Post-Kidney Transplant: 5 Pearls Segment

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Pearl 1: Post-transplant immunosuppressive medications

• Maintenance immunosuppression
  • Necessary to prevent rejection of the transplanted kidney
•  Transplant regimens:
  •  Usually contain
    • Tacrolimus
    • Mycophenolate
  • Sometimes contain
    • Prednisone
  • Newer medication:
    •  Belatacept
      • Can only be given to EBV IgG positive patients
• Immunosuppressive Medications:
  • Tacrolimus and cyclosporine:
    • Calcineurin inhibitors:  block IL-2 production in T-cells.
    • Given every 12 hours 
    • Trough level is dosed just prior to the AM dose
      • Goal - avoid toxicity and maintain a therapeutic window
        • Especially neurotoxicity
    • Side effects:
      • Hypertension, tremors
      • Tacrolimus - Hair loss, and new onset diabetes after transplant (NODAT)
      • Cyclosporine - hirsutism and gingival hyperplasia
  • Mycophenolic acid:
    • Inhibits T and B lymphocyte proliferation by blocking purine synthesis
    • Comes in two forms:
      • Mycophenolate mofetil (CellCept)
        • Original drug
        • Can cause GI upset
      • Enteric coated mycophenolate sodium (Myfortic)
        • Less likely to cause GI upset
    • Side effects:
      • Bone marrow suppression and gut toxicity
        • Can be spaced out to three times daily to reduce the frequency of diarrhea
  • Prednisone:
    • Decreases neutrophil movement across capillaries
    • Use according to local immunosuppressive protocols and underlying kidney disease

Pearl 2: How do you do a good medication reconciliation? What do you need to be mindful about in post-renal transplant patients’ med rec?

• Transplant regimens can be complex!
  • Understand what medications they take and when
    • Assess for medication compliance
      • Missing doses of immunosuppressive medication increases the risk of antibody mediated rejection
  • • Assess for possible drug-drug interactions (not comprehensive)
      • Medications that increase levels of tacrolimus:
        • Calcium channel blockers
        • Antifungals
        • Macrolides
      • Medications that decrease levels of tacrolimus:
        • Anti-seizure medications
        • Ciprofloxacin
      • Medications that decrease levels of mycophenolate:
        • Calcium carbonate
        • Magnesium carbonate
        • Proton-pump inhibitors
    • Note: Clinical context can also affect the levels of tacrolimus
      • Example: Diarrhea can affect tacrolimus trough levels variably in some patients!
        • Faster GI transit → Less breakdown of tacrolimus by p-glycoprotein  → higher trough levels

Pearl 3: AKI in patients post-transplant

• Assess acute kidney injury in the transplant patient similar to how it is assessed in patients with native kidneys!
  • • • Pre-renal
      • Renal
      • Post-renal.
  • Pre-renal AKI post-transplant:
    • Decreased oral intake → hypovolemia
      • As they may be used to fluid restrictions from before the kidney transplant
  • Intrarenal AKI post-transplant:
    • Tacrolimus can be nephrotoxic. Thus, we aim for trough levels within the therapeutic window
      • In the first few months post-transplant
        • Trough levels should be 10 to 12 ng/mL
      • Approximately 6 to 12 months post transplant
        • Trough levels should be around 5 to 7 ng/mL.
      • For chronic transplant patients, the target can be individualized to:
        • 4 to 6 ng/mL or
        • 5 to 7 ng/mL or
        •  6 to 8 ng/mL
    • Acute rejection can also cause increased creatinine level (more in Pearl 5)
  • Post-renal AKI post-transplant:
    • Assess causes using kidney ultrasound 
    • Place a Foley catheter if there is significant hydronephrosis
    • Percutaneous nephrostomy may be necessary in cases of ureteral strictures

Pearl 4: Infections in patients post-transplant

• Increased risk infections post-transplant:
  • CMV
    • Serologic status is determined for both donor and recipient prior to transplant
      • Highest risk of infection if donor is POSITIVE and recipient is NEGATIVE
    • Appears in first year post-transplant
    • Fever, diarrhea, malaise, leukopenia, and mild hepatitis
  • EBV
    • Serologic status is determined for both donor and recipient prior to transplant
      • Highest risk risk of infection if donor is POSITIVE and recipient is NEGATIVE
    • Presents as:
      • Mononucleosis
        • Fatigue, swollen glands, and pharyngitis
      • Post-transplant lymphoproliferative disorder (PTLD)
        • Fever, weight loss, malaise, and a new lymphadenopathy
  • BK virus
    • Asymptomatic
      • Screening is required to detect high viral load
      • Can cause kidney inflammation and injury
• Measuring viral load with PCR is useful to determine whether or not a patient is presenting with active infection!

Pearl 5: Life with a Kidney Transplant

• Acute transplant rejection:
  • Asymptomatic
    • Frequent labs post-transplant to carefully monitor creatinine for rejection
    • Requires biopsy for diagnosis of rejection
• Increased risk of certain cancers, particularly those that are related to ones that are kept in check by the immune system:
  • Non-melanoma skin cancer
    • Annual dermatology appointments are recommended
  • Oncogenic viruses
    • EBV → lymphoma
    • HPV → anogenital and oropharyngeal cancers
    • Hepatitis B → hepatocellular carcinoma
    • Hepatitis C → hepatocellular carcinoma
  • Routine age-appropriate malignancy screening is important!

Contributors

Shreya Trivedi, MD, ACP Member – Author
Marcus Foo, MD, ACP Member - Author
Anjellica Chen, MD - Author
Karin True, MD - Expert
*Martha Pavlakis, MD - Expert

Reviewers

Pitchaphon Nissaisorkarn, MD
**Jean Francis, MD
Aditya Pawar, MD

*Dr. Pavlakis is a consultant for Memo Therapeutics, Merck, and Vertex Pharmaceuticals

**Dr. Francis is a consultant for Alexion Pharmaceuticals

Those named above, unless otherwise indicated, have no relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All relevant relationships have been mitigated.

Release Date:  August 16, 2023

Expiration Date: August 15, 2026

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