Renal and Pancreatic Transplant - Antimicrobial prophylaxis

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Criteria for Renal or/and Pancreatic Transplant

Description 

  • ESKD patients who meet the following criteria will be suitable for recommendation for Renal or/and Pancreatic Transplant:
    • No malignancy or free of malignancy for at least 5 years
    • No serious cardiovascular disease or ischemic heart disease
    • (minimum Ejection Fraction of 40%)
    • No Major pulmonary disease
    • No major restriction or obstruction
    • No major urological disease
    • No major psychiatric illness
    • BMI< 35 kg/m2
    • Low preformed antibodies (PRAs). High PRAs are associated with the following – Multiple pregnancies
    • Multiple blood transfusions
    • Prior failed transplant
    • GI disorders should have been addressed
    • PUD
    • Pancreatitis
    • Diverticulitis
    • Infections
    • HIV patients can be transplanted as long as they meet the following:
    • CD4 >200copies/ml
    • On HAART for at least 6 months
    • VL undetectable
    • Adherence with cART
  • All other active infections should be treated first
  • Special considerations should be taken for HBV and HCV
  • Should not a smoker or chronic alcoholic

Investigations

  • Serum/blood
  • HIV test
  • HBsAg
  • Anti-HCV
  • Anti-CMV
  • Anti-EBV
  • Anti-HTLV-1
  • RPR
  • Blood group
  • PRAs
  • X match for CDC and flow cytometry 
  • Imaging/Invasive
  • CXR, Doppler US of femoral/iliac veins
  • ECG, VCU , Gastroscopy
  • Doppler of carotids for Diabetics
  • Other tests will be dependent on the condition of patients
  • Other aspects that patient need to meet which are dependent on dialysis adequacy
  • CaPO4 product should be acceptable
  • PTH within recommended levels
  • Hb 11-12g/dl
  • Potassium normal

A checklist should be done the day before transplant to make sure the candidate is ready if possible do the tests.

 Repeat HIV test as well unless already HIV positive Patients should be fully examined the day before transplant and ensure no comorbidity

  • Stop-or-go Strategy for Evaluation of a Potential Living Donor
  • Blood group determination: Stop if incompatible with recipient blood group….
  • Plasma Urea, creatinine; proteinuria; urinary sediment: Stop if abnormal
  • Viral tests: HBV, HCV, HIV Stop if positive
  • Renal ultrasound: stop if solitary kidney
  • HLA A, B, DR, DP and DQ typing
  • CDC Crossmatch; FC crossmatch: Stop if positive (T-cell positive X match with IgG)
  • Full medical evaluation of the potential donor
  • BMI, blood pressure, cardiac evaluation (at least EKG and ultrasound)
  • Aorto-iliac CT scan, and renal angiography; urography
  • Measurement of GFR: Cr51-EDTA, iohexol, or other methods
  • Blood glucose, HbA1c, cholesterol, microalbuminuria
  • Liver enzymes, alkaline phosphatases, gGT
  • Gynecologic evaluation: mammography, uterine cervix smear
  • Prostate evaluation, clinical and PSA
  • Evaluation of skin, lung, thyroid, infectious diseases,
  • Psychologic/ psychiatric evaluation
  • Validation by urologist and anesthesiologist
  • The best kidney donor
  • Iso blood group and HLA identical
  • Less than 50 years
  • Normal BP (< 140/90 mmHg)
  • BMI < 25 Kg/m2
  • GFR > 80 ml/min/ 1.73m2
  • Proteinuria < 300 mg/day; microalbuminuria <30mg/d
  • No hematuria
  • No diabetes nor dyslipidemia
  • No cardiac disease or history of cancer
  • No infectious (viral) disease
  • Immunosuppression in Live-donor Kidney Transplant patients
  • Immunosuppression can be started PRIOR to transplantation, g. one week before; this aims at achieving efficient immunosuppression.
  • This might result in avoiding induction therapy with ant lymphocyte preparations or monoclonal anti-IL2 receptor antibody
  • The HLA matching (D/R) can sometimes be very good, thereby allowing “lighter” immunosuppression, e.g. avoiding the use of calcineurin inhibitors
  • There is no cold ischemia time: thus the risk of delayed graft function is almost nil, decreasing the risk of acute rejection
  • Preoperative Investigations
    • FBC, urea, serum creatinine, sodium, potassium, PT/aPTT, liver function tests
  • Immunosuppression protocols
    • Pre-operative Investigations
    • Calcineurin inhibitors (Cyclosporine OR Tacrolimus) plus antiproliferative agent (azathioprine-AZA-OR mycophenolate mofetil – MMF) with OR without steroids
    • With or without induction therapy: anti-lymphocyte agents –ATG- OR anti-IL2 receptor monoclonal antibodies, e.g. basiliximab, daclizumab
    • Calcineurin inhibitors can be avoided (from the beginning or after a few months) provided there is the use of mTOR-inhibitors such as sirolimus or everolimus.
  • Induction
    • Basiliximab 20 mg pre-operative and day 4
    • Methylprednisolone 500mg-1000mg day 0 (in operating theatre)
    • MMF or Azathioprine 1.5g or 1-3mg/kg/day respectively
    • Cyclosporine 8-12mg/kg stat or Tacrolimus 15- 0.30mg/kg/day bd.
    • Maintenance
    • MMF 5g BD PO or Azathioprine 1-3mg/kg/day
    • Cyclosporine or Tacrolimus (dose adjusted according to C-2 levels or Tacrolimus levels)
    • Prednisolone 60mg first day and taper down fast as long as creatinine remains By end of the month, the dose should be 20mg or less.
  • Prophylaxis
    • INH 300mg od for 6 months
    • Valacyclovir 450mg bd PO (depending on CMV status of “donor and recipient”) for 3 months
    • Nystatin suspension 10mls od PO for 3months
    • Amphotericin B oral suspension for 3 months
    • Co-trimoxazole 960mg od PO for 6 months
    • Tacrolimus or Cyclosporine levels to be done daily till discharge then twice weekly then weekly, fortnightly and so on.
    • Kidney ultrasound and renogram will be routine within 5 days of transplant
    • Acute rejection will be defined based on an increase in serum creatinine or amylase (urine as well) and renal biopsy.
    • Rejection will be managed under the direct supervision of a Nephrologist but will require induction agents like ATG or Methylprednisolone or/and modification of maintenance regimen.
  • Fertility and Pregnancy post-transplant
  • Fertility restored
  • Pregnancy outcomes improve if renal function is normal and hypertension absent
  • Pregnancy accelerates graft loss
  • Advisable to wait for 2 years
  • So that renal function stabilises
  • Lowest doses of Immunosuppressive
  • Cyclosporine, prednisolone, Azathioprine safe, MMF no

Antimicrobial Prophylaxis

  • INH 300mg od for 6 months
  • Valacyclovir 450mg bd PO (depending on CMV status of “donor and recipient”) for 3 months
  • Nystatin suspension 10mls od PO for 3months
  • Amphotericin B oral suspension for 3 months
  • Co-trimoxazole 960mg od PO for 6 months