Veterinary Medicine - February 2008 - (Page 96) Managing feline kidney transplant patients PEER-REVIEWED at higher risk of developing clinical toxoplasmosis after immunosuppression.31 The best course of action to prevent possible recrudescence of infection in antibodypositive recipient cats is unclear; recommendations vary among institutions, with treatment with clindamycin varying from a two-week course before transplantation to lifelong therapy.31,32 Perform blood typing, and identify multiple compatible donors before surgery. Crossmatching typically occurs after patient transfer to the transplant center. Hyperthyroidism is a common concurrent disease in cats with chronic kidney disease. Affected cats are excluded unless de nitive treatment is completed before transplantation because hyperthyroidism treatment can further decrease the glomerular ltration rate and exacerbate chronic kidney disease.33 Perform a complete cardiac evaluation to detect underlying cardiomyopa- thy. Severe cardiac disease is a relative contraindication because of heightened anesthetic risk and anticipated shortened life span. and serum creatinine and urea nitrogen concentrations remained within reference ranges.36 Most transplant programs also require adoption of the donor cat, regardless of the outcome of the recipient. Donor cats The diagnostic evaluation of a donor cat is similar to that described for the recipient. Speci c investigation of urinary tract anatomy and function is performed by using abdominal ultrasonography, excretory urography, or computed tomography angiography.34 Cats positive for anti-Toxoplasma gondii antibodies are no longer used as donors. Ethical concerns have arisen regarding the use of living feline donors for kidney transplantation. In people, the risk of mortality associated with kidney donation is about 0.03%.35 Similar nominal risks have been observed in donor cats undergoing unilateral nephrectomy. In one study, no perioperative deaths were reported, IMMUNOMODULATION The crucial advance that made clinical organ transplantation feasible between unrelated individuals was the development of immunosuppressive drugs to prevent or control rejection. Foreign tissue rejection is determined by T cell-mediated recognition of cell surface major histocompatibility complex proteins and the peptides they display. Transplanting kidney allografts from unrelated, histoincompatible feline donors results in an acute rejection within ve to eight days.37 Organ transplant recipients are maintained on lifelong immunosuppressive therapy to prevent rejection of the foreign allograft (Table 3). The most current General Immunosuppression Protocol for Feline Kidney Transplant Drug Pretransplantation Cyclosporine Dose 3–5 mg/kg PO b.i.d. to t.i.d. Notes TABLE 3 Recipients* Microemulsified formulations are superior. Whole blood trough concentration should be approximately 500 ng/ml at time of surgery. Prednisone Maintenance (post-transplantation, lifelong therapy) Cyclosporine 0.25 mg/kg PO b.i.d. 3–5 mg/kg PO b.i.d. Decrease the dose from pretransplantation recommendations to achieve whole blood trough concentrations of 150–250 ng/ml if no episodes of rejection occur. Prednisolone 0.25 mg/kg PO b.i.d. for 30 days after transplantation; then if no episodes of rejection occur, decrease administration frequency to once per day 4–6 mg/kg IV b.i.d. 4–5 mg/kg IV b.i.d. to q.i.d. Treatment of acute rejection Cyclosporine Methylprednisolone sodium succinate *Specific drug and dose recommendations may differ among transplant surgeons. These general guidelines are modified from reference 38. 96 February 2008 VETERINARY MEDICINE
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