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Organ transplant
Patient Information
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Transplant Update
April 2006
Issue No.3
The continued success of solid organ transplantations has created a special role for primary care physicians in the overall care of post-transplant patients. As solid organ transplantation enters its sixth decade, and its fifth decade at UK HealthCare, the volume of work required to maintain high standards in patient management becomes an overwhelming task. This task cannot be accomplished without close cooperation between the transplant team at UK HealthCare and the primary care physician in the community. Therefore, the internist or family practitioner will continue to play a crucial role in the long-term care of transplant recipients.
At UK HealthCare, we encourage transplant recipients to return to their home-base three months post-transplant. The expectation is that his or her referring physician will provide general preventive medicine such as physical examinations and vaccinations; cancer surveillance; heart disease and hypertension management; diabetes and renal insufficiency. This system returns a healthier post-transplant patient to the community, provides positive feedback and is significantly more convenient for the patient. The local team possesses expertise in general care while the transplant team continues to monitor the allograft and the immunosuppression indefinitely.
After the three month milestone, patients continue to visit to the transplant center every three months for the first year and yearly thereafter. Our transplant coordinator serves as liaison with primary care physicians and reviews routine follow-up laboratory results of patients. The transplant surgeon on call is directly available 24 hours a day, seven days a week through UK•MDs by calling 859-257-5522 or toll free at 1-800-888-5533.
Post-transplant renal failure has emerged as a major source of morbidity for nonrenal transplant recipients. We have several protocols studying this vexing problem.
Obesity is quite prevalent in our patient population. Indeed, our standards for accepting patients for transplant candidacy are more relaxed than many other centers. It is largely due to the integrated effort of the transplant team and the referring physicians, so we are able to maintain the expected graft and patient survival in these high-risk patients. Pretransplant or post-transplant, you remain an integral part of our transplant care.
Transplantation of nonrenal organs is often complicated by chronic renal disease caused by a number of factors. Calcineurin inhibitor therapy (either cyclosporine or tacrolimus), a key component of immunosuppressive regimens for transplant patients, has been implicated as a principal cause of post-transplant renal dysfunction. There are many contributors to chronic renal failure in recipients of nonrenal organs, including renal disease before transplant; perioperative hemodynamics; the nephrotoxicity of other drugs; dyslipidemia; hypertension and diabetes.
Ojo et al.* reported a 7 percent to 21 percent risk of developing chronic renal dysfunction among nonrenal transplant recipients within five post-transplant years. They noted that liver and small intestine recipients had the highest incidence of chronic renal failure (18 percent and 21 percent respectively at 60 months). Data also showed that diabetes, hypertension, and hepatitis C virus infection were independent factors associated with chronic renal failure, although their prevalence and effect varied according to the type of organ transplanted.
Clearly, the risk of severe chronic kidney disease must be considered with other risks associated with the transplantation procedure, such as opportunistic infections, cancer or bone disease. The predominant cause of these clinicopathological abnormalities is the long-term use of calcineurin inhibitors.
Because calcineurin inhibitors have been the cornerstone of immunosuppressive therapy for the past two decades, their complete elimination from current regimens would require a well-validated basis, and this is not available today for recipients of nonrenal transplant. An alternative strategy involves a reduction in the maintenance dose of calcineurin inhibitors made possible by adding a non-nephrotoxic immunosuppressant, such as mycophenolate mofetil and sirolimus, to the regimen. Such strategies, which currently are being investigated extensively in renal transplantation patients, have resulted in improved renal function, at least in the short term. In addition, short-term results in nonrenal transplant recipients have been promising.
The rate at which chronic kidney disease develops and progresses post-transplantation probably can be reduced with meticulous preoperative and perioperative care; avoidance of drug-induced acute renal failure in the early post-transplant period; optimal long-term control of hypertension and hyperlipidemia as well as the use of ACE inhibitors or angiotensin II receptor blockers in patients with microalbuminuria or proteinuria.
Early referral and immunosuppression reduction or conversion strategies may play an important role in recovering kidney function in these patients. Unfortunately, the lifelong treatment needed to keep these patients healthy and forestall graft rejection often cause complications unto themselves. As more organ transplants are successful and patients who receive them live longer, more medical complications related to transplants surely will be revealed.
Physicians who treat transplant patients must understand the basic mechanisms of the underlying disease that causes the need for transplant and how such a condition should be managed after successful surgery has been accomplished. This understanding will permit proper treatment, allow referral when needed and drive development of new therapeutic strategies to obtain better clinical outcomes.
At UK HealthCare, we have several research protocols with new immune suppressive regimens for renal protection. More detailed information can be obtained by calling (859) 323-6585.
* Ojo AO, Held PJ, Port FK et al, Chronic renal failure after transplantation of a nonrenal organ. N Engl J Med. 2003 Sep 4;349(10):931-40.
Transplant centers have seen an increasing number of obese patients for transplantation. Some surgeons are reluctant to transplant severely obese patients due to higher risk of morbidity such as wound sepsis, respiratory complications, cardiovascular complications and thromboembolic disorders.
An earlier study, compared 46 obese (body mass index [BMI] > 30 kg/m²) and 50 non-obese renal transplant patients and found the following results for obese patients.
• Inferior patient survival rate (89 percent compared to 98 percent).
• One year graft survival rate (66 percent compared to 84 percent).
• Incidence of immediate graft function (38 percent compared to 64 percent).
In addition, when compared with non-obese patients, these obese patients had significantly higher rates of wound complications (20 percent compared to 2 percent), ICU admissions (10 percent compared to 2 percent), ventilator reintubations (16 percent compared to 2 percent) and new-onset diabetes (12 percent compared to zero percent).
Another study compared outcomes of 85 renal transplant patients having a BMI > 30 kg/m² with those of 85 matched patients having a BMI < 27 kg/m². Obese patients showed reduced five year patient and graft survivals (55 percent patient survival, 42 percent graft survival) in contrast to the non-obese controls (90 percent patient survival, 66 percent graft survival).
To address the impact of obesity in transplant recipients, another large study3 analyzed 51,927 patients and found survival was significantly worse in patients with a BMI < 18 kg/m² and in those with a BMI ≥ 28 kg/m². The most important increase in mortality risk was seen among patients with a BMI > 36 kg/m². Pelletier et al4 also found that a BMI of 35 kg/m² was the upper limit above which a survival advantage for transplant was not observed; this finding was similar to the data from the USRDS registry study, which showed that obesity is common in patients undergoing renal transplantation and is significantly associated with higher overall mortality and reduced allograft survival.
Due to the high prevalence, we frequently encounter obesity issues with transplant candidates. We offer comprehensive weight loss counseling, including dieting and exercise, for these patients while maintaining our upper limit of BMI as 35kg/m². Patient’s compliance to weight loss can be positively interpreted as possible good compliance to long-term immune suppression treatment after transplantation.
1. Holley JL, Shapiro R, Lopatin WB, et al. Obesity as a risk factor following cadaveric renal transplantation. Transplantation 1990; 49:387-389.
2. Gill IS, Hodge EE, Novick AC, Steinmuller DR, Garred D. Impact of obesity on renal transplantation. Transplant Proc.1993; 25: 1047–1048.
3. Meier-Kriesche HU, Arndorfer JA, Kaplan B. The impact of body mass index on renal transplant outcomes: a significant independent risk factor for graft failure and patient death. Transplantation. 2002 Jan 15;73(1):70-4.
4. Pelletier SJ, Maraschio MA, Schaubel DE et al, Survival benefit of kidney and liver transplantation for obese patients on the waiting list. Clin Transpl. 2003; 77-88.
Roberto Gedaly, MD, recently joined UK HealthCare. Prior to joining our transplant team, he served as a surgery instructor at the University of Tennessee in Memphis, Tenn. Dr. Gedaly earned his medical degree and completed his general surgery residency from University of Venezuela. He was subsequently trained for transplant surgery and hepatobiliary surgery at New England Deaconess Hospital, Harvard Medical School and University of Miami. He then built a large practice in hepatobiliary surgery before joining the University of Tennessee in 2003. Dr. Gedaly brings extensive experience in hepatobiliary surgery while participating in all activities in abdominal organ transplantation.
Gerald Robertson successfully underwent kidney transplantation from his brother in 2002. Gerald has maintained excellent graft function and health. To our great surprise, he continues to pursue his career as a competitive body builder. In 2005, he won first place at the Bluegrass Muscle Classic, a regional body building contest. Gerald’s surgical scar is barely noticeable on the right side of his lower abdomen. Despite having such a significant and sculpted muscle mass, his creatinine level remains between 1.2 and 1.4. We are thrilled with his resolve and steadfastness in pursuing his interests after transplantation.
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