Kidney Transplant Res Guide

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Kidney transplant res guide


<ul><li><p>Division of Organ Transplantation </p><p>Resident Manual </p><p> Rhode Island Hospital A Lifespan Partner </p><p>Compiled by: </p><p>Paul Morrissey, MD Revised: December 2011 </p><p>Available at: </p><p>Actuarial Survival </p><p>Tacrolimus + Mycophenolate regimen </p></li><li><p>2 </p><p>Table of Contents </p><p>ORDERS </p><p>Admissions to the Transplant Surgical and Medical Services </p><p>ORDERS after donor nephrectomy </p><p>ORDERS for renal transplant patients </p><p> Post-op </p><p>MEDICATIONS </p><p>Transplantation historical timeline </p><p>Immunosuppressive medications Mechanism of Action </p><p>Transplant medications - routine dosing and prescriptions </p><p>Steroids </p><p>GRAFT DYSFUNCTION </p><p>Early considerations after renal transplant </p><p>Algorithm for work-up of rising creatinine </p><p>Infectious complications </p><p>Late complications after transplantation (Ciba) </p><p>Clinical rejection </p><p> Hyperacute </p><p> Acute rejection </p><p> Chronic rejection </p><p>GENERAL INFORMATION </p><p>Success of renal transplantation </p><p>Live donor versus Cadaver Renal Transplant (CRT) </p><p>Organ Donation </p><p>Dialysis Access Game Plan </p><p>ASTS WEBSITE (Resident Education in Transplantation)</p><p>on/Resident1.aspx </p><p>Administrative issues </p><p>Transplant office and clinic </p><p> APC 921 </p><p> 444-5285 or 444-8345 </p><p>Transplant surgeons </p><p> Kevin Charpentier 350-3848 (b) </p><p> Paul Morrissey 350-1385 (b) </p><p>Transplant physicians </p><p> Reg Gohh 350-5553 (b) </p><p> Terri Montague 350-7227 (b) </p><p> Staci Fischer 350-9022 (b) </p><p>Transplant Manager </p><p> Bette Hopkins-Senecal 350-5523 (b) </p><p>Transplant Clinical Coordinators </p><p> Nancy McNamara, RN 444-3186 </p><p> Mary Ellen Espanola, RN 444-3284 </p><p>Rounds </p><p> The team meets at 9:00 (8:30 on Thursday for Journal Club) to </p><p>discuss patients. Walk rounds begin at 4:00 PM on 4A or 5ISC. </p><p>Clinic (Surgery residents attend one clinic per week) </p><p> Tuesday - Dr. Morrissey (1:00 PM) </p><p> Friday - Dr. Charpentier (9:30 AM) </p><p>Surgery </p><p> Renal transplant with Senior Resident or AR-III (cadaveric) </p><p> Donors by AR-II; AV access with AR I or II </p><p> PD catheters and PermCaths with AR I or II </p><p>Resident Duties Routine care of in-house transplant surgical </p><p>patients, discharge summaries, admissions, consultations and in-</p><p>house pre-ops. </p></li><li><p>3 </p><p>Kidney Donors Donor nephrectomy is unique among surgical procedures as the patient is </p><p>undergoing major surgery with all its risks (1% incidence of major </p><p>complication, 0.03% incidence of mortality) for no medical benefit. </p><p>Therefore, special attention to detail is required for the donors safety. </p><p>Eligible donors are in good health, ABO compatible with the recipient </p><p>and have normal renal function. Spouses and close friends are potential </p><p>unrelated donors. Pre-op testing consists of physical exam, labs, 24-hr. </p><p>urine collection for creatinine clearance, renal ultrasound and CT </p><p>angiogram (for renal anatomy). The surgery is performed (1) </p><p>laparoscopically, (2) mini-open nephrectomy via an anterior-</p><p>retroperitoneal approach or (3) via a flank incision (over 11th rib). </p><p>POST-OP Typical course through discharge </p><p>Prophylactic Rx: Spirometer, heparin 5000U sc bid x 48 hr </p><p>Sequential compression devices (Venodyne boots) </p><p>Pain management: PCA for 1-2 days </p><p>Clear liquid diet </p><p>POD #1 </p><p>Heplock or KVO I.V. when tolerates adequate P.O. </p><p>D/c Foley catheter; d/c Venodyne boots when ambulating </p><p>Advance to regular diet as tolerated. </p><p>Check CBC, BUN/creatinine </p><p>POD #2 </p><p>Check CBC, BUN/creatinine </p><p>POD #3 </p><p>D/c PCA </p><p>Vicodin (or Percocet) for analgesia </p><p>Laxative prn (begin P.O., then use suppository if no effect) </p><p>D/c to home today or next day </p><p>F/U 10-14 days in Transplant Clinic </p><p>One week supply of analgesics (usually 20-30 tablets) </p><p>Donors </p><p>There are two sources of kidneys: either a living donor (relative, </p><p>spouse or friend, e.g.) or a deceased donor (brain dead or donor </p><p>after circulatory death (DCD)). Live donors are preferred for many </p><p>reasons, especially the reduced time on dialysis for the recipient. </p><p>Item Live donor Deceased donor </p><p>Allograft half-life 12-14 years 8-9 years </p><p>Waiting time 2 - 4 months 18 - 48 months </p><p>Donor Age 18 - 65 4 - 70 </p><p>Quality of kidney Excellent Fair to excellent </p><p>Immediate function 97 % 50 % </p><p>DGF* 2 % 30 % </p><p>Hospital LOS 5 - 7 days 5 - 14 days </p><p>Surgery Planned Urgent </p><p>Immunosuppression Lower doses Standard </p><p>Risk of acute rejection 5 - 10 % 15 - 20% </p><p> *Delayed graft function requires dialysis after transplant. </p><p>Requirements for live donor renal transplants </p><p>1. Compatible blood type ABO, HLA matching not required </p><p>2. Excellent health low operative risk </p><p>3. Normal renal function 24 hour urine collection, U/S and CT </p><p>4. Proper motivation (voluntary donation) </p><p>Risks to the Donor </p><p>Hyperchloremic metabolic acidosis (Kellum JA. CCM 2002; 30: 259.) </p><p>Major complication &lt; 1 % (e.g. - bleeding, injure adjacent structure, </p><p>AMI, DVT or PE, significant injury to donor kidney) </p><p>Lifetime risk of HTN, ESRD same as general population. </p></li><li><p>4 </p><p>DECEASED ORGAN DONORS </p><p>Brain Dead Donor </p><p> Standard criteria donor (SCD) other than ECD </p><p> Expanded criteria donor (ECD) </p><p>1. Donor age &gt; 60 years or </p><p>2. Donor age &gt; 50 with 2 of the following: </p><p>a. Pre-retrieval creatinine &gt; 1.5 mg/dL </p><p>b. Death from CVA </p><p>c. History of hypertension </p><p>Donor after Circulatory Death (DCD) </p><p> Donor with irreversible brain injury, family decides on CMO </p><p>status, organs (usually kidneys liver) are recovered after </p><p>extubation and progression to circulatory arrest (5 minutes). </p><p>TRANSPLANT RECIPIENT MANAGEMENT - FLUIDS </p><p> 0.9 % Saline </p><p> Volume - most patients get 2-3 L in the OR and cc/cc </p><p>replacement of UO thereafter. Hypovolemia is unusual post-</p><p>op. The CVP is a rough (though inaccurate) measure; </p><p>however aiming for a CVP &gt; 10 is a reasonable guide. </p><p> Urine output most live donors have an initial UO of 200-1000 </p><p>cc/hr, while a deceased donor with ATN might be expected </p><p>to be oliguric. </p><p> BP - high normal or slightly elevated BP is best for renal </p><p>reperfusion. Even low normal BP can result in ATN and </p><p>requirements for dialysis post-op. Goal &gt; 130 mm Hg. </p><p>BP MANAGEMENT POST-OP </p><p> The short-term effects of hypotension (ATN, DGF) complicate </p><p>patient care after renal transplantation. The short-term effects </p><p>of hypertension are minimal, especially in this population with </p><p>&gt; 85% incidence of hypertension. SBP 130. Use neosynephrine PRN </p><p>for BP support if SBP and urine output are low. </p><p>ACTIVITY: OOB to chair POD #1, then ambulate </p><p>NURSING: </p><p> Strict I &amp; O </p><p> CXR in PACU R/O pneumothorax if new line placed. </p><p> Foley to gravity, d/c Foley catheter on POD #5 </p><p>MEDS: </p><p> Induction: Thymoglobulin (high immune risk or high risk </p><p>of DGF) or basiliximab (Simulect). </p><p> Immunosuppression: usually tacrolimus (Prograf), </p><p>mycophenolate mofetil (CellCept) or EC-MPA (Myfortic) </p><p>and steroid taper as below. </p><p> Day 1 Solumedrol 250 mg IV times one, then </p><p>Prednisone taper as follows: </p><p> STANDARD </p><p> Day 2-6 Prednisone 30 mg po BID </p><p>Day 7-14 Prednisone 20 mg po BID </p><p>Day 15-21 Prednisone 10 mg po BID </p><p>Day 22-28 Prednisone 10 mg po AM, 5 mg PM </p><p>Day 29 onward Prednisone 10 mg po QD. </p><p>or </p><p> RAPID TAPER </p><p> Day 1 Solumedrol 250 mg </p><p> Day 2 Prednisone 40 mg po BID </p><p>Day 3 Prednisone 20 mg po BID </p><p>Day 4 Prednisone 10 mg po BID </p><p>Day 5 onward. Prednisone 10 mg po QD </p></li><li><p>5 </p><p>POM contains order sets for the donor and recipient. Some </p><p>explanations and instructions are given below. </p><p>LABS: </p><p> Every 6 hours x 24 hours, then q 12 hr on POD#2, then QD. </p><p> Tacrolimus level or CsA level QD beginning day after </p><p>medication begins. </p><p> Ca, Mg, PO4 may become depleted with high volume diuresis. </p><p> CBC with differential (lymph count guides Thymoglobulin </p><p>dosing) </p><p>IV Fluids: </p><p> Replacement cc/cc of urine output due to tubular injury </p><p> Replacement IVF is NS (similar [Na+] to urine) </p><p> D5 NS is maintenance until adequate PO intake </p><p>Other management issues: </p><p> JP Drain d/c when output &lt; 50 cc/ day </p><p> Foley d/c on POD #5 </p><p> PCA d/c on POD # 2 </p><p> Dressing change prn and always by POD # 2 </p><p> Daily weights </p><p> CVL d/c on AM of discharge </p><p> RN may draw labs from CVL </p><p>Rationale for ancillary medications after renal transplant </p><p> Antacids Ulcer prophylaxis due to steroids and for dyspepsia </p><p>due to Cellcept (common side effect) </p><p> Bactrim Single Strength PCP, Nocardia and UTI prophylaxis </p><p> Mycelex Thrush prophylaxis </p><p> Ketoconazole - Fungal prophylaxis and CYT p450 3A </p><p>inhibition (used when CsA is 1* immunosuppressant). </p><p> Valganciclovir - CMV and EBV (Mononucleosis and </p><p>lymphoma) prophylaxis. </p><p> BP medications 85% of recipients have HTN. Blood pressure </p><p>at the time of discharge is often high (due in part to immuno-</p><p>suppression and volume overload) and BP is gradually adjusted </p><p>as an outpatient. </p><p> Insulin Type I DM or patients on oral agents at the time of </p><p>transplant invariably require insulin therapy on discharge. </p><p>Managing BS after transplant is optimally done with a QD </p><p>Lantus regimen and Humolog sliding scale transitioned to pre-</p><p>meal short-acting insulin. Minimally elevated FSBS (120 </p><p>200s) can initially be controlled with sliding scale insulin and </p><p>adding an oral agent or longer-acting preparation as indicated. </p><p>Prudent use of peri-operative Lantus (for patients on insulin pre-</p><p>transplant) and sliding scale insulin should limit the need for an </p><p>insulin drip in most patients. </p></li><li><p>6 </p><p>Preferred peri-operative and long-term blood pressure management: </p><p> Class Example Note </p><p> Beta-blocker Atenolol, Toprol First line </p><p> CaCB (Dihydropyridine) Norvasc Second line </p><p> Alpha blocker Cardura QHS dosing </p><p> Diuretic Lasix Volume overload </p><p>Treatment of Hypertensive Urgency vs. Emergency </p><p>A hypertensive emergency is a condition in which elevated blood </p><p>pressure results in acute target organ damage. The systems primarily </p><p>involved are the CNS, the CV system, and the kidneys. In order to </p><p>diagnose malignant hypertension, papilledema must be present. </p><p>Accelerated Htn is defined as a recent significant increase over </p><p>baseline blood pressure that is associated with target organ damage. </p><p>Funduscopic exam may show vascular damage (flame-shaped </p><p>hemorrhages). </p><p>Hypertensive urgency must be distinguished from emergency. </p><p>Urgency is defined as severely elevated blood pressure (systolic </p><p>&gt;220 mm Hg or diastolic &gt;120 mm Hg) with no evidence of target </p><p>organ damage. </p><p>Hypertensive emergencies require immediate therapy to decrease </p><p>BP within minutes to hours. No evidence suggests a benefit from </p><p>rapidly reducing BP in patients with hypertensive urgency. Such </p><p>aggressive therapy may harm the patient, resulting in cardiac, renal, </p><p>or cerebral hypo-perfusion. Increasing the dose of an existing BP </p><p>med or adding another medication is the best approach. </p><p>The cardiac presentation of malignant Htn is angina, AMI or CHF. </p><p>Neurological presentations are occipital headaches, cerebral infarct, </p><p>cerebral hemorrhage, or hypertensive encephalopathy. Hypertensive </p><p>encephalopathy is a symptom complex of severe hypertension, </p><p>headache, vomiting, visual disturbance, mental status changes, </p><p>seizure, and retinopathy with papilledema. Focal signs and </p><p>symptoms are uncommon. Renal disease presents as proteinuria, </p><p>microscopic hematuria, red blood cell casts, and oliguric renal </p><p>failure. </p><p>Differential Diagnosis: complications of pregnancy; cocaine; </p><p>withdrawal of alcohol, beta-blockers, or alpha-stimulants; renal </p><p>artery stenosis, pheo, Ao coarctation, and hyperaldosteronism. </p><p>Treatment of Hypertensive Urgency/Emergency borderline cases </p><p>requiring more than gradual increasing of Htn medication. </p><p>Labetalol (alpha and beta-blocker) is a safe and effective agent to </p><p>consider, provided that the patient does not have asthma, heart </p><p>failure, or heart block. </p><p>Add 2 vials of Labetalol (40ml) to 250 ml D5W and start at </p><p>3ml/min. The BP should start to drop within half an hour. Labetalol </p><p>can also be given as a 20mg bolus over 2 minutes; repeated with a </p><p>40 mg dose every 10 minutes until the desired BP is reached or 300 </p><p>mg have been given. Response is usually within 5-10 minutes. </p><p>Hypertensive Emergency (Encephalopathy, AMI, CHF or unstable </p><p>angina) - Admission to ICU is warranted. </p><p>Nitroprusside (Nipride, 0.25 ug/kg/min). It dilates both arteries and </p><p>veins and is not associated with tachyphylaxis. It's onset of action is </p><p>rapid and minute by minute BP monitoring is required. </p><p>Hydralazine 5-25 mg IV, coupled with a beta blocker to prevent </p><p>reflex tachycardia is a safe alternative. Hydralazine may be repeated </p><p>q4h as necessary. </p><p>Esmolol is also a reliable drug in this situation and can be </p><p>administered by IV infusion. </p></li><li><p>7 </p><p>Timeline of Immunosuppressive Agents in Transplantation </p><p> 1954 None available (Identical twin transplant - PBBH) </p><p> 1959 - Total body irradiation and cancer chemotherapeutics </p><p> Fraternal Twins in Boston and Paris are first successful </p><p>transplants with immunosuppression. </p><p> 1960 - 6-mercaptopurine </p><p> 1961 Azathioprine (imidazole derivative of 6-MP) </p><p> First successful Cadaver Renal Transplant reported. </p><p> 1962 - Prednisone </p><p> 1965 Polyclonal antibodies to T-cells: ALG / ATGAM with </p><p>serum obtained from horses, goats, and rabbits. </p><p> 1975 - Donor specific transfusions given pre-transplant </p><p> 1975 - OKT3 (mouse monoclonal Ab versus CD3) </p><p> CD3 = receptor expressed on all T cells </p><p> 1978 - Cyclosporine (available clinically in 1983) </p><p> 1994 - Tacrolimus (FK506) </p><p> 1995 - Mycophenolate mofetil (Cellcept) </p><p> 1998 - IL-2R monoclonal Ab (Simulect, Zenapax) </p><p> 1999 Thymoglobulin Rabbit ATG)* </p><p> 1999 - Sirolimus (Rapamune) </p><p>* FDA approved for treatment of rejection versus other agents </p><p>approved for the prevention of organ rejection following </p><p>renal transplantation. </p><p>Drug Protocols and Rationale </p><p>Triple Therapy: a three-drug combination for immunosuppression, </p><p>which allows for adequate immunosuppression with modest doses </p><p>of all three drugs. In theory, side effects of each drug are </p><p>minimized. Prograf (tacrolimus) </p><p> Cellcept (mycophenolate mofetil) of Myfortic (MPA) </p><p> Prednisone </p><p> Prograf (tacrolimus) </p><p> Imuran (azathioprine, if Cellcept not tolerated) </p><p> Prednisone </p><p> Neoral (cyclosporine) </p><p> Azathioprine or Cellcept </p><p> Prednisone </p><p> Rapamune may be substituted for Prograf, Neoral or Cellcept </p><p> Induction Therapy Antibody (Simulect, Thymoglobulin (rabbit </p><p>antithymocyte globulin) or OKT3) used at the time of the initial </p><p>transplant as prophylaxis rather than therapy for acute rejection. </p><p>Currently, we offer Ab induction to patients with a PRA &gt; 20%, </p><p>repeat transplant, high likelihood of delayed graft function or a plan </p><p>to limit other immunosuppression (steroid withdrawal, e.g.). </p><p> OKT3 monoclonal Ab to CD3 (First mAb ever in clinical use.) Used for the treatment of severe acute rejection. Associated with </p><p>cytokine release syndrome (fever, hypotension, CHF). </p><p> Basiliximab chimeric mouse-human mAb to IL-2 receptor (CD25) Benefit in reducing acute rejection (40% versus 20% at 6 </p><p>months) and allowing safe steroid minimization. </p><p> rATG polyclonal Ab against many T-cell antigens produced by immunizing rabbits with human thymocytes. Pre-medicate with </p><p>steroids, diphenhydramine (25 mg) and acetaminophen (650 mg) to </p><p>prevent cytokine release syndrome....</p></li></ul>