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π» AKI in patients with a kidney transplant can sometimes be βSCARIβ
π§΅Letβs talk about an approach I recently learned to some common causes of late (>3 months) allograft dysfunction to overcome the fear together #Tweetorial #NephTwitter
π» AKI in patients with a kidney transplant can sometimes be βSCARIβ
π§΅Letβs talk about an approach I recently learned to some common causes of late (>3 months) allograft dysfunction to overcome the fear together #Tweetorial #NephTwitter
2/
π Allograft dysfunction is defined by a rise in serum Cr of approximately 25%
π It is often asymptomatic, identified on routine blood work
π It can also present with nonspecific symptoms such as nausea, vomiting or diarrhea.
π Allograft dysfunction is defined by a rise in serum Cr of approximately 25%
π It is often asymptomatic, identified on routine blood work
π It can also present with nonspecific symptoms such as nausea, vomiting or diarrhea.
3/
Let's start with a not-so-SCARI case!
π¨π½ 50 y/o M with ESKD due to DM2 s/p deceased donor kidney transplant 5 yrs ago
π§ͺ Cr 2.0 (176 umol/L) baseline Cr 1.3 (115 umol/L). No change in urinary frequency, amount or color. No recent illness
What kidney imaging do you suggest?
Let's start with a not-so-SCARI case!
π¨π½ 50 y/o M with ESKD due to DM2 s/p deceased donor kidney transplant 5 yrs ago
π§ͺ Cr 2.0 (176 umol/L) baseline Cr 1.3 (115 umol/L). No change in urinary frequency, amount or color. No recent illness
What kidney imaging do you suggest?
4/
ποΈ For STRUCTURAL abnormalities, ultrasound is a great noninvasive, initial modality
Abnormal Renal Resistive Index (>0.8) on doppler can be a useful, albeit nonspecific, marker of graft dysfunction
ποΈ For STRUCTURAL abnormalities, ultrasound is a great noninvasive, initial modality
Abnormal Renal Resistive Index (>0.8) on doppler can be a useful, albeit nonspecific, marker of graft dysfunction
5/
π§ Hydronephrosis, lymphocele and renal artery stenosis are a few of the things to look out for
π Allograft dysfunction due to this category usually resolves with treatment of the underlying condition
π§ Hydronephrosis, lymphocele and renal artery stenosis are a few of the things to look out for
π Allograft dysfunction due to this category usually resolves with treatment of the underlying condition
6/
π CALCINEURIN inhibitor (CNI) toxicity is up next
A real Achilles heel in the transplant world, as it is secondary to the very same drugs that have made kidney transplants so successful in recent years
π CALCINEURIN inhibitor (CNI) toxicity is up next
A real Achilles heel in the transplant world, as it is secondary to the very same drugs that have made kidney transplants so successful in recent years
7/
CNIβs can cause nephrotoxicity by a few mechanisms:
πΈοΈ Arteriolar vasoconstriction
πΈοΈ Thrombotic microangiopathy
πΈοΈ Hyalinization
πΈοΈ Tubular epithelial cell vacuolization
π¬ All of which can be identified via kidney biopsy
CNIβs can cause nephrotoxicity by a few mechanisms:
πΈοΈ Arteriolar vasoconstriction
πΈοΈ Thrombotic microangiopathy
πΈοΈ Hyalinization
πΈοΈ Tubular epithelial cell vacuolization
π¬ All of which can be identified via kidney biopsy
8/
The ELITE-Symphony trial showed that use of low-dose tacrolimus is associated with
β¬οΈ incidence of graft dysfunction
β¬οΈ mean calculated GFR
compared to cyclosporine and sirolimus
nejm.org/doi/full/10.10β¦
The ELITE-Symphony trial showed that use of low-dose tacrolimus is associated with
β¬οΈ incidence of graft dysfunction
β¬οΈ mean calculated GFR
compared to cyclosporine and sirolimus
nejm.org/doi/full/10.10β¦
9/
π A trough level of the patient's CNI can help in diagnosis
β¬οΈ Higher serum concentration of CNI is associated with higher risk of allograft dysfunction
π Reduced dosing is usually the treatment of choice for acute CNI toxicity, which is often reversible
π A trough level of the patient's CNI can help in diagnosis
β¬οΈ Higher serum concentration of CNI is associated with higher risk of allograft dysfunction
π Reduced dosing is usually the treatment of choice for acute CNI toxicity, which is often reversible
10/
π π½ββοΈ With advances in immunosuppressive therapy, ACUTE REJECTION is a lot less common than in previous years
π π½ββοΈ However, it is still considered a major risk factor for allograft failure
π π½ββοΈ With advances in immunosuppressive therapy, ACUTE REJECTION is a lot less common than in previous years
π π½ββοΈ However, it is still considered a major risk factor for allograft failure
There are two types of acute rejection:
π« T cell mediated β‘οΈ lymphocytic infiltration of the tubules and interstitium on biopsy
π« Antibody mediated β‘οΈ presence of Donor Specific Antibodies in the serum
π« T cell mediated β‘οΈ lymphocytic infiltration of the tubules and interstitium on biopsy
π« Antibody mediated β‘οΈ presence of Donor Specific Antibodies in the serum
π Treatment of TCMR involves pulse dose steroids and T-cell depletion
π Treatment of ABMR involves plasmapheresis, IVIG +/- Rituximab
π Treatment of ABMR involves plasmapheresis, IVIG +/- Rituximab
13/
π Next is RECURRENT DISEASE
This cause is important to consider in patients with a primary GN as their cause for ESKD. This occurs most commonly in:
π₯ MPGN 27-65%
π₯ Idiopathic Membranous Nephropathy 30-40%
π₯ IgA nephritis 33%, FSGS 30%
cjasn.asnjournals.org/content/5/12/2β¦
π Next is RECURRENT DISEASE
This cause is important to consider in patients with a primary GN as their cause for ESKD. This occurs most commonly in:
π₯ MPGN 27-65%
π₯ Idiopathic Membranous Nephropathy 30-40%
π₯ IgA nephritis 33%, FSGS 30%
cjasn.asnjournals.org/content/5/12/2β¦
14/
π¬ Diagnosis is made via kidney biopsy
π Treatment is usually the same as if the GN had occurred in a native kidney
π¬ Diagnosis is made via kidney biopsy
π Treatment is usually the same as if the GN had occurred in a native kidney
15/
π¦ Finally, INFECTION
π Opportunistic viruses can also cause allograft dysfunction. Specifically, BK polyomavirus and CMV are associated with significant morbidity and graft failure
π¦ Finally, INFECTION
π Opportunistic viruses can also cause allograft dysfunction. Specifically, BK polyomavirus and CMV are associated with significant morbidity and graft failure
16/
π¦ BK virus is widely prevalent in the general population
β¬οΈ High viral load is associated with high dose immunosuppression, especially in those with multi organ transplant
β³ Long term infection can lead to a nephropathy that can eventually lead to graft failure
π¦ BK virus is widely prevalent in the general population
β¬οΈ High viral load is associated with high dose immunosuppression, especially in those with multi organ transplant
β³ Long term infection can lead to a nephropathy that can eventually lead to graft failure
17/
π BK viremia is screened for via a quantitative PCR test
π¬ Diagnosis of BK nephropathy is made via biopsy
π Treatment involves reduction in immunosuppression dose and monitoring of viral load
π BK viremia is screened for via a quantitative PCR test
π¬ Diagnosis of BK nephropathy is made via biopsy
π Treatment involves reduction in immunosuppression dose and monitoring of viral load
18/
π¦ CMV viremia can present in two ways
π₯΅ As a syndrome of fever, malaise, leukopenia
π As a tissue-invasive process that can affect any organ
π¦ CMV viremia can present in two ways
π₯΅ As a syndrome of fever, malaise, leukopenia
π As a tissue-invasive process that can affect any organ
19/
π CMV viremia is diagnosed via quantitative PCR
π¬ Kidney biopsy can identify the characteristic CMV inclusions
π Mild cases are treated with valganciclovir
π CMV viremia is diagnosed via quantitative PCR
π¬ Kidney biopsy can identify the characteristic CMV inclusions
π Mild cases are treated with valganciclovir
20/
To recap, when evaluating allograft dysfunction, make sure to include this SCARI list on your differential:
ποΈ Structural abnormalities
π CNI toxicity
π π½ββοΈ Acute rejection
π Recurrent disease
π¦ Infection
To recap, when evaluating allograft dysfunction, make sure to include this SCARI list on your differential:
ποΈ Structural abnormalities
π CNI toxicity
π π½ββοΈ Acute rejection
π Recurrent disease
π¦ Infection
21/
π» Hopefully this topic is no longer SCARI at all! Thanks for following along. Huge shout out to @DrFlashHeart @amyaimei @Nephro_Sparks for all the help and guidance #MedTwitter #NephTwitter #Tweetorial #Kidney #Transplant #NSMC2021 @NSMCInternship
π» Hopefully this topic is no longer SCARI at all! Thanks for following along. Huge shout out to @DrFlashHeart @amyaimei @Nephro_Sparks for all the help and guidance #MedTwitter #NephTwitter #Tweetorial #Kidney #Transplant #NSMC2021 @NSMCInternship
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