Abstract

Managing kidney transplant patients in an acute medical unit can be challenging, as patients have a single functioning kidney, underlying chronic kidney disease, and are immunosuppressed. Transplant patients develop AKI for all usual reasons but the differential diagnosis is wider and includes specific problems, such as obstruction of a single functioning kidney, vascular thrombosis, rejection, drug toxicity and drug-induced thrombotic microangiopathy. Septic AKI is common but again, the differential diagnosis of sepsis is wider. Transplant patients are at higher risk of developing both community and opportunistic infections, especially in the first year after the transplant or after any increase in immunosuppressive medication. In addition, there is always a risk of rejection, especially in case of reduction of immunosuppressive medications. Therefore, any change in the immunosuppressive therapy should to be discussed with the transplant team to achieve an appropriate balance between avoiding rejection and preventing opportunistic infections.

[download-attachments container="div" style="list" display_icon="1" display_count="1" display__size="0"]

References

1. Darmon M, Ostermann M, Cerda J, Dimopoulos MA, Forni L, Hoste E, et al. Diagnostic work-up and specific causes of acute kidney injury. Intensive Care Med. 2017;43(6):829-40.
2. Ostermann M, Joannidis M. Acute kidney injury 2016: diagnosis and diagnostic workup. Crit Care. 2016;20(1):299.
3. Fishman JA. Introduction: infection in solid organ transplant recipients. Am J Transplant. 2009;9 Suppl 4:S3-6.
4. Parasuraman R, Julian K. Urinary tract infections in solid organ transplantation. Am J Transplant. 2013;13 Suppl 4:327-36.
5. Kotagiri P, Chembolli D, Ryan J, Hughes PD, Toussaint ND. Urinary Tract Infections in the First Year Post-Kidney Transplantation: Potential Benefits of Treating Asymptomatic Bacteriuria. Transplant Proc. 2017;49(9):2070-5.
6. Britt NS, Hagopian JC, Brennan DC, Pottebaum AA, Santos CAQ, Gharabagi A, et al. Effects of recurrent urinary tract infections on graft and patient outcomes after kidney transplantation. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal
   Association. 2017;32(10):1758-66.
7. Rice JC, Safdar N. Urinary tract infections in solid organ transplant recipients. Am J Transplant. 2009;9 Suppl 4:S267-72.
8. Sawinski D, Trofe-Clark J, Leas B, Uhl S, Tuteja S, Kaczmarek JL, French B, Umscheid CA. Calcineurin Inhibitor Minimization, Conversion, Withdrawal, and Avoidance Strategies in Renal Transplantation: A Systematic Review and Meta-Analysis. Am J Transplant. 2016 Jul;16(7):2117-38.
9. Shihab F, Christians U, Smith L, Wellen JR, Kaplan B. Focus on mTOR inhibitors and tacrolimus in renal transplantation: pharmacokinetics, exposure-response relationships, and clinical outcomes. Transpl Immunol. 2014 Jun;31(1):22-32.
10. Venkataramanan R, Swaminathan A, Prasad T, Jain A, Zuckerman S, Warty V, McMichael J, Lever J, Burckart G, Starzl T. Clinical pharmacokinetics of tacrolimus. Clin Pharmacokinet. 1995 Dec;29(6):404-30.
11. Pennington CA, Park JM. Sublingual tacrolimus as an alternative to oral administration for solid organ transplant recipients. Am J Health Syst Pharm. 2015 Feb 15;72(4):277-84
12. Lake KD, Canafax DM. Important interactions of drugs with immunosuppressive agents used in transplant recipients. J Antimicrob Chemother. 1995 Oct;36 Suppl B:11-22.
13. Seifeldin R. Drug interactions in transplantation. Clin Ther. 1995 Nov-Dec;17(6):1043-61.
14. Bullingham RE, Nicholls AJ, Kamm BR. Clinical pharmacokinetics of mycophenolate mofetil. Clin Pharmacokinet. 1998 Jun;34(6):429-55.
15. Mele TS, Halloran PF. The use of mycophenolate mofetil in transplant recipients. Immunopharmacology. 2000 May;47(2-3):215- 45.