What are the management strategies for renal auto transplant?

Management Strategies for Renal Autotransplantation

Renal autotransplantation should be managed with a combination of immunosuppressive medications including a calcineurin inhibitor (preferably tacrolimus) and an antiproliferative agent (preferably mycophenolate mofetil), with or without corticosteroids, following standard kidney transplant immunosuppression protocols. 1

Perioperative Management

Surgical Considerations

• Renal autotransplantation is indicated for:

  • Complex renovascular disease (fibromuscular dysplasia, atherosclerosis)
  • Ureteral strictures or trauma
  • Upper urinary tract malignancies
  • Loin-pain hematuria syndrome
  • Complex renal stone disease (rare) 2

• Surgical approach options:

  • Traditional open nephrectomy and transplantation
  • Robot-assisted laparoscopic renal autotransplantation (showing improved perioperative outcomes) 2
  • Nephrectomy should be hand-operated laparoscopic rather than open when possible 1

• Technical considerations:

  • Cold ischemia time should be minimized (longer cold ischemia time is associated with higher complication rates) 3
  • Kidney should be perfused with cold preservation solution during bench surgery 4
  • Vascular anastomosis typically to iliac vessels 5

Immunosuppression Protocol

Induction Therapy

• Start immunosuppressive medications before or at the time of kidney transplantation 1
• Include induction therapy with a biologic agent:
  • IL2-receptor antagonist as first-line induction therapy
  • Consider lymphocyte-depleting agent for high immunologic risk patients 1

Initial Maintenance Therapy

• Use a combination of:

  • Calcineurin inhibitor (CNI): Tacrolimus preferred over cyclosporine 1
  • Antiproliferative agent: Mycophenolate mofetil preferred over azathioprine 1
  • With or without corticosteroids 1

• Tacrolimus dosing:

  • Monitor trough levels (C0) every other day during immediate post-operative period
  • Target trough levels: 7-20 ng/mL during first 3 months, then 5-15 ng/mL through first year 6
  • Adjust dose whenever there is a change in medication or patient status 1

Long-term Maintenance

• Use lowest planned doses of maintenance immunosuppressive medications by 2-4 months post-transplant if no rejection has occurred 1
• Continue CNIs rather than withdrawing them 1
• If prednisone is used beyond the first week, continue rather than withdraw 1

Post-Transplant Monitoring

Graft Function Monitoring

• Monitor serum creatinine and estimated GFR regularly
• Measure CNI blood levels:
  • Every other day during immediate post-operative period until target levels reached
  • Whenever there's a change in medication or patient status
  • When there's a decline in kidney function 1

Complication Surveillance

• Monitor for common complications:
  • Vascular thrombosis (most common cause of early graft loss) 7
  • Urine leaks
  • Infection
  • Hypertension 5

Special Considerations

Medication Adjustments

• mTOR inhibitors (if used) should not be started until graft function is established and surgical wounds are healed 1
• For patients with failing autografts:
  • Maintain CNI in low therapeutic range
  • Consider reduction in antiproliferative agent by 50% if complications develop 1

Cost Considerations

• If drug costs are prohibitive, consider strategies to reduce expenses:
  • Using ketoconazole to minimize CNI dose
  • Using a nondihydropyridine calcium channel blocker to minimize CNI dose
  • Using azathioprine rather than mycophenolate
  • Using adequately tested bioequivalent generic drugs 1

Outcomes and Prognosis

• Renal autotransplantation has high success rates with:
  • Low mortality (4%)
  • Low graft loss rate (3.6%) 7
  • Stable long-term renal function in most patients
  • Improvement in hypertension control in renovascular disease cases 5

Pitfalls and Caveats

• Avoid using generic compounds that have not been certified by an independent regulatory agency 1
• Inform patient and clinician of any change in prescribed immunosuppressive drug, including change to a generic drug 1
• After switching to a generic medication, monitor levels frequently until stable therapeutic target is achieved 1
• Be vigilant for signs of graft intolerance syndrome in failing grafts 1
• Recognize that pain recurrence occurs in approximately 35% of patients who undergo autotransplantation for chronic kidney pain 3

Renal autotransplantation, while uncommon, remains an important surgical option for select patients with complex renal conditions. Following established kidney transplant immunosuppression protocols provides the best outcomes for preserving graft function and patient quality of life.