KDIGO consensus report offers guidance on managing patients with a failing allograft
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Key Takeaways
The report addresses management of patients during and after allograft failure, including use of dialysis or a preemptive transplant.
The KDIGO panel said early detection of a failing allograft is critical.
Kidney Disease: Improving Global Outcomes has released a series of recommendations for the transplant team on how to manage patients with a failing kidney allograft.
The recommendations were developed during the KDIGO Controversies Conference on Challenges in Management of the Kidney Allograft: From Decline to Failure, which was held in March 2022. The recommendations were recently published in Kidney International.
“The conference brought together global experts to delve into the complexities of kidney allograft management and explore topics such as ascertaining prognosis and kidney failure trajectory; identifying optimal immunosuppression strategies; managing medical and psychological complications in transplant recipients; and preparing for ensuing kidney replacement therapy (ie, return to dialysis, re-transplantation or supportive care),” according to a KDIGO summary of the conference. “The report highlights the critical role of early detection, proactive intervention and personalized immunosuppressive care in minimizing the risk of rejection and mitigating long-term adverse effects.”
Michelle A. Josephson, MD, head of transplantation at the Transplant Institute, University of Chicago, and Martin Zeier, MD, of Heidelberg University, Germany, co-chaired the conference.
“Identifying and paying special attention to individuals with failing allografts was felt to be important in order to prepare patients psychologically, manage immunosuppression, address complications, prepare for dialysis and/or re-transplantation, and transition to supportive care,” Josephson and colleagues wrote. “Identifying patients with a failing allograft is challenging, and there are limited prognostication tools that support a clinician’s judgment or improve shared decision-making.”
One of the challenges facing medical staff is identifying when the allograft may start to fail.
“Since periods of depression are common for many patients, and they might be reluctant to share their plight, the conference participants recommended routine screening for depression and anxiety. Screening instruments that can be administered by nursing staff are available,” the authors wrote. “Positive screens can be further evaluated by social workers, and other mental health experts should be available and should be consulted as necessary.
“For patients who are in the process of losing a live-donor allograft, additional support may be needed to help resolve guilt and depression in not only the recipient but also the donor,” the authors wrote. “This period is one of psychological vulnerability for patients. Even if past behaviors, such as medication nonadherence, may have contributed to the outcome, caregivers should avoid blaming patients for graft failure, but rather should be supportive.”
The KDIGO report offered several key recommendations on managing the failing allograft, including the following:
- Wider implementation is needed of prognostication systems developed specifically for kidney transplant recipients that accurately predict allograft failure.
- Immunosuppression management in the transplant recipient with a failing or failed kidney transplant “must be individualized and based on [risk vs. benefit] considerations,” the authors wrote. “The management of immunosuppression in [kidney transplant recipients] KTRs with declining GFRs should balance the potential risks (eg, infection) and benefits (eg, avoiding sensitization). In current practice, immunosuppression is usually reduced or discontinued, despite the gap in knowledge as to whether this is better or worse for the patient ... The lack of consensus on the appropriate approach to immunosuppression management makes this issue relevant,” the authors wrote.
- Psychological support is important in managing patients with a failing or failed kidney transplant, Josephson and colleagues wrote. “From a patient perspective, psychological support for patients with a failing or failed kidney transplant is paramount. Patient outcomes could be improved by better preparing patients and minimizing adverse events during the transition phase.”
Reference:
KDIGO Direct. 2023, KDIGO Allograft Controversies Conference Report publishes in Kidney International. https://myemail-api.constantcontact.com/KDIGO-Direct---December-2023.html?soid=1134196072483&aid=l0muLjfkqrw, Published December 2023. Accessed Feb. 4, 2023.
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