What medications should be held in a kidney transplant patient with sepsis (Systemic Inflammatory Response Syndrome) and impaired renal function?

From the Guidelines

In kidney transplant patients with sepsis, it is crucial to hold or adjust several medications to prevent further kidney injury and drug toxicity, with a primary focus on minimizing morbidity, mortality, and optimizing quality of life. When managing kidney transplant patients with sepsis, the goal is to balance the need for immunosuppression with the risk of exacerbating the infection or causing further kidney damage.

• Calcineurin inhibitors (tacrolimus, cyclosporine) should typically be held or dose-reduced as they can worsen kidney function during acute illness 1.
• Mycophenolate mofetil (CellCept) should be temporarily discontinued due to its immunosuppressive effects that may impair the body's ability to fight infection.
• Mammalian target of rapamycin (mTOR) inhibitors like sirolimus and everolimus should also be held as they can delay wound healing and exacerbate cytopenias.
• Nephrotoxic antibiotics such as aminoglycosides (gentamicin, tobramycin) and vancomycin require careful monitoring or avoidance if possible.
• ACE inhibitors and ARBs should be suspended as they can reduce glomerular filtration rate during hemodynamic instability.
• NSAIDs should be strictly avoided due to their nephrotoxic potential, as recommended by the KDIGO clinical practice guideline for the care of kidney transplant recipients 1.
• Metformin should be held due to the risk of lactic acidosis in the setting of acute kidney injury. The decision to hold these medications should be made in consultation with the transplant team, and drug levels should be monitored closely when medications are reintroduced after the sepsis resolves. Maintaining adequate hydration and blood pressure is crucial during this period to support kidney perfusion. It is essential to prioritize the patient's overall clinical condition and adjust the management plan accordingly, considering the potential benefits and risks of each medication, as suggested by the most recent study on the failing kidney allograft 1.

From the Research

Medications to Hold in Kidney Transplant Patients with Sepsis

• The decision to hold certain medications in kidney transplant patients with sepsis should be based on the individual patient's condition and the potential risks and benefits of each medication 2.
• Immunosuppressive medications, such as tacrolimus and cyclosporine, may need to be adjusted or held in patients with sepsis to prevent further immunosuppression and increase the risk of infection 3, 4.
• However, holding these medications can also increase the risk of rejection, and the decision to do so should be made on a case-by-case basis 3, 4.
• Other medications, such as azathioprine and mycophenolate mofetil, may also need to be adjusted or held in patients with sepsis due to their immunosuppressive effects 2.
• The use of corticosteroids, such as prednisolone, may need to be carefully considered in patients with sepsis, as they can have both immunosuppressive and anti-inflammatory effects 2.

Considerations for Medication Management

• The management of immunosuppressive medications in kidney transplant patients with sepsis requires careful consideration of the potential risks and benefits of each medication 2.
• The decision to hold or adjust immunosuppressive medications should be based on the individual patient's condition, including the severity of sepsis and the risk of rejection 3, 4.
• Close monitoring of the patient's condition and adjustment of medications as needed is crucial to prevent complications and ensure the best possible outcome 2.
• The potential for drug-drug interactions should also be considered when managing immunosuppressive medications in patients with sepsis 2.