Description
Precision Transplant Medicine, a groundbreaking approach in healthcare, optimizes organ transplantation by tailoring treatments to individual patients. This case study delves into its transformative impact, showcasing personalized strategies that enhance donor-recipient compatibility, minimize rejection risks, and improve overall transplant outcomes. Through meticulous analysis of patient profiles and cutting-edge technologies, Precision Transplant Medicine emerges as a beacon of hope, revolutionizing the landscape of organ transplantation with unprecedented precision and efficacy.
Résumé
- The presentation focuses on individualizing therapy for better kidney transplant outcomes, including discussion of Precision Transplant Immunology. The topics covered include factors determining immunologic risk, case scenarios, induction and maintenance therapy, how to choose drugs for specific patients, and individualizing therapy based on complications.
- Currently, 120-130 transplants are performed annually at the presenter's institute. Diseased donor transplants are increasing after a dip around 2020-2021 during the COVID-19 pandemic. Pre-transplant, patients undergo immunologic profiling to assess risk, categorized as low or high based on clinical factors (pregnancy, blood transfusions, re-transplant, age) and lab results (HLA mismatches, DSA positivity, CPRA, blood group incompatibility, high anti-ABO titers).
- Induction therapy occurs during kidney implantation, while maintenance is lifelong. Available induction agents in India include ATG (Anti-Thymocyte Globulin) and Basiliximab. The choice is variable worldwide, center-specific, and patient-specific. ATG is favored for high-risk patients (HLA mismatch, younger recipients, older donors, high CPRA, DSA, cold ischemia time), while Basiliximab is an option for low-risk individuals or when ATG is poorly tolerated (cytopenia, hypotension).
- Maintenance therapy commonly involves a three-drug combination: a CNI (Cyclosporine or Tacrolimus), a steroid, and an antimetabolite (Azathioprine or Mycophenolate). Tacrolimus is the preferred CNI due to decreased rejection rates. Cyclosporine is used when Tacrolimus causes neurological side effects, new onset diabetes, frequent diarrhea, dyspepsia, vomiting, or alopecia. Individualization involves considering genetic polymorphisms, although they are not yet fully reliable.
- Common side effects of MMF (Mycophenolate) are GI issues, thrombocytopenia, and elevated liver enzymes. Azathioprine toxicity relates to TPMT activity; TPMT testing is often performed. Patients with diarrhea from Mycophenolate mofetil are switched to Mycophenolate sodium. Steroid dosing is not standardized, and is determined by individual patient needs and center protocols. Risks of steroids include osteoporosis, poor sugar control, diabetes, poor wound healing, cataract formation, hypertension, obesity, and lipid alterations.
- Initial maintenance therapy for low-risk patients is typically Tacrolimus, steroids, and Mycophenolate Mofetil. Those with persistent diarrhea may be switched to Mycophenolate Sodium. H identical grafts from monozygotic twins may require immunosuppression for only 1-3 months. Steroid minimization or withdrawal is increasingly common, especially in pediatric patients, to avoid stunted growth.
- Complete withdrawal of maintenance therapy is not advised except in monozygotic twins. Patients experiencing Calcineurin Inhibitor (CNI) toxicity are switched to MTOR inhibitors (Sirolimus or Everolimus). In patients on Cyclosporine and Azathioprine developing acute rejection, the treatment is often switched to Tacrolimus and Mycophenolate Mofetil or dosage is increased.
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