The National Guard Health Affairs guidelines for the medical management of renal transplant patients

Ziad Arabi; Abdulrahman Theaby; Mahfooz Farooqui; Mubarak Abdalla; Ali Hajeer; Khalid Abdullah

doi:10.4103/1319-2442.248311

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SPECIAL ARTICLE

Year : 2018 | Volume : 29 | 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

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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

Surveillance testing.........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

Vaccinations.........1459

Treatment of acute rejection.........1459

Cellular mediated rejection (ACR).........1459

Antibody-mediated rejection (AMR).........1459

Alternative medications.........1460

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.........1463

DSA monitoring.........1463

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

Gallbladder disease.........1466

Catheter-induced thrombosis.........1466

SVC obstruction (symptomatic or asymptomatic).........1466

Antibiotic prophylaxis before dental procedures.........1466

IVF management post renal transplant.........1466

Acknowledgment.........1467

References.........1467

List of Abbreviations

AMR: Antibody-mediated rejection

CMV: Cytomegalovirus

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

PCN: Penicillin

PCR: Polymerase chain reaction

TB: Tuberculosis infection

BKV: BK virus

ACMR: Acute cell-mediated rejection

MFI: Mean fluorescence intensity

D: Donor

FK: Tacrolimus

PRA: Panel reactive antibody

ACR: Acute cellular rejection

PP: Plasmapheresis

R: Recipient

[Figure 1]

Figure 1: Management of refractory antibody-mediated rejection.
References: 1,3,25,26

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[Table 1]

Table 1: Recipient antibody titer testing table.

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[Table 2]

Table 2: Recipient antibody titer and number of required sessions of plasmapheresis.

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[Table 3]

Table 3: Compatible recipient and donor fresh frozen plasma.

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[Figure 2]

Figure 2: ABO desensitization protocol: Example: Initial Anti A/B IgG isoagglutinin titer 1:32.
References: 1,4,31,36,37,43-45

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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.

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Correspondence Address:
Ziad Arabi
Division of Adult Transplant Nephrology, Department of Organ Transplant Center, King Abdulaziz Medical City, Riyadh
Saudi Arabia