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INICI DE DIÀLISI EN PACIENTS ESPECIALS: TRASPLANTAT RENAL

Francesc Moreso

Servei Nefrologia

Hospital Universitari Vall d’Hebron

2 Inici de diàlisi en pacients especials: Trasplantat renal

Guió:

1. Magnitud del problema.

2. Morbi-mortalitat a l’inici de diàlisi.

3. Diferències amb la resta de pacients incidents a diàlisi.

4. Aspectes especials del pacient TR (FAV, empelt, IS i PRA)


Lamb et al. Am J Transplant 2011;11:450-462

PÈRDUA ANNUAL DE L’EMPELT RENAL ALS EEUU (n>250.000)


2010-11 Predicció

NOMBRE DE PACIENTS QUE INICIA DIÀLISI DESPRÉS DE PERDRE UN EMPELT ALS EEUU


MAGNITUD DEL PROBLEMA (RMRC)

13% 3.3%


MODALITAT DE DIÀLISI EN PACIENTS INCIDENTS

141 HD vs. 7 DP (95.3%) 866 HD vs. 125 DP (87.4%)


Guió:




4. Aspectes especials del pacient TR (FAV, empelt i IS)


Gill JS et al. Kidney Int 2007

MORTALITAT EN LLISTA D’ESPERA, TRASPLANTAT O DESPRÉS DE PERDRE UN EMPELT

(EEUU, n=89.202 vs. 47.433 vs. 5.461)




(EEUU, n=89.202 vs. 47.433 vs. 5.461)

11 Inici de diàlisi en pacients especials: Trasplantat renal Perl J et al. Nephrol Dial Transplant 2012


Perl J et al. Nephrol Dial Transplant 2012


FACTORS DE RISC DE MORTALITAT EN DIÀLISI (RMRC)

TR: 2.55 (2.05-3.19) 1.47 (0.48-4.99)


CAUSES DE MORTALITAT EN DIÀLISI I TR (RMRC)


Guió:




4. Aspectes especials del pacient TR (FAV, empelt, IS i PRA)


PACIENT INCIDENTS A DIÀLISI: DE NOVO vs. FRACÀS TR

ASPECTE VARIABLES

URÈMIA Cl Cr + Cl urea /2, Kt/V

MODALITAT HD = DP

ACCES VASCULAR FAVI (no catéter)

ANÈMIA Hemoglobina, metabolisme Fe, Índex resistència AEE

METABOLISME OSSI-MINERAL Fòsfor, PTH-i, 25OH-vitD

MALNUTRICIÓ-INFLAMACIÓ-ATEROSCLEROSI

Albúmina, PCR, factors de risc CV (HTA, DM, DL, obesitat)


TR-CAN: 70 patients. ERCA: 122 patients

PACIENT INCIDENTS A DIÀLISI: DE NOVO vs. FRACÀS TR

Arias M et al. Kidney Int 2002 (S85-S88)


Rosansky S et al. Clin J Am Soc Nephrol 2010


Cooper BA et al. N Eng J Med 2010

Initiating Dialysis Early and Late (IDEAL trial)


Wright S et al. Clin J Am Soc Nephrol 2010

(n = 896.456)


Wright S et al. Clin J Am Soc Nephrol 2010


Rosansky S et al. Clin J Am Soc Nephrol 2010


Perl J et al. Clin J Am Soc Nephrol 2011


Solid CA et al. Kidney Int 2007

n = 210.625

n = 9.922


Lopez-Gomez JM et al. J Am Soc Nephrol 2004

Previous failed Tx Incident ESRD


Lopez-Gomez JM et al. J Am Soc Nephrol 2004


FACTORS DE RISC CARDIOVASCULAR SEGONS MODALITAT DE TRACTAMENT


Guió:




4. Aspectes especials del pacient TR (FAV, empelt, IS, PRA)


Unger P et al. Transplantation 2002


Soleimani MJ et al. IJKD 2012

35 Inici de diàlisi en pacients especials: Trasplantat renal Einollahi B et al. IJKD 2012

Although AVF ligation following kidney transplantation may be

valuable for both cardiac and kidney function, there is no

consensus on routine ligation of fistula. In addition, despite the

controversial findings, many clinicians do not recommend

routine AVF closure for patients with functioning AVFs. In

addition, the risk of graft loss should be considered, as it might

eventually lead to creation of a new vascular access.

Therefore, closure of the AVF should be restricted to those

who definitely meet the criteria including presence of a large

AVF with a high flow, persistent left ventricle dilatation, low

probability of graft loss, cosmetic reasons, and a high risk of

cardiovascular diseases. Because the increase in diastolic

blood pressure after AVF ligation can occur, we strongly

recommend that blood pressure be monitored after AVF

closure.


J Vasc Access. 2012 Jul 16:0. doi: 10.5301/jva.5000086. [Epub ahead of print] Should functioning AV fistulas be ligated after renal transplantation? Yaffe HC, Greenstein SM. Abstract Purpose: There is limited literature available to guide physicians on a course of action when they are approached by renal transplant recipients regarding the status of their vascular accesses. However, this is a frequent topic of discussion with these patients and there should be guidelines available to assist in the decision of whether to maintain or ligate an arteriovenous fistula (AVF) in a successful renal transplant patient. This review intends to present some of the literature, as well as to establish guidelines for management. Methods: The medical literature was reviewed and anecdotal information from our clinical experience was collected. Results: Taking into account 10-year adjusted renal transplant graft survival rates, and the relative paucity of donors, it is possible that a successfully transplanted patient will have to return to dialysis at some point. After review of the literature, the impact of AVF ligation on the transplant patient’s cardiac morphology and function is not clear. Patient and graft survival do not appear to be impacted by persistent AVFs. Emergent closure of the AVF might be required in cases of severe venous hypertension, risk of rupture from pseudoaneurysm, significant high output cardiac failure or ischemic hand. Conclusions: We recommend that following successful renal transplantation, functioning AVFs should almost never be ligated. Many patients require return to dialysis and the physiologic impact of the patent AVF on these patients does not strongly advocate routine ligation following transplant.

http://www.ncbi.nlm.nih.gov/pubmed?term=Augustine%20JJ%5BAuthor%5D&cauthor=true&cauthor_uid=22955228






http://www.ncbi.nlm.nih.gov/pubmed?term=Yaffe%20HC%5BAuthor%5D&cauthor=true&cauthor_uid=22865530



http://www.ncbi.nlm.nih.gov/pubmed?term=Greenstein%20SM%5BAuthor%5D&cauthor=true&cauthor_uid=22865530




Messa P et al. Nephrol Dial Transplant 2008


¿QUÈ FER AMB EL RONYÓ NO FUNCIONANT?

39 Inici de diàlisi en pacients especials: Trasplantat renal Perez-Flores I et al. Nefrología 2009

NEFRECTOMIA vs. EMBOLITZACIÓ DE L’EMPELT RENAL NO FUNCIONANT

40 Inici de diàlisi en pacients especials: Trasplantat renal Messa P et al. Nephrol Dial Transplant 2008


Cubero JJ et al. Nefrología 2009


Del Bello A et al. Clin J Am Soc Nephrol 2012


Goldfarb-Rumyantzev et al. Nephrol Dial Transplant 2005

RE-TRASPLANTAMENT RENAL EN PRE-DIÀLISI


Transplantation. 2012 Oct 15;94(7):738-43. doi: 10.1097/TP.0b013e3182612921.

Independent of nephrectomy, weaning immunosuppression leads to late sensitization after kidney

transplant failure.

Augustine JJ, Woodside KJ, Padiyar A, Sanchez EQ, Hricik DE, Schulak JA.

Abstract

BACKGROUND:

Patients returning to dialysis therapy after renal transplant failure have a high rate of human leukocyte

antigen antibody sensitization, and sensitization has been linked to allograft nephrectomy. We hypothesized

that nephrectomy for cause is a consequence of weaning immunosuppression and that weaning leads to

sensitization even in the absence of nephrectomy.

METHODS:

We examined outcomes in 300 consecutive patients with kidney allograft failure and survival of more than 30

days after failure. We analyzed a subset of 119 patients with a low panel reactive antibody (PRA) before

transplantation and follow-up PRA testing at 6 to 24 months after failure (late PRA).

RESULTS:

By late PRA testing, 56% of patients were highly sensitized (class I or II PRA ≥80%). On multivariate

analysis controlling for human leukocyte antigen matching, allograft nephrectomy, and other variables,

weaning of immunosuppression predicted high sensitization (odds ratio, 14.34; P=0.004). In a subset of

patients, the percentage of those who were highly sensitized increased from 21% at the time of failure on

immunosuppressive therapy to 68% by late PRA after weaning (P<0.001). Conversely, patients who

maintained immunosuppression showed minimal sensitization after failure. Transplant nephrectomy was

required in 41% of patients who weaned immunosuppression versus 0% of the 24 patients who maintained

immunosuppression with calcineurin inhibitor therapy after failure (P<0.001).

CONCLUSIONS:

Weaning immunosuppression was a triggering event leading to late rejection and allograft nephrectomy and

was an independent predictor of alloantibody sensitization after kidney allograft failure.



http://www.ncbi.nlm.nih.gov/pubmed?term=Woodside%20KJ%5BAuthor%5D&cauthor=true&cauthor_uid=22955228

http://www.ncbi.nlm.nih.gov/pubmed?term=Padiyar%20A%5BAuthor%5D&cauthor=true&cauthor_uid=22955228

http://www.ncbi.nlm.nih.gov/pubmed?term=Sanchez%20EQ%5BAuthor%5D&cauthor=true&cauthor_uid=22955228

http://www.ncbi.nlm.nih.gov/pubmed?term=Hricik%20DE%5BAuthor%5D&cauthor=true&cauthor_uid=22955228

http://www.ncbi.nlm.nih.gov/pubmed?term=Schulak%20JA%5BAuthor%5D&cauthor=true&cauthor_uid=22955228


RESUM

1. El 13% dels pacients que inicien diàlisi al nostre país han tingut prèviament un empelt renal que ha fracassat.

2. L’inici de diàlisi s’associa a un augment de mortalitat especialment d’origen infecciós.

3. L’inici de diàlisi així com la tècnica utilitzada (HD vs. DP) ha de ser igual a la dels pacients no trasplantats prèviament, tenint especial cura de disposar d’un accés vascular madur per als que faran HD.

4. El tractament immunosupressor i/o el fet de portar un empelt renal no funcionant s’associen a un estat inflamatori crònic amb més anèmia i major resistència als AEE.

5. El tractament immunosupressor ha de ser retirat en un periode prudencial (< 6 mesos) per evitar les complicacions associades al seu ús (anèmia i infeccions).

6. No està justificada la trasplantectomia sistemàtica. En els casos amb intolerància clínica i/o amb signes d’inflamació crònica (PCR, IRE) que no es controlen amb tractament mèdic cal valorar embolització vs. trasplantectomia.

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