1. Long Term Complications in Renal Transplantation SALEH A.A BINSALEH

2. DATABASE Renal transplantation is the preferred modality for renal replacement in end- stage renal disease In U.S >12000 kidney transplant were performed in 1998, and the waiting list for transplantation increased from 13000 in 1988 to 43000 in 1999

3. FACTS The field of transplantation was advanced by the introduction of cyclosporine in the early 1980s, and this agent remains the mainstay of immunosuppresion at most centers This agent and others,have lowered the incidence of acute rejection, and has improved long term survival of both the graft and the host

4. FACT (cont.) This improved survival rate also associated with medical complications that impair the quality of life of the transplant recipient Long term complications of renal transplant is defined by those occurring more than 3 months from the time of surgery.

5. L.T.Cs INFECTIONS MALIGNANCY BONE DISEASE CARDIOVASCULAR DISEASE,HYPERTENTION POST TRANSPLANT D.M CATARACT POST TRANSPLANT ERYTHROCYTOSIS CHRONIC REJECTION

6. L.T.Cs INFECTIONS MALIGNANCY BONE DISEASE CARDIOVASCULAR DISEASE,HYPERTENTION POST TRANSPLANT D.M CATARACT POST TRANSPLANT ERYTHROCYTOSIS CHRONIC REJECTION

7. INFECTIONS One of the most important medical complications of transplantation of all types The incidence has dropped from 70% in the early days of renal transplantation to 15 – 44% recently Mortality due to infection ranged from 11 to 40% in the former to less than 5% in the later. These improvement attributed to many factors? When prescribing antibiotics, it is important to be aware of the drug interactions that may result with other immunosuppresives Example?

8. UTI The most common infection in the host Incidence of more than 30% in the first 3 months post transplant Clinical presentation variable from asymptomatic bacteruria to pyuria to pylonephritis and septicemia. Many centers encourage the use of septrin as prophylaxis against UTI,as well as PCP,Listeria,and Nocardia.

9. CMV One of the most common infections in renal transplant pts.,with incidence of 34 – 55 % Onset between1 – 4 months post TX Transmission can occur through transplantation of an infected organ or through blood products transfusion from a seropositive donor The commonest clinical presentation is: fever,malaise,leukopenia,chorioretinitis, pneumonitis,diarrhea.

10. CMV (cont.) Many centers now use oral Gancyclovir as prophylaxis of recipients of seropositive donor kidneys. Other newly introduced prodrug is Valacyclovir (a prodrug of Acyclovir ) which showed effectiveness in the prevention of CMV disease compared to placebo,as well as reduction in the number of acute rejection episodes.

11. EBV Plays a central role in the development of post transplant lymphoproliferative disorder (PTLD) Milder form of the disease include a mononucleosis syndrome,consisting of fever,malaise,leukopenia,atypical lymphocytosis. Gold standard prophylaxis and treatment is by Acyclovir.

12. Herpes Simplex Virus Usually reactivation infection Frequently seen in transplant recipient during the first months. Incidence reduced with Acyclovir prophylactic use. Gancyclovir also has activity against herpetic lesions.

13. VZV Cause reactivation infection. Manifested by zoster lesions in a localized dermatomal pattern. Primary disease in seronegative host exposed to VZV can be life threatening,with pneumonia,encephalitis,hepatitis,and DIC. Rx by varecella zoster IG early in the disease course.

14. T.B. Either primary infection or reactivation of quiescent one Many centers give INH for prophylaxis for 6 – 12 months in pts with +ve PPD

15. Viral Hepatitis The major cause of liver disease in the renal transplant pts,mainly HBV+HCV. With the use of immunosuppressives, 50% of transplanted carriers will develop end-stage liver disease or hepatocellular cancer within 10 years. Vaccination prior to Tx is advocated for individuals without antibodies to HbsAg

16. V.H (cont.) HBV accounts for only a small fraction of renal transplant pts with chronic liver disease,in contrast,HCV accounts for all of the 10-15% of transplant pts who develop chronic liver disease. Treatment with interferon-alpha has been disappointing,and allograft rejection is a major concern.

17. OTHERS Common cold,influenza,pneumococcal pneumonia,STD,diarrheal syndromes. Parasitic diseases: Toxoplasma Fungal diseases: Candida

18. Recommendations All prospective transplant pts should receive vaccinations against hepatitis A and B,tetanus,diphtheria, and pneumococcal disease.

19. Thank you