Loading ...



Q.732. What are the complications of withdrawal?kidney transplant complications kidney transplant requirements kidney transplant rejection symptoms ki

Solid-organ transplant (SOT) TR are immunocompromised  and may be at higher risk for severe COVID-19 disease as compared to general population. Two large observational studies of SOT recipients with COVID-19, about 80-90 % of ptns required hospitalization; of those, nearly 40 % required intensive care & 30 % required mechanical ventilation. At one month, mortality (MR) exceeds > 20 %. These findings suggest: TR are at a higher risk for poor outcomes, multivariate analyses in both studies reported that age & chronic co-morbidities were the primary drivers of MR rather than immunosuppression.

@ Kates OS, Haydel BM, Florman SS, et al. COVID-19 in solid organ transplant: A multi-center cohort study. Clin Infect Dis 2020.

Leeaphorn N, Thongprayoon C, Chon WJ, et al. Outcomes of kidney retransplantation after graft loss as a result of BK virus nephropathy in the era of newer immunosuppressant agents. Am J Transplant 2020; 20: 1334. 


Q.732. What are the complications of withdrawal?

A. Complications of withdrawal: Continued  immunosuppression (im/m.) administration to ptn é R. allograft failure would, at first glance, appear to be unnecessary, since such agent increase risk of infection without providing obvious benefits. However, withdrawal of im/m. may be ass. é significant complications:

1)   Precipitation of rejection, requiring Tx. nephrectomy.

2)   Secondary adrenal insufficiency.

3)   Loss of residual renal function (Kru).

4)   Potentially adverse immunologic effects é those pursuing another Tx.

Q.733. What are the indications of nephrectomy?

A.Indications for Tx. nephrectomy: onset of Sm and/or complications rel. to Rj. after withdrawal of im/m., and P.H. of early graft failure(with or without Sm and/or complications): Sm resulting fr. Rj. & necrosis incl.:[graft tenderness, fever, hematuria, localized edema & occasionally infection]. Less fulminant Rj. may present é unusual Sm, such as [wt loss, anemia, fatigue, G.I. complaints, neurologic disturbances & resistance to Epo.].  Ptn. who have early graft failure (= return to DX é one y. of Tx.) are much more likely to development graft-related complication requiring nephrictomy thn are those é late allograft failure, independent of whether im/m. medications are withdrawn. Alth. such complications may be obs. in ptns in whom withdrawal is not initiated, abruptwithdrawal of im/m. among those é early graft failureincrease risk of ppt Rj. tht requires nephrectomy. In addition, morbidity & mortality fr. nephrectomy hs improved markedly over the last 3 decades. These obs. hv led most centers to adopt a policy of immediate withdrawal of im/m. combined é + preemptive nephrectomy for ptns é early allograft failure.

Indications for Tx. nephrectomy in late allog. failure after initiation of DX are not clearly defined, but may be considered in ptns é Sn & Sm of a ch. inflmm. state . Some clinicians, advocate allog. removalé features of such an inflmm. state, while others sugg. nephrectomy only é Sm.  Analysis based éU. S. Renal Data System suggest.: survival is improved after Tx nephrectomy. Among nearly 11,000 DX ptns with a failed kidney allograft, 32%underwent nephrectomy between 1994 &2004. The relative risk for all-cause death was signif. Lower for those é Tx nephrectomy. Although nephrectomy is the conventional approach to removing failed R. allografts, some centers have rep. some success é vascular embolization. Further study is required to clarify the role for this technique, é some concern related to M.R. & absence of data é hematologic & biochemical outcomes.

Q.734.What are the methods of withdrawal?

A. No controlled, prospective studies have been performed to clatify the best method for tapering/withdrawing im/m. following R. allog. failure. Most centers have sp. protocols. The foll. approachstable nephrectomy rate of apprx. 30%: Most Tx. centers have adopted a policy of immediate withdrawal of im/m. combined épreemptive nephrectomy for early allograft failure:[failure occur <one y. after surgery].Withdraw im/m. é later allograft failure, é no one remaining on any type of im/m. for longer thn 6 m. fr. time of allograft failure. A standard protocol is to immediately withdraw {Csp. or Tcrol, and Aza or MMF}; subsequently taper{pred. by 1 mg/m.} until the drug is discontinued, carefully watching for Sm. of adrenal insufficiency. Different appr. if ptn hs continued toproduce urine despite allograft failure: withdraw the anti-metabolite immediately,🠋CNI dose to once/d.in the morning&🠋pred. to 5mg/d.; both remaining im/m. ag. are tapered slowly over 3-6 m..This approach allows ptn to obtain benefits of additional solute & waterclearance& recover nutritionally; this permits the ptn to tolerate a nephrectomy, if necessary, without risking immediate Rj & need for Tx. nephrectomy while balancing the risks of ongoing im/m..Further studies are needed to determine if slower taper of other im/m. ag., such as CNI, can🠋incid. of nephrectomy without untoward S.E. in DX ptn. Patient developing Sm. of allog. Rj é withdrawal, some give 5-7 d., pred.0.3-1.0mg/kg/d.; thenrefere  for surgery. Some nephrologists advocate immediate nephrectomy é even mild Sms of Rj. after im/m. withdrawal.

Q.735.What are the reasons for withdrawal ? 

A.The most compelling reasons to withdraw im/m. medications in DX ptns é failed R.Tx.: [Incresed risk of infection, malignancy & complications ass. é long-term corticosteroid im/m. use]. Infectionis the 2nd leading cause of death in this setting. Another problem: dosing of some im/m. ag. is difficult in R.F.

Q.736.What is the role of HLA matching in graft survival in R.Tx.?

A. HLA system Ag.s:=Mj. barrier to acceptance of R.Tx.. The Mj. impact comes fr. mismatch of  👉 DR Ag.& to a lesser degree,B Ag., élittle effect fr. A Ag.. Each Ag. exerts its effect at different timespost-Tx: maximal effect of DR&B mismatching occ. é 1st6 m.s & two y.s post-x., resp.. Degree of mismatching is ass. é long-term graft survival, though not early Rj.. Long-term survival is best in HLA-identical, esp. living related, kid. & worst in randomly matched cadaver kidney. Despite the importance of HLA-DR matching, some seemingly well-matched kid. are still rejected, wch. reflects the incomplete accuracy of routinely used tissue typing methods. Cold isch. time>36 h. No benefit fr. HLA matching. This’s important since if there were no cold ischemic time effects, a strategy of national allocation & shipping of all kidneys (not just zero mismatches) to 🠋 HLA mismatches wd generate the largest graft survival improvement & cost savings. This longer preservation times & 🠝cold ischemic time negatively affects outcome & costs.


Distribution of HLA Ag.s in U.S. & frequency of deceased donor donation differs é racial groups, thereby affecting organ allocation. Between 1987&1995, black ptn.s received only 6% of fully matched kid.s despite constituting one 1/3rdof the national waiting list. Conversely, 30% of partially or fully mismatched kid. go to black recip., approximating frequency é wch blacks appear on waiting list. To address this relative inequity, the national allocation policy of U.S. ws changed to nolonger give priority points for fewer HLA-B mis-matches. Other histocompatability Ag.s incl. MHC class I-related chain A (MICA) & H-Y Ag. A.B. directed agnst MICA may adversely affect allog. function & survival. Some authors hv therefore recomm. universal testing of R.Tx. ptn. for A.B. post-Tx. & careful monitoring of s. cr. if A.B. are detected. However, such testing is not widely performed. We test for such A.B.s in select ptn.s é unexplained Rj.. Reactivity agnst Y chromosome H-Y encoded gene products: Tx. fr. donor to recip. 🠝risk of Rj. However, role of gene products in R. Tx. is unclear



Hemodialysis,21,My Publications,2,Peritoneal dialysis,14,Prevention of renal failure,61,Renal face,43,Renal Transplantation,49,TOP RECENT,37,
Q.732. What are the complications of withdrawal?kidney transplant complications kidney transplant requirements kidney transplant rejection symptoms ki
Loaded All Posts Not found any posts VIEW ALL Readmore Reply Cancel reply Delete By Home PAGES POSTS View All RECOMMENDED FOR YOU LABEL ARCHIVE SEARCH ALL POSTS Not found any post match with your request Back Home Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sun Mon Tue Wed Thu Fri Sat January February March April May June July August September October November December Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec just now 1 minute ago $$1$$ minutes ago 1 hour ago $$1$$ hours ago Yesterday $$1$$ days ago $$1$$ weeks ago more than 5 weeks ago Followers Follow THIS PREMIUM CONTENT IS LOCKED STEP 1: Share to a social network STEP 2: Click the link on your social network Copy All Code Select All Code All codes were copied to your clipboard Can not copy the codes / texts, please press [CTRL]+[C] (or CMD+C with Mac) to copy Table of Content