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Kidney Transplant Medicine

Trey Richardson

Introduction

  • The goal of this section is to serve as a guide for tackling the most common transplant complications as well as offer a few tips for managing immunosuppression while kidney transplant patients are admitted to the hospital

Alphabet soup

  • PRA: panel reactive antibodies

  • DSA: donor specific antibodies

  • CMV (-/+): indicates the CMV status of both the recipient and the donor

  • FK506 or FK: another name for tacrolimus

  • KDPI: Kidney donor profile index used to “grade” the quality of the donated organ

  • X/6 MM: indicates the number of HLA subtypes that are mismatched between donor and recipient

Infections in Kidney Transplant Recipients

Background

  • Infections in a kidney transplant recipient can be divided into 3 phases:

  • \<1-month post-transplant

    • Surgical site infections, nosocomial infections (e.g. C. Diff, CAUTIs, and CLABSIs), and donor-derived infections/reactivation of latent recipient infections predominate

  • 1-6 months post-transplant

    • Depleted immune-system regenerates increased risk for disseminated fungal (e.g. PJP, histo/blasto) and viral infections (HSV, adenovirus)

  • >6 months post-transplant

    • Risk for atypical infections persists, but common community acquired syndromes should still be on the differential

  • This section will focus on the most common infection in kidney transplant recipients- infections of the urinary tract

Evaluation

  • UA with culture 

  • Examine the native kidneys (CVA tenderness) AND the allograft (almost always in RLQ, denervated so the graft itself will not be tender, but the surrounding soft-tissue may)

  • Renal U/S (of both allograft and native kidneys) or CT AP if:

    • Early post-op (1 month)

    • Recurrent (2+ episodes in year)

    • History of nephrolithiasis or if sepsis/bacteremia

  • Blood cultures if systemic signs/symptoms

  • Consider testing for C. urealyticum, and sending fungal and AFB urine cultures if UA is recurrently positive but culture negative

Management

  • Remove or replace indwelling catheters

  • Review prior culture susceptibilities (if available)

  • Empiric antibiotic regimens:

    • Asymptomatic bacteriuria: treat with FQ or beta lactam for 5-7 days if \<3 mos post-transplant

    • Simple cystitis: Fluoroquinolones (ciprofloxacin 250 BID or Levaquin 500 mg daily), Augmentin (500 mg BID), 3rd gen cephalosporin (cefpodoxime 100 mg BID or cefixime 400 mg daily) or nitrofurantoin 100 mg BID (if GFR>30, only treats cystitis since drug only concentrates in the urine)

      • \< 6 mos post-transplant: treat for 10-14 days

      • >6 mos post-transplant: treat for 5-7 days

    • Complicated UTI/Pyelonephritis (cover Pseudomonas, gram negatives and Enterococcus): Ceftriaxone 2g daily (preferred), Cefepime 2g q8hrs (add Vancomycin when using cephalosporin if suspicious for enterococcus) or Pip-tazo 3.75g q6hrs, can also use meropenem 1g q8h (need ID approval)

      • Treat for 14-21 days

      • For stable pts with mild complicated UTI, can consider giving more narrow empiric antibiotics: Augmentin 875 mg BID or ciprofloxacin 500 mg q12h

    • MDR UTI: Consult transplant ID

      • Options: meropenem-vaborbactam, ceftolozone-tazobactam, ceftazidime-avibactam

    • In pts w/PCKD, include lipophilic antibiotic (such as ciprofloxacin) to penetrate cysts

Prevention

  • Bactrim used for PJP prophylaxis during first 6 mos post-transplant also prevents UTIs

  • Basic infection prevention measures for all comers (e.g. hydration, frequent voiding, wiping front to back, voiding after sexual intercourse)

Rejection - See Kidney Transplant Rejection section

AKI - See AKI of Kidney Transplant Section

Kidney Transplant Immunosuppression

Background

  • Most patients with kidney transplants are on triple therapy with an anti-metabolite (azathioprine or mycophenolate compound) or mTOR inhibitor + calcineurin inhibitor + prednisone

  • You may also come across patients who are on monthly infusions with belatacept, a selective T-cell co-stimulation blocker

Calcineurin inhibitors

  • Tacrolimus (FK), cyclosporine (CsA)

  • Envarsus XR is a once a day long acting formulation of tacrolimus

    • Common side-effects

      • Worsening kidney function: mediated by vasoconstriction to the afferent arterioles

      • Hypertension- treat with CCBs

      • Diabetes

      • Hand tremors, headache, nausea

      • Thrombotic microangiopathy

      • T4 RTA- hyperkalemia

      • Gingival hyperplasia

mTOR Inhibitors

  • Sirolimus, everolimus

    • Major side effects: Poor wound healing, rarely pneumonitis

Anti-metabolites

  • Azathioprine

  • Mycophenolate preparations: Mycophenolate mofetil (Cellcept, MMF), Mycophenolic acid (Myfortic)

  • Side effects: Bone marrow suppression- hold for lymphopenia; GI upset- hold for diarrhea

Additional Information for Overnight Admits:

  • Do not change immunosuppression

    • Exception: If pt has severe diarrhea, can hold night tacro dose and inform the day team

  • Daily tacrolimus or cyclosporine level (order qam at 5:00). Always order tacrolimus or cyclosporine dose at 6:00 am and 6:00 pm (regardless of what time patient takes at home, lab can only run am tacro levels at a certain time in batches)

    • EXCEPTION: If late afternoon admission, consider paging the fellow (since its early) and ask if they want the evening dose held until the am level comes back

  • Transplant patients with normal kidney function can have regular diet

Last update: 2022-06-23 16:24:11