kidney transplant: new opportunities & challenges · new opportunities & challenges ....
TRANSCRIPT
Liza A. Lucero MSN, FNP
Renal Medicine Associates
12th Annual Southwest Nephrology Symposium
February 29, 2020
Kidney Transplant:
New Opportunities & Challenges
Disclosure
I have NO disclosure related to this presentation
To ligate or not to ligate AV fistula
Vaccine prevention in kidney transplant
Cannabis abuse post kidney transplantation
To Ligate OR
Not to Ligate? !
CLINICAL TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry URL: https://www.anzctr.org.au. Unique Identifier: ACTRN12613001302741.
Coates et al; Circulation. 2019;139:2809–2818. DOI: 10.1161/CIRCULATIONAHA.118.038505 June 18/25, 2019 2809
Study Findings
The key primary finding was a 15% reduction in LV mass in the AVF
ligation group associated with a decrease in cardiac output. There was
≈20% decrease in LV and atrial sizes and also a reduction in N-terminal
pro–B type natriuretic peptide levels.
Discussion
The hemodynamic effects after AVF creation include decreased peripheral resistance and thus increased cardiac output.
As the AVF increases in size the myocardium may decompensate a leading to CHF
Reestablishment of renal function after kidney transplantation and avoidance of the pronounced intravascular volume shifts occurring during thrice-weekly hemodialysis therapy consistently reduce LVH.
LV regression reaches its nadir at second year post transplant and persists thereafter ( lower CV mortality in Kidney transplant then waiting list )
Study Limitations
Study was not powered to detect differences in CV and survival
outcomes. Whether the decrease in LV mass and reversal of LVH after
AVF closure imparts a protective effect and changes the trajectory of
patient outcomes is still a matter to be resolved.
A risk stratification using surrogate markers such as fistula blood
flow measurements or the fistula site (upper arm Vs. forearm AVF) has
not been applied. Patients with a fistula blood flow >2 L/min or an
upper arm AVF are at increased risk for the development of CHF and
perhaps would benefit more from fistula closure.
Study Limitations
Risk VS benefit of having a functional AFV was not addressed ,
especially in patients who will potentially return to hemodialysis during
their lifetime, was note addressed . No doubt, preservation of the AVF or
a flow reduction procedure may be preferable to fistula closure for
younger patients.
When is the best time to ligate an AVF after successful KT? It may be
that the benefit on CV or even graft outcomes is greater if the fistula is
ligated 3 to 6 months post-KT presuming stable graft function.
Suggestions
Fistula closure should be reserved for stable KT recipients with
A) symptoms of overt cardiac failure or
B ) pulmonary hypertension and
C) access-related complications (mainly aneurysm formation with risk
of rupture, steal syndrome, infection, or high fistula blood flow).
For the rest, an individualized patient-centered approach that
will include patients’ preferences and beliefs is deemed more
appropriate.
Vaccine Prevention in
kidney transplant candidates
Background
Solid organ transplant (SOT) candidates are at risk of developing
infections, with higher attack rates and risks for severe and complicated illness especially after TX, because of preexisting health conditions, lifelong immunosuppression, and increased exposure during frequent visits to the clinics
Prevention of infections through vaccination is the least invasive &
most cost‐effective way to reduce morbidity & mortality in SOT recipients.
Diseases that can potentially be prevented through vaccination include
varicella zoster virus (VZV), measles, influenza, invasive pneumococcal diseases, tetanus, and hepatitis A and B virus infection
Study Aim
To evaluate the need for, &efficacy of,
vaccine catch‐up assessed by vaccine serology before (at
time of listing) and at transplant from Jan1, 2014, to Nov 30, 2015.
Rohner et al, Am J Transplant. 2019;19:512–521
.
Conclusion
Serology is much more important than history ( 25 % reported tetanus but 88 % immune )
Tetanus toxoid provided strong immunity
HBV immunity is low
Catch up immunization resulted in increased immunity to
Hep A & Strep pneumonia but NOT HbV
Cannabis abuse post kidney
transplantation
Lentine et al; Transplantation 2019;103: 2373–2382
Introduction
Cannabis is the most commonly used illicit drug in the USA
3 % of people meet criteria for cannabis abuse despite harm
Cannabis is a schedule 1 substance in the USA, Opioids class 2
Guidance for physicians & patients in kidney transplant is lacking
Study linked SRTR data to Medicare claims of cannabis abuse
Study
52,000 kidney-only transplant recipients from 2007 to 2015
Had Medicare coverage for 1 year before & after transplant
only 0.5% (n = 254) had cannabis abuse in the year before transplant and 0.3% (n = 163) had it in the first-year posttransplant.
Recipients with cannabis abuse were more likely to be young, male, black, and
have lower education and likelihood of employment. This should not be used to
create stereotype or to decrease access to kidney transplant in this already disadvantaged group, but rather to direct education and support services.
Study limitation
The frequency of cannabis abuse in this sample of kidney transplant recipients was
substantially lower than the frequency of cannabis use reported in the general population.
The study was not designed to identify occasional “social” or legally prescribed medical cannabis use, because use without detrimental consequences does not qualify as cannabis abuse.
Coding practices may vary and are not subject to the rigorous data quality assessments that are typically conducted within clinical trials
the available data do not include frequency, duration, dose, or type (recreational versus medical) of cannabis use
The retrospective design can identify associations but not prove causation.
Conclusion
Cannabis is not totally benign .Abuse travels with the psychosocial conditions that we must monitor an support
Seven states joined the organ transplant protection for medical cannabis users, including Arizona, Delaware, Illinois, Minnesota, New Hampshire, California and Washington.
Some suggesting reschedule cannabis to schedule II in order to allow
further research into its therapeutic value ( after all it is LEGAL )
Fistula ligation may be indicated in certain patients
population post kidney transplant.
Catch up vaccination improves the vaccination rate in
CKD patients but for hep B vaccine.
Cannabis dependence appears to have prognostic
implications for allograft & patient out come post Tx.
Thank You
• Thank You to Ehab Saad, MD, FASN, FACP, MA professor of
Medicine & Surgery Kidney & Pancreas Medical Director
Medical College of Wisconsin Division of Nephrology