Renal Flashcards
What associated features need to be examined for in polycystic kidneys?
Hepatic and splenic cysts HTN Anaemia or polycythaemia U/A: blood from ruptured cysts Mitral prolapse CNIII palsy (pComm aneurysm) Abdominal hernias
What 4 criteria should suggest renal allograft rejection following renal transplant?
- Cr rise > 25% from baseline, or higher than expected
- Worsening HTN
- Proteinuria > 1g/d
- Plasma donor-derived cell-free DNA > 1%
How are the following patient groups treated for antibody-mediated rejection?
- Rejection before 1 year
- Rejection after 1 year
Before 1 year: Prednisone, plasmapheresis, IVIG +/- rituximab
After 1 year: Prednisone, IVIG +/- rituximab
All improve short term but not long term outcomes
At the time of renal transplant, what is the recommended induction immunosuppression?
- First line: Basiliximab
- High risk: rATG
What should be commenced at the time of renal transplant?
- Tacrolimus
- Mycophenolate
- In low immunological risk, steroids may be ceased within 1st week
What strategies may be used to reduce drug costs?
- Limiting biologics to those who are high risk for rejection
- Ketoconazole or a non-dihydropyridine CCB (eg verapamil) to reduce CNI doses
- Using AZA rather than mycophenolate
- Using prednisone long term
What drug monitoring should be recommended in renal transplant?
CNIs 12-hour trough
- Initially until levels are within target range
- Following drug dose adjustment or pt status may affect blood levels
- Decline in renal function suggesting nephrotoxicity or rejection
Mycophenolate
- Weekly until stable for 4 weeks then
- Fortnightly for 2 months then
- Monthly
How should acute rejection be treated?
Acute cellular rejection:
- Steroids
- OKT3 (muromonab) for those who do not respond to steroids. Anti-CD3.
Antibody-mediated rejection:
- May employ steroids
- Plasma exchange
- IVIG
- Anti-CD20
- OKT3 (muromonab)
- Add MMF, or change AZA to MMF
How should chronic allograft injury be treated?
- Reduce or replace CNI if CNI toxicity occurs (biopsy)
- if eGFR>40 and total protein excretion < 500mg per gram of Cr, change CNI to mTORi
How should recurrent kidney disease be treated after renal transplant?
- FSGS or minimal change => plasmapheresis
- ANCA-associated or anti-GBM => high dose steroids, cyclophosphamide
- Hyperoxaluria => pyridoxine, high calcium/low oxalate diet
What are the vaccination recommendations in kidney transplants?
- No vaccinations within 6 months post transplant, except fluvax, which may be given after 1 month post transplant
- No live vaccinations
- HBV vaccination (ideally pre-transplant) and HBsAb titres 6-12 weeks later
- Annual HBsAb titres
- Revaccination if HBsAb titre falls below 10
What does KDIGO say about viral Mx post renal transplant?
BK virus
- Quantitative plasma NAT for the first year 1-3monthly
- Check whenever unexplained rise in Cr or after acute rejection episode
- Reduce immunosuppression if BK NAT > 10,000
CMV
- Valganciclovir for at least 3months post transplant and at least 6 weeks after T-cell depleting mAb
- In those with CMV disease => weekly NAT monitoring
- Serious CMV infection => IV gangiclovir
- Reduce immunosuppressives if CMV infection is life-threatening
EBV
- Monitor high risk pts (D+R-) with EBV NAT for the first year post- transplant and after acute rejection
- In active disease, reduce or cease immunosuppression
Hep C
- Monitor ALT 3-6 monthly + annual US for HCC
Hep B
- HBsAg pos => prophylaxis with tenofovir or entecavir
- During antiviral Rx, measure HBV DNA and ALT every 3 months
HIV
- Screen, if not already done
PCP
- Bactrim prophylaxis for 3-6 months post transplant
TB
- Consider substituting rifabutin for rifampicin to minimise interactions
UTI
- Bactrim prophylaxis for 6 months post transplant
Candida
- Nystatin prophylaxis for 1-3 months post transplant
How should CV risk factors be optimised in renal transplant patients?
NODAT
- HbA1c annually
- Monitor for hyperglycaemia if CNI, mTORi or steroid doses increase
- Target HbA1c 7-7.5%
- Consider aspirin 100mg daily in diabetics
HTN
- Target BP < 130/80
- ACEI if proteinuria>1g daily
Lipids
- Treat if elevated
Smoking
- Assist cessation
What are the recommendations re: skin cancer monitoring in renal transplant?
- Annual skin checks
- Consider acitretin in those with a Hx of skin cancer
How should those with Kaposi sarcoma and renal transplant be treated?
mTORi rather than CNI
What are the aspects of monitoring necessary in kidney transplants?
- Acute and chronic rejection
- Kidney disease recurrence (eg FSGS)
Infection
- Vaccination
- Viruses: BK, CMV, EBV
- Hep B treatment if HBsAg pos
- HIV screening
- PJP
Metabolic and CVS
- NODAT
- Hyperuricaemia and gout
- Bone disease
- CV risk factors
Drug side effects
- Skin cancers
- Immunosuppresive Rx levels
- Monitor FBC. Treat erythrocytosis with ACEIs
Fertility
- Stop mycophenolate and mTORi before conception
What is the primary biomarker used to differentiate Ab-mediated rejection from other rejection?
Donor-derived cell-free DNA (dd-cfDNA)
What are the markers of complement fixation used to assess for antibody-mediated rejection?
C1q or C3d DSAs, or C4d staining.
In 50% of pts C4d staining is negative => Dx on biopsy – increased expression of gene transcripts or classifiers.
What are the consequences of donor-specific antibodies?
Increased risk of antibody-mediated rejection
More severe Ab-mediated injury
Overexpression of allograft genes responsible
What questions need to be asked about renal transplant?
Cause of renal failure Source of transplant HLA and ABO compatibility CMV status Rejection Hx (fever, swelling, tenderness) Biopsies Immunosuppression - Cyclosporin: hirsutism, tremor, renal impairment, hyperkalaemia, hypomagnesaemia, gout, HTN, gingival hypertrophy, haematological malignancy - Infections - Malignancy IHD, PVD
What are the dietary recommendations in CKD?
Normal diet if eGFR>60
Protein restriction
- Not dialysis + not nephrotic => restriction to 0.6-0.8g/kg
Sodium
- HTN, volume overload or proteinuria => 2g or less Na daily
- None of the above => 2.3g or less Na daily
Potassium
- Stage III or IV => restrict to 2-4g K daily
Calcium 800-1000mg daily
Phosphurus < 1g daily in dialysis pts
What are the different forms of renal osteodystrophy (CKD-MBD)?
- Osteitis fibrosa cystica - caused by secondary hyperparathyroidism
- Adynamic bone disease - caused by excessive parathyroid gland suppression
- Osteomalacia - low bone turnover in combination with abnormal mineralisation
What are the main aspects of CKD management?
Diet
- Protein, K, Na, Ca restriction
Anaemia
- Start Erythropoiesis Stimulating Agent when Hb < 100
- Aim Tsat ≥ 30% and Ferritin ≥ 500 in anaemia
- If not anaemic, aim Tsat ≥ 20% and Ferritin ≥ 100
CKD-MBD
- Commence calcitriol 0.25mcg 3 times weekly if PTH > 2.3-3.0 x ULN
When should planning for dialysis be commenced?
When should dialysis commence?
Vascular access planning at eGFR 20
Dialysis at eGFR 7-10
