Yilin Zhang, MD
Expert review by Raimund Pichler, MD (University of Washington, Division of Nephrology) and Iris De Castro, MD (University of Washington, Transplant Nephrology)
- Differentiate between pre-renal, intra-renal, and post-renal causes of acute kidney injury in a patient with a kidney transplant
- Name transplant specific complications that result in acute kidney injury
- Evaluate a patient with acute allograft dysfunction
Plan to spend at least 30 minutes preparing for this talk by using the Interactive Board for Learning/Preparing. After you feel comfortable with the content you can prepare to present this talk in one of two ways.
- Project the Interactive Board for Presentation OR
- Reproduce a drawing of the differential diagnosis figure and timeline on a whiteboard.
The entire talk will take ~30-45 min.
- Slide 1: (5 min) Build a framework for a general approach to AKI. Click on "what is your differential" which will bring up the categories of prerenal, intrarenal, and postrenal etiologies. In patients with kidney transplants, these can be further separated into transplant specific causes and typical causes (click on the category buttons to reveal the differential for each). Very quickly ask your learners to call out some non-transplant causes of AKI in pre/intra/postrenal categories (click on the "differential?" button to reveal the differential. This should take no more than 2 min. Then ask for transplant specific causes. Remind your learners that while there are transplant specific complications, it's still important to include non-transplant causes in their differential.
- Slide 2: (15-30 min) Discuss that timing from transplant can help narrow guide your differential. You can click on any of the category or timeline buttons, though we suggest moving from "1 week" to "3 months" to "6 months" categories. After you reveal each of the different causes of AKI in their respective pre/intra/postrenal categories, click on specific causes (the arrows) to discuss the clinical presentation, laboratory findings, and diagnosis in depth. You may choose to only highlight a few of them. At the end, click on the "toolbox" icon to review the additional tests that are in your "toolbox" when evaluating someone with AKI in a renal transplant.
- Slide 3: (10-15 min) Practice cases. Put the framework you taught into use! Click on each case to reveal the case stem. Ask your learners to choose from tests in your toolbox and click each test button to reveal the underlying cause. Not all tests may be necessary in all cases. Click the "diagnosis" to reveal the answer.
Use for Self-Directed Learning and Preparing to Present
Use For Presenting (Less Text and Fewer Pop-ups)
TAKE HOME POINTS:
- Differential of AKI in a renal transplant patient should include 5 transplant specific causes of AKI – CNI toxicity (acute and chronic), renal artery stenosis/thrombosis, viral infections (BK, adenovirus, CMV), rejection and ureteral stenosis.
- Work-up can include renal ultrasound with duplex, viral studies (BK or CMV PCR), CNI trough levels, and involvement of renal transplant team to consider further work-up for rejection such as biopsy and DSAs.
- Goldberg, RJ, Weng, FL, & Kandula, P. 2016. Acute and Chronic Allograft Dysfunction in Kidney Transplant Recipients. Medical Clinics of North America. 100 (3):487-503
- Kadambi, PV, Brennan, DC & Chon, JW. Evaluation and diagnosis of the patient with renal allograft dysfunction. Lam, AQ, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on October 20, 2017.)
- Vella, J & DC. Hypertension after renal transplantation. Lam, AQ, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on October 20, 2017.)
- Limaye, AP &B Brennan, DC. Clinical manifestations and diagnosis of BK virus-induced (polyomavirus-induced) nephroatphy in kidney transplantation. Lam, AQ & Thorner, AR, eds. UpToDate, Inc. http://www.uptodate.com (Accessed on October 20, 2017.)
- Santos, CAQ, Vella, J & Brennan, DC. Clinical manifestations, diagnosis, and management of cytomegalovirus disease in kidney transplant recipients. Lam, AQ & Bond, S, eds. UpToDate, Inc. http://www.uptodate.com (Accessed on October 20, 2017.)
- Bennet, WM. Cyclosporine and tacrolimus nephrotoxicity. Lam, AQ, ed. UpToDate, Inc. http://www.uptodate.com (Accessed on October 20, 2017.)
- Hatlen, T et al. Disseminated Adenovirus Nephriis After Kidney Transplantation. Kidney Int Rep. 2018 Jan; 3(1): 19–23.