Immunosuppression (IST) Can Be Safely Ceased during Chemotherapy for PTLD in Renal Transplant Patients.

Abstract Aim. The optimal management of IST in renal transplant patients with PTLD is uncertain. As chemotherapy regimens used for PTLD are in themselves immunosuppressive, IST may not be required during this phase of treatment. Subsequent long-term reduction in IST is important to prevent relapse. We examined whether a protocol (instituted in 1994) of ceasing IST during chemotherapy for PTLD and recommencing IST at reduced doses after chemotherapy (calcineurin inhibitor at 50%, prednisolone <6mg daily and no third agent) was associated with deleterious effects on renal graft function. Methods. We performed a retrospective audit of adult renal transplant patients with PTLD requiring chemotherapy who were managed according to this protocol. Outcomes were compared (matched 1 case to 2 controls) to renal transplant patients without PTLD matched for age, gender, diabetes, graft type (cadaveric or live donor) and year of transplant. Matching was performed blinded to outcome. Results. 20 cases were identified: median age at PTLD diagnosis 39yrs; 85% male; 17 late onset PTLD; median time to onset of PTLD post-transplant 110 months (range, 5–276). 18 patients received prior triple combination IST (cyclosporine/tacrolimus plus azathioprine/mycophenolate mofetil plus prednisone). All patients received anthracycline-based chemotherapy with additional therapies of rituximab in 6 and radiation therapy in 4. 85% attained complete remission. 4 patients have relapsed. The 5yr OS was 75% with a median follow-up of 67 months from PTLD diagnosis. 6 cases (30%) had died (5 due to PTLD, 1 unknown) compared to 1 control (2.5%). Of the surviving 14 cases, 2 patients had failed renal allografts at 14 and 19yrs post-transplant and recommenced haemodialysis compared to 18 controls; neither case was retransplanted compared to 8 controls. 2 cases had >25% increment in serum creatinine but not requiring dialysis (assumed secondary to chronic allograft nephropathy) compared to 4 controls. 10 cases had normal functional allografts with no significant decrement in renal function. The cumulative rate of renal allograft failure requiring change of treatment to dialysis at 22yrs post-transplant was 34% vs 63% for cases and controls, respectively (p<0.05). Figure Figure Conclusions. IST can be safely ceased during chemotherapy for PTLD in renal transplant patients and recommenced at reduced doses after chemotherapy, without deleterious effects on renal graft function.

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Reduction of calcineurin inhibitor dosages can stabilise renal graft function in paediatric renal transplant patients,

Inpharma Weekly ◽

10.2165/00128413-200615630-00047 ◽

2006 ◽

Vol &NA; (1563) ◽

pp. 16

Author(s):

&NA;

Keyword(s):

Renal Transplant ◽

Calcineurin Inhibitor ◽

Graft Function ◽

Renal Graft ◽

Transplant Patients ◽

Renal Transplant Patients

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P1616ASSESSMENT OF SEQUENTIAL CHANGES OCCURRING IN THE BODY FLUID COMPOSITION BY BIO-IMPEDANCE ANALYSER IN PRE AND EARLY POST RENAL TRANSPLANT PATIENTS

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p1616 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Lalithambika devi B.N ◽

Sanjay Maitra

Keyword(s):

Renal Transplant ◽

Body Fluid ◽

Graft Function ◽

The Body ◽

Fluid Composition ◽

Transplant Recipients ◽

Post Transplant ◽

Transplant Patients ◽

Renal Transplant Patients ◽

Functioning Kidney

Abstract Background and Aims Chronic kidney disease is now recognized as major causes of death in India. The Global Burden of Disease (GBD) study 2015, ranked chronic kidney disease as 17th among the causes of deaths globally (age standardized annual death rate of 19·2 deaths per 100 000 population). Deaths due to renal failure constituted 2·9% of all deaths in 2010–13 among 15–69 year-olds, an increase of 50% from 2001–03. These are varies metabolic derangements in CKD patients, among which volume overload is the major problem contributing uncontrolled hypertension and increases cardiovascular mortality. There will be increased total body water (TBW) and extracellular water (ECW) at the expense of reduced intracellular water (ICW). Renal replacement therapies such as dialysis or kidney transplantation are the major treatment modalities. Renal transplantation is the treatment of choice for end stage renal failure patients. Despite improving renal dysfunction, patients are at risk for existing or new onset of conditions after transplantation and may alter the body fluid physiology. Till date, renal transplant patients received little attention towards fluid balance and nutritional status. There are many studies supporting the use of bioimpedance analyzer as a reliable tool in assessing the fluid status in haemodialysis patients, but there are very few studies done in post renal transplant patients to know their fluid status with single functioning kidney where Glomerular filtration rate are generally much lower than normal. Method fifty renal transplant recipients were followed in our centre for 6 months (68 males, maximum were in 31-45years of age). Biochemical parameters like haemoglobin, urea, creatinine, electrolytes, albumin, estimated glomerular filtration rate (eGFR); TBW, ECW, ICW and over hydration (OH) measured using bioimpedance analysis (BCM, Fresenius) were evaluated at baseline (pre-transplant) and after transplant at 3 and 6 months. Baseline biochemical and bio-impedance values were compared with 3 and 6 months post transplant. Patients were divided into 3 sub-groups based on eGFR: good graft function (eGFR >60 ml/min), borderline graft function (eGFR 30-60 ml/min) and severe graft dysfunction (eGFR >30 ml/min/1.73m2). TBW, ECW, OH and ICW were compared between the sub groups of eGFR at 3 and 6 months post transplant. Results Comparing before transplant with 3 and 6 months post-transplant, TBW, ECW and OH were reduced while ICW increased significantly with good graft function. On comparing 3 months to 6 months post-transplant, ECW, TBW, OH reduced further but there was not much difference in ICW. OH at 6 months post-transplant was 0.6 L (within normal range of gender-matched individuals from the reference population, that is, −1.1 to 1.1 L). In patients with severe graft dysfunction (<30ml/min), TBW, ECW and OH were remained high when compared to borderline (31-60ml/min) and with good graft function group (>60ml/min). Biochemical improvement was comparable with bio-impedance parameters at 3 months and 6 months post transplant with good graft function. Conclusion The BIA showed significant reduction in TBW, ECW and OH by 6 months post transplant and ICW increased as graft function improved post transplantation by 3 months and thereafter, change was not significant. Parameters of Bio-impedance analyzer of well-functioning kidney transplant recipients showed that the altered body water compartments quickly normalizes which is never achieved by a hemodialysis session. We found that Bio-impedance analyzer was useful to know the changes in body fluid composition in post renal transplant patients.

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Immunosuppression (IST) Can Be Safely Ceased During Chemotherapy For Post-Transplant Lymphoproliferative Disorders (PTLD) In Renal Transplant Patients

Blood ◽

10.1182/blood.v122.21.1780.1780 ◽

2013 ◽

Vol 122 (21) ◽

pp. 1780-1780

Author(s):

Emma Taylor ◽

Mark Jones ◽

Matthew J Hourigan ◽

David W Johnson ◽

Devinder S Gill ◽

...

Keyword(s):

Overall Survival ◽

Renal Transplant ◽

Conflicts Of Interest ◽

Graft Function ◽

Primary Cns Lymphoma ◽

Post Transplant ◽

Transplant Patients ◽

Increased Risk ◽

Renal Transplant Patients

Abstract Introduction The optimal reduction of IST in renal transplant patients with PTLD is uncertain. As chemotherapy used to treat PTLD is inherently immunosuppressive, IST may be able to be stopped during this time without compromising graft function. Subsequent long-term reduction of IST is important to reduce PTLD relapse, but may increase long-term risk of graft rejection. Methods We performed a retrospective matched cohort study of adult renal transplant patients where IST was ceased during chemotherapy and then resumed at lower dose (calcineurin inhibitor at 50%, prednisolone <6mg daily, no third agent). Outcomes were compared to renal transplant patients without PTLD, matched for creatinine at the equivalent time post-transplant that PTLD was diagnosed in the cases, as well as age, gender, year of transplant and age at transplant. The primary endpoint of time to renal deterioration, defined as the time from PTLD diagnosis (cases) or study entry (controls) to a 25% increase in creatinine, was analysed using competing risk survival analyses. Additional endpoints were time to renal allograft failure requiring dialysis or re-transplant and overall survival. Results 24 cases were identified: median age at PTLD diagnosis 45yrs; 75% male; median time to onset of PTLD post-transplant was 9 years. 22 cases received CHOP-like chemotherapy and 2 received primary CNS lymphoma protocols, 7 received concurrent rituximab and 4 had consolidation radiation therapy. 88% attained complete remission. Five patients have relapsed. The 5 yr overall survival for the cases was 71% with a median follow-up of survivors of 11.9 years. The 24 PTLD cases were compared to 84 well matched controls. There were 11 deaths in the cases and 5 in the controls. Three cases recommenced dialysis, compared to 3 controls (HR 2.5, p=0.27). The 5 yr rate of 25% increase in creatinine was 36% in cases and 20% in controls (HR 1.8, p=0.098). Of the 11 cases with ≥25% increase in creatinine, only 1 of these occurred within 6 months of IST cessation in the setting of rapidly progressive PTLD and early death. Only 2 of these 11 cases received rituximab. In contrast 5 of the 7 patients given rituximab did not develop a ≥25% deterioration in renal function. Conclusions IST can be safely ceased during chemotherapy for PTLD in renal transplant patients. Whilst long-term reduction in IST is necessary to reduce PTLD relapse, this is associated with a trend to increased risk of chronic allograft nephropathy. Prospective trials are needed to address the ideal reduction of IST in PTLD. Disclosures: No relevant conflicts of interest to declare.

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