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Kidney Transplant Induction, Desensitization, and Rejection Protocols

Kidney Transplant Induction, Desensitization, and Rejection Protocols - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Medications, Related


UW Health Kidney Transplant Induction and Desensitization Protocols
Donor
Status
Protocol
Virtual
XM
Sum MFI
PE + IVIG (100mg/kg
after each PE);
MPA / TAC
Desensitization
Induction Regimen
Prednisone
Taper
Live
D0 Negative -
- ESW: Alemtuzumab 30mg x1 • Discontinue POD5
- Non-ESW: Basiliximab 20mg x1
• Discharge on 30mg/day
• Reduce daily dose by 5mg
each week
• Target dose 5mg/day
D1
Weak
positive
100 -
1,000
MPA/TAC:d(-7)
Alemtuzumab 30mg x1
OR
Thymoglobulin 1.5mg/kg daily x 4
• Discharge on 30mg/day
• Reduce daily dose by 5mg
each week
• Target dose 10mg/dayD2 Positive
1,000 -
4,000
PE/IVIG: 2-3 pre-Tx and
post-Tx;
MPA/TAC:d(-7)
Thymoglobulin 1.5mg/kg daily x 4
Deceased
D5a Negative -
- ESW: Alemtuzumab 30mg x1 • Discontinue POD5
- Non-ESW: Basiliximab 20mg x1
• Discharge on 30mg/day
• Reduce daily dose by 5mg
each week
• Target dose 5mg/day
-
Non-ESW + High DGF Risk:
Alemtuzumab 30mg x1
OR
Thymoglobulin 1.5mg/kg daily x 4
D5b
Weak
positive
100 -
1,000
-
Alemtuzumab 30mg x1
OR
Thymoglobulin 1.5mg/kg daily x 4
• Discharge on 30mg/day
• Reduce daily dose by 5mg
each week
• Target dose 10mg/dayD5c Positive
1,000 -
4,000
PE/IVIG: Pre-Tx: 1
Post-Tx: 2-3
Thymoglobulin 1.5mg/kg daily x 4
Post-reperfusion biopsy recommended for all patients • Patients with GN should receive Thymoglobulin and steroid continuation.

Rejection Protocols (dexamethasone dosed daily, prednisone total daily dose split BID)
R1 Inpatient: Dex 50mg IV x 1, Dex 44mg IV x 1, then prednisone taper
1
; Outpatient: Dex 50mg IV x 1, then prednisone taper
1
R2 Dex 100mg IV x1, Dex 50mg IV x1, Dex 44mg IV x1 (omit for outpatients), followed by prednisone taper
1

R3 R2 + Thymo (1.5mg/kg daily x 4-7)
R4 Early rejection
3
: R2 + PE/IVIG (100mg/kg) x 4-6 ± Ritux
2
375 mg/m
2
x1
Late rejection
3
: R2 + IVIG (200mg/kg/q2week) x 3 ± Ritux
2
375 mg/m
2
x 1
Persistent rejection (ABMR on 12 week follow-up biopsy): R2 + IVIG (500mg/kg/week) x 4 ± Ritux
2
375 mg/m
2
x 1
R5 R2 + PE/IVIG (early only
3
) x 4-6 + Thymo (1.5mg/kg daily x7) ± Ritux
2
375 mg/m
2
x1 ± Bortezomib (1.3 mg/m
2
BSA d0, 3, 7, 10)
1
Standard Prednisone Taper: 180mg x1, 150mg x1, 120mg x1, 90mg x1, 60mg x1, 30mg daily x 7 days, then 20mg daily x 7 days,
then 10 mg daily until clinic appointment
2
Ritux use not recommended if ABMR injury is minimal (focal C4d, without microcirculation inflammation); following PE if concurrent
3
Early is defined as 0-3 months following transplant, late is >3 months following transplant
All weight-based medication dosing should use IBW unless other weight is specified
Abbreviations
ABMR=Antibody mediated rejection; CMV=Cytomegalovirus, d=Day; Dex=Dexamethasone IV; DGF=Delayed Graft Function; DSA=Donor Specific Antibody; ESW=Early Steroid Withdrawal;
GN=Glomerulonephritis; IBW=Ideal Body Weight; IVIG=Intravenous Immune Globulin; MFI=Mean Fluorescent Intensity; MPA=Mycophenolic Acid; PE=Plasma Exchange; POD=Post-Op Day;
PJP=Pneumocystis Jiroveci Pneumonia; PUD=Peptic Ulcer Disease; Ritux=Rituximab; TAC=Tacrolimus; TCMR=T-cell Mediated Rejection; Thymo=Thymoglobulin; XM=Cross match
Contact for Content: Didier Mandelbrot, MD - Nephrology
(608) 262-4352 • damandel@medicine.wisc.edu
Contact for Changes: David Hager, PharmD – Pharmacy
(608) 890-8993 • dhager@uwhealth.org
uwhealth.org/transplant
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Disclaimer: This Clinical Practice Guideline outlines the preferred approach for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely establish
the only appropriate approach to a problem.
Copyright 2017 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
UW Health Kidney Rejection Treatment Protocols
Type TCMR ABMR Mixed
Banff Suspicious IA IB IIA IIB III Banff 2013 -
Protocol # R1 R2 R3 R4 R5
Start CMV, thrush, PJP, PUD prophylaxis
Follow-up biopsy recommended at 12 weeks (± 1 week) for all patients
DSA Monitoring: Monthly x 3 months, 6 months, 12 months, annually