Special Issue: KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients

Abstract

Journal compilation © 2009 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/j.1600-6143.2009.02834.x S2 American Journal of Transplantation 2009; 9 (Suppl 3): S2-S2Since the first successful kidney transplantation in 1954 It is our hope that this document will serve several useful purposes. Our primary goal is to improve patient care. We hope to accomplish this in the short term by helping clinicians know and better understand the evidence (or lack of evidence) that determines current practice. By making this guideline broadly applicable, our purpose is to also encourage and enable the establishment and development of transplant programs worldwide. Finally, by providing comprehensive evidence-based recommendations, this guideline will also help define areas where evidence is lacking and research is needed. Helping to define a research agenda is an often neglected, but very important function of clinical practice guideline development.We used the GRADE system to rate the strength of evidence and the strength of recommendations. In all, there were only 4 (2%) recommendations in this guideline for which the overall quality of evidence was graded 'A,' whereas 27 (13.6%) were graded 'B,' 77 (38.9%) were graded 'C,' and 90 (45.5%) ' and 148 (74.7%) graded '2.' There were 3 (1.5%) recommendations graded '1A,' 16 (8.1%) were '1B,' 18 (9.1%) were '1C, ' and 13 (6.6%) were '1D.' There was 1 (0.5%) graded '2A,' 11 (5.6%) were '2B,' 59 (29.8%) were '2C, ' and 77 (38.9%) BackgroundExcept perhaps for transplantation between identical twins, all kidney transplant recipients (KTRs) need immunosuppressive medications to prevent rejection. Induction therapy is treatment with a biologic agent, either a lymphocyte-depleting agent or an interleukin 2 receptor antagonist (IL2-RA), begun before, at the time of, or immediately after transplantation. The purpose of induction therapy is to deplete or modulate T-cell responses at the time of antigen presentation. Induction therapy is intended to improve the efficacy of immunosuppression by reducing acute rejection, or by allowing a reduction of other components of the regimen, such as calcineurin inhibitors (CNIs) or corticosteroids. Available lymphocytedepleting agents include antithymocyte globulin (ATG), antilymphocyte globulin (ALG) and monomurab-CD3. Basiliximab and daclizumab, the two IL2-RAs that are currently available in many parts of the world, bind the CD25 antigen (interleukin-2 [IL2] receptor a-chain) at the surface of activated T-lymphocytes and thereby competitively inhibit IL2-mediated lymphocyte activation, a crucial phase in cellular immune response of allograft rejection. Rationale• There is high-quality evidence that the benefits of IL2-RA vs. no IL2-RA (or placebo) outweigh harm in a broad range of KTRs with variable immunological risk and concomitant immunosuppressive medication regimens.• There is moderate-quality evidence that a lymphocytedepleting agent vs. no lymphocyte-depleting a...

Immunosuppressive therapy for kidney transplantation in children and adolescents: systematic review and economic evaluation

“…188 Kidney transplantation appears to result in a significant increase in the incidence of diabetes mellitus in the first year post transplant (and especially in the first 6 months), after which incidence falls to similar levels to those seen in people on dialysis (see figure 2 of Woodward et al 188 ). TAC has been repeatedly associated with the development of NODAT 5,178 and the same incidence pattern is observed of significantly elevated incidence in the first year post transplant. Pre-existing diabetes mellitus in the cohort was not modelled, only NODAT within 12 months.…”

“…Acute kidney rejection occurs when the immune response of the graft recipient attempts to destroy the graft as the graft is deemed foreign tissue. 5 Therefore, immunosuppressive therapy is implemented to reduce the risk of kidney rejection and prolong survival of the graft. Prior to renal transplantation, growth retardation in children and adolescents with CKD may already be an issue owing to a combination of inadequate nutritional intake, acidosis, renal osteodystrophy and alterations to the growth hormone insulin-like growth factor.…”

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“…We evaluated anti-GBM antibodies before transplant in these 2 patients, as it is optimal to delay RT until anti-GBM antibodies are undetectable in the serum for 12 months and the disease has been in remission for at least 6 months without the use of cytotoxic agents. 19 Recurrent Goodpasture syndrome after RT is rare, but it can occur at any time and should be considered when late graft dysfunction is present. 20 Reportedly, many patients develop linear IgG deposits along the glomeruli of the renal allograft, but this development does not cause histologic or functional damage to the graft.…”

Induction Immunosuppressive Therapy in Kidney Transplantation

“…The Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines recommend induction therapy with a biologic agent as part of the initial immunosuppressive regimen in kidney transplant recipients (grade 1A recommendation). 75 In addition, these guidelines recommend that an IL-2R antagonist be used as first-line induction therapy (grade 1B recommendation) and suggest the use a lymphocytedepleting agent and not an IL-2R antagonist for recipients that have high immunologic risk (grade 2B recommendation). 75 Many centers hesitate to use potent induction therapy because of the risks of infection or malignancy and unavailability of long-term data about graft survival.…”

“…75 In addition, these guidelines recommend that an IL-2R antagonist be used as first-line induction therapy (grade 1B recommendation) and suggest the use a lymphocytedepleting agent and not an IL-2R antagonist for recipients that have high immunologic risk (grade 2B recommendation). 75 Many centers hesitate to use potent induction therapy because of the risks of infection or malignancy and unavailability of long-term data about graft survival. The choice of induction agent is controversial.…”