KIDNEY FOUNDATION FOR CHILDREN

      SAVING YOUNG LIVES

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  • HBsAg positivity has for long been considered as a contraindication for kidney transplantation as it was an independent ,significant risk factor for progressive hepatic decompensation,mortality and graft loss.
  • The availability of effective nucleos(t)ide analogue (NA) therapy has permitted a striking increase in patient 81-(89% and graft survival(86%) at 10 years. through inhibition of viral replication,retardation of liver disease progression and lower incidence of hepatocellular carcinoma
  • All HBsAg positive transplant candidates should be evaluated for  ,LFTHBV - DNA and Liver histology
  • HBsAg positive patients can be candidates for kidney transplantation only if they do not have cirrhosis..Patients with cirrhosis  are at high risk for hepatic decompensation following isolated renal transplantation. high risk ov.They require simultaneous liver and kidney transplantation.
  • The non-cirrhotic HbsAg positive , HBV -DNA positive patients should be treated with NA to maintain undetectable HBV-DNA, reduce liver fibrosis and prevent hepatic decompensation after renal transplantatioon.
  • Non -cirrhotic HBsAg positive ,HBV-DNA negative patients should receive preemptive NA begining 2 weeks prior to transplantation regardless of baseline histological severity because the immunosuppressive terapy after transplantation has been associated with a risk of rapidly progressive fibrosing cholestatic hepatitis even in patients with mild or inactive liver disease prior to transplantation,
  • In 2009,KDIGO recommended entecaavir,, tenofovir or lamuvidine for HBsAg transplant recepients.
  • Antiviral options include nucleos(t)ide analogues classified into nucleosides and nucleotides.(Table1) Entacavir is the drug of choice as it is very potent and has a high genetic barrier(less risk of developing drug resistamce.). Lamivudine is associated with veery high long-term resistance rates and recurrence of proteinuria after its discontinuation.It is therefore not the drug of choice but may be used when cost is a consideration.(KDIGO2009).
  • During therapy,HBV -DNA and ALT levels should be monitored 3 monthly to monitor efficacy and emergence of drug resistance.
  • Treatment should be continued for the entire duration oimmunosuppression or at least 2 years to maintain undetectable HBV-DNA levels
  • Interferon alpha therapy is contraindicated in transplant recepients due to low antiviral potency and an increased risk of acute rejection..
 Last week Tanzil came to the CKD OPD. for a pre transplant evaluation..Tanzil is a 14 year old boy with ESRD due to  bilateral grade 4 VUR and secondary FSGS.  To everyone's dismay he tested  HBsAg + ve..

Questions racing in my mind were

1.Should Tanzil be advised to opt for longterm maintenance dialysis?

2.Can he undergo renal transplantation?

3.What are his chances of graft and patient  survival?

4. What was his risk of hepatic decompensation?


1. .Pipli CL, Paptheodoridis GV, Evangelos C,Cholongitas EC.Treatment of hepatitis B in patients with chronic kidney disease.Kidney International (2013),84.880-885


2. Kidney Disease Improving Global Outcomes(KDIGO) Transplant work group.KDIGO clinical practice guidelines

for the care of kidney transplant recepients.Am J Transpalnt (2009) 9(suppl 3) S 19-20



FELLOWS 'FORUM

from one fellow to another

 

 What I learnt about kidney transplantation in a

HBxAg +ve child with ESRD


I should have known better than ask my Boss these questions in the midst of the busy OPD.. I was promptly asked to read up and present a seminar in the weekly meet.These were some of the good articles that I reviewed.


drug dosages for children

nucleosides    NUCLEOTIDES


Lamivudine                         Adefovir

Telbivdine                           Dipivoxil

Entecavir                             Tenofovir

                                            Disoproxil fumarate

ENTECAVIR DOSE  ONCE DAILY


10 -11 kg  0.15 mg   ( 3ml)

11-14 kg   0.2mg      ( 4 mi

14 - 17 kg  0.25 mg (5ml)

17 - 20 kg  0.3 mg   ( 6 ml )

20-23 kg  0.35 mg (7 ml )

26-30 kg  0.4 mg   ( 9 ml )

>   30 kg    0.5  mg  ( 10 ml)) or 1 tab 0.5 mg



LAMUVIDINE DOSAGE

 eGFR   15 - 30 ml / min

Initial    4 mg / kg

Maintenance  2.5 mg/kg

         antiviral options

Dr. Arpana Hanchinmani