Monitoring Renal Transplants

1
Monitoring Renal Transplants

• Planning follow up based on risks cost

2
Early outpatient visits

• Timing
• First month 2 3 visits/wk
• 1 3 months weekly visit
• 4 12 months monthly
• Risks (immediate)
• Acute rejection
• Infection (months 1 6)
• Drug monitoring

3
Adverse distant outcomes

• Long term risks include
• Cardiovascular disease
• Hyperlipidemia
• Hypertension
• Cancer
• Chronic allograft nephropathy
• Non-adherence (non-compliance)

4
Importance of early visits

• Frequent visits early on
• Reassure patient
• Emphasize importance of monitoring
• May increase compliance
• Some data suggest that patients dislike long
  intervals between visits

5
Monitoring function

• In stable patient, check creatinine
• Twice weekly first month
• Weekly in the second month
• Biweekly months three and four
• Monthly from month five to end of year
• Bimonthly during second year
• Quarterly thereafter
• Educate patients on importance of Cr
• Calculate GFR at baseline
• May periodically measure 24 hour clearance

6
Monitoring function

• Sudden changes suggest
• Acute rejection
• Infection
• Volume depletion
• Obstruction
• Creatinine creep
• Chronic transplant nephropathy
• Drug toxicity
• Other causes (see above)

7
Proteinuria

• Transient (rejection issues)
• Persistent
• gt 0.5 to 1.0 gm / 24 hours for gt3-6 mo
• Occurs in 10 25
• Associates with glomerular lesions
• Chronic allograft nephropathy
• Recurrent glomerular disease

8
Proteinuria -- screening

• Check baseline at 2 wks post KT
• Screen urine at least every 3 6 mo for year one
• After year one, screen every 6 12 mo
• Screen every 2 wks for 2 months if pt with FSGS
• Protein/creatinine ratio is OK, but can start
  with dipstick (gt1 pushes test)

9
Protocol biopsies

• Clinically silent rejection is seen in 15 30
  of patients with DGF
• Silent rejection is seen in 4 27 at three
  months
• Borderline acute rejection in 21 71 at three
  months
• Borderline and subclinical rejection each seen in
  a quarter at 6 months
• At two years subclinical rejection seen in 2

10
Protocol biopsies

• Chronic allograft nephropathy in
• 3 to 38 at three months
• 50 to 70 at two years
• Those who do protocol biopsies treat based on
  results
• The impact of this activity on outcome is not
  established

11
Cyclosporin

• Nephrotoxicity
• Decreased RBF and GFR
• Other
• HTN 41 82
• Hypercholesterolemia 37
• Hyperuricemia 35 52
• Hyperkalemia 55
• Tremor 12 43
• DM 2 13
• Gingival hyperplasia 7 43
• Hirstutism 29 44

12
Cyclosporin

• Low trough levels may be associated with more
  rejection
• High trough levels may be associated with more
  side effects
• Relationships are imprecise
• Pharmacokinetic studies are better than trough
  levels.

13
Tacrolimus

• Graft survival similar to cyclosporin
• Fewer acute rejections
• Side effects
• Decreased renal function (35 420
• Diarrhea (22 44)
• Constipation (31 35)
• Vomiting (13 29)
• Hypertension (37 50)
• Infections (72 76)
• CMV (14 20)

14
CyA vs Tac

• CMV about the same
• Tremor about the same
• Gingival hyperplasia more in CyA
• Hirstutism more in CyA

15
CyA and Tac

• Monitor with
• Periodic history
• Check BP, renal function, glucose
• Follow blood levels
• Frequent early
• Measure after changes
• Measure after new drugs

16
Sirolimus

• The data used by Kassiske are so limited as to be
  useless
• He does, however, recommend periodic monitoring
  of glucose, K, and lipids

17
MMF

• Consider MMF toxicity when taking history and
  doing physical
• CBC weekly for first two months, biweekly the
  next two months, monthly for the rest of year
  one, and then quarterly to semi annually

18
Azathioprine

• Check for toxicity with HP
• CBC as for MMF
• LFTs monthly for the first 3 months, then q 3
  months for one year, then yearly

19
Steroids

• Check for toxicity with HP
• Follow growth in children
• Measure BP, glucose, lipoproteins
• Annual eye exams
• Spine and hip bone densities (how often?)

20
CVD

• At 15 years
• CAD in 23
• Cerebrovascular in 15
• PVD in 15
• Follow risk in regular exams
• No evidence for utility of EKG, ETT, or carotid
  Dopplers
• Consider aspirin

21
Hyperlipidemia

• Screen once in first six months and at one year
• Annually thereafter

22
PTDM

• Weekly FBS for first three months, biweekly for
  next three months, monthly for rest of first year
• After year one, at least yearly FBS and A1C

23
Erythrocytosis

• 10 to 20 of cases
• Detect with scheduled CBCs

24
Anemia

• Probably gt10
• Follow CBC

25
Osteoporosis

• Up to 60
• Bone densitometry at KT, 6 months, and then q
  year if abnormal

26
Secondary hyperpara

• 10 20 hypercalcemia
• Monthly serum calcium for 6 months, bimonthly for
  rest of year
• Correct for albumin
• PTH at 6 and 12 months, then yearly

27
Hypophosphatemia

• More than 50
• Check monthly for 6 months, then bimonthly for
  rest of year, then annually

28
Hypomagnesemia

• 25 if on CyA, increased risk with loop diuretics
• Check monthly for 6 months, then bimonthly for
  rest of year

29
Nutrition

• 10 risk of malnutrition, 40 risk of obesity in
  first year
• Follow weight
• Measure albumin 2 t0 3 times in first year

30
Cancer

• Skin risk 50 at 20 year
• Monthly self check , yearly physical
• Anogenital 2.5
• Yearly physical with PAP
• Treat warts
• KS 0.4 to 4 based on ethnicity
• Yearly exam

31
Cancer

• PTLD risk 1 to 5
• Complete HP quarterly first year and then yearly
• Uroepithelial and renal Ca risk 0.5 to 4
• No good screen recommendation

32
Cancer

• Hepatobiliary risk varies by area
• Alpha feto protein, sono if high risk
• Cervical cancer risk 9
• Annual PAP smear
• Breast cancer risk not increased
• Same as with KT
• Colorectal Ca risk 0.7
• Screen as for others