Biopsy, Parvo, BK virus, CMV, Tacrolimus. Running in clinic.
Welcome to the medical university of south carolina what’s a kidney transplant biopsy kidney transplant biopsy is performed to obtain a tissue sample from your kidney transplant that tissue will be examined by a pathologist under a microscope to get a closer look at the structure of the kidney why do we do a biopsy we perform a kidney transplant biopsy for a variety
Of reasons primarily we’re looking to diagnose the type of kidney injury one of the causes is rejection this means your body immune system has figured out that there is an intruder and is trying to fight it off we also look for other possible injuries including recurrence of native kidney disease infection of the graft and the amount of viable tissue in the graft
By biopsying the kidney we can diagnose the cause of kidney injury and determine the appropriate treatment what does a biopsy entail before your kidney biopsy you will meet with your doctor to talk about what to expect this is a good time to ask questions about the procedure and make sure you understand the benefits and risks your doctor or nurse will let you know
When and what to stop taking certain medications on supplements and for how long examples are aspirin plavix or other blood thinners these medications are usually stopped five days before the procedure and then started again five days after the procedure you may be asked not to drink or eat for eight hours before the kidney biopsy during the procedure we will be
Using an ultrasound to help to guide our biopsy when you first arrive in the room we will have you lay flat and lift your gown to expose your abdomen this is how the room setup will roughly look like using the ultrasound probe we will look for a good view of your kidney transplant where we can safely biopsy once we find a safe view to perform the biopsy we will
Sterilize your abdomen with a small medicated sponge you will then receive the numbing medicine injected into your abdomen this is meant to numb the path that the biopsy needle is about to take ensuring that you feel no pain you may feel a burning sensation when the local anesthetic is given and you may feel pressure once the biopsy needle itself is inserted but
You should never feel pain after numbing your abdomen we make a small incision in the skin and pass the biopsy needle through using the ultrasound to guide our needle will slowly advance to the kidney and obtain a sample you will hear a click sound when the tissue is obtained a pathologist will be in the room to determine if we need a second tissue sample or if
The first sample was adequate afterwards we will hold pressure for 10 minutes a repeat ultrasound is performed to make sure that there is no bleeding and then we’re done you’ll stay in the recovery area for approximately two to four hours on bed rest following the procedure you’re advised not to lift anything heavy for two weeks take it easy and avoid exerting
Yourself what are the risks of a kidney transplant biopsy bleeding is the biggest risk this is why we make sure your blood pressure is well controlled prior to the procedure and you stop all blood thinners you may notice blood in your urine following the biopsy this is not uncommon but it should lessen each time you urinate soreness or pain are other possible
Side effects these should be mild and improve in hours following your biopsy infection is also a risk of this procedure this is why we use steroid technique to minimize exposure to pathogens if the bleeding or pain worsens call your transplant coordinator immediately or go to the nearest emergency room under certain circumstances we seek interventional radiology
For a ct-guided biopsy few examples include when part of the small bowel is overlying the kidney as the risk of accidentally poking the bowel is too great another scenario if a bleed has developed after the ultrasound-guided biopsy within or around your kidney intervention radiology will be called to emergently embolize or zap the bleeding vessel or the arterial
Venous fistula formed within the kidney as a side note bleeding my subside completely after a kidney biopsy but starts to appear few hours to days later if this happens call your transplant coordinator immediately or go to the nearest emergency department as this may be a sign that an arterial venous fistula has developed within the kidney and needs attention
Cytomegalovirus or cmv is an enveloped double-stranded dna virus it belongs to the herbs of iridi family and is one of the most common viruses that causes severe infection in organ transplant recipients cmv can be transmitted through an infected person’s blood and other bodily fluids such as saliva genital secretions and urine as well as through the transplanted
Organ itself during primary infection the virus usually invades and multiplies an epithelial cells such as those found in the oral gastrointestinal or urinary mucosa during the post-transplantation period the recipient is usually given immunosuppressive medication to prevent the recipient’s immune system from recognizing the transplanted tissue as foreign and
Rejecting it however one significant disadvantage of this approach is that the weakened immune system is unable to protect the body from pathogens such as cmv when the immune system is weakened the dormant virus takes the opportunity hence called opportunistic infection and can reactivate and cause disease cmv destroys the structure of the infected cells this
Causes enlarged cells with intranuclear violet inclusion bodies giving the appearance of an owl’s eye cmv also infects blood monocytes and establishes a latent infection which means the virus remains dormant for a long period of time cmv has the potential to affect nearly every organ in the body symptoms vary according to the affected organ including encephalitis
With alter mental status seizures and weakness retinitis with blurring of vision dark spots individual feeds called scotomas or even total blindness pneumonia with cuff and shortness of breath hepatitis with jaundice and liver failure gastroenteritis with diarrhea nausea vomiting and abdominal pain and of course transplant rejection very prominent and important
Alarms to watch for including diarrhea abdominal pain and leukopenia which is low i count manifestations usually appear one to six months after discontinuation of prophylaxis post-transplant almost always the transplanted organ is harmed this is because virally infected cells attract immune cells to the site which recognize the foreign transplanted cells and may
Attack them in the process of killing the virus what’s the risk status a high risk status indicates that the donor has been exposed to the virus and has antibodies to it whereas the recipient has never been exposed to the virus and has no antibodies to it we keep these patients on antiviral prophylaxis which is valcite for six months post-transplant if the recipient
And donor were not previously exposed to the virus this is called low risk status if the recipient was previously exposed to the virus regardless of the donor this is called the moderate risk status we keep antivirus prophylaxis valcite for those patients for about three months post-transplant few more definitions to know cmv viremia is detection of the virus in
The blood by a technique called pcr or polymerase chain reaction cmv syndrome means fever more than 38 degrees celsius for at least two days within a four day period cmv viremia and either low white count which is neutropenia or low platelet count which is thrombocytopenia cmv disease consists of end organ disease and cmv syndrome infected patients may have low
Level viremia which is viral count in the blood but have cmv disease with organ infection cmv infections are diagnosed by isolating the virus from the blood sample using a test called cmv plasma pcr or from body fluids or tissues using a biopsy example column biopsy treatment consists of entire viral medications in various doses such as intravenous gancyclovir
Po valgan cyclovir intravenous phoscarnet for cmv resistance po maribervir and cytogam which is intravenous immunoglobulin specifically directed against cmv tachrolimus the generic name is the cornerstone anti-rejection drug for patients after transplant providing the most protection from transplant rejection patients will take this medication most commonly in
The form of long acting 24 hours duration or short acting 12 hours duration as part of the immunosuppression regimen while it does its job very well it’s a double-edged sword that we must closely monitor what does that mean it can be toxic to the kidneys causing neurological symptoms make blood sugar difficult to control and cause abnormalities with minerals and
Acids in the bloodstream as you can see it’s a balancing act to make sure that there is enough tacrolimus to prevent rejection but not so much to cause problems for this reason we must monitor the level of tacrolimus in the bloodstream regularly and adjust each patient’s dose accordingly when your transplant provider checks your tachronis level they are looking
For a trough level what’s a trough level think about a wave with peaks and valleys the amount of tachrolimus in the bloodstream follows this pattern when you take tacrolimus your body absorbs the medication causing the amount on your bloodstream to rise throughout the day the tacrolimus is broken down and used by your body causing the amount in your bloodstream
To decrease as such the level peaks shortly after taking your medication then hits a low point which we call a trough level before your next dose is due your provider uses this trough level to decide if you need to increase decrease or continue with the same dose of tachromius this is why it is important to take your tacrolimus those at the same time every day
And to have labs drawn just before your next dose is due if the labs are drawn too early or too late it’s not a true trough and your provider cannot accurately determine how much the chromos you need let’s give some examples johnny takes his lung acting tacrolimus every 24 hours at 8 am every morning he remembered to wait to take his long acting tacrolimus until
After labs but he does not arrive at the lab until 11 a.m for his lab draw his tachramus level will be 27 hours after his last long-acting tacrolimus dose this means it will not be a true trough and the level will likely seem lower than it actually is susie does the opposite she takes her short acting techrolimus every 12 hours at 11 am and 11 pm but arrives at
The lab for blood draw at 8 a.m before work this tacrolimus level will be 9 hours since she last took her short acting techrolimus dose her level would not be a true trough either and it will likely seem higher in the bloodstream than it actually is so does it matter what time you take your tacrolimus no you can decide to take your tachrolimus at whatever time
Works best for you what matters is that you take it at the same time every day and have your level checked just before your next dose is due finally for the long-acting tacrolimus make sure to take it on an empty stomach one hour before or two hours after meals dogs no way not that one partial virus that affects dogs is not the same as a human parvo b19 virus
Parvo of dogs is different and cannot be passed from dogs to humans we will talk today about the virus that affects humans the parvo b19 it was first discovered in 1974 while testing blood units for hepatitis b virus and asymptomatic donors the name originates from the coding of a serum sample number 19 and panel b that gave anomalous results it was first linked
To clinical disease in 1981 and in transplant patients in 1986. let’s give the story a listen throughout petra’s pregnancy all of her friends came to see her at home one of them sneezed in her face infecting her with a powerful b19s virus which is the smallest single-stranded naked non-enveloped dna virus petra the mom later developed chronic arthritis from the
Virus in her small joints and that was it if this happened early in pregnancy her baby could have developed hydrops fatalis or suffered a miscarriage fortunately she was in her third trimester and the pregnancy was uneventful paula her baby grew up and started kindergarten paris paula’s friend in the kindergarten sneezed in her face and transmitted the parvo
B19 virus to her paula began to experience flu-like symptoms a week later she developed a rash on her face that looked like someone has slapped her on the cheek and the rash spread to her entire body parvovirus b19 is also known as the fifth disease the virus travels through the blood which is the viremia phase and resides in the bone marrow precursor red blood
Cells where it arrests and destructs them therefore it causes aplastic anemia with a low reticulocyte count the rash with arthritis and arthralgia are caused by the killing phase of the precursor red blood cells as a side note remember the first disease is measles the second is rubella the third is chickenpox and the fourth is rhodiola up till now there is no
Vaccine available for disease number four and five rosiola and parvo clinical presentation of parvovirus b19 is white as previously mentioned it resides in the bone marrow precursor red blood cells and may be completely asymptomatic patients with sickle cell anemia hematological disorders and immunocompromised patients including transplant recipients may develop
Significant red cell precursor destruction resulting in erythropoietin resistant aplastic anemia low white blood cell count and low platelets furthermore the viral infection can result in chronic arthritis arthralgia hepatitis which is liver inflammation neurological side effects myocarditis and most importantly kidney craft dysfunction ranging from protein in
Urine to failure in transplant patients the parvo b19 virus may be donor derived which means it is transmitted with a transplanted kidney so keep an eye out if the donor was zero positive igg positive and the patient was heavily immunosuppressed how do we make a diagnosis if there is a clinical suspicion check parvo b19 plasma pcr in transplant patients a bone
Marrow biopsy is almost never required the key is to have a good clinical sense resistant anemia arthritis myocarditis and graft dysfunction how do we handle a positive result simply let the patient’s immune system handle it reduce their immune suppressive medicine cut the mmf dose by half or discontinue it entirely depending on the clinical severity you can also
Give your transplant patients extra immunity by giving them ivig typical dose is 0.4 gram per kg times 5 doses you can give it weekly or every other day total of 2 grams per kg continue to monitor parvo b19 pcr on a weekly basis welcome to the medical university of south carolina there is no vaccine for hepatitis c the only way to prevent this infection is to lessen
Your risk of coming in contact with hepatitis c virus in this video i’m going to share with you some tips that may prevent the spread of hepatitis c virus make sure you wash your hands often with soap and water for at least 20 seconds if soap and water are not available use hand sanitizer cover any cuts or open sores on your skin to prevent spreading of hepatitis c
Virus avoid swimming or using hot tubs if you have open sores or wounds do not share toothbrushes nail clippers or razors do not share needles or syringes avoid handling blood or other body fluids without gloves or other protection avoid getting tattoos or body piercing in shops or other places that are not clean use a condom every time you have vaginal oral or
Anal sex be sure to use it correctly each time both females and males should wear condoms condoms should be kept in place from the beginning to the end of sexual activity latex condoms should be used if possible these offer the best protection keep all follow-up visits as told by your health care provider this is very important you may need a follow-up visit every 6 to 12 months you
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Clinic Video Mixture of Videos By Dr Karim Soliman
