Monitoring Renal Transplants Planning follow up based on risks & cost

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

Adverse distant outcomes Long term risks include: –Cardiovascular disease –Hyperlipidemia –Hypertension –Cancer Chronic allograft nephropathy Non-adherence (non-compliance)

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

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

Monitoring function “Sudden” changes suggest –Acute rejection –Infection –Volume depletion –Obstruction Creatinine “creep” –Chronic transplant nephropathy –Drug toxicity –Other causes (see above)

Proteinuria Transient (rejection issues) Persistent –> 0.5 to 1.0 gm / 24 hours for >3-6 mo –Occurs in 10 – 25% –Associates with glomerular lesions Chronic allograft nephropathy Recurrent glomerular disease

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 (>1+ pushes test)

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%

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

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%

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….

Tacrolimus Graft survival similar to cyclosporin Fewer acute rejections Side effects –Decreased renal function (35 –42%0 –Diarrhea (22 – 44%) –Constipation (31 – 35%) –Vomiting (13 – 29%) –Hypertension (37 – 50%) –Infections (72 – 76%) –CMV (14 – 20%)

CyA vs Tac CMV about the same Tremor about the same Gingival hyperplasia more in CyA Hirstutism more in CyA

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

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

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

Azathioprine Check for toxicity with H&P CBC as for MMF LFTs monthly for the first 3 months, then q 3 months for one year, then yearly

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

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

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

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

Erythrocytosis 10 to 20% of cases Detect with scheduled CBC’s

Anemia Probably >10% Follow CBC

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

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

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

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

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

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

Cancer PTLD risk 1 to 5% –Complete H&P quarterly first year and then yearly Uroepithelial and renal Ca risk 0.5 to 4% –No good screen recommendation

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