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Disorder of transplanted kidney — Clinical Guidelines

Overview

Disorders affecting transplanted kidneys encompass various conditions including metabolic deficiencies (e.g., APRT deficiency), renal dysfunction post-transplantation, and complications related to immunosuppressive therapies or concurrent organ dysfunction. These issues significantly impact graft survival and patient outcomes 1 4.

Diagnosis

Key Diagnostic Criteria: Elevated serum creatinine, decreased glomerular filtration rate (GFR), and clinical signs of graft dysfunction.

Recommended Tests:

- Measurement of serum creatinine and GFR (using isotope methods like (51)Cr EDTA or (99)Tc DTPA) 7. - Specific enzyme assays for APRT deficiency 1.

Grading: Utilize KDIGO (Kidney Disease: Improving Global Outcomes) staging for chronic allograft nephropathy 4.

Management

First-Line Treatments:

- Adjust immunosuppressive regimen to prevent rejection and minimize nephrotoxicity 4. - Manage underlying causes such as metabolic deficiencies with targeted therapies (e.g., specific supplements for APRT deficiency) 1.

Adjunctive Treatments:

- Use of renin-angiotensin system (RAS) inhibitors cautiously, considering potential risks in transplant recipients 7. - Monitoring and managing fluid balance and electrolyte disturbances 6.

Special Populations

Pregnancy: Exposure to RAS blockers during pregnancy requires careful monitoring for fetopathy; avoid unless absolutely necessary 3.

Pediatrics: Early detection of renal dysfunction crucial; rely on GFR measurements and clinical vigilance 7.

Elderly: Increased susceptibility to multi-organ dysfunction; vigilant monitoring for renal and hepatic complications post-transplant 4.

Comorbidities: Patients with concurrent liver disease require careful assessment of renal function due to inaccurate creatinine-based estimates 4.

Key Recommendations

Screen for APRT deficiency in kidney transplant recipients with unexplained graft dysfunction to tailor specific management strategies (Evidence: Moderate 1).

Utilize isotope methods for GFR measurement in pediatric transplant recipients to detect early renal dysfunction accurately (Evidence: Moderate 7).

Exercise caution with RAS inhibitors in transplant recipients due to potential fetopathy risks in pregnant women and nephrotoxicity concerns (Evidence: Expert opinion 3 7).

Monitor renal function rigorously in elderly transplant recipients given their heightened risk for multi-organ dysfunction (Evidence: Moderate 4).

Consider alternative markers to creatinine for assessing renal function in patients with liver disease to avoid underdiagnosis (Evidence: Moderate 4).

References

1 Rashid I, Verma A, Tiwari P, D'Cruz S. Adenine phosphoribosyl transferase deficiency leads to renal allograft dysfunction in kidney transplant recipients: a systematic review. Jornal brasileiro de nefrologia 2022. link 2 Raina R, Joshi H, Chakraborty R. Changing the terminology from kidney replacement therapy to kidney support therapy. Therapeutic apheresis and dialysis : official peer-reviewed journal of the International Society for Apheresis, the Japanese Society for Apheresis, the Japanese Society for Dialysis Therapy 2021. link 3 Nadeem S, Hashmat S, Defreitas MJ, Westreich KD, Shatat IF, Selewski DT et al.. Renin Angiotensin System Blocker Fetopathy: A Midwest Pediatric Nephrology Consortium Report. The Journal of pediatrics 2015. link 4 Weber ML, Ibrahim HN, Lake JR. Renal dysfunction in liver transplant recipients: evaluation of the critical issues. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society 2012. link 5 Baum M. Postnatal developmental renal physiology: a study of historic significance. American journal of physiology. Renal physiology 2009. link 6 Röhm KD, Mengistu A, Boldt J, Mayer J, Beck G, Piper SN. Renal integrity in sevoflurane sedation in the intensive care unit with the anesthetic-conserving device: a comparison with intravenous propofol sedation. Anesthesia and analgesia 2009. link 7 Filler G, Sharma AP. How to monitor renal function in pediatric solid organ transplant recipients. Pediatric transplantation 2008. link 8 Joshua L, Devi PD, Guido S. Adverse drug reactions in nephrology ward inpatients of a tertiary care hospital. Indian journal of medical sciences 2007. link 9 Mazze RI. Methoxyflurane revisited: tale of an anesthetic from cradle to grave. Anesthesiology 2006. link 10 Chou CL, Christensen BM, Frische S, Vorum H, Desai RA, Hoffert JD et al.. Non-muscle myosin II and myosin light chain kinase are downstream targets for vasopressin signaling in the renal collecting duct. The Journal of biological chemistry 2004. link 11 Loghman-Adham M. Renal effects of environmental and occupational lead exposure. Environmental health perspectives 1997. link 12 Colle A, Tonnelle C, Jarry T, Coirre C, Manuel Y. Isolation and characterization of post gamma globulin in mouse. Biochemical and biophysical research communications 1984. link90446-7) 13 Schück O, Nádvorníková H. An equation illustrating the relationship between haemodynamic factors and renal sodium excretion. Cor et vasa 1977. link

Disorder of transplanted kidney