Management Of Renal Transplant Recipients Research Articles

Perioperative anaesthesia management of renal transplant recipients - A national cross-sectional survey.

Perioperative anaesthesia management of renal transplant recipients - A national cross-sectional survey.

An Anaesthetic Challenge: Perioperative Management of Renal Transplant Recipient Undergoing total Hip Replacement Surgery

An Anaesthetic Challenge: Perioperative Management of Renal Transplant Recipient Undergoing total Hip Replacement Surgery

Anaesthetic challenges in the management of renal transplant recipients - An institutional review.

Objective: To provide an overview of our institutional experience with anaesthetic management of renal transplant data in terms of demographics, preoperative status, anaesthesia management, and postoperative care. Study Design: Descriptive study. Setting: Pakistan Kidney and Liver Institute and Research Center, Lahore. Period: January 2022 to June 2022. Material & Methods: This descriptive study included 203 cases of renal transplant. We reviewed the medical records of these patients for demographics, preoperative anaesthetic assessment, intraoperative anaesthesia records, and postoperative care unit notes. Data was analyzed using SPSS Version 25. Results: The mean age of the patients was 35.75 + 10.1 years, and most of the patients had co-morbidities. The preoperative echocardiographic findings were significant in 52.7% of the patients, and 87.2% were on dialysis preoperatively. General anaesthesia was used in 99.5% of cases. Mean volume of intravenous fluid was 5.8 L, and 9.35% required ionotropic support, 9.9% received transfusion intraoperatively while 3.9% required postoperative mechanical ventilation. Conclusions: Renal transplant recipients have significant co-morbidities and require a meticulous approach for successful perioperative anaesthetic management.

Peculiarities of management of renal transplant recipients with COVID-19: a clinical case report

Peculiarities of management of renal transplant recipients with COVID-19: a clinical case report

Our experience in the management of renal transplant recipients in the COVID-19 pandemic

169 patients with a functioning kidney transplant were observed. In 51 patients from 169 were diagnosed with COVID-19. The virus was verified by polymerase chain reaction in all patients and in 74% of cases immunoglobulins M and G were detected by immunological blood tests. Patients who underwent COVID-19 were divided into the following groups: Group 1 – kidney transplant recipients who recovered after COVID-19 (n=44); Group 2 – kidney transplant recipients who died (n=7). Lymphopenia, which was directly proportional to the severity of the disease, was observed in Group 2 patients. The serum C-reactive protein content of Group 2 patients did not differ significantly from that of Group 1. In Group 2 patients, the D-dimer content was significantly higher than that of Group 1. When we analyzed the percentage of lung lesions of the examined patients, it was found that in patients of Group 2 this figure was 68.0 [63.5; 75.0], which was probably higher than that of Group 1 patients (p<0.05). Kidney transplant dysfunction was observed in 16 recipients (31%) during the follow-up period of patients with COVID-19. Complications observed during the disease and arising from the treatment of patients accounted for 15.2%, of which thrombosis of various localizations – 1.5%, myocardial damage – 2.5%, bleeding – 3.4%. The mortality rate of kidney transplant recipients was 13.7%. The main cause of death was acute respiratory syndrome in combination with sepsis (in 8.1% of patients), pulmonary embolism (in 3.2%), and acute cerebrovascular accident (in 2.4%). According to our studies, the risk factors for an unfavorable outcome of COVID-19 are comorbid syndrome, the severity of lung damage, hyperalbuminuria, an increase in C-reactive protein, D-dimer, platelets and lymphopenia. Keywords: chronic kidney disease, kidney transplant, COVID-19.

A1099 - Contemporary management of renal transplant recipients with de novo urinary stones. A single institution experience

A1099 - Contemporary management of renal transplant recipients with de novo urinary stones. A single institution experience

Therapeutic monitoring of mycophenolic acid in renal transplanted patients by a validated HPLC method.

Mycophenolate mofetil and its active metabolite mycophenolic acid are routinely used as immunosuppressant drugs in solid organ transplantation in a fixed daily dose regimen in association with cyclosporine, tacrolimus and steroids. Therapeutic drug monitoring for mycophenolic acid concentration has been suggested to optimize outcomes by reducing rejection and drug related toxicities in clinical renal transplantation. To determine the predose concentration of mycophenolic acid in renal transplanted patients by a validated proposed high-performance liquid chromatography (HPLC) method and to estimate the interindividual variability based on the therapeutic target. An HPLC method combined with protein precipitation has been validated for mycophenolic acid determination in the human plasma obtained from 21 renal transplant recipients. HPLC analysis was carried out using the chromatographic system Agilent Technologies 1200 DAD. Samples were injected manually, and the compounds were separated on a LiChrosphere® select B C18 analytical column. The mobile phase was 45:55 (v/v) acetonitrile-buffer phosphate, pH 2.5, flow rate of 1.0 mL/min and column temperature of 30°C. Detection was performed at 215 nm. Whole blood samples were collected into vacutainers containing EDTA and separated at 6000 g for 10 minutes. A 200-μL aliquot of patient plasma was transferred to a tube, followed by addition of 10 μL of naproxen as internal standard and 400 μL of acetonitrile (v/v) as a protein precipitating agent. Each tube was vortex-mixed for 30 sec and then centrifuged for 10 min at 10000 rpm. 20 μL of the supernatant was injected into the HPLC system for analysis. The method showed appropriate linearity for MPA with correlation coefficient greater than 0.999. High inter-patient variability is observed with 18% of patients within the target trough concentration range, 27% of patients below the target trough concentration range and 54% over the range with risk of toxicity. Therapeutic monitoring of MPA might contribute to a better management of renal transplant recipient with the goal of optimizing therapeutic regimens in order to reduce the risk of rejection and MPA-related toxicity.

Antenatal follow-up, anesthesia management and perinatal outcomes in pregnancy with renal transplant

Objective:Due to the recent increase in the successful pregnancies after renal transplant, the number of renal transplant recipients having vaginal or cesarean delivery possibly associated with high maternal, fetal and/or neonatal risk requiring team approach increased. We aimed to evaluate antenatal follow-up, perinatal outcomes, and anesthesia management in pregnancies with renal transplantation and to compare them with the current literature.Materials and Methods:After ethics committee approval, renal transplant recipients who gave birth in our hospital between January 2010 and December 2019 were documented in this retrospective study. Demographic characteristics, comorbidities, antenatal follow-up, anesthesia management, and maternal, fetal, and neonatal outcomes were presented.Results:A total of 20 pregnant women who underwent renal transplant were identified. The mean age of the parturients was 31±5 years. The median interval from transplantation to conception was 8.15±4.8 years. Antenatal mean serum creatinine level and proteinuria were 1.48±1.39 mg/dL and 1.397±1.316 mg/dL, respectively. No allograft rejection was recorded. Comorbidities including hypertension (n=12), preeclampsia (n=6), and preterm delivery (n=10) were noted. The median gestational age was 35±3 weeks and the median newborn weight was 2.520±832 gram. There was one abortion, two pregnancy terminations, and 17 deliveries (3 vaginal and 14 cesareans). Cesarean sections (11/14; 78.6%) were mostly performed under spinal block and general anesthesia was performed in three (21.4%) women. Epidural analgesia for vaginal delivery was recorded in one parturient.Conclusion:Despite the presence of preterm delivery and comorbidities, antenatal/peripartum follow-up and analgesia/anesthesia management of renal transplant recipients revealed good perinatal outcomes.

Preemptive HLA Antibody Screening Prior to Episodic Transplant Renal Biopsy Enables Early Diagnosis and Therapeutic Response in Asymptomatic Chronically Active Antibody-Related Rejection: A Case Report

Common management of renal transplant recipients includes episodic renal biopsy based on clinical findings such as an increase in proteinuria or serum creatinine. When antibody-related rejection is suspected from the renal biopsy, subsequent testing for donor-specific antibodies (DSAs) is performed. We instead performed preemptive screening of asymptomatic post–renal transplant recipients for DSAs prior to renal biopsy. In this case, a 30-year-old woman with a secondary transplant was positive for 61 anti-HLA antibodies of class I and class II, among which DQ2 was a DSA with a mean fluorescence index of 2039. The patient had a living kidney transplant 9 years earlier. She had never been diagnosed with rejection, her serum creatinine was around 1.0 mg/dL, and her proteinuria was negative. Following the positive DSA result, a renal biopsy was performed, and she was diagnosed as C4d-negative chronic-active antibody-mediated rejection (CAABMR) with a Banff score of cg1b, (g + ptc) ≥ 2, and C4d 0. Intravenous steroid pulse, deoxyspagarin, antithymocyte globulin, rituximab, and oral everolimus were administrated. The treatment resulted in a gradual decrease in the DSA, which became negative 1 year later. The patient’s serum creatinine remains around 1.0 mg/dL, and proteinuria remains negative. Treatments for advanced CAABMR are often expensive and ineffective. Our present case suggests that early detection and treatment through preemptive HLA antibody screening could improve the prognosis of renal transplants.

P1744EFFECT OF TREATMENT WITH ALLOPURINOL ON BLOOD PRESSURE, CREATININ CLEARENCE AND PROTEINURIA IN ADULT RENAL ALLOGRAFT RECIPIENTS: A RANDOMIZED CONTROLLED TRIAL

Abstract Background and Aims Hyperuricemia has been associated with the development of hypertension, cardiovascular, and renal disease. However, there is no data about the effect of lowering uric acid level on hypertension, renal function, and proteinuria in renal transplant patients. We therefore conducted a prospective study to investigate the benefits of allopurinol treatment in renal transplant patients and to investigate indirectly its effect on graft survival. Method A total of 105 Renal transplant recipients(RTRs) were included in this study. Patients were randomized to receive either placebo (n=51) or 300 mg/day allopurinol (n=54). We have examined uric acide, urinary albümin/Cr ratio, eGFR, CRP and blood pressure before and 24 weeks later after treatment in both group. Results In the allopurinol group, the mean serum uric acid levels, eGFR, creatinine urinary albümin/Cr ratio significantly improved(P < 0.001). However, blood pressure, CRP not statistically significant (P > 0.05). No correlation was observed between changes in uric acide and changes in CRP, or blood pressure in the allopurinol group. No significant changes were observed in the control group (P > 0.05). Multivariable regression analysis showed that uric acide was positively correlated with UACR (r= 0,473, β = 0.021, P = 0.002) and negatively correlated with eGFR ( r= -0554 β = 0.016, P = 0.001) in RTRs. Conclusion We bring indirect evidence that hyperuricemia increases urinary albümin/Cr ratio, and decreases eGFR. Hence, management of hyperuricemia may prevent the progression of renal disease, even in patients with normal renal function, suggesting that early treatment with allopurinol should be an important part of the management of renal transplant recipients. Long-term follow-up studies are warranted to identify the benefits of uric acid management on renal function and proteinuria.

A Multidisciplinary Technique for Concurrent Panniculectomy-Living Donor Renal Transplantation.

Recently, it has been shown that panniculectomy concurrent to living donor renal transplantation is a safe option for management of renal transplant recipients with a large focal pannus. This combined management requires precise coordination of teams. We describe the technique, timing, and sequence for combined renal transplantation and panniculectomy. We conducted a retrospective chart review of adult patients (≥18 years old) who underwent simultaneous living donor renal transplantation-panniculectomy from 2015 to 2019. A multi-team approach that included urology, transplant, and plastic surgery was used to perform the combined operations. Typically, the plastic surgery team initiates the operation by performing the panniculectomy. This is followed by kidney transplantation and graft anastomosis. The plastic surgery team then completes the operation with closure of the wound. Twenty patients were identified. Most were male (12:8) with a mean age of 55 years and an average body mass index of 35 kg/m. The mean total operative duration was 394 minutes. On average, 17% of operating time was devoted to panniculectomy. At 90 days follow-up, there was 100% graft survival and all patients had primary graft function. There was a 25% wound complications rate and a 15% reoperation rate. By performing panniculectomy first in the sequence, concurrent panniculectomy provides wide exposure and a large operative field for transplantation. Wound closure by plastic surgeons may mitigate the high complication rate commonly seen in obese patients with end-stage renal disease. Future studies are needed to evaluate the cost-benefit of the combined living donor renal transplantation-panniculectomy.

Perioperative management of adult cadaveric and live donor renal transplantation in the UK: a survey of national practice

BackgroundThere is a limited evidence base and no national consensus regarding the perioperative management of patients undergoing renal transplantation. We developed an electronic survey to capture an overview of renal transplant perioperative practice across UK renal transplant centres and determine the need for future guidelines on patient management. MethodsA 29-question survey was developed to encompass the entire renal transplant perioperative pathway and input was sought from clinicians with expertise in renal transplant surgery, anaesthesia, nephrology and intensive care. The survey was sent to lead renal anaesthetists at each of the 23 transplant centres across the UK. ResultsA 96% response rate was achieved with 22 out of 23 centres returning complete responses. There was limited evidence of guideline-based approaches to preoperative workup. Questions regarding intraoperative fluid management, blood pressure targets, vasopressor administration and central venous pressure (CVP) monitoring identified a broad range of practice. Of note, the routine use of goal-directed fluid therapy based on cardiac output estimation was reported in six (27.3%) centres, while nine centres (40.9%) continue to target a specific CVP intraoperatively. In all, 12 (54.5%) centres perform transversus abdominis plane blocks with fentanyl-based patient-controlled analgesia as the most common mode of postoperative analgesia. A single centre reported a renal transplant-specific Enhanced Recovery after Surgery programme for cadaveric organ recipients. ConclusionsThis questionnaire highlighted a high degree of heterogeneity in current UK practice as regards the perioperative management of renal transplant recipients. Development of evidence-based national consensus guidelines to standardize the perioperative care of these patients is recommended in order to improve patient outcomes and focus areas of future research.

Nutritional management in renal transplant recipients: A transplant team opportunity to improve graft survival

AimsThe nutritional management of renal transplant recipients (RTR) represents a complex problem either because the recovery of renal function is not complete and for the appearance of “unavoidable” metabolic side effects of immunosuppressive drugs. Nevertheless, it remains a neglected problem, whereas an appropriate dietary intervention could favorably affect graft survival. Data synthesisRenal transplantation is associated with steroids and calcineurin inhibitors administration, liberalization of diet after dialysis restrictions, and patients’ better quality of life. These factors predispose, from the first months after surgery, to body weight gain, enhanced post transplant diabetes, hyperlipidemia, metabolic syndrome, with negative consequences on graft outcome. Unfortunately, specific guidelines about this topic and nutritional counseling are scarce; moreover, beyond the low adherence of patients to any dietary plan, there is a dangerous underestimation of the problem by physicians, sometimes with inadequate interventions. A prompt and specific nutritional management of RTR can help prevent or minimize these metabolic alterations, mostly when associated with careful and repeated counseling. ConclusionsA correct nutritional management, possibly tailored to enhance patients' motivation and adherence, represents the best preventive maneuver to increase patients’ life and probably improve graft survival, at no cost and with no side effects.

Two-year management after renal transplantation in 2013 in France: Input from the French national health system database

The objective of this study was to describe the management of patients undergoing renal transplantation in 2013 and over the following two years on the basis of healthcare consumption data. The National Health Insurance Information System was used to identify 1876 general scheme beneficiaries undergoing a first isolated renal transplantation (median age: 53 years; men 63%). Overall, 1.2% of patients died during the transplantation hospital stay (>65 years 3.3%) and 87% of patients had a functional graft at 2 years. Thirty-three percent of patients were readmitted to hospital for 1 day or longer during the first month, 73% the first year and 55% the second year. At least 10% of patients were hospitalised for antirejection treatment during the first quarter after renal transplantation, 16% the first year and 9% the second year. The first year, 32% of patients were hospitalised for renal disease (12% the second year), 14% were hospitalised for cardiovascular disease (9% the second year), 13% for infectious disease (5% the second year) and 2% for a malignant tumour (2% the second year). Almost 80% of patients consulted their general practitioner each year (almost 50% consulted every quarter). During the second year, 83% of patients were taking antihypertensives, 45% lipid-lowering drugs, 26% antidiabetic drugs, 77% tacrolimus, 18% ciclosporin, 88% mycophenolic acid and 69% corticosteroids. This study highlights the important contribution of healthcare consumption data to a better understanding of the modalities of management of renal transplant recipients in France, allowing improvement of this management in line with guidelines.

Assessment of Spleen Filtrate Function in Renal Transplant Recipients Using Technetium-99m Stannous Colloid Liver-Spleen Scan

BackgroundFunctional hyposplenism (FH) is indicated by an anatomically present spleen that fails to take up radiolabeled colloid. The occurrence of FH has been reported in a small group of renal transplant recipients based on hematologic parameters. The aim of this study was to replicate this association in a larger group of renal transplant recipients with the use of technetium-99m–stannous colloid liver-spleen scan to assess the spleen function. MethodsThis survey based on single samples enrolled 101 unselected adult patients with functional kidney grafts >180 days after transplantation. All patients underwent 99mTc-stannous colloid scan to assess spleen function as well as bone marrow uptake of radiocolloid along with an anatomic and blood flow study of the spleen and kidney with the use of Doppler sonography. ResultsThe prevalence of hyposplenism was 32.7% (33/101) for the cohort, and increased uptake of radiocolloid by the bone marrow was seen in 9.9% (10/101). According to the multivariate analysis, the frequency of hyposplenism was significantly influenced by indirect bilirubin and hemoglobin, and direct bilirubin and neutrophil count remained as independent predictors of bone marrow uptake. ConclusionsThis study demonstrated that a group of renal transplant recipients has FH. In addition, bone marrow uptake might be interpreted as liver dysfunction. In this situation, the small amount of contrast (spleen compared with liver) would leave hyposplenism undiagnosed. Further prospective and longitudinal clinical studies are needed to determine the clinical impact of this condition on the management of renal transplant recipients.

Successful Management of Renal Transplant Recipients with Hepatitis C by Direct-Acting Antiviral Therapy: A Report on Three Cases

We evaluated the efficacy of direct-acting antiviral (DAA) therapy in the management of renal transplant recipients with hepatitis C virus (HCV) infection. Methods: We treated two of our renal transplant recipients (Patients 1 and 2) who were HCV-RNA-(genotype 1b) positive with daclatasvir and asunaprevir. Another recipient (Patient 3), who was positive for HCV (genotype 2b), was treated with sofosbuvir and ribavirin. Patient 1 received DAA treatment following unsuccessful pegylated-interferon therapy. Prior to DAA therapy, his HCV-RNA level was 6.0 log IU/mL. After 8 weeks of treatment, DAA therapy was discontinued due to allograft dysfunction. In Patient 2, HCVRNA level before DAA therapy was 6.9 log IU/mL. In Patient 3, DAA therapy was initiated 4 months after renal transplantation, when the patient's HCV-RNA level was 7.4 log IU/mL. Results: In all cases, HCV-RNA was undetectable within 4 weeks of the initiation of DAA therapy and a sustained virological response was maintained. In Patient 1, transient deterioration of renal function gradually recovered. Patient 3 developed BK virus nephropathy (BKN) 5 weeks after completion of DAA therapy, although the relationship between DAA and BKN remains unclear. Conclusion: DAA therapy was successful in the therapeutic management of our three HCV-infected renal transplant patients. Although physicians should be aware of the possibility of complex drug interactions, DAA therapy under such conditions may provide promising short-term outcomes.

Renal transplant ultrasound: The nephrologist's perspective.

One of the principal roles of a nephrologist is to closely monitor renal transplant allograft function and promptly evaluate any dysfunction. Renal transplant sonography has a major role in this assessment process given its ability to easily define renal transplant anatomy and surrounding structures. Abnormalities can be extrarenal or involve vascular, parenchymal and urological components of the graft and these can acutely or chronically influence graft function and survival. Procedural guidance as is required during allograft biopsy, as well as routine surveillance and screening for post transplant complications such as malignancy are also important applications of ultrasound in the management of renal transplant recipients. This article outlines key ultrasound findings and applications in renal transplantation from the clinician's perspective.

Estimating glomerular filtration rate in kidney transplantation: Still searching for the best marker.

Kidney transplantation is the treatment of choice for end-stage renal disease. The evaluation of graft function is mandatory in the management of renal transplant recipients. Glomerular filtration rate (GFR), is generally considered the best index of graft function and also a predictor of graft and patient survival. However GFR measurement using inulin clearance, the gold standard for its measurement and exogenous markers such as radiolabeled isotopes ((51)Cr EDTA, (99m)Tc DTPA or (125)I Iothalamate) and non-radioactive contrast agents (Iothalamate or Iohexol), is laborious as well as expensive, being rarely used in clinical practice. Therefore, endogenous markers, such as serum creatinine or cystatin C, are used to estimate kidney function, and equations using these markers adjusted to other variables, mainly demographic, are an attempt to improve accuracy in estimation of GFR (eGFR). Nevertheless, there is some concern about the inability of the available eGFR equations to accurately identify changes in GFR, in kidney transplant recipients. This article will review and discuss the performance and limitations of these endogenous markers and their equations as estimators of GFR in the kidney transplant recipients, and their ability in predicting significant clinical outcomes.

Pharmacist Chart Reviews Cannot Replace Direct Care in the Management of Renal Transplant Recipients.

OBJECTIVE: The aim of this study was to determine if a pharmacist executed comprehensive chart review may serve as a sufficient substitution for direct participation during clinic visits beyond the immediate post-transplant period. METHODS: This was a prospective 3 month study of kidney transplant recipients that had a scheduled visit within 3 years of transplant. Within 1 week prior to the visit, a clinical pharmacist completed a comprehensive review of the medical record and placed a note in the chart focusing on identifying all medication-related issues and providing recommendations for management. Providers were notified about the review and, following the visit, were asked to complete a survey about the utility of the note. After the appointment, the visit plan was compared with the pharmacist's note to determine whether the provider accepted the recommendations. An independent blinded transplant surgeon graded the recommendations by severity. Accepted recommendations were identified as novel if the evidence supporting it had been available to the provider but was not previously acted upon. RESULTS: During the study, pharmacists provided 1,401 recommendations from 170 chart reviews. Providers followed 397 (28%) of the recommendations; 232 (34%) of the recommendations pertaining to pharmacologic therapy were accepted, while 410 (29%) were graded as having at least a significant severity (Table 1). Providers completed the usefulness survey after 44 visits and 75% indicated that the pharmacist note impacted their interventions. Greater than 80% of the accepted recommendations were considered novel. CONCLUSIONS: This study demonstrates that a pharmacist chart review was not routinely utilized by providers during follow-up visits and suggests that this method of pharmacist involvement in transplant recipient care may not be effective or efficient. Future analyses should directly compare this form of intervention with direct patient-provider interactions.Table: No Caption available.

Gender-dependent predictable pharmacokinetic method for tacrolimus exposure monitoring in kidney transplant patients

Tacrolimus (Tac) is an immunosuppressive drug with a narrow therapeutic width and highly variable pharmacokinetics. Therefore, monitoring of Tac blood concentrations is of utmost importance in the management of renal transplant recipients. The occurrence and intensity of adverse effects depend on blood concentration and total exposure of the organism to this drug. This implies finding a new gender-dependent predictable method for Tac exposure monitoring based on determination of the area under the time concentration curve (AUC). The primary aim of this study was to investigate gender differences in systemic body exposure to Tac in renal transplant patients after the first oral dose and in a steady state by determining 12-h AUC (AUC(0-12)). The secondary objective was to find the best sampling time in which measured Tac concentration best predicts AUC value with respect to gender. Tac pharmacokinetic study was conducted in 20 kidney transplant recipients (10 men/10 women) on quaternary immunosuppressive therapy. The first oral Tac dose (0.05 mg/kg) was given on the fifth day post-transplant. After reaching steady state, regimen stabilized and dosage was adjusted in accordance with the level of Tac. Blood concentrations were measured by microparticle enzyme immunoassay method. AUC(0-12) for each patient was calculated after the first oral Tac dose and in the steady state from a plot of Tac concentration versus time from 0 to 12 h using the trapezoid rule. Associations between each sampling time point of concentrations within 12 h after the administration and AUC(0-12) were evaluated by Pearson correlation coefficients. Abbreviated sampling equations were derived by multiple stepwise regression analyses. Statistically significant difference was found in AUC(0-12) between male and female patients after the first oral dose (p < 0.01), but this difference was lost in a steady state. In female recipients C(2) seemed to be good indicator of total body exposure to Tac after the first oral dose and this was also confirmed in a steady state. The three-point sampling method was required for calculating AUC after the first oral dose in male patients, whereas in the steady state, concentration of C(8) seemed to be a good indicator of abbreviated AUC for a Tac monitoring strategy in male patients. Non-compartment Tac pharmacokinetic and regression analysis showed gender difference in total Tac exposure and determined the best predictable Tac concentrations after the first oral dose. Our study confirmed gender-dependent pharmacokinetics in a steady state in terms of best sampling time in which measured Tac concentration best predicts AUC value.