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Important: Protocol superseded July 2009 - see new version here at www.edren.co.uk.
That website is in development - you can ignore the 'This website is not ready' signs ONLY for the Transplant protocols. Others are not updated or fully transferred. |
The page describes the immediate and later post-operative management of renal transplant patients in Edinburgh.
| 1. | Check FBC and Us& Es immediately post-op. Serum K+ must be known and result discussed with Registrar, if possible hyperkalaemia should be managed with Insulin/dextrose and nebulised Salbutamol rather than haemodialysis. Subsequent repeat Us & Es 12 hourly (more frequently if indicated or as decided by Registrar). |
| 2. | Arrange chest X-ray for position of central line. |
| 3. | Initial IV fluid replacement is Normal Saline at 40 mls/hr + last hour's output. This should be adjusted according to clinical assessment and CVP. Usual target CVP is 5-10 cm water. Boluses of Normal Saline (or colloid) may be needed to raise a low CVP. Failure of the patient to respond to IV Fluid with a rise in CVP or BP should raise possibility of bleeding. These measures should always be instigated by a senior member of staff. If there is a possibility of bleeding a transplant surgeon must be contacted. |
| 4. | Continuing IV fluid replacement should be maintained with alternating 5% Dextrose and Normal Saline initially - more dextrose if high volumes of urine. |
| 5. | Analgesia is by PCA morphine/Fentanyl. Inadequate pain relief may herald serious pathology and should be discussed with a senior surgical colleague/Anaesthetist. NSAIDs are absolutely avoided. Live donors will receive an epidural infusion (see Appendix VI) |
See Immunosuppression section
All patients on triple therapy reeceive COTRIMOXAZOLE 480mg daily for the first three months to prevent Pneumocystis carinii pneumnonia. For more info see Pneumocystis page.
If the patient is sensitive to Septrin then the Sulphonamide de-sensitisation protocol should be instigated. (See Pneumocystis).
For the management of CMV negative recipients who receive a kidney from a CMV positive donor refer to the CMV protocol.
- U's & E's daily marked "PRIORITY"; result returned by fax
- FBC daily
- LFTs, glucose, urate, Ca and PO4 - daily
- Tacrolimus or Ciclosporin level - M/W/F
- MSU each Monday and at other times if clinically indicated
- Chart all results on flow sheets and plot creatinine on log graph dailly
Redivac drain removed at 24 - 48 hours at surgeon's discretion.
Urinary catheter removed at day 5 unless
- the patient is anuric (may be removed earlier)
- the patient is polyuric (may be removed later)
Check catheter function. Gentle catheter irrigation should only be performed after surgical consultation and preferably by the surgeon. Seek advice urgently if urine output has started but subsequently ceased.
Any drop in urine output, rise in creatinine or change in log creatinine slope should be discussed immediately with a senior colleague. Management will depend on the clinical situation but acute rejection must always be suspected. The physical signs are often absent and urgent investigation is required.
A routine graft biopsy is preformed around day 5 if there is a delayed graft function and subsequently at weekly intervals until function is established. This is to diagnoses acute rejection co-existing with ATN.
Any deterioration in graft function may require a graft biopsy which will be requested by a senior member of staff. Refer to full biopsy protocol.
See approach to altered graft function and full protocol for treatment of rejection
Due to prolonged ischaemic times/ATN etc., not all kidneys function immediately and some take a few days or even weeks before functioning. During this time the aim is to ensure that we are not missing concomitant rejection or other catastrophe.
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DAY 1 |
Duplex scanRoutine immunosuppression. Alternatively Basiliximab may be given Day 0 and Tacrolimus dosage halted. |
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DAY 5 |
If no evidence of improvement then biopsy to exclude rejection. |
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Around DAY 12 |
Repeat Duplex/biopsy. |
Uncomplicated patients usually discharged day 10-14.
See below for patients from other hospitals. Patients are usually seen three times monthly at first, in the OPD1 Transplant Clinic on Monday, Wednesday and Friday mornings. An appointment and transport if requried must be arranged prior to discharge. It there is no clinic or if patient needs to be seen more frequently then they will be seen in Ward 206 following discussion with the nurse in-charge.
Appointments in ward 206 - If patient needs to attend for bloods on day when there is no transplant clinic in OPD1 the patient will attend ward 206. Appointments should be recorded in the Diary including what tests are required, any special arrangements and the date of the next appointment. Patients should always attend before 9.15 am so that their drug assays may be run the same day. Blood forms should be completed in advance so that the phlebotomist can take their blood during the ward round.
Tacrolimus / Ciclosporin / MMF shared care protocol must be included with the immediate discharge letter. Formal discharge summary is dictated as soon as possible.
At each out-patient review the following are checked:
- Blood pressure, (pulse, temperature; if necessary)
- Weight
- Blood taken for U & Es, LFT, CAP, FBC and Tacrolimus/Ciclosporin
- MSU
- Urine dipstick
- Medication - any alteration to immunosuppression required should be documented on the patients medication sheet which was issued to the patient on discharge, and up-dated on the patient's computerised record by the clinician making the alteration.
- PTH checked 1 month, 3 months and 6 months.
Results of out-patient bloods must be checked as soon as possible and patients may be recalled for repeat checks or 'phoned' to alter their dose of Tacrolimus/Cyclosporin. Any alteration to dose should be documented in the patients case notes and on the drug screen of Proton.
Transferred when stable as an in-patient to the Renal Unit at the referring Hospital (as out patients only if recovery quick or transfer delayed).
Prior to discharge the centre must be contacted before and on day of discharge. A copy of the patient transfer details sheet (medical and nursing) (See Appendix 5) with a computer printout of the biochemistry, haematology, Tacrolimus results and discharge letter should accompany patient on transfer and/or faxed to receiving unit.
Transferred from Out-patient department when stable. A letter must be sent to the patient’s local consultant prior to transfer.
There are many factors to be considered. More detailed guidance is available in the outpatient protocols booklet, available separately. Major considerations besides graft function include:
- Immunosuppression: consider long-term level
- Urine infections
- Hypertension
- Hyperlipidaemia
- Glucose intolerance
- Arterial disease risk profile - weight, smoking, diet (lipids, hypertension)
- Gout and uric acid (note dangerous interaction between allopurinol and azathioprine)
- Bones - osteoporosis, renal osteodystrophy, hyperparathyroidism
- SKIN - sun avoidance, surveillance
- Contraception
- Pregnancy advice
- Cervical smears - annually
Acute rejection and drug toxicity remain important causes at all stages of a transplant. Review all the features mentioned above under post-op management – graft dysfunction. Consider too:
Biopsies should be examined with all these possibilities in mind – so include samples for electron microscopy and immunofluorescence.
These are pdf files:
Transplant protocols developed on the Edinburgh Transplant Unit. This page first published September 2002, updated December 2006 and last modified
NOTE that the accuracy of any statements in this information CANNOT be guaranteed. It is published in the belief that it is correct, and we endeavour to keep it so - but we do make mistakes. Furthermore, over some subjects there are differing opinions, or differing degrees of certainty. We have usually not attempted to discuss these here because the aim has been to provide an immediate and brief guide. In all areas, prior medical knowledge is assumed. The EdRenHANDBOOK is not suitable for use by those without such a background. Contact us by email or at the address given at the foot of the contents page with any comments or corrections.