Nefrologia kliniczna

The problem of drug interactions is becoming more and more important in clinical practice. When using immunosuppressive drugs, the risk of pharmacokinetic interactions increases, which is directly related to their pharmacokinetic-pharmacodynamic profile. Knowledge of the most common interactions that occur in clinical practice allows for their active prevention, which in turn increases both the effectiveness and safety of the treatment used.

Tacrolimus, is a calcineurin inhibitor used in immu­nosuppressive treatment after kidney transplanta­tion with known potential neurotoxic effects. A rare complication that may occur even several years of tacrolimus therapy and manifest by serious vi­sual loss is optic neuropathy. Discontinuation of tacrolimus therapy rarely leads to improvement, but carries the risk of transplanted organ dysfunc­tion.

We present the history of 53-years old female with 41.5 BMI, who was treated with peritoneal dialysis due to the lack of regular vascular access to hemodialysis and contraindications to kidney transplantation. We contin­ued peritoneal dialysis for 6 years without any compli­cations resulting from this method of treatment. Introduction of peritoneal dialysis to obese persons is not an easy decision and should be always indi­vidualized.

Infectious complications and rejection processes constitute two major types of post-transplant complications. The gold standard of post-transplant patients’ management is to keep recipient’s immune system at such optimal level of competence that is low enough to prevent rejection being the same time high enough to protect them from serious infectious complications.

Patients after kidney transplantation may have com­plications from the eye. It is caused by both chronic immunosuppressive treatment and diseases that the patient is burdened with before kidney transplanta­tion and those that he develops after transplantation. The most important diseases affecting the condition of the eyes are diabetes and hypertension. Eye dis­eases such as glaucoma are also not without im­pact.

Encapsulating peritoneal sclerosis is a rare, but associated with high morbidity and mortality complication on long-term peritoneal dialysis (PD). The International Society for Peritoneal Dialysis (ISPD) in 2017, based on current literature data, prepared the 2009 update of the Position Statement regarding the effect of PD treatment time on EPS risk as well as prevention, diagnosis and treatment of this complication.

The incidence of surgical site infections (SSI) after organ transplantation is similar to other surgical procedures of comparable complexity. Compared to the beginning of transplant medicine, a general reduction in the occurrence of infections in transplant patients is observed, this results from the introduction of newer surgical techniques, immunosuppressive drugs and from perioperative antibiotic prophylaxis. Perioperative care is not without significance. Nevertheless, SSI in transplantology concerns, according to various sources, from 2% to even 40% of recipients and remains an important therapeutic and nursing challenge. The incidence of SSI is highest after intestinal transplantation, followed by liver and pancreas; however, after the transplantation of the kidney and heart, the percentage of SSI is much smaller. However, it concerns about 8% of kidney recipients. The aim of the work is to point to SSI risk factors, modifiable and unmodifiable, and to present the role of nursing staff in preventing SSI.

Diabetes mellitus remains the most frequent comorbid conditions in patients with chronic kidney disease (CKD) frequently leading to chronic kidney failure. Progression of CKD triggers several metabolic disorders, including those related to carbohydrate metabolism. Patients with CKD are characterized by an insulin resistance, additionally aggravated by several co-morbid conditions (such as for example chronic low-grade inflammation). Treatment with anti-diabetic medications in patients with CKD remains a challenge, since along with the progression of a disease dosing of several drugs needs to be adjusted (especially of those which are excreted with urine intact or as active metabolites). CKD progression also increases the risk of hypoglycemia in patients treated with anti-diabetic drugs and other adverse drug reactions. Usefulness of the new generation drugs has not yet been verified in patients with advanced kidney disease (although some of them act through the kidney-related mechanisms). The current position statement of the Polish Society of Nephrology Working Group provides the practical guidelines for the diagnosis and treatment of type 2 diabetes mellitus in patients with CKD.

Post-transplantation diabetes (PTDM) is a frequent problem in patients after solid organ transplantation. PTDM is more common in recipients with risk factors of diabetes mellitus, may also be associated with the immunosuppressive regimen used. No specific guidelines for diagnosis and pharmacotherapy of this type of diabetes have been established, therefore those for the treatment of diabetes in general population are followed. The basis of non-pharmacological treatment are diet, weight loss, regular physical exercise. In the choice of antidiabetic therapy in PTDM, additionally graft function and possible drug interactions (especially with immunosuppressive therapy) should be considered. Linagliptin, a dipeptidyl peptidase-4 inhibitor belonging to a relatively new group of diabetic drugs, appears to be an effective and safe drug in monotherapy, but also in combination with other hypoglycemic medications in patients with PTDM.

Calcimimetics provide a potential therapeutic benefit through suppressing parathyroid hormone (PTH) release without increasing calcium and phosphorus concentrations in patients with secondary hyperparathyroidism. In this report we present one center experience with cinacalcet given to six peritoneal dialysis (PD) patients. We observed 60–80% decrease of the baseline PTH concentration. In four patients we noticed very low PTH level which resulted in discontinuation of cinacalcet. There are only a few studies concerning calcimimetics application in PD patients. We would indicate that long-term cinacalcet therapy requires a regular PTH monitoring and very strict sequential dose titration especially in PD patients because of the increased risk of low-turnover bone disease.