Commentary
KDOQI US Commentary on the 2009 KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients

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In response to recently published KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for the care of kidney transplant recipients (KTRs), the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) organized a working group of transplant nephrologists and surgeons to review these guidelines and comment on their relevance and applicability for US KTRs. The following commentaries on the KDIGO guidelines represent the consensus of our work group. The KDIGO transplant guidelines concentrated on aspects of transplant care most important to this population in the posttransplant period, such as immunosuppression, infection, malignancy, and cardiovascular care. Our KDOQI work group concurred with many of the KDIGO recommendations except in some important areas related to immunosuppression, in which decisions in the United States are largely made by transplant centers and are dependent in part on the specific patient population served. Most, but not all, KDIGO guidelines are relevant to US patients. However, implementation of many may remain a major challenge because of issues of limitation in resources needed to assist in the tasks of educating, counseling, and implementing and maintaining lifestyle changes. Although very few of the guidelines are based on evidence that is strong enough to justify their being used as the basis of policy or performance measures, they offer an excellent road map to navigate the complex care of KTRs.

Section snippets

KDIGO Guideline Process

The KDIGO transplant guideline concentrated mainly on aspects of transplant care most important to this population in the posttransplant period, such as immunosuppression, infection, malignancy, and cardiovascular care. The guidelines do not address pretransplant evaluation or issues related to patients returning to dialysis therapy with a failed allograft. The target audience for the guideline is physicians, coordinators, pharmacists, and other medical professionals who directly or indirectly

KDOQI Process for Interpretation of the KDIGO Guideline in the Care of US Transplant Patients

Differences in target population, individual patient immunologic risk, prevalence of concomitant diseases (such as diabetes mellitus), availability of resources, and systems of payment must all be considered in interpreting global recommendations to specific regions. The following commentaries on the KDIGO guideline represent the consensus of a work group convened by KDOQI to evaluate the relevance and applicability of the guideline to US patients and practices. It is beyond the scope of our

KDIGO Recommendations in Chapter 1: Induction Therapy

  • 1.1:

    We recommend starting a combination of immunosuppressive medications before, or at the time of, kidney transplantation. (1A)

  • 1.2:

    We recommend including induction therapy with a biologic agent as part of the initial immunosuppressive regimen in KTRs. (1A)

    • 1.2.1:

      We recommend that an IL2-RA [interleukin-2 receptor antagonist] be the firstline induction therapy. (1B)

    • 1.2.2:

      We suggest using a lymphocyte-depleting agent, rather than an IL2-RA, for KTRs at high immunologic risk. (2B)

KDOQI Rationale and Commentary

It clearly is important to start

Summary of Commentary on Section I: Immunosuppression

KDIGO Recommendations in Chapter 8: Monitoring Kidney Allograft Function

  • 8.1:

    We suggest measuring urine volume (2C):

    • Every 1-2 hours for at least 24 hours after transplantation (2D);

    • Daily until graft function is stable. (2D)

  • 8.2:

    We suggest measuring urine protein excretion, (2C) at least:

    • Once in the first month to determine a baseline (2D);

    • Every 3 months during the first year (2D);

    • Annually, thereafter. (2D)

  • 8.3:

    We recommend measuring serum creatinine, (1B) at least:

    • Daily for 7 days or until hospital discharge, whichever occurs sooner (2C);

    • 2-3 times per week for weeks 2-4 (2C);

Summary of Commentary on Section II: Graft Monitoring and Infections

KDIGO Recommendations in Chapter 15: Diabetes Mellitus

  • 15.1:

    Screening for New-Onset Diabetes after Transplantation

    • 15.1.1:

      We recommend screening all nondiabetic KTRs with fasting plasma glucose, oral glucose tolerance testing, and/or HbA1c (1C) at least:

      • weekly for 4 weeks (2D);

      • every 3 months for 1 year (2D);

      • and annually, thereafter. (2D)

    • 15.1.2:

      We suggest screening for NODAT with fasting glucose, oral glucose tolerance testing, and/or after starting, or substantially increasing the dose, of CNIs, mTORi, or corticosteroids. (2D)

  • 15.2:

    Managing NODAT or Diabetes Present at

Summary of Commentary on Section III: CVD

KDIGO Recommendations in Chapter 18: Cancer of the Skin and Lip

  • 18.1:

    We recommend that KTRs, especially those who have fair skin, live in high sun-exposure climates, have occupations requiring sun exposure, have had significant sun exposure as a child, or have a history of skin cancer, be told that their risk of skin and lip cancer is very high. (1C)

  • 18.2:

    We recommend that KTRs minimize life-long sun exposure and use appropriate ultraviolet light blocking agents. (1D)

  • 18.3:

    We suggest that adult KTRs perform skin and lip self-examinations and report new lesions to a

Summary of Commentary on Section IV: Malignancy

KDIGO Recommendations in Chapter 21: Transplant Bone Disease

  • 21.1:

    In patients in the immediate post kidney transplant period, we recommend measuring serum calcium and phosphorus at least weekly, until stable. (1B)

  • 21.2:

    In patients after the immediate post kidney transplant period, it is reasonable to base the frequency of monitoring serum calcium, phosphorus and PTH on the presence and magnitude of abnormalities, and the rate of progression of CKD. (Not Graded)

    • 21.2.1:

      Reasonable monitoring intervals would be (Not Graded):

      • In CKD stages 1–3T, for serum calcium and

Summary of Commentary on Section V: Other Complications

Research

At the end of each section, members of the KDIGO work group made several suggestions for areas of future research. Our KDOQI work group agreed with the critical importance of research in these areas to create evidence upon which future recommendations and guidelines can be based.

Conclusion

The new KDIGO guideline for the care of kidney transplant patients are broad in scope and should serve as guide for all clinicians caring for KTRs, including transplant clinicians, nephrologists, nurses, and fellows in training. Our KDOQI work group concurred with many of the KDIGO recommendations except in some important areas related to immunosuppression. Decisions about immunosuppression in the United States are largely made by transplant centers and are dependent in part on the specific

Acknowledgements

Guideline recommendations included in this article originally were published in the American Journal of Transplantation3 and were reproduced with permission from KDIGO.

We thank Robert Harland, MD, for input on the applicability of the KDIGO guideline for US KTRs; Drs Jeffrey Stein and Oscar Colegio for input on the pediatric and skin cancer recommendations; Drs Jeffrey Berns and Michael Rocco for careful review of this manuscript; and Anita Viliusis and Kerry Willis from the National Kidney

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    • The impact of induction therapy in low-immunological risk kidney transplant recipients regardless of HLA matching

      2023, Transplant Immunology
      Citation Excerpt :

      The authors recommended the use of interleukin 2 receptor antagonist (IL2-RA) as a first-line induction therapy in low immunological risk kidney transplanted recipients (KTRs) (Grade 1B). Besides, lymphocyte-depleting agents like rabbit anti-thymocyte globulin (rATG) are used for induction therapy in high immunologic risk patients (Grade 2B) [5,6]. In 2010, Cochrane Collaboration performed a meta-analysis of randomized control trials in low-risk KTRs to compare the efficacy of IL2-RA and Thymoglobulin.

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    Originally published online as doi:10.1053/j.ajkd.2010.04.010 on July 2, 2010.

    Reprint requests to Kerry Willis, PhD, National Kidney Foundation, 30 E 33rd St, New York, NY 10016. E-mail: [email protected]

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