Liza A. Lucero MSN, FNP

Renal Medicine Associates

12th Annual Southwest Nephrology Symposium

February 29, 2020

Kidney Transplant:

New Opportunities & Challenges

Disclosure

I have NO disclosure related to this presentation

To ligate or not to ligate AV fistula

Vaccine prevention in kidney transplant

Cannabis abuse post kidney transplantation

To Ligate OR

Not to Ligate? !

CLINICAL TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry URL: https://www.anzctr.org.au. Unique Identifier: ACTRN12613001302741.

Coates et al; Circulation. 2019;139:2809–2818. DOI: 10.1161/CIRCULATIONAHA.118.038505 June 18/25, 2019 2809

Study Findings

The key primary finding was a 15% reduction in LV mass in the AVF

ligation group associated with a decrease in cardiac output. There was

≈20% decrease in LV and atrial sizes and also a reduction in N-terminal

pro–B type natriuretic peptide levels.

Discussion

The hemodynamic effects after AVF creation include decreased peripheral resistance and thus increased cardiac output.

As the AVF increases in size the myocardium may decompensate a leading to CHF

Reestablishment of renal function after kidney transplantation and avoidance of the pronounced intravascular volume shifts occurring during thrice-weekly hemodialysis therapy consistently reduce LVH.

LV regression reaches its nadir at second year post transplant and persists thereafter ( lower CV mortality in Kidney transplant then waiting list )

Study Limitations

Study was not powered to detect differences in CV and survival

outcomes. Whether the decrease in LV mass and reversal of LVH after

AVF closure imparts a protective effect and changes the trajectory of

patient outcomes is still a matter to be resolved.

A risk stratification using surrogate markers such as fistula blood

flow measurements or the fistula site (upper arm Vs. forearm AVF) has

not been applied. Patients with a fistula blood flow >2 L/min or an

upper arm AVF are at increased risk for the development of CHF and

perhaps would benefit more from fistula closure.

Study Limitations

Risk VS benefit of having a functional AFV was not addressed ,

especially in patients who will potentially return to hemodialysis during

their lifetime, was note addressed . No doubt, preservation of the AVF or

a flow reduction procedure may be preferable to fistula closure for

younger patients.

When is the best time to ligate an AVF after successful KT? It may be

that the benefit on CV or even graft outcomes is greater if the fistula is

ligated 3 to 6 months post-KT presuming stable graft function.

Suggestions

Fistula closure should be reserved for stable KT recipients with

A) symptoms of overt cardiac failure or

B ) pulmonary hypertension and

C) access-related complications (mainly aneurysm formation with risk

of rupture, steal syndrome, infection, or high fistula blood flow).

For the rest, an individualized patient-centered approach that

will include patients’ preferences and beliefs is deemed more

appropriate.

Vaccine Prevention in

kidney transplant candidates

Background

Solid organ transplant (SOT) candidates are at risk of developing

infections, with higher attack rates and risks for severe and complicated illness especially after TX, because of preexisting health conditions, lifelong immunosuppression, and increased exposure during frequent visits to the clinics

Prevention of infections through vaccination is the least invasive &

most cost‐effective way to reduce morbidity & mortality in SOT recipients.

Diseases that can potentially be prevented through vaccination include

varicella zoster virus (VZV), measles, influenza, invasive pneumococcal diseases, tetanus, and hepatitis A and B virus infection

Study Aim

To evaluate the need for, &efficacy of,

vaccine catch‐up assessed by vaccine serology before (at

time of listing) and at transplant from Jan1, 2014, to Nov 30, 2015.

Rohner et al, Am J Transplant. 2019;19:512–521

.

Conclusion

Serology is much more important than history ( 25 % reported tetanus but 88 % immune )

Tetanus toxoid provided strong immunity

HBV immunity is low

Catch up immunization resulted in increased immunity to

Hep A & Strep pneumonia but NOT HbV

Cannabis abuse post kidney

transplantation

Lentine et al; Transplantation 2019;103: 2373–2382

Introduction

Cannabis is the most commonly used illicit drug in the USA

3 % of people meet criteria for cannabis abuse despite harm

Cannabis is a schedule 1 substance in the USA, Opioids class 2

Guidance for physicians & patients in kidney transplant is lacking

Study linked SRTR data to Medicare claims of cannabis abuse

Study

52,000 kidney-only transplant recipients from 2007 to 2015

Had Medicare coverage for 1 year before & after transplant

only 0.5% (n = 254) had cannabis abuse in the year before transplant and 0.3% (n = 163) had it in the first-year posttransplant.

Recipients with cannabis abuse were more likely to be young, male, black, and

have lower education and likelihood of employment. This should not be used to

create stereotype or to decrease access to kidney transplant in this already disadvantaged group, but rather to direct education and support services.

Study limitation

The frequency of cannabis abuse in this sample of kidney transplant recipients was

substantially lower than the frequency of cannabis use reported in the general population.

The study was not designed to identify occasional “social” or legally prescribed medical cannabis use, because use without detrimental consequences does not qualify as cannabis abuse.

Coding practices may vary and are not subject to the rigorous data quality assessments that are typically conducted within clinical trials

the available data do not include frequency, duration, dose, or type (recreational versus medical) of cannabis use

The retrospective design can identify associations but not prove causation.

Conclusion

Cannabis is not totally benign .Abuse travels with the psychosocial conditions that we must monitor an support

Seven states joined the organ transplant protection for medical cannabis users, including Arizona, Delaware, Illinois, Minnesota, New Hampshire, California and Washington.

Some suggesting reschedule cannabis to schedule II in order to allow

further research into its therapeutic value ( after all it is LEGAL )

Fistula ligation may be indicated in certain patients

population post kidney transplant.

Catch up vaccination improves the vaccination rate in

CKD patients but for hep B vaccine.

Cannabis dependence appears to have prognostic

implications for allograft & patient out come post Tx.

Thank You

• Thank You to Ehab Saad, MD, FASN, FACP, MA professor of

Medicine & Surgery Kidney & Pancreas Medical Director

Medical College of Wisconsin Division of Nephrology