Transplants

Question 1

How would you manage this patient with recurrent infection who is on chronic immunosuppression? (initial spiel for any case before the “balancing”)

Answer 1

Goals

• Minimize episodes of infection
• Minimise disease progression/graft rejection/function
• Address modifiable risk factors - patient-specific

Assess current situation

• Infection:
  
  • Frequency & Severity
  • Review WCC, CRP, cultures, other relevant previous investigations
    
    • Do Immunoglobulin levels (hypo-gamma)
• Immunosuppression
  
  • Disease activity & Graft function
  • Markers of disease severity & graft function
  • Drug levels

Management

• Currently, emphasis should be put on … based on above
• If infection more severe now
  
  • Consider decreasing ImmSx
  • Carefully monitor disease activity/graft function (state which and how frequent)
• If ImmSx more important now
  
  • Increase ImmSx
  • Monitor signs of infection - history, exam, investigations (state frequency)

Address modifiable risk factors

• Non-pharm
  
  • Avoiding exposures, hygiene
  • Vaccination
  • Optimise nutrition - involve dietician
  • Smoking/ETOH cessation
• Pharm
  
  • Infection prophylaxis - see what’s missing

Question 2

What are the absolute contraindications for kidney transplants? - General 6. Specific 3.

Answer 2

Active infection

Active cancer (2 years of remission - considered)

Active substance abuse

Adherence - documented non-adherence

Uncontrolled psychiatric disease

Significantly shortenend life-expectancy

Specific to renal transplant

Severe ischaemic heart disease

Active vasculitis or anti-GBM disease

Occlusive aorto-iliac disease