 25% if on CyA, increased risk with loop
diuretics
• Check monthly for 6 months, then
bimonthly for rest of year
Nutrition
• 10% risk of malnutrition, 40% risk of
obesity in first year
• Follow weight
• Measure albumin 2 t0 3 times in first
year
Cancer
• Skin risk ~ 50% at 20 year
– Monthly self check , yearly physical
• Anogenital ~ 2.5%
– Yearly physical with PAP
– Treat warts
• KS 0.4 to 4% based on ethnicity
– Yearly exam
Cancer
• PTLD risk 1 to 5%
– Complete H&P quarterly first year and then
yearly
• Uroepithelial and renal Ca risk 0.5 to
4%
– No good screen recommendation
Cancer
• Hepatobiliary risk varies by area
– Alpha feto protein, sono if high risk
• Cervical cancer risk 9%
– Annual PAP smear
• Breast cancer risk not increased
– Same as with KT
• Colorectal Ca risk ~ 0.7%
– Screen as for others