This document provides an overview and outline of topics related to kidney transplantation outcomes and complications. It discusses:
- Short and long-term outcomes of kidney transplantation, including factors that affect allograft survival such as donor and recipient characteristics.
- Common complications that kidney transplant recipients face, including post-transplant diabetes mellitus, hypertension, dyslipidemia, and bone disease.
- Guidelines for screening, diagnosing, and managing these complications through lifestyle modifications and medication adjustments.
- National data on kidney transplantation trends, outcomes, and challenges in improving long-term allograft survival.
Newer Oral Anticoagulant in Chronic Kidney DiseaseAbdullah Ansari
Kidney specific mechanisms leading to atrial fibrillation
Possible mechanism of CKD progression in atrial fibrillation
Atherosclerosis Risk in Communities (ARIC) study
Guidelines
Pulmonary embolism & deep vein thrombosis
Nephrotic syndrome
Problems with Vit K antagonists in CKD
Non Vit K oral anticoagulants
Site of action of NOACs and VKAs
Pharmacology of Direct Oral Anticoagulants
Trials for NOACs
Dose NOACs according to renal function
Laboratory monitoring of NOACs
Anticoagulant reversal of NOACs
There are several key points in the document:
1) Kidney transplant recipients face risks of infection from both donor-derived and recipient-derived sources.
2) Infections can occur at different time periods after transplantation depending on factors like immunosuppression level and type of infection.
3) Common viral infections include CMV, which is a significant risk especially in high-risk patients like those who are CMV-negative receiving an organ from a CMV-positive donor.
4) Bacterial, fungal and parasitic infections also pose risks to transplant recipients depending on individual risk factors and the timeline after transplantation.
- English version of this lecture is available at:
https://youtu.be/V3UGzJTwAWw
- Arabic version of this lecture is available at:
https://youtu.be/hGLaUde2ue4
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The document summarizes the evaluation of an adult kidney transplant recipient. It discusses timing transplantation based on GFR levels, screening for contraindications like infections and cardiovascular disease, evaluating immunological factors like PRA and HLA typing, and special considerations for populations like diabetics, children, and those on dialysis. The goal of the evaluation is to minimize risks and maximize outcomes for the recipient and longevity of the transplanted kidney.
Clinical guidelines for kidney transplantation 0FarragBahbah
This document provides clinical guidelines for kidney transplantation. It covers pre-transplant, transplant, and post-transplant processes and procedures. Key points include:
- Pre-transplant procedures include patient referral and assessment, immunization, tuberculosis testing, approval process, and status while waiting for a transplant.
- During transplant, patients are admitted, undergo the transplant operation, and begin an immunosuppression regimen.
- Post-transplant care involves managing complications, rejection, viral issues, follow-up appointments, and long-term medication and lifestyle protocols. Guidelines are provided for various post-transplant scenarios.
Basics of immunosuppression in kidney transplantationFarragBahbah
Immunosuppression is needed after kidney transplantation to prevent organ rejection. A combined immunosuppression protocol is usually used, consisting of induction therapy followed by a maintenance regimen. The optimal protocol is unclear and depends on factors like time since transplant, graft function, and risk of rejection. While immunosuppression prevents rejection, it carries long-term costs like infection, malignancy, and side effects from the drugs. Careful management of immunosuppression is required.
Newer Oral Anticoagulant in Chronic Kidney DiseaseAbdullah Ansari
Kidney specific mechanisms leading to atrial fibrillation
Possible mechanism of CKD progression in atrial fibrillation
Atherosclerosis Risk in Communities (ARIC) study
Guidelines
Pulmonary embolism & deep vein thrombosis
Nephrotic syndrome
Problems with Vit K antagonists in CKD
Non Vit K oral anticoagulants
Site of action of NOACs and VKAs
Pharmacology of Direct Oral Anticoagulants
Trials for NOACs
Dose NOACs according to renal function
Laboratory monitoring of NOACs
Anticoagulant reversal of NOACs
There are several key points in the document:
1) Kidney transplant recipients face risks of infection from both donor-derived and recipient-derived sources.
2) Infections can occur at different time periods after transplantation depending on factors like immunosuppression level and type of infection.
3) Common viral infections include CMV, which is a significant risk especially in high-risk patients like those who are CMV-negative receiving an organ from a CMV-positive donor.
4) Bacterial, fungal and parasitic infections also pose risks to transplant recipients depending on individual risk factors and the timeline after transplantation.
- English version of this lecture is available at:
https://youtu.be/V3UGzJTwAWw
- Arabic version of this lecture is available at:
https://youtu.be/hGLaUde2ue4
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
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The document summarizes the evaluation of an adult kidney transplant recipient. It discusses timing transplantation based on GFR levels, screening for contraindications like infections and cardiovascular disease, evaluating immunological factors like PRA and HLA typing, and special considerations for populations like diabetics, children, and those on dialysis. The goal of the evaluation is to minimize risks and maximize outcomes for the recipient and longevity of the transplanted kidney.
Clinical guidelines for kidney transplantation 0FarragBahbah
This document provides clinical guidelines for kidney transplantation. It covers pre-transplant, transplant, and post-transplant processes and procedures. Key points include:
- Pre-transplant procedures include patient referral and assessment, immunization, tuberculosis testing, approval process, and status while waiting for a transplant.
- During transplant, patients are admitted, undergo the transplant operation, and begin an immunosuppression regimen.
- Post-transplant care involves managing complications, rejection, viral issues, follow-up appointments, and long-term medication and lifestyle protocols. Guidelines are provided for various post-transplant scenarios.
Basics of immunosuppression in kidney transplantationFarragBahbah
Immunosuppression is needed after kidney transplantation to prevent organ rejection. A combined immunosuppression protocol is usually used, consisting of induction therapy followed by a maintenance regimen. The optimal protocol is unclear and depends on factors like time since transplant, graft function, and risk of rejection. While immunosuppression prevents rejection, it carries long-term costs like infection, malignancy, and side effects from the drugs. Careful management of immunosuppression is required.
- English version video of this lecture is available at:
https://youtu.be/z9P_1IiFR5I
- Arabic version video of this lecture is available at:
https://youtu.be/qmDeWgsAY9Q
- Visit our website for more lectures: www.NephroTube.com
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- English version of this lecture is available at: https://youtu.be/_Efu52kZRS4
- Arabic version of this lecture is available at: https://youtu.be/8eGHpjQIy3I
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1) The document discusses treatment guidelines for lupus nephritis (LN), including immunosuppressive therapies for different classes of LN.
2) Cyclophosphamide and mycophenolate mofetil (MMF) are recommended as primary induction therapies, with cyclophosphamide preferred for more severe disease and MMF shown to be equally effective and better tolerated.
3) Outcomes are improved with complete or partial remission of proteinuria and hematuria as well as attaining normal creatinine levels, which predictive factors include lower chronicity index and proteinuria at baseline.
- English version of this lecture is available at: https://youtu.be/WHu05hmExBY
- Arabic version of this lecture is available at: https://youtu.be/GIvZjcq2Eis
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This document discusses autosomal dominant polycystic kidney disease (ADPKD). It is characterized by multiple bilateral renal cysts and cysts in other organs caused by mutations in PKD1 and PKD2 genes. The proteins encoded by these genes, polycystin 1 and 2, are involved in maintaining renal tubule structure and calcium homeostasis. Disruption of their function leads to cyst formation through abnormal cell proliferation and fluid secretion. ADPKD causes kidney enlargement and failure but has a variable phenotype. Management involves blood pressure control, pain management, and treating complications like infections.
- English version of this lecture is available at:
https://youtu.be/XRD-QqGFP18
- Arabic version of this lecture is available at:
https://youtu.be/c9PoavAtNKM
- Visit our website for more lectures: www.NephroTube.com
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Non diabetic renal disease with or without diabetic nephropathy dr.amgad el-...FarragBahbah
This document discusses non-diabetic renal disease in diabetic patients. It begins by describing diabetic nephropathy and its characteristics. It then discusses the prevalence of proteinuria in type 1 and type 2 diabetes. Several case studies are presented showing patients with atypical presentations for diabetic nephropathy who were found to have non-diabetic renal diseases like lupus nephritis or focal segmental glomerulosclerosis instead. The document emphasizes that a renal biopsy can identify these non-diabetic diseases and lead to improved outcomes versus assuming diabetic nephropathy. It reviews several studies finding prevalence rates of non-diabetic renal disease in diabetics ranging from 17-85% depending on biopsy criteria
ABO Incompatible Kidney Transplantation, Michael Casey, MD (W-0007)UF Nephrology
Welcome to the Division of Nephrology, Hypertension, & Renal Transplantation within the Department of Medicine at the University of Florida. The University of Florida is an exciting academic community filled with people passionate in their academic pursuit. The Division of Nephrology, Hypertension, & Renal Transplantation is distinguished by the impact, breadth, and depth of its clinical, training, and research programs. It is the Highest ranked Division of Nephrology within Florida, 13th top program nationally, and is comprised of distinguished faculty, all of whom are involved in patient care, research and education. Our research interests include cutting edge research and collaborations with Departments throughout the University.
For CME Credit, visit our website to register and complete the necessary requirements.
http://nephrology.medicine.ufl.edu
This document discusses treatment of hepatitis C in patients with chronic kidney disease. It begins by establishing the association between HCV infection and CKD, noting that HCV can cause renal impairment and progression of kidney disease through various mechanisms. It then reviews outcomes in this population such as increased prevalence of CKD, faster progression to ESRD, higher mortality rates, and poorer outcomes after renal transplant compared to those without HCV infection. The document next evaluates earlier treatment options with interferon-based regimens, which had low efficacy and significant side effects. It then discusses approval and study of newer direct-acting antiviral regimens, finding improved efficacy and safety particularly with sofosbuvir and glecaprevir/pibrentasvir
Renal disorders can cause complications like chronic kidney disease (CKD) that increase risks during dental procedures and surgery. Patients with CKD are more likely to experience bleeding due to platelet and blood vessel dysfunction, and also have increased risk of infection. They may also develop dental problems such as periodontal disease, tooth discoloration and loss of enamel. When undergoing surgery, CKD patients are at higher risk of complications including bleeding, infections, cardiovascular and thrombotic events due to changes in fluid, electrolyte and acid-base balance as well as altered drug metabolism and clearance. Careful preoperative evaluation and management involving nephrologists can help reduce these perioperative risks.
1) ARPKD can cause systemic hypertension both before and after kidney transplant due to activation of the intra-renal renin-angiotensin system and impaired urinary dilution. Aggressive blood pressure control is important to slow progression to end-stage renal disease.
2) Kidney transplant is often necessary for those with ARPKD, with 60% requiring it by age 10. Preparatory work includes managing complications like liver disease, hypertension, and nutrition. Living related donors are preferred over deceased donors.
3) Outcomes of kidney transplant for ARPKD are generally good, with 5-year graft survival rates around 80%. However, mortality related to liver complications like cholangitis can be
- English version video of this lecture is available at:
https://youtu.be/z9P_1IiFR5I
- Arabic version video of this lecture is available at:
https://youtu.be/qmDeWgsAY9Q
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- English version of this lecture is available at: https://youtu.be/_Efu52kZRS4
- Arabic version of this lecture is available at: https://youtu.be/8eGHpjQIy3I
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1) The document discusses treatment guidelines for lupus nephritis (LN), including immunosuppressive therapies for different classes of LN.
2) Cyclophosphamide and mycophenolate mofetil (MMF) are recommended as primary induction therapies, with cyclophosphamide preferred for more severe disease and MMF shown to be equally effective and better tolerated.
3) Outcomes are improved with complete or partial remission of proteinuria and hematuria as well as attaining normal creatinine levels, which predictive factors include lower chronicity index and proteinuria at baseline.
- English version of this lecture is available at: https://youtu.be/WHu05hmExBY
- Arabic version of this lecture is available at: https://youtu.be/GIvZjcq2Eis
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
This document discusses autosomal dominant polycystic kidney disease (ADPKD). It is characterized by multiple bilateral renal cysts and cysts in other organs caused by mutations in PKD1 and PKD2 genes. The proteins encoded by these genes, polycystin 1 and 2, are involved in maintaining renal tubule structure and calcium homeostasis. Disruption of their function leads to cyst formation through abnormal cell proliferation and fluid secretion. ADPKD causes kidney enlargement and failure but has a variable phenotype. Management involves blood pressure control, pain management, and treating complications like infections.
- English version of this lecture is available at:
https://youtu.be/XRD-QqGFP18
- Arabic version of this lecture is available at:
https://youtu.be/c9PoavAtNKM
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
Non diabetic renal disease with or without diabetic nephropathy dr.amgad el-...FarragBahbah
This document discusses non-diabetic renal disease in diabetic patients. It begins by describing diabetic nephropathy and its characteristics. It then discusses the prevalence of proteinuria in type 1 and type 2 diabetes. Several case studies are presented showing patients with atypical presentations for diabetic nephropathy who were found to have non-diabetic renal diseases like lupus nephritis or focal segmental glomerulosclerosis instead. The document emphasizes that a renal biopsy can identify these non-diabetic diseases and lead to improved outcomes versus assuming diabetic nephropathy. It reviews several studies finding prevalence rates of non-diabetic renal disease in diabetics ranging from 17-85% depending on biopsy criteria
ABO Incompatible Kidney Transplantation, Michael Casey, MD (W-0007)UF Nephrology
Welcome to the Division of Nephrology, Hypertension, & Renal Transplantation within the Department of Medicine at the University of Florida. The University of Florida is an exciting academic community filled with people passionate in their academic pursuit. The Division of Nephrology, Hypertension, & Renal Transplantation is distinguished by the impact, breadth, and depth of its clinical, training, and research programs. It is the Highest ranked Division of Nephrology within Florida, 13th top program nationally, and is comprised of distinguished faculty, all of whom are involved in patient care, research and education. Our research interests include cutting edge research and collaborations with Departments throughout the University.
For CME Credit, visit our website to register and complete the necessary requirements.
http://nephrology.medicine.ufl.edu
This document discusses treatment of hepatitis C in patients with chronic kidney disease. It begins by establishing the association between HCV infection and CKD, noting that HCV can cause renal impairment and progression of kidney disease through various mechanisms. It then reviews outcomes in this population such as increased prevalence of CKD, faster progression to ESRD, higher mortality rates, and poorer outcomes after renal transplant compared to those without HCV infection. The document next evaluates earlier treatment options with interferon-based regimens, which had low efficacy and significant side effects. It then discusses approval and study of newer direct-acting antiviral regimens, finding improved efficacy and safety particularly with sofosbuvir and glecaprevir/pibrentasvir
Renal disorders can cause complications like chronic kidney disease (CKD) that increase risks during dental procedures and surgery. Patients with CKD are more likely to experience bleeding due to platelet and blood vessel dysfunction, and also have increased risk of infection. They may also develop dental problems such as periodontal disease, tooth discoloration and loss of enamel. When undergoing surgery, CKD patients are at higher risk of complications including bleeding, infections, cardiovascular and thrombotic events due to changes in fluid, electrolyte and acid-base balance as well as altered drug metabolism and clearance. Careful preoperative evaluation and management involving nephrologists can help reduce these perioperative risks.
1) ARPKD can cause systemic hypertension both before and after kidney transplant due to activation of the intra-renal renin-angiotensin system and impaired urinary dilution. Aggressive blood pressure control is important to slow progression to end-stage renal disease.
2) Kidney transplant is often necessary for those with ARPKD, with 60% requiring it by age 10. Preparatory work includes managing complications like liver disease, hypertension, and nutrition. Living related donors are preferred over deceased donors.
3) Outcomes of kidney transplant for ARPKD are generally good, with 5-year graft survival rates around 80%. However, mortality related to liver complications like cholangitis can be
1. The document provides information on chronic kidney disease (CKD) management in primary care, including screening, evaluation, goals of care, and complications.
2. It emphasizes the primary care provider's important role in early CKD detection through testing at-risk patients, managing blood pressure and diabetes, and referring to nephrology as appropriate.
3. A collaborative care model between primary care and nephrology can improve outcomes through coordinated management and addressing patient safety issues in CKD.
1. The document provides information on chronic kidney disease (CKD) management in primary care, including screening, evaluation, goals of care, and complications.
2. It emphasizes the primary care provider's important role in early CKD detection through testing at-risk patients, managing blood pressure and diabetes, and referring to nephrology as appropriate.
3. A collaborative care model between primary care and nephrology can improve outcomes through coordinated management and addressing patient safety issues in CKD.
This document provides guidance on evaluating and screening potential renal transplant recipients. It discusses:
1. General concepts to consider include referring all end-stage renal disease patients for transplant evaluation once renal replacement therapy is needed within 12 months, and encouraging preemptive kidney transplantation when feasible.
2. The evaluation process involves assessing medical history and conditions, performing initial screening tests, and evaluating any cardiovascular, infectious, or other systemic diseases to identify any absolute contraindications to transplantation or conditions requiring further treatment and monitoring.
3. Cardiovascular disease is a major cause of death for transplant recipients, so candidates undergo cardiac screening and testing based on risk factors to clear them for surgery or identify any need for pre-operative cardiac
Diabetic nephropathy considered one of the most common complications of DM. This presentation answer the question are some diabetic patient immune to diabetic nephroapthy
This document summarizes a talk on the role of pancreas transplantation in managing diabetes. The talk discusses how pancreas transplants can normalize blood sugar levels but require lifelong immunosuppression. It reviews the types of pancreas transplants and their outcomes. Combined kidney-pancreas transplants are most common and indications for them are discussed. Technical challenges of pancreas transplants and monitoring outcomes are also summarized. The role of pancreas transplants for both type 1 and type 2 diabetes is evaluated based on available data.
This document discusses cardiorenal syndrome and provides details about a patient case. It defines cardiorenal syndrome as disorders of the heart and kidneys that can cause acute or chronic dysfunction in one organ and induce dysfunction in the other. The document summarizes the patient's history of rheumatic heart disease, heart failure, and acute kidney injury. It also reviews pathophysiology, types, prevalence, risk factors, prognosis, diagnosis, and treatment approaches for cardiorenal syndrome.
Topic scleroderma and kidney Chaken ManiyanCHAKEN MANIYAN
Systemic sclerosis is a systemic autoimmune disease characterized by abnormal collagen deposition and fibrosis of the skin and internal organs. Scleroderma renal crisis is an uncommon but significant complication of systemic sclerosis that can lead to high mortality. It is defined as new onset hypertension accompanied by renal failure and microangiopathic hemolytic anemia. Early diagnosis and treatment with angiotensin-converting enzyme inhibitors has been shown to improve survival outcomes for patients with scleroderma renal crisis.
Bernstein Oct 29 2008 Defining Ckd And Risk Factorsguest6940925
1) Around 1 million people in North Carolina have chronic kidney disease (CKD), defined as kidney damage or decreased kidney function lasting over 3 months. 11,000 people in the state currently receive dialysis for end-stage renal disease.
2) Estimated glomerular filtration rate (eGFR) is a measure of kidney function that is calculated based on age, gender, ethnicity and serum creatinine level. An eGFR below 60 ml/min/1.73m2 for over 3 months indicates CKD.
3) Major risk factors for CKD include diabetes, hypertension, family history of kidney disease, African American or Native American ethnicity. Early detection of risk factors and treatment can help prevent or
This document discusses chronic kidney disease (CKD) in the United States. It notes that CKD is a major public health problem, with millions of Americans affected and kidney failure deaths exceeding many common cancers. The economic costs of CKD are also high. The document calls for increased screening and treatment of at-risk groups like diabetics and hypertensives to slow CKD progression and reduce complications. Primary care providers have an important role to play in early detection and management of CKD to reduce burden.
The document discusses chronic kidney disease (CKD) prognosis and factors that impact it, including cause of CKD, glomerular filtration rate (GFR) category, albuminuria category, and comorbidities. It also discusses guidelines for initiating renal replacement therapy (RRT), specifically dialysis, noting that recent evidence suggests late initiation may be safe for some patients and associated with improved survival compared to early initiation. The document outlines RRT modality options including transplantation, hemodialysis, peritoneal dialysis, and discusses preserving residual renal function for dialysis patients.
1. Chronic kidney disease (CKD) is a major public health problem affecting millions of Americans. Early detection and treatment can help slow progression of the disease and prevent complications.
2. Screening high-risk groups such as those with diabetes or hypertension can help identify CKD earlier. Estimating glomerular filtration rate (GFR) using the MDRD equation is recommended for detection and staging of CKD.
3. A three-pronged initiative is needed to screen for CKD risk factors, develop early detection processes, and establish collaborative disease management between primary care and nephrology. This can help address issues of underdiagnosis and late referral currently associated with CKD.
Management strategies for renal artery stenosisReza Mofidi
This document discusses management strategies for renal artery stenosis. It summarizes evidence from several clinical trials comparing medical management to percutaneous transluminal renal angioplasty with stent placement (PTRAS). The evidence suggests that PTRAS provides only modest benefits for controlling hypertension and arresting the decline of renal function compared to medical therapy alone. PTRAS is associated with risks of procedure complications and stent thrombosis. Overall, there is little evidence that PTRAS should be a first-line treatment for renal artery stenosis. The document also discusses potential new approaches like renal protection devices and mitochondrial protection during interventions.
This document discusses chronic kidney disease (CKD) and its management. It provides definitions of CKD and outlines its stages according to the KDIGO classification system. Diabetes and hypertension are highlighted as leading causes of CKD globally. Early detection of CKD is important as it can be asymptomatic for long periods. Screening high-risk individuals through estimated GFR and urine albumin or protein tests is recommended. Left unmanaged, CKD can progress to end-stage renal disease requiring renal replacement therapies like dialysis, which are costly treatments.
The document discusses hypertension and its effects on the kidney. It begins by defining normal blood pressure regulation and the role of the kidney in long-term blood pressure control. It then discusses the epidemiology of hypertension globally and in various countries. The document also covers the epidemiology of chronic kidney disease, how hypertension affects the kidney and can lead to hypertensive nephropathy, and how chronic kidney disease in turn affects blood pressure. It concludes by outlining blood pressure targets and treatment strategies for patients with hypertension and chronic kidney disease.
Management of kidney transplant recipient (ayman refaie)FarragBahbah
1. The document discusses the management and follow-up of renal transplant patients, including important considerations at the initial visit post-transplant and routine follow-up visits.
2. It outlines the various risks transplant patients face, such as cardiovascular disease, diabetes, infection, malignancy, and drug-drug interactions.
3. Maintaining optimal immunosuppression while minimizing side effects is an art that requires monitoring multiple risk factors to support long-term graft and patient survival.
Simultaneous kidney-pancreas transplantation (SPK) provides several benefits over kidney transplantation alone for patients with diabetes and kidney failure. SPK improves both patient survival and quality of life by restoring insulin independence and preventing or reversing diabetic complications. However, SPK also carries higher short-term surgical risks compared to kidney transplantation alone. Long-term data shows that while SPK can help preserve kidney and pancreas function for over 10 years, benefits on microvascular complications take longer to manifest and may not outlive insulin independence. Careful patient selection balancing risks and benefits is important for SPK.
This study compared balanced crystalloids (lactated Ringer's and Plasma-Lyte A) to normal saline in over 15,000 critically ill patients admitted to ICUs at Vanderbilt University Medical Center. The primary outcome was a composite of major adverse kidney events within 30 days. Results showed the absolute risk of the primary outcome was 1.1% lower in patients who received balanced crystalloids compared to saline. Subgroup analyses found greater differences in patients with sepsis and those receiving larger fluid volumes. The authors conclude balanced crystalloids may reduce the risk of new renal replacement therapy, persistent renal dysfunction, or death compared to saline in critically ill adults.
Acute Allograft rejection in kidney transplantation 2017 ChakenCHAKEN MANIYAN
This document discusses transplant immunology and the immune response after kidney transplantation. It provides details on the innate and adaptive immune system, acute T cell mediated rejection and antibody mediated rejection, and the updated 2015 Banff classification system. The summary describes:
1. The innate and adaptive immune system work together to identify and remove foreign substances from the body. The adaptive system has antigen recognition and memory capabilities.
2. Acute rejections can be T cell mediated or antibody mediated. T cell mediated rejection involves T cell infiltration and tubulitis, while antibody mediated rejection is caused by donor-specific antibodies binding to the graft.
3. The 2015 Banff classification system categorizes rejection and provides standardized grading scales for inflammation
This document summarizes a case presentation of a 74-year-old Thai female patient undergoing peritoneal dialysis who presented with increasing fatigue. Her peritoneal dialysis prescription was adjusted and tests revealed a left pleural effusion. Further imaging with nuclear scintigraphy confirmed omental wrapping around the peritoneal catheter. The patient was temporarily switched to hemodialysis and underwent catheter revision surgery. The importance of proper peritoneal catheter placement and design is discussed to reduce complications.
Cardiorenal syndrome describes conditions where acute or chronic dysfunction in the heart leads to acute or chronic kidney disease, and vice versa. There are five subtypes classified based on temporal presentation and direction of organ dysfunction. Ultrafiltration is a treatment for fluid overload in heart failure that works by removing excess fluid without changing electrolyte levels. Several studies have found ultrafiltration improves congestion symptoms and reduces rehospitalization rates compared to intravenous diuretics alone. Larger and longer term studies are still needed to establish optimal use of ultrafiltration in cardiorenal syndrome.
Renal cell carcinoma after kidney transplantation 2017CHAKEN MANIYAN
This case discusses a patient who underwent a living related kidney transplant and subsequently developed increased creatinine levels and CMV viremia. Further workup revealed an enhancing nodule in the patient's native right kidney. The patient underwent surgery where a 3x3cm solid mass was removed from the right lower pole of the native kidney. A review of literature on renal cell carcinoma after kidney transplantation showed it can develop through transmission from donor, de novo occurrence in recipient, or recurrence in recipient. Immunosuppression places transplant patients at higher risk for developing various cancers.
UTI in kidney transplantation recipients 2017CHAKEN MANIYAN
This patient is a 21-year-old female kidney transplant recipient who presented with dysuria and suprapubic pain. Initial investigations revealed a urinary tract infection with E. coli. She was treated with ciprofloxacin initially but symptoms did not improve. Further workup found hydronephrosis of the transplant kidney and myoma uteri. She was hospitalized and treated with ertapenem intravenously. Repeat investigations showed improvement in symptoms and graft function.
Intensive blood pressure control aimed at a systolic blood pressure under 120 mm Hg was associated with a small increased risk of developing chronic kidney disease over 3 years compared to standard blood pressure control between 135-139 mm Hg. However, the intensive control group had a lower risk of cardiovascular events and death, outweighing the kidney disease risk. While some patients in the intensive group saw acute drops in kidney function, long term outcomes were unclear and many recovered function. The study suggests the benefits of intensive blood pressure control likely outweigh the risks, but some patients may weigh kidney disease risk more heavily than cardiovascular outcomes.
Journal club multitarget therapy lupus nephritis maintenance chaken CHAKEN MANIYAN
Multitarget therapy of tacrolimus, mycophenolate mofetil and steroids achieved a 45.9% complete remission rate in induction treatment of lupus nephritis. This study assessed the efficacy of continuing multitarget therapy versus switching to azathioprine as maintenance treatment over 18 months. The cumulative renal relapse rate was lower in the multitarget group at 5.47% compared to 7.62% in the azathioprine group. More patients in the multitarget group maintained complete remission during maintenance treatment with no significant differences in safety profiles between the groups.
Vascular access in hemodialysis chaken 2018CHAKEN MANIYAN
This document provides guidelines and information about vascular access for hemodialysis. It discusses:
- Types of vascular access including arteriovenous fistulas, grafts, and catheters. Fistulas have the lowest risk of complications but the highest risk of early failure.
- Evaluations for permanent access including history, physical exam, ultrasound of arteries and veins, and central vein evaluation.
- Placement of fistulas at least 6 months before starting dialysis to allow for maturation. Grafts can be placed 3-6 weeks before starting.
- Goals for types of access used - 50% of patients should have fistulas, 40% grafts, and no more than 10%
This document provides information on membranoproliferative glomerulonephritis (MPGN), including its classification, pathogenesis, clinical presentation, pathology, and treatment. MPGN is classified based on immunofluorescence and electron microscopy findings. It can be immune-mediated via immune complex deposition or complement-mediated via dysregulation of the alternative complement pathway. On pathology, it is characterized by thickened glomerular basement membranes, mesangial hypercellularity, and endocapillary proliferation. Clinical presentation varies from asymptomatic to nephrotic syndrome or renal failure.
Journal club NEJM kidney transplantation IDES 2017CHAKEN MANIYAN
1) IdeS is a recombinant enzyme that cleaves IgG antibodies. The study assessed IdeS's efficacy in eliminating donor-specific HLA antibodies (DSAs) in highly sensitized patients undergoing kidney transplantation.
2) After IdeS treatment, IgG and DSA levels were significantly reduced, allowing successful transplantation in 24 of 25 patients. Graft survival and function were good.
3) While IdeS reduced rejection risk, 10 patients still experienced antibody-mediated rejection, which responded well to treatment. One patient had unexpected hyperacute rejection from non-HLA antibodies.
This document discusses infection following renal transplantation. It covers four main categories of exposures that can lead to post-transplant infection: donor-derived, recipient-derived, nosocomial, and community. It then discusses the timeline of various infections, highlighting that CMV and opportunistic infections are most common in the first 6 months. BK virus is also reviewed in depth, including its virology, risk factors for BK virus nephropathy, diagnosis, clinical management and treatment through immunosuppression modification. Cytomegalovirus infection is also summarized, covering terminology, risk factors, diagnostic methods including histopathology, viral culture, serology and molecular assays to detect viral load.
Basic science apol1 gene and nephrocyte chakenCHAKEN MANIYAN
This study generated transgenic Drosophila lines expressing human APOL1-G0 and APOL1-G1 alleles. Ubiquitous expression caused developmental lethality. When expressed specifically in nephrocytes (analogous to human podocytes and proximal tubules), APOL1 initially increased nephrocyte endocytosis and size but over time impaired organelle acidification and accelerated cell death. As flies aged, nephrocytes expressing APOL1-G1 in particular became much larger and fewer in number, with accumulation of cell debris. This Drosophila model provides insights into how APOL1 overexpression causes cytotoxicity and progressive nephrocyte dysfunction.
Advanced in hemodialysis and biocompatbility chaken pmkCHAKEN MANIYAN
This document discusses advanced hemodialysis technologies and their role in improving outcomes for hemodialysis patients. It begins by outlining several challenges with hemodialysis including high mortality rates from cardiovascular causes and insufficient removal of toxins like phosphate, middle molecules, and protein-bound solutes. It then describes several modalities for advanced hemodialysis like super high flux membranes, hemodiafiltration, and adsorptive therapies that aim to remove more toxins. The document reviews landmark trials on high flux membranes and discusses how newer technologies may provide benefits like improved clearance of beta-2 microglobulin and phosphate.
Major Chaken Maniyan provides an outline on heat regulation physiology, classifications of heat-related injuries, cooling methods, management of complications, and new interventions. The document discusses heat transfer mechanisms, signs and symptoms of heat-related illnesses ranging from mild to severe including heat rash, heat edema, heat syncope, heat cramps, heat exhaustion, and heat stroke. Cooling techniques like ice water immersion and evaporative cooling are presented, as well as treatments for complications of heat stroke such as renal failure, rhabdomyolysis, and electrolyte abnormalities. Risk factors, pathogenesis, and organ dysfunction in heat stroke are also reviewed.
Induction treatment in Kidney transplantation chaken 2017 CHAKEN MANIYAN
The document discusses various induction immunosuppression agents used after kidney transplantation. It defines induction therapy as treatment given before or at transplantation to deplete or modulate T-cell responses. The major agents covered are depleting antibodies like thymoglobulin, alemtuzumab, and OKT3, and non-depleting antibodies like basiliximab and daclizumab. Clinical trials generally find depleting agents reduce acute rejection rates but increase infection risks, while non-depleting agents have fewer side effects but may have higher rejection rates. Guidelines recommend considering risks and benefits for each patient's situation.
Journal club harmony trial chaken maniyan 2016CHAKEN MANIYAN
This randomized controlled trial compared rabbit antithymocyte globulin (ATG) induction versus basiliximab induction for allowing rapid steroid withdrawal in renal transplant recipients on tacrolimus and mycophenolate mofetil immunosuppression. The primary outcome was biopsy-proven acute rejection rates within 1 year, and secondary outcomes included patient and graft survival, post-transplant diabetes, and cardiovascular risk factors. Results showed that rabbit ATG was not superior to basiliximab in preventing acute rejection. However, rapid steroid withdrawal significantly reduced post-transplant diabetes rates without compromising efficacy or safety.
This document discusses post-transplant renal artery stenosis (TRAS). TRAS occurs in 1-23% of kidney transplant recipients, usually within the first 2 years after transplantation. Risk factors include technical errors during surgery, atherosclerosis, and immunosuppression. Clinical manifestations include worsening hypertension and graft dysfunction. Diagnosis involves renal duplex ultrasound showing elevated peak systolic velocities. Treatment options are medical management with ACE inhibitors for mild cases, percutaneous transluminal angioplasty with stenting for significant stenosis, or surgical revascularization for failed angioplasty. Angioplasty with drug-eluting stents has lower restenosis rates compared to angioplasty alone.
1) Several novel urinary biomarkers such as KIM-1, NGAL, and LFABP have been shown to be early predictors of acute kidney injury (AKI), rising in the urine within hours of injury compared to the rise in serum creatinine which occurs later.
2) Biomarkers like NGAL and KIM-1 have been shown to predict progression of AKI severity and long-term outcomes like need for renal replacement therapy and mortality.
3) Studies have demonstrated the utility of biomarkers like plasma NGAL measured at the time of clinical diagnosis of AKI after cardiac surgery to predict AKI severity and risk stratify patients for worse outcomes.
This document discusses the pathophysiology of acute kidney injury (AKI). It covers pre-renal, post-renal and intrinsic renal AKI. For intrinsic renal AKI, it focuses on acute tubular necrosis (ATN). It describes the hemodynamic changes, endothelial dysfunction, inflammatory response and tubular injury that occur in ATN. Hemodynamic changes like renal hypoperfusion can cause ischemia. This results in endothelial activation, leukocyte recruitment and coagulation changes. Tubular injury involves loss of polarity, cytoskeleton disruption and cell death via necrosis or apoptosis. The document provides details on the molecular mechanisms and pathways involved in each step of the pathophysiological process of ATN.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
1. Topic Review
Maj. Chaken Maniyan M.D.
Division of Nephrology,
Department of Medicine
Phramongkutklao Hospital
17.2.2017
Outcome and complication of
kidney transplantation
2. Outline
§Outcome of kidney transplantation
§Complication & medical management of KTRs
§ Post transplant diabetes mellitus
§ Hypertension
§ Dyslipidemia
§ Electrolyte disturbance
§ Bone disease
§ Recurrent diseases
§ Malignancy
§ Failing kidney & allograft nephrectomy
3. Difficulties are opportunities
, said Dr. Murray
1954, First Kidney transplantation by
Joseph E. Murray at Brigham Hospital
in Boston for identical Twin
(Richard and Ron Herrick)
1990 Noble prize
4. Risk of death of kidney transplantation
compare to dialysis
Wolfe RA, Ashby VB, Milford EL, et al: N Engl J Med 341:1725–1730, 1999.
5. Timeline of kidney transplantation,
threats, and opportunities
Adnan Sharif, Solomon Cohney et al , Lancet Diabetes Endocrinol 2016; 4: 337–49
6. One-year deceased donor kidney allograft survival and
rejection episodes over time
on
Comprehensive Clinical Nephrology, 5th Edition
8. Trends in incidence rate of treated ESRD
(per million population/year), by country, 2001-2014
2016 ANNUAL DATA REPORT, VOL 2, ESRD,
Ten countries having the
highest % rise in ESRD
9. Percent distribution of type of RRT modality
by country, 2001-2014
2016 ANNUAL DATA REPORT, VOL 2, ESRD,
10. Assessing Allograft Outcomes in
Kidney Transplantation
§Main outcome :Allograft survival
§Surrogate outcomes
§Allograft function (SCr level)
§Patient survival
§Rejection episodes
§Days of hospitalization
§Quality of life indices
Brenner and Rector's The Kidney, 10th edition
11. Short term outcome
§ 0-12 month after kidney transplantation
§ Main causes of allograft loss
§Acute rejection
§Thrombosis
§Primary non-function kidney
§Patient death
Brenner and Rector's The Kidney, 10th edition
12. Long term outcome
§ After 12 month after kidney transplantation
§ Main causes of allograft loss
§Patient death
§Chronic allograft injury (CAI)
§Late acute rejection
§Recurrent disease
Brenner and Rector's The Kidney, 10th edition
13. Before 5 years After 5 years
Causes of death with functioning graft in Thailand
15. Factors associated with allograft survival
§ Donor factors
§ Recipient factors
§ Donor – recipient interaction factors
§ Recurrent disease
§ Proteinuria
Brenner and Rector's The Kidney, 10th edition
16. Donor factors
§Donor source: deceasedVS living donor
§Donor age
§Donor gender
§Donor ancestry and ethnicity
§Cold ischemia time
§Expanded criteria donors
§Donation after cardiac death (DCD)
Brenner and Rector's The Kidney, 10th edition
17. Expanded Criteria Donors
§60 years or older
§50 to 59 with two of the following criteria
§ (1) CVA as cause of death
§ (2) history of hypertension
§ (3) Serum creatinine >1.5 mg/dL
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
18. Recipients factors
§Recipient age
§Recipient race and ethnicity
§Recipient gender
§Recipient sensitization
§Acute rejection
§Recipient immunosuppression
§Recipient compliance
§Recipient cause of ERSD
§Recipient hypertension
Brenner and Rector's The Kidney, 10th edition
19. Donor – recipient interaction factors
§ Delayed graft function
§ Human leukocyte antigen matching
§ Cytomegalovirus status of donor and recipient
§Timing of transplantation
§ Center effect
Brenner and Rector's The Kidney, 10th edition
27. Improving allograft survival outcome
§ Maximizing organs available for KT
§ National campaign
§ Education of medical staff/ family members
§ Expanded criteria donor and DCD
§ Maximize life span of donated organs
§Criteria used for allocation of deceased donor
§Youngest and healthiest, maximizing the life years
from transplantation (LYFT) gained
§Maximized the early marker of allograft injury
Brenner and Rector's The Kidney, 10th edition
28. Biopsy gene expression to
identify KTRs at risk of chronic injury
O’Connell PJ, Zhang W, Menon MC, et al. Lancet 2016; 388: 983–93.
29. Outline
§Outcome of kidney transplantation
§Complication & medical management of KTRs
§ Post transplant diabetes mellitus
§ Hypertension
§ Dyslipidemia
§ Electrolyte disturbance
§ Bone disease
§ Recurrent diseases
§ Malignancy
§ Failing kidney & allograft nephrectomy
32. Cardiometabolic risk profi le of
immunosuppression
Adnan Sharif, Solomon Cohney et al L, ancet Diabetes Endocrinol 2016; 4: 337–49
33. Toxicity profiles of immunosuppressive
medications
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
34. Risk factor for NODAT
Non-modifiable Potentially modifiable Modifiable
Ethnicity (non-
Caucasian) Infections
HCV
CMV
Immunosuppressive
Therapy
Age >40 years-old • Tacrolimus
Male gender • Cyclosporine
Donor's gender (M) IGT (pretransplantation) • Corticosteroid
Family history of DM • Sirolimus
HLA Obesity
HLA (mismatches)
Cadaveric donor
OPTN/UNOS database, Am J Kidney Dis. 2010 Dec;56(6):1127-39.
35. NODAT : Screening
§Screening all nondiabetic KTRs with FPG, OGTT,
and/or HbA1c (1C) at least:
§weekly for 4 weeks (2D)
§every 3 months for 1 year (2D)
§annually, thereafter (2D)
§Screening after starting, or increasing CNIs, mTORi
or corticosteroids. (2D)
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
36. NODAT : Screening
§ Criteria for the diagnosis of diabetes
§FPG ≥126 mg/dL (7.0 mmol/L) OR
§S/S of hyperglycemia and CBG ≥ 200 mg/dL OR
§Two-hour glucose ≥200 mg/dL during OGTT
§ glucose load (75 g anhydrous glucose dissolved in water)
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
37. Risk factor of NODAT
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
38. Management of PTDM
§ Dietary modification
§ Lifestyle modifications
§ Adjustment or modification in immunosuppressive meds
§Rapid steroid taper, steroid-sparing or steroid avoidance
protocols
§Tacrolimus to cyclosporine conversion therapy
§Pharmacologic therapy
§Screening for microalbuminuria
§Regular ophthalmologic exam
§Regular foot care
Brenner and Rector's The Kidney, 10th edition
39. Management of NODAT
§ Modifying immunosuppressive regimen to reverse
diabetes, after weighing risk of rejection and other
potential adverse effects. (Not Graded)
§ Target HbA1c 7.0–7.5%
§ Avoid HbA1c ≤ 6.0%, esp if hypoglycemic (Not Graded)
§ Aspirin (65–100 mg/day) use for 1o prevention of
CVD be based on patient preferences balancing the
risk for ischemic/bleeding (2D)
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
40. Pharmacological management of
diabetes in KTRs
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
41. Medications for diabetes control in
first 6 months post-transplant
2014 ANNUAL DATA REPORT, VOL 2, ESRD,
42. Strategies to prevent and treat PTDM
§ Steroid minimization
§ Avoidance of tacrolimus
§ Lifestyle modification
Brenner and Rector's The Kidney, 10th edition
43. Rapid Steroid Withdrawal after Renal
Transplantation (Harmony Trial)
Oliver Thomusch et al , Lancet Volume 388, 17 December 2016
Cumulative probability of post-transplantation diabetes mellitus
44. Aspirin in Diabetes
§Use aspirin 75–162 mg/day as 2nd prevention in DM history
of ASCVD (grade B)
§Consider as1ry prevention in diabetes who increased CV
risk (grade C)
§ Aged > 50 years with least one risk factor
§ Family history of premature ASCVD
§ Hypertension
§ Dyslipidemia
§ Smoking
§ Albuminuria
§And are not at increased risk of bleeding
American Diabetes Association Standards of Medical Care in Diabetes 2017
45. Outline
§Outcome of kidney transplantation
§Complication & medical Management of KTRs
§ Post transplant diabetes mellitus
§ Hypertension
§ Dyslipidemia
§ Electrolyte disturbance
§ Bone disease
§ Recurrent diseases
§ Malignancy
§ Failing kidney & allograft nephrectomy
46. Hypertension after KT
§ Prevalence of hypertension 60-80%.
§ Causes include
§Steroids
§CNIs
§Weight gain
§Allograft dysfunction
§Native kidney disease
§TRAS
Brenner and Rector's The Kidney, 10th edition
47. FAVORIT (Folic Acid for Vascular Outcome
Reduction in Transplantation) trial
Carpenter MA et al, J Am Soc Nephrol. 2014 Jul;25(7):1554-62
Key:
1.Each increase of 20 mm Hg in SBP
↑32% CV events
↑13% death
2. Each drop of 10 mm Hg in DBP
from baseline 70 mmHg
↑ 31% CV events and death
48. Hypertension
§ Maintaining SBP at <130 mmHg and DBP <80
mmHg in adults (2C)
§To treat hypertension (Not Graded): use any class
of antihypertensive agent;
§monitor closely for adverse effects and
§drug–drug interactions
§When urine protein excretion ≥1 g/day à ACE-I
or ARB as first-line therapy.
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
49. Intervention
§ Nonpharmacologic :
§ Weight loss,
§ Reduced sodium intake,
§ Reduced alcohol intake,
§ Treatment of OSA
§ Increased exercise
§ Pharmacologic :
§Minimized steroids and CNIs
§Antihypertensive drug therapy is still frequently
required.
Brenner and Rector's The Kidney, 10th edition
50. Major antihypertensive agent in KTRs
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
51. § CCB may be preferred as first line agents for
hypertensive kidney transplant recipients.ACEi have
some detrimental effects in kidney transplant recipients.
More high quality studies reporting patient centred
outcomes are required.
52. Outline
§Outcome of kidney transplantation
§Complication & medical Management of KTRs
§ Post transplant diabetes mellitus
§ Hypertension
§ Dyslipidemia
§ Electrolyte disturbance
§ Bone disease
§ Recurrent diseases
§ Malignancy
§ Failing kidney & allograft nephrectomy
53. Dyslipidemia after KT
§Prevalence of DLP after transplant is very high
§Causes :
§Steroids
§CNIs (cyclosporine > tacrolimus)
§Sirolimus
§Minimizing steroid dosage and switching cyclosporine
to tacrolimus
§Dose of a statin should be reduced by 50% (CNIs
increase statin levels)
Brenner and Rector's The Kidney, 10th edition
54. Toxicity profiles of immunosuppressive
medications
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
55. Effect of fluvastatin on cardiac outcomes in renal transplant
recipients: a multicentre, randomised, placebo-controlled trial
Hallvard Holdaas et al , Lancet 361 : 2024 –2031, 2003
ALERT Trial
32%. Risk reduction with
fluvastatin for
primary endpoint
risk ratio 0·83 [CI 0.64–1.06
p=0·139
56. § Statins may reduce CV events in KTRs
transplant recipients, although treatment effects are
imprecise.
§Statin treatment has uncertain effects on
overall mortality, stroke, kidney function,
and toxicity outcomes in kidney transplant
recipients.
57. Dyslipidemia
§ Measure a complete lipid profile in all adult
§ 2–3 months after transplantation;
§ 2–3 months after a change in treatment
§ at least annually, thereafter
§Evaluate 2nd causes of dyslipidemia
§If fasting TG ≥500 mg/dL
§LSM and a triglyceride lowering agent
§If LDL-C ≥100 mg/dL treat to reduce LDL-C to <100
mg/dL
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
58. Outline
§Outcome of kidney transplantation
§Complication & medical Management of KTRs
§ Post transplant diabetes mellitus
§ Hypertension
§ Dyslipidemia
§ Electrolyte disturbance
§ Bone disease
§ Recurrent diseases
§ Malignancy
§ Failing kidney & allograft nephrectomy
59. Biochemical Abnormalities in KTR
After KT – 12 mo After 12 mo
GFR rapid change Stable graft function achieved.
Hypophosphatemia Normalized phosphate
Mild hypercalcemia Normalized Calcium
PTH decrease significantly in 3 mo PTH typically stabilizes at elevated
values
Low levels of 1,25(OH)2D
typically do not reach normal
values until 18 mo
KDOQI guideline : Evaluation and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder
60. Hypercalcemia & Hypophosphatemia
§ Hypercalcemia after KT
§persistent hyperparathyroidism
§calcium and vitamin D supplement
§Hypophosphatemia after KT
§common in early post KT period
§reduced PO4 absorption (vitamin D depletion)
§urinary phosphate wasting(high FGF-23 and PTH)
§tubular effects of CNIs, sirolimus, and high-dose
steroids
Brenner and Rector's The Kidney, 10th edition
61. § reserve oral phosphate when < 1-1.5 mg/dL or
symptomatic hypophosphatemia.
62. Hyperkalemia
§Mild hyperkalemia is common
§Principle cause is
§CNI-induced impairment of tubular potassium
secretion.
§Poor allograft function
§High potassium intake
§ACEIs and β-blockers
63. Outline
§Outcome of kidney transplantation
§Complication & medical Management of KTRs
§ Post transplant diabetes mellitus
§ Hypertension
§ Dyslipidemia
§ Electrolyte disturbance
§ Bone disease
§ Recurrent diseases
§ Malignancy
§ Failing kidney & allograft nephrectomy
64. Bone disease after KT
Incidence
Persistent secondary hyperparathyroidism 50%
Post-transplant osteoporosis 44% (28–88%)
Symmetric bone pain syndrome 11%
Spontaneous femoral head necrosis/ localized
osteonecrosis b2M amyloidosis
3%
Hypercalcaemia 50% in 3 months
15% in 2 years
Hypophosphataemia 90% in 4 months
40% in 1 year
Hypomagnesaemia 40%
H. Sperschneider and G. Stein et al, Nephrol Dial Transplant (2003) 18: 874–877
65. Persistent 2nd hyperparathyroidism
§Residual hyperparathyroidism can persist for years.
§Main risk factors for hyper PTH
§Pretransplant iPTH level
§Dialysis vintage
§Inadequate vitamin D stores
§Poor allograft function (de novo 2nd hyperparathyroidism)
66. Indications for parathyroidectomy (postKT)
§ Severe symp. Hypercalcemia which failure in
medication
§ Persistent, moderately severe hypercalcemia
(serum calcium level ≥ 12.5 mg/dL) >1 year
§ Calcific uremic arteriolopathy (calciphylaxis)
Brenner and Rector's The Kidney, 10th edition
73. Effect of CsA in bone loss
§CsA results in accelerated bone turnover, with
both increased formation and resorption.
74. Post KT- Osteoporosis
§ If eGFR > 30 mL/min/1.73m2
§ measuring BMD in first 3 months if
§Receive corticosteroids
§Risk factors for osteoporosis as in general
population. (2D)
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
75. §In first 12 mo after KT , eGFR > 30 mL/min/1.73 m2 and
low BMD,
§We suggest
§Vitamin D (calcitriol/alfacalcidiol) OR
§Bisphosphonates be considered. (2D)
§Consider bone biopsy to guide treatment , before
bisphosphonates use due to the high incidence of
adynamic bone disease. (Not Graded)
§Insufficient data to guide treatment after the first 12
months. (Not Graded)
Post KT- Osteoporosis
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
76. §CKD stages 4–5T
§ BMD testing not be performed routinely
§ BMD does not predict fracture risk as it does in
the general population
Post KT- Osteoporosis
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
77. §Treatment with a bisphosphonate, vitamin D sterol or
calcitonin after kidney transplantation may protect
against immunosuppression-induced reductions in BMD
and prevent fracture.
78. Hyperuricemia and gout
§ Suggest treating hyperuricemia in KTRs when
there are complications, such as gout, tophi, or uric
acid stones. (2D)
§colchicine for treating acute gout, with
appropriate dose reduction for reduced kidney
function and concomitant CNI use. (2D)
§ Avoiding allopurinol in patients receiving
azathioprine. (1B)
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
79. Outline
§Outcome of kidney transplantation
§Complication & medical Management of KTRs
§ Post transplant diabetes mellitus
§ Hypertension
§ Dyslipidemia
§ Electrolyte disturbance
§ Bone disease
§ Recurrent diseases
§ Malignancy
§ Failing kidney & allograft nephrectomy
80. Recurrent primary disease
§The risk of recurrence by prevalence
§FSGS
§IgA
§MPGN
§HUS
§Primary oxalosis
§Fabry’s disease
§Lupus nephritis
§AntiGBM disease
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
81. Screening for recurrent diseases
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
82. Recurrent disease : FSGS
§ Sporadic recurrence is approximately 30%
§ Risk factors for recurrence
§Recurrent FSGS in a previous KT (strongest risk)
§white recipient
§younger recipient (6-15 yr)
§rapidly progressive FSGS in native kidneys
§diffuse mesangial proliferation on histology
§Treatment options: plasmapheresis or, high-dose
CyclosporinA ,ACEIs,
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
83. § Incidence of recurrence varies from 13% to 53%
§ Single-nucleotide polymorphisms in IL-10 and
TNF-alpha genes shown to predict recurrence risk
§ACEI/ARBs reduce proteinuria and preserve
kidney function in recurrent IgAN
§Use of ATG as induction therapy was associated
with a reduction in recurrence risk from 41% to 9%
when compared to IL2 receptor antagonists
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
Recurrent disease : IgAN
84. Survival without recurrence and induction
therapy in IgAN recipients
Berthoux F, et al.. Transplantation 2008; 85: 1505–1507.
85. Outline
§Outcome of kidney transplantation
§Complication & medical Management of KTRs
§ Post transplant diabetes mellitus
§ Hypertension
§ Dyslipidemia
§ Electrolyte disturbance
§ Bone disease
§ Recurrent diseases
§ Malignancy
§ Failing kidney & allograft nephrectomy
86. Vaccination
§ Approved, inactivated vaccines, by general schedules ,except HBV
vaccination. (1D)
§ ideally prior to KT and HBsAb titers 6–12 weeks after course (2D)
§ annual HBsAb titers. (2D)
§ revaccination if Ab titer falls below 10 mIU/ mL. (2D)
§ Avoiding vaccinations, in first 6 months after KT (except influenza vaccination, )
(2C)
§Additional vaccine : epidemiological risk
§ Rabies, (2D)
§ Tick-borne meningoencephalitis, (2D) •
§ Japanese B encephalitis—inactivated, (2D)
§ Meningococcus, (2D)
§ Pneumococcus, (2D)
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
87. Contraindicated vaccinations after KT
Varicella zoster
BCG
Smallpox
Intranasal influenza
Live oral typhoidTy21a and other newer vaccines
Measles (except during an outbreak) /Mumps/Rubella
Oral polio
Live Japanese B encephalitis vaccine
Yellow fever
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
88. Cancer after Kidney Transplantation
§ Overall incidence of cancer in KTRs recipients is
greater than in dialysis patients and general population
§ Mechanism
§1) inhibits normal tumor surveillance mechanisms,
allowing unchecked proliferation of “spontaneously
occurring” neoplastic cells
§2) immunosuppression allows uncontrolled
proliferation of oncogenic viruses
§3) factors related to primary kidney disease or the
ESRD milieu (acquired renal cystic disease) might
promote neoplasia.
Brenner and Rector's The Kidney, 10th edition
89. § Routine use of CNIs increased risk of skin cancers
§ Sirolimus has antineoplastic effects
§ Everolimus effective in treatment of RCC
Cancer after Kidney Transplantation
Brenner and Rector's The Kidney, 10th edition
90. Cancers categorized by SIR for kidney
transplant patients and cancer incidence
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
92. Posttransplant Lymphoproliferative
Disorder (PTLD)
§ Can occur early after KT and high morbidity and mortality
§ 90% are non-Hodgkin’s lymphomas
§ Extranodal, GI tract, and CNS lymphoma is more common
§ Most cases occur in first 24 months after transplant
§Risk factors include
§(1) EBV- positive donor and EBV-negative recipient
§(2) CMV-positive donor and CMV-negative recipient
§(3) pediatric recipient
§(4) aggressive immunosuppression, esp with
antilymphocyte antibody or tacrolimus.
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
94. EBV and PTLD
§Monitoring high-risk (donor EBV +/recipient-) NAT
PCR(2C):
§once in 1st week after KT(2D);
§then at least monthly for 3–6 months then q 3 months
until the end of the first post-transplant year (2D)
§after treatment for ac rejection. (2D)
§EBV-seronegative pts with increasing EBV load à
immunosuppressive medication reduced. (2D)
§ We recommend that patients with EBV disease, including
PTLD, have a reduction or cessation of immunosuppressive
medication. (1C)
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
95. Smoking
§ General populationà strong evidence smoking
causes CVD, cancer, chronic lung disease and
premature death
§In KTRs, cigarette smoking is associated with CVD
and cancer.
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
96. Pharmacological therapies for
smoking cessation in KTRs
Class Drug Consideration
Nicotine replacement Nicotine gum, inhaler,
nasal spray, lozenge and
patch
combinations with other
nicotine and non-
nicotine replacement
agents
Antidepressant Bupropion SR Monitor CsA blood
levels and increase CsA
dose as needed
a4b2 nicotinic receptor
partial agonist
Varenicline Caution : including
depression and suicidal
ideationa
KDIGO Guideline for the Care of Kidney Transplant Recipients American Journal of Transplantation 2009; 9 (Suppl 3): S42–S43
97. Outline
§Outcome of kidney transplantation
§Complication & medical Management of KTRs
§ Post transplant diabetes mellitus
§ Hypertension
§ Dyslipidemia
§ Electrolyte disturbance
§ Bone disease
§ Recurrent diseases
§ Malignancy
§ Failing kidney & allograft nephrectomy
98. Allograft nephrectomy
§Indication
§ Allograft failure with symptomatic rejection
fever, malaise, hematuria, and graft pain
§ Infarction due to thrombosis
§ Severe infection e.g. emphysematous pyelonephritis
§ Allograft rupture
Brenner and Rector's The Kidney, 10th edition
99. Failing kidney
§ Preparation for dialysis
§ Immunosuppression weaned gradually
§prevent acute rejection, resulting in transplanted
nephrectomy
§ Listed again for another transplant if no contraindication
Brenner and Rector's The Kidney, 10th edition