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.
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