eGFRsupport: Renal support : renal transplant recipients electronic guideline (686)

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Introduction

Renal transplant recipients are at increased risk of infection, cardiovascular disease, drug interaction, various degrees of renal impairment and transplant rejection. Early discussion with the renal on-call will allow tailored advice and expedite investigation in case of potential rejection.

Assessment / monitoring

Clinical history:

  • Ask about adherence to medication, additional new drugs, transplant pain,urine output and weight changes.

Clinical examination:

  • Review patient observations. Remember pyrexia may be masked.
  • Examine for evidence of infection, transplant pain and assess fluid status


Investigations:

  • UEs, LFTS, Bone, FBC, CRP
  • If relevant check trough level of ciclosporin or tacrolimus (EDTA tube in themorning before morning medication).
  • Send at least one urine sample for culture, even in the absence of dipsticknitrites or leucocytes

Management

General principles

  • Transplant patients should not miss doses of immune suppression unless adecision has been made to withhold drugs e.g. due to sepsis.

  • Be aware there are multiple interactions between common acute prescriptions(e.g. antibiotics) and immunosuppression. Check for interaction risk in all newprescriptions.

 

Infection

  • Common infections may present atypically in on immunosuppressed patients. Alltransplant recipients presenting with a fever, nausea or general decline should bescreened for infection with a urine dip and MSU, blood culture and CMV/EBVPCR as baseline tests. Further investigations should be guided by the clinicalpresentation.

  • Although community acquired organisms remain more common, Pneumocystispneumonia may present, even several years, following a transplant. Clinicalsuspicion should be raised by hypoxia (more marked following exertion), arelatively normal respiratory examination and bilateral infiltrates on CXR.Diagnosis requires induced sputum or BAL and all suspected cases should bediscussed with the renal unit.

  • Urinary infection is common and may present with transplant dysfunction.Urinalysis is not always informative. Send a mid-stream urine for culture in allsuspected of UTI.

  • In severe sepsis it is usually advisable to increase their steroid, withhold the antiproliferative (MMF/Azathioprine) and monitor, reduce or stop their tacrolimus orciclosporin.

  • Where reduction of immunosuppression is being considered in sepsis all casesmust be discussed with the renal unit.

 


Renal dysfunction

  • Acute renal dysfunction in transplant recipients can occur for all the samereasons as those without a transplant. Refer to AKI section.

  • Unique considerations include: increased risk of infection, transplant drug toxicity,transplant obstruction, vascular abnormalities and rejection.

  • We advise all case of transplant function are assessed as per AKI advice abovewith the addition of: transplant ultrasound, ideally with vascular doppler, in thosewith significant (doubling in baseline SCr) or slow to resolve AKI (no improvementwithin 24 of treatment) and trough drug levels (ciclosporin or tacrolimus)

  • We advise all cases of AKI in transplant recipients are discussed with renal toallow rapid organisation of biopsy, if necessary.

Drug therapy/treatment options

Immunosuppression

  • With the exception of severe sepsis, immunosuppression should continueuninterrupted during hospitalisation. Reductions must be discussed with the renalon-call.

  • If nil by mouth, we advise insertion of an NG tube and continuing enteral dosingunless otherwise contra-indicated.

  • If conversion to IV is required discuss the case with a renal pharmacist for adviceon dosing and monitoring.
Drug Monitoring Notes
Prednisolone Not required

In those on long term steroid there is a risk of hypoadrenalism during cases of physiological stress (e.g. sepsis or surgery).

A transient increase in steroid dose (doubling) can limit this, although is rarely required in those on ≥20mg daily.

Tacrolimus *Monitor trough serum concentration.

Multiple drug interactions exist, most commonly noted following use of macrolide antibiotic (e.g. clarithromycin for LRTI) and antifungals leading to toxic levels.


Consider withholding in severe sepsis


NBM: when converting to IV give one fifth of total daily dose over 24 hours and monitor levels

Ciclosporin *Monitor trough serum concentration.

Multiple drug interactions.


Consider withholding in severe sepsis


NBM: when converting to IV give one third to one half of oral dose as a bolus infusion

Mycophenolate May cause neutropenia, monitor FBC

An ‘antiproliferative’. Withhold in cases of sepsis, review daily. Restart once sepsis improving.


Major side effect is GI upset which may necessitate a dose reduction.

Azathioprine May cause neutropenia, monitor FBC

An ‘antiproliferative’. Withhold in cases of sepsis, review daily. Restart once sepsis improving.


Risk of severe pancytopenia (and agranulocytosis) if concurrently prescribed with Allopurinol. Avoid this combination completely

Co-trimoxazole Monitor U&Es

Used prophylactically in first 6 months following acute transplant and in treatment of PJP pneumonia.


Risk of hyperkalaemia, hyponatraemia and renal dysfunction. Monitor daily U&Es when on treatment doses.

Box 1 – Common transplant medication considerations


*trough serum concentrations are best checked on a morning sample. The patientmust know to withhold their dose of tacrolimus or cyclosporine until their blood sample is taken, then take their usual dose. Results are usually available by late afternoon and dose adjustments made after reviewing the level. Contact the renal-on call for advice on levels.

Other information

Discharge planning

Contact the renal-on call on discharge to ensure appropriately timed follow-up is in place and a clear plan is made to re-instate immune-suppression if alterations were made.

Last reviewed: 09 March 2022

Next review: 09 March 2025

Author(s): Mark Findlay

Version: Version 3

Approved By: Regional Services Directorate Clinical Governance Board

Document Id: 686