Kidney transplantation

what meds might be a recipient be prescribed and why

• immunosuppressants

• VTE prophylaxis

• anti-microbials

• anti-virals

• analgesia

• laxatives

• surgical abx prophylaxis

what drugs stop before a transplant

• anti - HT

• phosphate binders

• allopurinol

• quinine

• erythropoetin

• alfacalcidol

co-morbidities

• bmi

• age/frailty

• CB risk

• HIV/hepatitis

• hx of malignancy

• diabetes

surgical complexity/anatomical deviation

induction agents

basiliximab (IL-2 inhibitor)

given day 0 and day 4

big immunosuppression and needs to be given at time of transplantation

• to prevent early acute rejection

maintenance immunosuppression

• steroids (prednisolone)

• calcineurin inhibitor (tacrolimus/ciclosporin)

• antiproliferative agent

CNI side effects

What are the two calcineurin inhibitors given for maintenance immunosuppression

• How are they given

Tacrolimus

• empty stomach (1 hr before or 2-3 after meal)

Ciclosporin

• Oral solution should be diluted immediately b4 being taken

Different brands are not interchangeable

antiproliferative agents used for maintenance I/S

mycophenolate mofetil

• really hard on gut

Myciogenolate sodium

• prodrug. reduce GI side effects? more expensive i think

Azathioprone (2nd line)

• not teratogenic

• should be held during acute illness

How is sirolimus used

immunosuppressant given BEFORE surgery, as poor wound healing

• not as nephrotoxic

• can’t use the first 3-6 months after surgery

• taken OD

who is sterioid minimising regime for

for those who are diabetic or have a history of psychosis

• inc tacrolimus (CI inhibitor)

• MMF (myophenilate)

non immuno drugs given POST transplant

1. Aspirin

2. PCP prophylaxis (e.g., co-trimoxazole)

3. CMV prophylaxis

4. atorvastatin

5. GI protection

6. TB prophylaxis if high risk

7. Hep B prophylaxis

Tacrolimus/ciclosporin interactions

1. Levels increased by macrolide Abx (e.g clarithromycin, erythromycin etc)

2. Antifungals (levels increase)

3. Grapefruit juice (levels increase)

4. Nothing that boosts the immune system

5. levels decrease by rifampicin, orlistat, st John’s Wort

azathioprine interactions

allopurinol/febuxostat increases levels of azathioprine

how do you treat rejection

• pulsed methylprednisolone for 3 days: 500mg IV

• ATG (t cells pop)

do you omit immunosuppression during NBM

nope! never bc will get rejection

tacrolimus/ciclosporin regime during NBM

• Tactro: give 1/5 oral dose as continuous IV infusion, avoid PVC bags.

• Ciclo: give 2/5th oral dose IV, short time, so PvC not a problem

steroid regime for NBM patients

5mg pred= 20mg hydrocortisone . HC has a shorter half life

azathioprone effect on FBC

can reduce lymphocyte count to reduce inflammation

which meds to avoid in transplanted kidney

• NSAID

• aminoglycosides e.g gentamycin

• enzyme inhibitors/inducers affecting tacrolimus/ciclosporin

how to monitor pt on tacrolimus

flu-like symptoms, fever, weight gain, decreased urination, pain, fatigue)

(tacrolimus levels and monitor  renal function)

is transplantation a cure for ESKD?

nope, its a form of renal replacement therapy (RRT)

aim of transplantation for ESKD

aim is to keep ppl from needing dialysis , ideally transplant pre-emptively .

dialysis inc mortality/ morbidity

who is transplantation for

mostly CKD stage five requiring RRT

why stop the following before transplant?

1. phosphate binders

2. alfacalidol

3. erythropoeitin

After transplant:

• New kidney excretes phosphate again

• Kidney can activate vitamin D again

• New kidney produces EPO → Hb improves naturally

essential medication to contrinue before transplant

diabetes, thyroid therapy etc- essential ones

gastroprotection

cholesterol lowering agents

what is PCP prophylaxis and when given

post transplant

prevents serious fungal infections in immunocompromised individuals

which drugs have to be brand specific

tacroliimus/ ciclosporin - not interchangeable.