Complications and Risk Factors in Kidney Transplantation
Explore the complexities and risks associated with kidney transplants, including key complications such as infections, bone disorders, diabetes, and more. Understand the importance of managing risk factors for a successful transplant outcome through proper treatment and care.
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Vlnas komplikcijas pc nieres transplant cijas. Kristina Tolo ko.MF-VI
Ievads Vid ja nieres transplant ta dz vildze no miru donora ir 10 gadi , bet no dz va donora 18 gadi Laika period no devi desmitiem gadiem l dz m sdien m vid ja transplant ta dz vilze pieauga par 2 % no miru a donora un par 4% no dz va donora neskatoties uz progresu im nsupres vaj terpij un jaun m irur isk m tehnolo ij m. Nosac ti v l ns p ctransplant cijas periods ir > 12 m ne i p c nieres transplant cijas. http://www.ncbi.nlm.nih.gov/pubmed
Svargkas komplikcijas Sirds un asinsvadu slim ba Infekcijas Audz ji Kaulu slim bas P ctransplant cijas cukura diab ts Hroniska transplant ta nefrop tija Pamatslim bas recid vs vai de novo glomerulonefr ts Hematolo iskas komplik cijas
Sirds un asinsvadu sistmas slimbas Galvenais n ves celonis slimniekiem ar funkcion jo u nieru transplant tu (NT) KSS saslim anas bie ums ir 5-10 x liel ks, nek visp r j popul cij Past v neatkar gie SAS riska faktori : 1)SAS pirms NT transplant cijas 2)CD 3)vecums 4)v riesu dzimums 5 ) seruma holester ns 6) sme ana 7)ak tu atgr anas epizo u skaits
Sirds un asinsvadu sistmas riska faktori slimniekiem ar NT Netradicion lie riska faktori Tradicion lie riska faktori CRO homociste ns Protein rija Antifosfolip du AV Im nsupres vie medikamenti C hepat ts CMV Hiperparatireo disms P ctransplant cijas eritrocitoze Hipertensija Dislipid mija Aptauko an s Sme ana Cukura diab ts An mija transplant ta f-ja R.Rozent ls,I.Folkmane , Nieru transplant cija , Nacion lais apg ds, 2008
Riska faktori SAS pacientiem ar nieru transplantciju Ilgs predial zes periods (ur mija) Imunosupres vie medikamenti Hiperlipid mija Hipertensija Hiperglik mija Hiperparatireodisms A/v kalcifik cija Hroniska transplant ta disfunkcija CD Pre-CD Protein rija Hiperlipid mija p rstr d ts no htpp: //www.renalfellow.blogspot.com
rstana Agres vi rst t hipertensiju Agres vi rst t dislipid miju P rliecin t slimnieku atmest sm anu Svara kontrole Apsvert profilaktisku rst ana ar aspirinu R.Rozent ls,I.Folkmane , Nieru transplant cija , Nacion lais apg ds, 2008
Hipertensija J uztur asinsspiedienu < 130 mm Hg sistolisko un < 80 mm Hg diastolisko , ja pacientam ir 18 gadi rst anai var izmantot jebkuras grupas AH terapijas medikamentus, bet j ievero z u mijedarb ba un blaknes Ja diennakts ur na prote na ekskr cija 1 g / dnn , tad j apsver AKEI un ARB pirmas rindas terapiju American Journal of transplantation , Krigo Clinical practice Guideline for care of kidney transplant recipients, supplement 3 , vol.9 , 2009
American Journal of transplantation , Krigo Clinical practice Guideline for care of kidney transplant recipients, supplement 3 , vol.9 , 2009
Labks un populrkas medikamentu kombncijas Diur ti i + AKEI/ A II RB var pievienot KKB KKB + BAB + diur ti i Vazodilatatori + BAB + diur ti i Ja hipotens va farmakoterapija ir neefekt va un vienlaic gi pasliktin s transplant ta f-ja , j apsver nieres art rijas stenoze Diagnostic : MR angiogr fija, nieres arteriogr fija R.Rozent ls,I.Folkmane , Nieru transplant cija , Nacion lais apg ds, 2008
Angiogrfija , niere artrijas stenoze pirms (a) un pc (b) stenta implant cijas
Dislipidmija ZBLH m r a l menis ir < 100 mg / dL ( 2,5mmol / L) Pacientiem ar CD vai iepriek jo KVS < 70 mg / dL (1,8mmol/ L) [1] Lip du l meni IS medikamenti : sirolimus , ciklospor ns , tacrolimus , prednizolons P t jum ALERT pierad ta fluvastat na efektivit te pacientiem ar NT Grundy S, Cleeman J, Merz CN, Brewer HB Jr, Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines.Circulation 110 :227 239,2004
Dislipidmija (2) Stat nus ar ciklospor nu j lieto piesardz gi , jo tie metaboliz jas caur CYP 3A4 sist mu , var pieaugt stat nu koncentr cija asin s un manifest ties toksicit te Fluvastat ns metaboliz jas caur CYP 2C9 , t dej di tas ir teor tiski dro ks [2] Kombin jot fibr tus kop ar stat niem palielin s mioz ta un rabdomiol zes risks Fibr ti pa i kop ar ciklospor tu palielina kreatin na l meni asin s Kasiske B, Cosio FG, Beto J, Bolton K,et al. A report from the Managing Dyslipidemias in Chronic Kidney Disease Work Group of the National Kidney Foundation Kidney Disease Outcomes Quality Initiative. Am J Transplant 4[ Suppl 7]:13 53,2004
Infekcijas Infekciju bie ums samazin j s no 70 % transplant cijas pirmsakumos l dz 15-45% , transplant cijas pirmsakumos Visbie k pacienti ar NT slimo ar ur nce u infekcij m , kas izskaidrojams ar to , ka recipientam tiek implant ti donora ur nvadi vi a pa a ur np sl , daudziem pacientiem ir CD Daudzi centri profilaktiski noz m TMP/SMX , lai papildus piesegtu ar Pneumocystis carinii, Listeria un Nocardia John R. Silkensen , Long term complications in Renal transplantation, J Am Soc Nephrol 11 : 582-588 , 2000
Vrusu infekcijas Bakteri las infekcijas Oport nistiskas infekcijas Pneimocystis pneumonia (Pneumocystis carinii) Toxoplasmosis (Toxoplasma gondii) Nocardiosis ( Nocardia species ) Aspergillosis ( Aspergillus species ) Listeriosis ( Listera monocytogennes ) Candidiasis ( Candida species) Cryptococcosis(Cryptococc us neoformans)Histoplasmos is(Histoplasma capsulatum)Coccidiomyco sis(Coccidiodes immitis)Blastomycosis ( Blastomyces dermatitidis Hronisks hepat ts (HBV,HCV) Gripa(gripa A un B) P ctransplant cijas limfoproliferat vie trauc jumi (CMV, Ep teina Barra v russ) Kapo i sarkoma ( HHV- 8) Skvamozo nu karcinomas (papillomas v rusi ) Ur nce u infekijas (gram- negat vie organismi) Intraabdomin lais sepsis (gram-negat vie organismi) Celul ts ( gram - pozit vie organismi ) Pneimonija ( gram - pozit vie organismi ) Tuberkuloze(Mycobacter im tuberculosis)
CMV CMV infekcija visbie k sastopama pacientiem ar NT Bez profilaktiskas arst anas simptom tiska CMV infekcija att st s 8 % pacientu Profilaksei rekomend ganciklov ru un valganciklov ru 3 m ne u p c transplant cijas un p c rst anas ar monoklon l m antiviel m , kas ietekm T unas [1] CMV v l nas komplik cijas bie k saist tas ar im nmodul jo m pa b m , sp ju izrais t superinfekciju Kl nika : visbie k drudzis , nogurums , leikop nija ; var manifist ties ar horeoretin tu , pneimon tu un KZT trauc jumiem [2]
Citomegalovruss CMV- Histology Owl's Eye Inclusions (http://www.asm.org/division/c/photo/cmv1.jpg)
HCV/HBV Palielin ts risks saslimt dial zes un asinstransf ziju d 2007.gad Latvij ar HCV vai HBV bija infic ti 24 % NT slimnieku HBV ierobe oj s ar vakcin cijas ievie anu dial zes slimniekiem IS medikamenti v rusa replik ciju un slim bas progresiju HCV ietekme uz transplant tu : 1)ak ta vai hroniska glomerulop tija 2)im nkompleksu-asoci ta glomerulop tija 3)trombotisko mikroangiop tiju
HCV rstanas taktika Pacienti sa em interferonu , ja terapijas ieguvums ir p r ks par atgr anas risku Pacienti ar HCV-asoci to glomerulop tiju nesa em interferonu Katrus 3-6 m ne u j nosaka protein riju ( dnn prote ns , vai proteina/kreaten na attic ba ) Ja ir jauna protein rija , j veic nieru biopsija American Journal of transplantation , Krigo Clinical practice Guideline for care of kidney transplant recipients, supplement 3 , vol.9 , 2009
Citas infekcijas Nopietna probl ma ir tuberkulozes reaktiv cija Ja pacients ir bijis ce ojum , tad j dom par oport nistisk m infekcij m Histoplasma,Coccidioides, un Blastomyces Ierosin t ju izdala no audiem vai uzs j kult ru rst jot infekcijas NT pacientiem, j atcer s ar par pla i izplat tiem ierosin t jiem Noz m jot a/b terapiju , j atcer s par z u mijedarb bu Eritromic ns un citi makrol di inhib CYP450-IIIA, k rezultat ciklospor na koncentr ciju John R. Silkensen , Long term complications in Renal transplantation, J Am Soc Nephrol 11 : 582-588 , 2000
Audzji Audz ju risks ir nek visp r j popul cij , kumulat vas imunsupr sijas d Pierad ta ciklospor na sp ja sekm t audz ja nu aug anu , ietekm jot TGF- Visbie k ir predispoz cija das audz jiem Smag ka audz ju forma ir p ctransplant cijas limfoproliferat vie trauc jumi (PTLT) , bie i saist ti ar EBV induc to B- nu prolifer ciju risks saslit ar Kapo i sarkomu TGF- transform jo ais aug anas faktors -
Raksturgas das izmaias pacientam ar Kapo i sarkomu
rstana un profilakse J bridina pacientus izvar ties no sau o anas un lietot aizsargk mus J veic regul ra individu la audz ju skrininga programma, pacientiem ar HBV un HCV hepat tiem katru gadu j veic USG v dera dobumam un j parbauda feto-prote na l meni Pacientiem, ar malignit ti pal dz imunosupres vas terapijas samazin ana American Journal of transplantation , Krigo Clinical practice Guideline for care of kidney transplant recipients, supplement 3 , vol.9 , 2009
Svargkie rstanas principi NT slimniekiem v l naj period Reduc t im nsupres vo terapiju, kad vien ir iesp jams Izveidot t du rst anas strat iju, lai mazin tu nel dzest bu Regul ri monitor t nieru funkciju Savlaic gi izdar t nieres punkcijas biopsiju,lai diagnostic tu v l nu ak tu tremi Agres vi rst t dislipid miju Agres vi rst t hipertensiju
Svargkie rstanas principi NT slimniekiem v l naj period (2) P rliecin t slimniekus atmest sm anu Regul ri veikt kr u, dzemdes kakla, prostatas, kolorekt l un das audz ju skr ningdiagnostiku Vakcin t slimniekus pret gripu un pneimokoku pneimoniju Apsv rt profilaktisko rst anu ar aspir nu, kalciju, hormonaizvietojo o terapiju R.Rozent ls,I.Folkmane , Nieru transplant cija , Nacion lais apg ds, 2008
