Grand Round in Transplant Nephrology

  1.  Approach on How to Work up a Kidney Transplant Candidate with Multiple Co-morbidities
  2. Post-transplant graft dysfunction case in high infection area
  3. Post-transplant diabetes in paediatric kidney transplant recipients
  4. Treatment of post-transplant recurrent FSGS in children

Robert Freercks

South Africa

Chih-Wei Yang

Taiwan

Maria Theresa Bad-ang

Phillipines

Fritz Diekmann

Spain

Jamailah Macabanding

Philippines

Arpita Lahiri

India

Aniruddha Datta

India

Debasish Banerjee

UK

Rukshana Shroff

UK

Rouba Garro

USA

Naorem Lakshmee Devi

India

Indira Agarwal

India

Rupesh Raina

USA

Nancy Rodig

USA

Jaime Restrepo

Colombia

Javier Andrés Tascón Hernández

Colombia

David Andres Ballesteros Castro

Colombia

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Approach on How to Work up a Kidney Transplant Candidate with Multiple Co-morbidities
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Open to view video. This case involves a 56-year-old male with Ankylosing Spondylitis, developing Chronic Kidney Disease due to chronic NSAID use. Comorbidities include hypertension, gouty arthritis, and nephrolithiasis. Despite being on hemodialysis, he pursued a kidney transplant. Complications during transplant evaluation led to the deferral of the procedure and discontinuation of immunosuppression. Subsequent challenges included septic shock, anaphylactic reactions, severe anemia, and thrombocytopenia, requiring multiple interventions. Postponed transplantation, COVID-19, and a catheter-related bloodstream infection further complicated the patient’s journey. Despite setbacks, he resumed the transplant workup, highlighting the intricate management required in navigating complex medical conditions. Learning objectives: To discuss a case of kidney transplant candidate who has several co-morbidities. To discuss the approach to the work-up of a kidney transplant patient. To evaluate the specific transplantation risk factor related to organ system disease of a transplant candidate. Further reading: Danovitch, Gabriel M., Handbook of Kidney Transplantation. 6th edition, 2017. 2022 American College of Rheumatology/ American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Timing of Elective Surgery and Risk Assessment after SARS-CoV-2 Infection:2023 Update Kidney Transplantation in Adults: HLA-incompatible Transplantation Interpreting Anti-HLA Antibody Testing Data: A Practical Guide for Physicians.
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Post-transplant graft dysfunction case in high infection area
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Open to view video.  |   Closed captions available A 42-year-old man with diabetes on hemodialysis received a deceased donor kidney transplantation. Immunosuppression included anti-thymocyte globulin, methylprednisolone followed by tacrolimus, mycophenolate mofetil and prednisolone. A week later a biopsy done due to rising creatinine showed acute tubular necrosis from which he recovered and was discharged. Few days later he was admitted with fever, dry cough, lung nodules which responded to broad spectrum antibiotics. He was readmitted with fever, cough, purulent expectoration, hyperglycemia, klebsiella urine infection, reappearance of lung nodules and AKI requiring dialysis. Aspergillus was isolated from sputum. Learning objectives: Early postoperative graft dysfunction: approach to diagnosis Balancing net Immunosuppression and rejection risk. Improving organ allocation algorithm: minimize over immunosuppression, improve long term outcome
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Post-transplant diabetes in paediatric kidney transplant recipients
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Open to view video.  |   Closed captions available Post transplant Diabetes (PTDM) is a well-recognized complication after Kidney transplantation. Recent updates include recognition of impaired glucose tolerance, optimization of immunosuppression, prevention of PTDM and incorporation of new glucose lowering agents. Peri-transplant hyperglycemia is being increasingly identified and treated in paediatric population. We discuss a case series of children who developed post transplant hyperglycemia. Two of them were asymptomatic, two of them had high tacrolimus levels and two of them required insulin therapy. Optimization of immunosuppression and insulin therapy resulted in resolution of hyperglycaemia. Learning objectives: Describe the course of Post transplant diabetes (PTDM) Outline the challenges of balancing immunosuppressive medications in the presence of post-transplant hyperglycaemia Discuss the prevention and treatment strategies of PTDM. Further reading: Adnan Sharif, Harini Chakkera, Aiko P J de Vries, Kathrin Eller et al International consensus on post-transplantation diabetes mellitus, Nephrology Dialysis Transplantation, Volume 39, Issue 3, March 2024, Pages 531–549 Esteban L. Porrini, Armando Torres, Jose M. Díaz et al, Clinical evolution of post-transplant diabetes mellitus, Nephrology Dialysis Transplantation, Volume 31, Issue 3, March 2016, Pages 495–505 Juan M Munoz Pena, Kenneth Cusi, Posttransplant Diabetes Mellitus: Recent Developments in Pharmacological Management of Hyperglycemia, The Journal of Clinical Endocrinology & Metabolism, Volume 109, Issue 1, January 2024, Pages e1–e11
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Treatment of post-transplant recurrent FSGS in children
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Open to view video.  |   Closed captions available Up to 60% of pediatric renal transplant recipients with end‐stage renal disease due to primary focal and segmental glomerulosclerosis (FSGS) may develop recurrent disease. Such recurrence is associated with poor prognosis if no remission is achieved. There are different experiences with protocols based on plasmapheresis and increased immunosuppression that have resulted in a high long‐lived remission rate. Although a large number of therapies have been employed to treat FSGS recurrence, there is currently no consensus treatment and most of the treatments have not been evidence-based largely due to the lack of prospective randomized controlled trials. The decision to increase immunosuppression in FSGS recurrence in children is further complicated since most of these children have already had significant pretransplant exposure to immunosuppression as part of attempts to reverse FSGS in their native kidneys. Concerns for cumulative toxicity of certain medications, such as cyclophosphamide, may lead to decisions to forgo the use of what may be an efficacious therapy, especially when there is not clarity as to the best overall therapy or the best population for that drug’s efficacy. The paucity of prospective controlled studies not only exacerbates the lack of clarity as to best current management strategies but also complicates the assessment of novel therapies as they become available. For instance, rituximab and LDL-apheresis have both been used increasingly to treat FSGS recurrence, but their utility in children with recurrent disease in general is difficult to assess when there has been little formal assessment of current therapies to allow baseline levels of expectation. The importance of identifying the best therapies is underscored by long-term outcomes in successfully transplanted patients as compared to those with failed allografts. FSGS recurrence that does not respond to treatment leads to early graft loss and return to dialysis, and most often pretends future episodes of recurrence with subsequent transplantation Learning objectives: To describe biochemical and immunologic characteristics of Nephrotic syndrome different to SSNS: FSGS To point out options for Kidney transplantation in children with FSGS To show results from different approach to Kidney transplantation using: plasmapheresis, high dose of Inhibitors of calcineurin (Cyclosporine, Tacrolimus), rituximab or Cyclophosphamide. Further reading: Raina R, Jothi S, Haffner D, et al. Post-transplant recurrence of focal segmental glomerular sclerosis: consensus statements. Kidney Int. 2024;105(3):450-463. doi:10.1016/j.kint.2023.10.017 Kopp JB, Anders HJ, Susztak K, et al. Podocytopathies. Nat Rev Dis Primers. 2020;6:68. Watts AJB, Keller KH, Lerner G, et al. Discovery of autoantibodies targeting nephrin in minimal change disease supports a novel autoimmune etiology. J Am Soc Nephrol. 2022;33:238–252. VincentiF AA, Ghiggeri GM (2023) State of the art in childhood nephrotic syndrome: concrete discoveries and unmet needs. Front Immunol 14:1167741. https://doi.org/10.3389/fimmu.2023.11677 Trautmann A, Vivarelli M, Samuel S et al (2020) IPNA clinical practice recommendations for the diagnosis and management of children with steroid-resistant nephrotic syndrome. Pediatr Nephrol 35:1529–1561. https://doi.org/10.1007/ s00467-020-04519-1 Francis A, Didsbury M, McCarthy H, Kara T. Treatment of recurrent focal segmental glomerulosclerosis post‐kidney transplantation in Australian and New Zealand children: a retrospective cohort study. Pediatr Transplant. 2018;22. https://doi.org/10.1111/petr.13185. Baum MA, Ho M, Stablein D, Alexander SR. Outcome of renal transplantation in adolescents with focal segmental glomeruelosclerosis. Pediatr Transplant. 2 Filler G, Restrepo JM. The urgent need for more research on how to treat recurrent focal and segmental glomerulosclerosis. Pediatr Transplant. 2018;22. https://doi.org/10.1111/petr.13215. Outcome of renal transplantation in adolescents with focal segmental glomerulosclerosis
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