|Year : 2018 | Volume
| Issue : 6 | Page : 1452-1469
|The National Guard Health Affairs guidelines for the medical management of renal transplant patients
Ziad Arabi1, Abdulrahman Theaby1, Mahfooz Farooqui2, Mubarak Abdalla2, Ali Hajeer3, Khalid Abdullah4
1 Consultant in Renal Transplantation, Adult Transplant Nephrology, Organ Transplant Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
2 Consultant in Nephrology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
3 Professor of Laboratory Medicine and Immunology, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
4 Chairman, Organ Transplant Center and Hepatobiliary Sciences Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Click here for correspondence address and email
|Date of Submission||09-Dec-2017|
|Date of Acceptance||09-Dec-2017|
|Date of Web Publication||27-Dec-2018|
|How to cite this article:|
Arabi Z, Theaby A, Farooqui M, Abdalla M, Hajeer A, Abdullah K. The National Guard Health Affairs guidelines for the medical management of renal transplant patients. Saudi J Kidney Dis Transpl 2018;29:1452-69
|How to cite this URL:|
Arabi Z, Theaby A, Farooqui M, Abdalla M, Hajeer A, Abdullah K. The National Guard Health Affairs guidelines for the medical management of renal transplant patients. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2021 Jan 23];29:1452-69. Available from: https://www.sjkdt.org/text.asp?2018/29/6/1452/248311
| Introduction|| |
There are only few published international guidelines for renal transplant immunosuppression. International guidelines are generally specific to their population and there are no published guidelines in this area in Saudi Arabia. Here, we present the first guidelines for the medical management of renal transplant patients in KSA.
These guidelines were subject to an extensive review according to the most up-to-date international guidelines tighter with experience and literature in Saudi transplant patients.
These guidelines establish the standards for the management of kidney transplants including immunosuppression, infection prophylaxis, surveillance testing, treatment of rejection, ABO incompatible transplantation and desensitization.
The desensitization protocols detailed here for transplantation across incompatible HLA and ABO are presented in a very clear and stepwise approach for desensitization according to the estimated risk.
These guidelines also address several complex and commonly encountered issues such as the management of recipient with gallbladder disease, catheter-induced thrombosis, or supra vena cava obstruction. Antibiotic prophylaxis before dental procedures, intravenous fluid management post renal transplant and the timing of urinary stent removal are also reviewed.
These practical guidelines are designed to be easy to be read, follow, and adopt in the transplant centers.
These guidelines, like any other international guidelines, are based mostly on expert opinion and centers practices and not necessarily supported by well-established evidence from randomized controlled studies.
While these guidelines present personal recommendations from the authors and not endorsed by any formal society or institution, these guidelines present the first step to unify the practices among the transplant centers in KSA. This step is very essential for any future research to evaluate current practices in KSA.
In summary, these guidelines are one of the few internationally published guidelines of renal transplant immunosuppression with specific emphasis for transplant patients managed in KSA.
| Table of Contents|| |
List of abbreviations.........1453
Renal transplant immunosuppression.........1454
Kidney transplant prophylaxis.........1455
At-risk recipients for HBV.........1456
At-risk recipient for TB.........1456
At-risk for Schistosoma.........1456
At-risk for recurrent aHUS.........1457
Treatment of BK viremia.........1458
Treatment of CMV disease.........1458
Treatment of acute rejection.........1459
Cellular mediated rejection (ACR).........1459
Antibody-mediated rejection (AMR).........1459
Intravenous immune globulin administration guideline.........1461
Rituximab administration guideline.........1461
Bortezomib subcutaneous administration guideline.........1462
HLA incompatible kidney transplants.........1462
Risk stratification and desensitization protocol.........1462
Desensitization while on the waiting list of DDKT.........1463
ABO incompatible kidney transplant.........1463
Risk stratification of ABO-incompatible renal transplant.........1463
Desensitization protocol of ABO incompatible renal transplant.........1464
Urinary stent removal.........1466
PD catheter removal.........1466
SVC obstruction (symptomatic or asymptomatic).........1466
Antibiotic prophylaxis before dental procedures.........1466
IVF management post renal transplant.........1466
| List of Abbreviations|| |
AMR: Antibody-mediated rejection
CNI: Calcineurin inhibitors
DDKT: Deceased donor kidney transplant
DGF: Delayed graft function
DSA: Donor-specific antibodies
EBV: Epstein–Barr virus
FFP: Fresh frozen plasma
IVIG: Intravenous immunoglobulin
LATB: Latent tuberculosis infection
LKT: Living donor kidney transplant
MMF: Mycophenolate mofetil
PCR: Polymerase chain reaction
TB: Tuberculosis infection
BKV: BK virus
ACMR: Acute cell-mediated rejection
MFI: Mean fluorescence intensity
PRA: Panel reactive antibody
ACR: Acute cellular rejection
|Figure 1: Management of refractory antibody-mediated rejection.|
Click here to view
|Table 2: Recipient antibody titer and number of required sessions of plasmapheresis.|
Click here to view
|Figure 2: ABO desensitization protocol: Example: Initial Anti A/B IgG isoagglutinin titer 1:32.|
Click here to view
Many thanks to Almarastani, Mohamad; Al Tamimi, Abdulrahman; Kashkoush, Samy, Ohali, Wael Abdulazi; Faisal, Nabiha; Sibai, Abdul Razak; Al Khairy, Omar; Hajeer, Ali; Aloudah, Noura, Al Marshdi Al Otaibi, Nouf; Moaquel, Mohammed.
Conflict of interest: None declared.
This document was designed to aid the qualified health-care team in making clinical decisions about patient care, but it should not be construed as dictating exclusive courses of treatment and/or procedures. No health-care team member should view these documents and their bibliographic references as a final authority on patient care. Variations from these guidelines may be warranted in actual practice based on individual patient characteristics and clinical judgment in unique care circumstances.
| References|| |
The Current Immunosuppression Practice at KAMC.
KDIGO Guideline for the Care of Kidney Transplant Recipients. Am J Transplant 2009;9 (Suppl 3) :S1-155.
Tropey N, Moghal N, Watson E, Talbot D. Handbook of Renal Transplantation. Oxford University Press: New York; 2010.
Kotton CN, Kumar D, Caliendo AM, et al. Updated international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation. Transplantation 2013; 96:333-60.
Razonable RR, Humar A; AST Infectious Diseases Community of Practice. Cytomegalo-virus in solid organ transplantation. Am J Transplant 2013;13 Suppl 4:93-106.
Azevedo LS, Pierrotti LC, Abdala E, et al. Cytomegalovirus infection in transplant recipients. Clinics (Sao Paulo) 2015;70(7):515-23.
Goto N, Futamura K, Okada M, et al. Management of Pneumocystis jirovecii pneumonia in kidney transplantation to prevent further outbreak. Clin Med Insights Circ Respir Pulm Med 2015;9:81-90.
Iriart X, Bouar ML, Kamar N, Berry A. Pneumocystis pneumonia in solid-organ transplant recipients. J Fungi (Basel) 2015;1:293-331.
Huprikar S, Danziger-Isakov L, Ahn J, et al. Solid organ transplantation from hepatitis B virus-positive donors: Consensus guidelines for recipient management. Am J Transplant 2015;15:1162-72.
Hirsch HH, Randhawa P; AST Infectious Diseases Community of Practice. BK polyo-mavirus in solid organ transplantation. Am J Transplant 2013;13 Suppl 4:179-88.
Danziger-Isakov L, Kumar D; AST Infectious Diseases Community of Practice. Vaccination in solid organ transplantation. Am J Transplant 2013;13 Suppl 4:311-7.
Guidelines for vaccination in kidney transplant recipients. Indian J Nephrol 2016;26 Suppl 1: S19.
Kim M, Martin ST, Townsend KR, Gabardi S. Antibody-mediated rejection in kidney transplantation: A review of pathophysiology, diagnosis, and treatment options. Pharmacotherapy 2014;34:733-44.
Kurtin S, Knop CS, Milliron T. Subcutaneous administration of bortezomib: Strategies to reduce injection site reactions. J Adv Pract Oncol 2012;3:406-10.
Bentall A, Cornell LD, Gloor JM, et al. Five-year outcomes in living donor kidney transplants with a positive crossmatch. Am J Transplant 2013;13:76-85.
Keith DS, Vranic GM. Approach to the highly sensitized kidney transplant candidate. Clin J Am Soc Nephrol 2016;11:684-93.
Marfo K, Lu A, Ling M, Akalin E. Desensiti-zation protocols and their outcome. Clin J Am Soc Nephrol 2011;6:922-36.
Tambur AR, Herrera ND, Haarberg KM, et al. Assessing antibody strength: Comparison of MFI, C1q, and titer information. Am J Transplant 2015;15:2421-30.
Schwenger V, Morath C. Immunoadsorption in nephrology and kidney transplantation. Nephrol Dial Transplant 2010;25:2407-13.
Honoré PM, Jacobs R, De Waele E, Van Gorp V, Spapen HD. Immunoadsorption versus therapeutic plasma exchange. Will fibrinogen make the difference? Blood Purif 2014;38:158-9.
Vo AA, Petrozzino J, Yeung K, et al. Efficacy, outcomes, and cost-effectiveness of desensiti-zation using IVIG and rituximab. Transplantation 2013;95:852-8.
Vo AA, Peng A, Toyoda M, et al. Use of intravenous immune globulin and rituximab for desensitization of highly HLA-sensitized patients awaiting kidney transplantation. Transplantation 2010;89:1095-102.
Alachkar N, Lonze BE, Zachary AA, et al. Infusion of high-dose intravenous immuno-globulin fails to lower the strength of human leukocyte antigen antibodies in highly sensitized patients. Transplantation 2012;94:165-71.
Marfo K, Ling M, Bao Y, et al. Lack of effect in desensitization with intravenous immuno-globulin and rituximab in highly sensitized patients. Transplantation 2012;94:345-51.
Kozlowski T, Andreoni K. Limitations of rituximab/IVIg desensitization protocol in kidney transplantation; is this better than a tincture of time? Ann Transplant 2011 ;16:19-25.
Montgomery RA, Locke JE, King KE, et al. ABO incompatible renal transplantation: A paradigm ready for broad implementation. Transplantation 2009;87:1246-55.
Böhmig GA, Farkas AM, Eskandary F, Wekerle T. Strategies to overcome the ABO barrier in kidney transplantation. Nat Rev Nephrol 2015;11:732-47.
Zachary AA, Mongomery RA, Leffell MS. Desensitization protocols improving access and outcome in transplantation. Clin Appl Immunol Rev 2005;5:373-95.
Montgomery RA, Lonze BE, King KE, et al. Desensitization in HLA-incompatible kidney recipients and survival. N
Engl J Med 2011; 365:318-26.
Jackson AM, Kraus ES, Orandi BJ, et al. A closer look at rituximab induction on HLA antibody rebound following HLA-incompa-tible kidney transplantation. Kidney Int 2015; 87:409-16.
Mannu GS, Bettencourt-Silva JH, Gilbert J. The ideal timing of ureteric stent removal in transplantation patients. Transpl Int 2014;27: e96-7.
Parapiboon W, Ingsathit A, Disthabanchong S, et al. Impact of early ureteric stent removal and cost-benefit analysis in kidney transplant recipients: Results of a randomized controlled study. Transplant Proc 2012;44:737-9.
Ali Asgari M, Dadkhah F, Tara SA, et al. Early stent removal after kidney transplantation: Is it possible? Nephrourol Mon 2016;8:e30598.
Sutariya V, Tank A. An audit of laparoscopic cholecystectomy in renal transplant patients. Ann Med Health Sci Res 2014;4:48-50.
] [Full text]
Division of Adult Transplant Nephrology, Department of Organ Transplant Center, King Abdulaziz Medical City, Riyadh
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
| Article Access Statistics|
| Viewed||1545 |
| Printed||9 |
| Emailed||0 |
| PDF Downloaded||248 |
| Comments ||[Add] |