Guidelines to assist outpatient management of people with kidney transplants
These guidelines are not an exhaustive manual covering all aspects of outpatient care. They are a summary of information covering points of information that we hope will help staff manage patients - especially those coming into the outpatient service. The clinical information included is neither exhaustive not updated frequently hence, wherever possible, links to authoritative guidelines provided by specialist professional bodies have been used. However, there is no such a thing as 'standard' or 'average' transplant recipient. Guidelines are there to support, not replace, experienced and considered medical opinion. We welcome and encourage feedback on what's good and what could be better, in the spirit of quality improvement.
Clinics are held on Monday, Wednesday and Friday mornings in OPD1 at the Royal Infirmary of Edinburgh (RIE). NHS Lothian doctors also provide outreach clinics for patients attending the Borders General Hospital and St John's Hospital.
Suggested schedule for outpatient appointments
- Three per week for first two weeks after discharge
- Weekly until week 8.
- Twice weekly until week 12-16 (depending on graft function).
- Monthly until end of first six months.
- Two - three monthly until end of first year.
- Three- six monthly during year two and beyond if stable with satisfactory graft function.
Clinic records and communication
- Ensure that medications, weight and blood pressure are kept up to date in the electronic patient record (EPR).
- Create immediate entry in EPR for patients returning to clinic the same week, mindful that paper letters may not be ready in time for next visit.
- Urgent changes to medications should be communicated immediately to the patient and the GP if they are required to issue a prescription or perform monitoring. All changes to medications or doses must be updated in Patient electronic record at the time of the change.
- Copy all clinic letters to patients unless they request otherwise. Encourage patient enrolment with Renal Patient View to avoid the necessity of copying all letters.
- Think carefully about the other clinicians who also require copies of letters – e.g. home renal unit if from another Health Board, other hospital clinics – e.g. Diabetes, Cardiology etc.
- Note the immunosuppression regime the patient is following clearly in problem lists – e.g. Standard protocol, higher risk protocol, Trial Protocol (e.g. 3C) etc – with desired Tacrolimus trough range where relevant.
Key actions post-transplant
- Remove stent – usually at 8 weeks
- Stop co-trimoxazole – usually at 3 month
- Adjust Valganciclovir dose according to Cockcroft-Gault Creatinine Clearance
- Stop Valganciclovir – usually at 6 months
At every visit check for
- Graft dysfunction: rejection, infection, obstruction, ischaemia, toxic/metabolic injury
- Metabolic Disease
- Cardiovascular disease
- Progressive graft failure requiring preparation for further dialysis/transplant
For useful information on commonly prescribed medications, please see the immunosuppression appendix on the last page of this handbook. This includes details of drug interactions with these agents.
Specific issues to consider post-transplant
New onset diabetes after transplantation (NODAT)
NODAT is a well-recognised phenomenon. Risk factors/precipitants include medications – especially steroids, CNIs & Sirolimus, previous impaired glucose tolerance and family history of diabetes. An HbA1c >6.5% (IFCC>48) may be suggestive of NODAT.
Where confirmed with either a diagnostic fasting blood sugar (>7 mmol/L) or with a positive glucose tolerance test (>11.1mmol/L 2 hours after 75g glucose), patients should be referred to a hospital diabetic clinic for further assessment and education. Where sugar levels are not controlled with avoidance of high sugar food, oral hypoglycaemic agents may be started by the transplant clinic or – preferably – the General Practitioner or Diabetes clinic.
Medications – especially immunosupressent drugs – should be reviewed in the Transplant clinic and consideration given to steroid withdrawal and/or CNI/Sirolimus dose reduction. Such decisions should be made on a case by case basis with a full assessment of risk of rejection, including discussion with Consultant H&I Clinical Scientists and review of previous episodes of rejection with Consultant Pathologist.
Secondary hyperparathyroidism is common after transplantation and usually represents persistent disease in patients who have been on dialysis, often for years. The current evidence is that this may take over a year to settle down with good graft funcation and therefore it would be premature to recommend anything other than medical treatment for at least the first year. There is no current evidence in the literature as to what level of parathyroid hormone is acceptable in transplant patients.
Our current policy is that it should be normalised as far as possible using Alfacalcidol 0.25 - 1ug daily.
All patients continuing with corticosteroids should be on Alfacalcidol 0.25 1ug/day, Calcitriol 500ngs and calcium supplementation (up to 2 tabs) daily or Calcichew D3 ( if they have normal kidney function).
PTH should be checked at 1 month, 3 months and 6 months after transplant and thereafter at 6 monthly intervals. Patients uncontrolled (tertiary) hyperparathyroidism should be referred for surgery or considered for cinacalcet therapy if not appropriate for surgical parathyroidectomy.
Hyperuricaemia and associated arthropathy (‘gout’) are common problems for renal transplant recipients. Risk factors include reduced eGFR, diet rich in uratogenic nutrients and medications that increase plasma urate levels, including commonly used immunosuppressants and drugs to treat cardiovascular disease.
Treatment of gout requires some modification from standard therapy in non-transplant patients. These include:
- Avoid NSAIDs if at all possible
- Use new/increased dose of Prednisolone as first line treatment for attacks. Eg 15mg OD for 5 days (with a further 5 days if increasing the dose of xanthine oxidase inhibitor.
Note high risk of adverse interaction between azathioprine and allopurinol
- Consider colchicine (0.5mg bd if tolerated) as alternative therapy for acute attacks but beware significant risk of diarrhoea, increasing risk of acute kidney injury, deranged tacrolimus levels or non-compliance.
Benzbromarone can be used as alternative prophylactic agent but patients need to be conselled on the risk of liver damage (estimated 1:70000 risk of severe liver damage). There's also a theorectical risk of crystal nephropathy. Read Lee et al for a recent review on the risks and benefits of benzbromarone.
- Some drugs – including diuretics and some beta-blockers can increase the risk of hyperuricaemia. Conversely, LOSARTAN (but not other A2RBs or ACEis) decreases serum uric acid levels and can be used as an adjunctive treatment for gout. Read the 2012 BMJ review by Choi et al for further information.
Transplant recipients have a very high relative risk of developing skin cancers – approximately 50x that of untransplanted/non-immunosupressed comparable people. The single greatest risk for skin cancer is UV damage to DNA, acquired through exposure to direct sunlight or artificial ‘tanning’ machines.
Patients should be questioned about the appearance of new skin lesions at follow up outpatient consultations. New lesions should be examined by an experienced doctor and, if features of concern are present, referral made to Dermatology Outpatient Dept, Lauriston Buildings, Edinburgh with the heading ‘Possible skin malignancy’ at the top of the letter.
Professor Jonathon Rees (Grant Professor of Dermatology, Edinburgh University) has produced an online textbook of skin malignancies and their mimics, which we strongly recommend consulting.
Consider any changes to immunosuppression that may be required – eg conversion of tacrolimus to ciclosporin and/or MMF to azathioprine. Refer for pre-conception counselling clinic (joint Obstetrician/Nephrologist service).
Advice on male fertility or risk of birth defects for male transplant recipients can be obtained from the Edinburgh Fertility Centre, RIE. In general, risks for clinically significant disorders of spermatogenesis are very low.
Recommended resources for common clinical problems encountered in the Renal Transplant Clinic