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Kidney medicine and Immunosuppression: Top ten facts for acute/general physicians Richard Smith.

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Presentation on theme: "Kidney medicine and Immunosuppression: Top ten facts for acute/general physicians Richard Smith."— Presentation transcript:

1 Kidney medicine and Immunosuppression: Top ten facts for acute/general physicians Richard Smith

2 IFN-  AAAAAAAGGGHHHH ! IL-2 TNF-  IL-4 CD4 CD8

3 KIDNEYS

4 74 year old male with 12 year history of T2DM presents to casualty unwell with lower abdominal pain. Known to have diverticular disease Most recent HbA1c 7.4% First thoughts? Case 1 Rx Ramipril 5mg daily and Metformin 500mg bd

5 74 year old male with 12 year history of T2DM presents to casualty unwell with lower abdominal pain. Known to have diverticular disease Rx Ramipril 5mg daily and Metformin 500mg bd Pyrexial. BP 130/74. Euvolaemic WCC 10.6x10 9 /l CRP 48ng/ml eGFR 42ml/min with a potassium of 4.2mmol/l Case 1

6 92 year old is seen in clinic having been found by GP to have ‘CKD4’ She is well with an eGFR of 26ml/min Rest of biochemistry is safe, urine reveals neither blood nor protein What do I do? Case 2 USS shows echobright kidneys of 8.2cm and 8.4cm with no evidence of obstruction eGFR was 28ml/min in 2008

7 Fact 1: Make sure patient is safe Fact 2: Direction of travel is everything! Fact 3: Risk factors for AKI include age >65, diabetes and ACEI/ARB Fact 4:Infection is a trigger for AKI in at risk patients even if not involving urinary tract

8 Case 3 A 36 yr old woman who has been previously fit and well and who rarely attends the surgery presents complaining of increased tiredness. She is an active sportswoman who has noticed reduction in exercise tolerance over 3 weeks such that she has struggled on hills when jogging. For 3 days she has had a sore throat, ‘painful’ fingers and noticed a few ‘red spots’ on her right thigh. On examination you confirm that she has a palpable non-blanching purpuric rash on her thigh. BP is 164/90 but examination is otherwise unremarkable. What do I do?

9 Case 3 A 36 yr old woman who has been previously fit and well and who rarely attends the surgery presents complaining of increased tiredness. She is an active sportswoman who has noticed reduction in exercise tolerance over 3 weeks such that she has struggled on hills when jogging. For 3 days she has had a sore throat, ‘painful’ fingers and noticed a few ‘red spots’ on her right thigh. On examination you confirm that she has a palpable non- blanching purpuric rash on her thigh. BP is 164/90 but examination is otherwise unremarkable. What do I do Dipstick of urine revealed blood ++ and protein ++

10 Fact 5: Dipstick of urine is your get out of jail free card. Particularly if hypertension.

11 Is glomerular perfusion threatened ? Any suggestion of intrinsic kidney disease Any suggestion of obstruction Kidney medicine in primary care: 7 minutes

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13 48 yr old man. Routine health check. Found to have eGFR of 35ml/min Referred for investigation of his “CKD 3” No previous eGFR Protein ++++ No haematuria BP 122/74 Case 4

14 78 year old with stable CKD3. Rx Ramipril 5mg daily eGFR June ml/min April ml/min Cares for terminally ill husband therefore deferred R hip replacement What pain killers would you recommend? Case 5 Pharmacist recommended Ibuprofen 400mg daily 4 th July ml/min Stopped Brufen 14 th July ml/min

15 Fact 6: NSAID/COX inhibitors/COX-2 inhibitors X Fact 7: Consider stopping ACEI/ARB Even in patient with stable kidney function if ‘at risk’

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17 NICE Guidance 28 th August 2013 The National Confidential Enquiry into Patient Outcome and Death found that only half of patients with AKI had received 'good' care Up to 30 per cent of cases of AKI can be prevented - that equates to at least 12,000 unnecessary deaths per year Inadequate assessment of risk factors in 24% of patients admitted with AKI Commonest risk factors not assessed were medication, co-morbidity and hypovolaemia

18 Immunosuppression

19 Antibodies CnI: Tacrolimus and ciclosporin Mycophenolate mofetil/Myfortic/Azathioprine Sirolimus

20 BTS Guidelines CnI + Steroid + MMF Less immunogenic CnI + Steroid Marginal donor Steroid + Ab + CnI + MMF CRAN Steroid + MMF Steroid + Rapamycin More immunogenic CnI + Steroid + MMF + Antibody

21 38 year old female simultaneous pancreas kidney transplant recipient of 3 years. Stable graft function Rx Tacrolimus, prednisolone and mycophenolate mofetil Normally well Presented to GP with vesicular rash on left side of chest Case 6

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23 Fact 8: Beware herpes viruses! Good at evading immune system Need T cell responses and antibody responses to clear efficiently

24

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26 Fact 8a: …………. and pneumocystis Fact 9: For transplant patient continuation of immunosuppression critical

27 Perhaps commonest immunosuppressed patient to raise adrenaline levels will be transplant patient Herpes viruses are main issue Varicella strikes fear into my heart! EBV main cause of lymphoma CMV common. Needs to be recognised but not overdiagnosed. Also pneumocystis. Soft story of breathlessness. No pyrexia. No signs. Desaturate on exercise.

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