What should I do for a kidney transplant patient with impaired renal function and elevated creatinine, who has been lost to follow-up for 2 years but continues to take immunosuppressants?

Management of a Kidney Transplant Patient with Elevated Creatinine After Loss to Follow-up

A kidney transplant patient with a creatinine of 7 mg/dL who has been lost to follow-up for 2 years but continues taking immunosuppressants requires immediate hospitalization, comprehensive evaluation of graft function, and urgent nephrology consultation to determine the cause of allograft dysfunction and implement appropriate management strategies. 1

Initial Assessment and Management

• Immediately hospitalize the patient for comprehensive evaluation of the failing allograft and to determine the cause of the severely elevated creatinine 1
• Obtain urgent nephrology consultation, preferably with a transplant nephrologist, to guide management 1
• Perform a comprehensive metabolic panel including electrolytes, BUN, creatinine, and calculate estimated GFR using appropriate equations 1
• Assess for uremic symptoms and complications of advanced kidney disease that may require immediate intervention 2
• Evaluate for signs of graft intolerance syndrome (fever, pain over graft site, hematuria, tenderness) 1
• Review current immunosuppressive regimen and medication adherence 1

Diagnostic Workup

• Obtain urinalysis and urine protein-to-creatinine ratio to assess for proteinuria and hematuria 2, 3
• Perform ultrasound of the transplanted kidney to evaluate for hydronephrosis, vascular complications, or other structural abnormalities 1
• Consider transplant kidney biopsy to determine the cause of allograft dysfunction (rejection, recurrent disease, CNI toxicity, etc.) 1
• Check donor-specific antibody (DSA) levels to assess for antibody-mediated rejection 1
• Evaluate for infections that may be contributing to allograft dysfunction 1, 4

Management Strategy

For Salvageable Graft Function:

• Optimize immunosuppression based on biopsy findings and clinical status 1
• If rejection is present, consider pulse steroids and adjustment of maintenance immunosuppression 1, 4
• Manage complications of CKD including anemia, metabolic acidosis, hyperphosphatemia, and secondary hyperparathyroidism 2
• Optimize blood pressure control and consider ACE inhibitors or ARBs if proteinuria is present 2, 3

If Graft Failure is Confirmed:

• Prepare for transition to renal replacement therapy (dialysis) if not already required 1

• Develop a plan for immunosuppression tapering based on:

  • Candidacy for re-transplantation 1
  • Residual kidney allograft function 1
  • Risk of complications from overimmunosuppression 1

• For patients who are candidates for re-transplantation:

  • Maintain calcineurin inhibitors (CNIs) at low therapeutic levels 1
  • Reduce mycophenolate mofetil (MMF) by 50% 1
  • Continue low-dose prednisone 1
  • Monitor for graft intolerance syndrome 1

• For patients who are not candidates for re-transplantation:

  • Follow a more aggressive immunosuppression tapering schedule 1
  • Stop anti-metabolites (MMF) first 1
  • Reduce CNI by 50% after 3-6 months 1
  • Gradually taper prednisone to minimal effective dose 1

Long-term Planning

• Refer for re-transplantation evaluation if the patient is a suitable candidate 1
• Establish baseline panel reactive antibody (PRA) value to assess sensitization 1
• Arrange for vascular access creation if dialysis is needed 1
• Establish a shared-care model between transplant center and general nephrology 1
• Monitor for complications of immunosuppression including infections and malignancies 4, 5

Common Pitfalls and Caveats

• Avoid abrupt discontinuation of immunosuppression, which can precipitate acute rejection or graft intolerance syndrome 1
• Do not assume that elevated creatinine is solely due to chronic rejection; other causes such as recurrent disease, medication non-adherence, or CNI toxicity should be considered 1
• Recognize that some patients may recover renal function even after prolonged periods of severe dysfunction or dialysis dependence 6
• Be aware that the decision to continue or withdraw immunosuppression should balance the risks of sensitization against the risks of infection and malignancy 1
• Consider that race-based eGFR equations may lead to inaccurate assessment of kidney function and potentially delayed referral for re-transplantation 1