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

Richard Smith

IFN-g

AAAAAAAGGGHHHH !

IL-2

TNF-aIL-4

CD4

CD8

KIDNEYS

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

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 10.6x109/l CRP 48ng/ml

eGFR 42ml/min with a potassium of 4.2mmol/l

Case 1

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

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

involvingurinary tract

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?

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 ++

Fact 5: Dipstick of urine is your get out of jail free card.

Particularly if hypertension.

Is glomerular perfusion threatened ?

Any suggestion of intrinsic kidney disease

Any suggestion of obstruction

Kidney medicine in primary care: 7 minutes

48 yr old man. Routine health check. Found to have eGFR of 35ml/minReferred for investigation of his “CKD 3”

No previous eGFRProtein ++++ No haematuriaBP 122/74

Case 4

78 year old with stable CKD3. Rx Ramipril 5mg daily

eGFR June 2011 47ml/min April 2014 41ml/min

Cares for terminally ill husband therefore deferred R hip replacement

What pain killers would you recommend?

Case 5

Pharmacist recommended Ibuprofen 400mg daily

4th July 2014 16ml/min

Stopped Brufen

14th July 2014 39ml/min

Fact 6: NSAID/COX inhibitors/COX-2 inhibitorsXFact 7: Consider stopping ACEI/ARB

Even in patient with stable kidney function if ‘at risk’

NICE Guidance 28th 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

Immunosuppression

Antibodies

CnI: Tacrolimus and ciclosporin

Mycophenolate mofetil/Myfortic/Azathioprine

Sirolimus

BTS Guidelines

CnI + Steroid + MMF

Less immunogenicCnI + Steroid

Marginal donorSteroid + Ab + CnI + MMF

CRANSteroid + MMFSteroid + Rapamycin

More immunogenicCnI + Steroid + MMF + Antibody

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

Fact 8: Beware herpes viruses!

Good at evading immune system

Need T cell responses and antibody responses to clear efficiently

Fact 8a: …………. and pneumocystis

Fact 9: For transplant patient continuation of immunosuppression critical

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.