Kidney Transplant Guide

UCLA Kidney and Pancreas Transplant Program

The goal of the kidney transplant service is to provide optimal medical and surgical care of patients with chronic kidney disease (CKD). In most cases, a kidney transplant is the optimal therapeutic modality. These patients receive a thorough pre-transplant evaluation. If necessary, additional tests are reviewed prior to determining if the patient is a suitable candidate for the procedure. When a suitable kidney donor is identified, the patient is admitted to the hospital and quickly evaluated to ensure that it is safe to proceed with kidney transplantation. The patients usually have a brief hospital stay until they are able to take medications orally. They are then followed very closely as outpatients to manage the immunosuppression. Approximately 25 patients are referred for evaluation each week. We currently have over 1900 patients on the cadaveric waiting list and we transplant over 280 patients per year. This program has developed an excellent national reputation because of the close working relationship between Nephrology and Urology. The kidney and pancreas transplant staff are available to answer any questions regarding the care of these patients.

Staff

Gabriel M. Danovitch, MD Medical Director 07097

Alan H. Wilkinson, MD Medical Director 10530

Thu Pham, MD Transplant Nephrologist 18062

Edmund Huang, MD Transplant Nephrologist 20911

Suphamai (Mike) Bunnapradist, MD Transplant Nephrologist 17839

Irene Marker, NP Transplant Nurse Practitioner 25823

Robert Ettenger, MD Pediatric Transplant Nephrologist 07485

Eileen Tsai, MD Pediatric Transplant Nephrologist 23173

Elaine Reed, MD Histopathologist 90885

H. Albin Gritsch, MD Transplant Surgical Director 10142

Jeffrey Veale, MD Transplant Surgeon 24145

Jennifer Singer, MD Transplant Surgeon 16322

Gerald Lipshutz, MD Transplant Surgeon 23424

Peter Schulam, MD Urologist – Donor Surgeon 18088

Melissa Dunbar-Forrest Kidney Dept. Nurse Manager 96371

Malou Blanco-Yarosh, MSN 8 E/W Clinical Nurse Specialist 91341

Elisabeth Hands, RN In-Patient Transplant Coordinator 94108

Angela Phelps, RN In-Patient Transplant Coordinator 93696

Scott Snider, RN In-Patient Transplant Coordinator 95587

Jenny Marik, RN Pediatric Coordinator 96692

Yolanda Tejedor, RN Pediatric Coordinator 95664

Suzanne McGuire, RN Donor Transplant Coordinator 90448

Tonya Frazier, RN Donor Transplant Coordinator 92307

Jennifer Makely, RN Donor Transplant Coordinator 98877

Mishon Surprenant, RN Transplant Coordinator-Active 90456

Prest Oshodi, RN Transplant Coordinator-Active 97138

Christine Lee, RN Transplant Coordinator-Pre 97101

Jill Strejc, RN Transplant Coordinator-Pre 96819

Myrlin Agunod, RN Clinic Transplant Coordinator 90447

Ilana Berg, RN Clinic Transplant Coordinator 94503

Mara Hersh-Rifkin, MSW Transplant Social Worker 94483

Andrea Gast, MSW Transplant Social Worker 65552

Tedd Sievers, Pharm. D. Transplant Pharmacist 90159

Pamela Anderson RD Transplant Dietician 96169

Scheduling your time

The unpredictable nature of deceased donor transplantation will necessitate a constant changing of priorities for patient care. The UCLA Urology house staff will round on the kidney transplant patients on the urology service. The Liver Transplant Fellow will be responsible for the pancreas transplant patients, while the General Surgery or Kaiser Urology Resident will also be responsible for the adult and pediatric kidney transplant patients. The Urology Chief Resident will be notified by the on-call transplant coordinator of all cases and will schedule the case with the operating room. The Nephrology Fellow will round on the adult kidney and pancreas transplant patients and be responsible for communication with the medical teams for the patients on the medical service. The key to efficient patient care is teamwork, communication and anticipation of potential problems. When one resident is in the operating room, the other residents need to assume patient care so that the appropriate tests are obtained and management decisions can be made in a timely fashion during afternoon rounds.

In-patients should be examined in the morning. Generally, newly transplanted and ICU patients should be seen first. One fellow should follow-up any in-patient issues and the other fellow should be in clinic by 9 a.m. to manage the out-patients. At 0930 am we meet in the 8W rounding room and start rounds with the attending transplant nephrologist. On Monday, Tuesday, and Thursday afternoons, new patients are evaluated in the clinic. Every other Wednesday at 3:00 p.m. we have the selection committee meeting where decisions regarding appropriate kidney transplant recipients are discussed. On other Wednesdays at 3:00 to 5 p.m. we have either our Kidney/Pancreas Transplant M & M’s or QAPI meetings.

ADULT KIDNEY TRANSPLANT SERVICE

PRE TRANSPLANT

1. The on call transplant coordinator will notify the renal fellow, surgeon and the urology chief resident that a patient is being admitted for cadaver transplant surgery after having cleared the patient with the transplant attending. The coordinator will inform the chief resident of the OR time, if known, and the chief resident will inform the junior members of the service. Recipients will be admitted as private patients of the transplant surgeon and transplant attending.

2. Patients will be seen by the nephrology team. Preop orders will be initiated by the renal fellow who must complete and write up a standard work-up including a thorough H&P, with review of CXR, EKG and routine pre-op labs. The pre-op chart must be screened for special instructions and information. Patients with known infections, extreme debilitation, unresolved cardiac issues; etc. may not be cleared for surgery. Standard orders can be found in the 8 West rounding room file cabinet. The Pre-transplant chart is located in the Kidney Transplant Program’s offices located at 1000 Westwood Boulevard, suite 200. The code to the office is 1414; however it is strongly advised not to go to this office alone after hours. The in-house kidney transplant coordinator will bring the chart to the hospital during regular hours.

3. It is the responsibility of the surgical team (urology service) to arrange OR time and obtain informed consent. The surgical house staff will follow the transplant recipients under the direction of the renal fellow, transplant surgeon and transplant attending.

4. Living donors will be admitted as private patients of the nephrectomy surgeon. The urology service will have responsibility for care of these donors throughout their stay.

POST TRANSPLANT

1. Responsibility for the patients after transplant will be shared. The renal fellow will be responsible for dialysis, immunosuppression, and fluid orders under direction of the transplant attending. The surgical team will be responsible for all the surgical aspects of the patient’s care (wound care and drains, Foley catheter, re-establishment of oral feedings). Any conflict in orders must be discussed between the surgeon and the renal fellow and/or the transplant attending. Standard post renal transplant orders for ICU and floor are located in the 8 west rounding room filing cabinet.

2. Post transplant patients will be transferred to 8 West or 8 East from ICU or Recovery Room and will remain there until discharge.

3. The transplant coordinator will work with other members of the transplant team to make sure all necessary management is being carried out. Patient discharge teaching, including all medication instruction and follow up care, is the responsibility of the transplant coordinator.

READMISSIONS

1. Patients readmitted for management of problems such as rejection, infection, or delayed graft function will be admitted to the medicine service. The renal transplant team will be consulted on any patient who has a functional graft. The renal service attending MD will discuss all readmissions with the medicine attending MD daily at 11:30 am after morning rounds.

2. Patients readmitted for management of surgical problems such as ureteral leaks, stent removal, or incisional hernia repair will be admitted as patients of the urology service under responsibility of the transplant team.

3. Pancreas recipients will be admitted to as patients of the liver team and will also be followed by the kidney transplant team.

4. Attempt to readmit all kidney transplant recipients to 8 West or 8 East when possible.

Preop Transplant Preparation

Deceased Donor Kidney Transplant:

Fellow receives the following info from On Call Coordinator and is expected to know:

Recipient:

Name, ID number, diagnosis, ETA to UCLA, last dialysis, last stress test, other pertinent medical/surgical issues(i.e. hospital admissions since last seen at UCLA, cardiac issues, previous transplants, serologies, prior transplants, etc), PRA, HLA and cross match results(if available), tentative transplant OR time.

Donor:

Age/sex/race, admit date, cause of death, peak and final creatinine (if available), UOP, down time or warm ischemia time, cross clamp time(if available), HLA, pertinent med/soc history and other info ie HTN, ECD(expanded criteria donor), DACD(donor after cardiac death),serologies (CMV, HCV), pertinent anatomy and/or biopsy results(if available).

Obtain recipient’s Prechart

The Pre-transplant paper chart is located in the Kidney Transplant office at 1000 Westwood Blvd. However since all the information is also scanned into the electronic system, you should not attempt to retrieve the paper chart after hours unless it is absolutely necessary. If you must go to the office after hours, have a hospital security guard or UCLA police escort you.

Please make sure you know how to retrieve the Precharts prior to your first On Call responsibilities.

Preop Transplant Preparation

Deceased Donor Kidney Transplant:

Fellow receives the following info from On Call Coordinator and is expected to know:

Recipient:

Name, ID number, diagnosis, ETA to UCLA, last dialysis, last stress test, other pertinent medical/surgical issues(i.e. hospital admissions since last seen at UCLA, cardiac issues, previous transplants, serologies, prior transplants, etc), PRA, HLA and cross match results(if available), tentative transplant OR time.

Donor:

Age/sex/race, admit date, cause of death, peak and final creatinine (if available), UOP, down time or warm ischemia time, cross clamp time(if available), HLA, pertinent med/soc history and other info ie HTN, ECD(expanded criteria donor), DACD(donor after cardiac death),serologies (CMV, HCV), pertinent anatomy and/or biopsy results(if available).

Obtain recipient’s Prechart

The Pre-transplant paper chart is located in the Kidney Transplant office at 1001 Westwood Blvd. However since all the information is also scanned into the electronic system, you should not attempt to retrieve the paper chart after hours unless it is absolutely necessary. If you must go to the office after hours, have a hospital security guard or UCLA police escort you.

Please make sure you know how to retrieve the Precharts prior to your first On Call responsibilities.

Preop Transplant Preparation (cont)

Once patient arrives to 8West:

Renal Fellow responsibilities:

Completes H&P and standard preprinted preop and post op orders (located in 8West rounding room filing cabinet): stat K, labs, CXR, EKG

Follow up on K+ . The recipient may need dialysis preoperatively. Review other labs, CXR, EKG, and determine if further testing needed (i.e. cardiology or pulmonary clearance).

Discuss case with Attending on duty, and determine which

induction/ immunosupression is indicated.

Standard induction/immunosuppression: Simulect or thymobuglobulin, prednisone, tacrolimus or cyclosporine (Neoral), and Mycophenolate.

(See Immunosuppression Protocol Info for dosing and target drug levels)

Cyclosporine must be written as Neoral (not cyclosporine) otherwise Sandimmune will be dispensed)

All patients should be screened for possible Research Studies

If patient is increased risk for DM (i.e. strong family history of DM, obesity, HCV pos) or has DM but is not on insulin Cyclosporine may be used instead of Tacrolimus in an attempt to avoid insulin.

If patient is high risk for rejection (high PRA, positive crossmatch) or if Delayed Graft Function (DGF) is anticipated, thymoglobulin may be used as induction (see Thymo Protocol).

Standard post op orders are placed in chart prior to transplant.

Urology Intern responsibilities: Ensures that patient is consented for surgery and possible blood transfusion. Requests OR time for transplant (drops OR slip).

Transplants may be cancelled due a positive crossmatch, an unsuitable organ or an unsuitable recipient. If a patient does not receive the transplant and is discharged home after being admitted to hospital, the On Call Coordinator must be notified ASAP so that the organ can be allocated quickly to the next patient on the list (the next patient may or may not be a UCLA patient). If the patient is unsuitable, the patient will be placed on “Hold” for further organ offers. The Discharge Summary must be completed by the Urology Intern with the plan for the patient clearly stated (if patient will never be a candidate or if any further testing or follow up is needed).

Living Donor Transplant:

Pre-transplant charts on the recipient and donor are brought to 8West by In House Coordinators 1 business day prior to scheduled transplant.

At the final appointment prior to transplant the recipient is instructed to have dialysis the day prior to admission (preferably in the afternoon or evening).

Patients are usually admitted on the day of transplant.

On the day prior to transplant Fellow reviews recipient chart and completes H&P (except physical exam), standard Pre and Post op orders, reviews patient’s case with attending M.D. to decide plan and induction/immunosupression.

Fellow brings orders to PTU(x79800) located the second floor

All care of the living donor is provided by Urology Team.

Post Transplant:

Responsibility of the patient after transplant will be shared.

The renal fellow is responsible for dialysis, immunosupression and fluid orders under direction of the Transplant Attending. The surgical team is responsible for all the surgical aspects of the patient’s care (wound care, drains, foley catheter, J-P drain, initiation and advancement of diet).

Any conflict in orders must be discussed between the surgeon and renal fellow and/or the transplant attending. Open communication between Nephrology and Urology is critical for good patient care!

The transplant coordinator will work with all members of the Team to make sure all necessary management is being carried out. Patient discharge teaching including all medication instruction and follow up care is the responsibility of the transplant coordinator.

Discharge

Patients with an uncomplicated course are usually discharged on Post Op day # 4-5. The Urology Intern removes the CVC line, writes discharge order, and dictates Discharge Summary. The Coordinator makes sure teaching is complete and all discharge meds are ordered and given to patient prior to discharge. Since newly transplanted patients are seen two days after discharge, they are rarely discharged on Thursday.

If a patient is discharged on a weekend or holiday the fellow is responsible for documenting any changes on patient’s medication list and/or giving patient any new prescriptions if needed.

Every effort should be made to discharge patients prior to 11am.

POST TRANSPLANT MANAGEMENT

FLUID MANAGEMENT

1. In the euvolemic patient, urine output is to be replaced hourly with D5 1/2 NS cc per cc up to 200 cc. If the urine volume is greater than 200 cc/hr, give 200 cc + 1/2 cc for each cc > 200.

2. Other fluid and electrolyte replacement will be determined appropriately for each individual patient after clinical assessment of volume status.

3. All fluids to be replaced by IV until oral fluids are re-established by the surgeon.

4. See diabetic protocol for insulin drip.

MEDICATIONS

1. Mycostatin 500,000 units (4 cc), swish and swallow, PC and HS

2. Colace 100 mg PO BID

3. Protonix 40 mg PO QD

4. Cardizem CD 180 mg PO QD

5. Bactrim SS 1 tablet PO QHS

6. Nephrovite 1 PO QD

7. Vicodin 1-2 tablets PO Q 6 hr PRN pain

8. CMV Prophylaxis Protocol

CMV (-) donor to CMV (-) recipient

Acyclovir 400 mg PO QHS only for herpes prophylaxis

CMV (+) donor to CMV (-) recipient

During antibody treatment Gancyclovir 2.5 mg/kg IV QD,

Following antibody treatment Valcyte PO QD x 6 mos*

If no antibody treatment Valcyte PO QD x 3 mos*

Order CMV DNA Q2 wks x 3 months

CMV (+) or (-) donor to CMV (+) recipient

During antibody treatment Gancyclovir 2.5 mg/kg IV QD,

Following antibody treatment Valcyte PO QD x 6 mos*

If no antibody treatment Acyclovir 400 mg PO QHS

order CMV DNA Q 2 wks x 3 months

*adjusted to kidney function

creatinine < 1.5 give Valcyte 900mg PO QD

creatinine > 1.5 <2.0 give Valcyte 450mg PO QD

creatinine > 2.0, consult the Transplant Pharmacist for dosing

Gancyclovir doing is rounded to within 5mg

9. Immunosuppression per standard protocol.

IMAGING STUDIES

1. Mag3 renal scan PRN per kidney transplant staff.

2. Ultrasounds and other x-rays for clinical indication.

Post Transplant Tips

Rounds begin at 0930 am on 8 West in the rounding room. On the weekends, the Fellow and Attending usually round in the morning.

Post Transplant Diabetes:

If patient is a diabetic prior to transplant, even if controlled by diet, they will most likely need scheduled insulin post transplant due to steroids and a functioning kidney. Be proactive in controlling blood sugars and adjust doses of insulin daily to avoid delayed discharges (BS’s over 300 is unacceptable on day of discharge). There are two insulin order forms (insulin drip and SQ) that you can customize to each patient. Usually NPH scheduled QD or BID and Novolog sliding scale are ordered. Lantus is usually not used during immediate preoperative period as it may be more difficult to control blood sugars while steroid dose is decreasing and kidney function is improving.

If patient required insulin prior to transplant, an insulin drip immediately post op may best control high blood sugars.

The endocrinology service should be consulted for any patient with an insulin pump.

Statins:

Neoral and Prograf increase blood levels of statins, order half pretransplant dose if patients are to be restarted on their statin.

ASA:

Do not restart any ASA until kidney function is adequate (may need biopsy) and okay with surgeon.

Usual antihypertensives post transplant:

Metoprolol

Nifedipine CR/Amlodipine

Usually avoid the following drugs:

Minoxidil (due to increase risk of edema and increased incidence of hursuitism if pt on Neoral)

Ace Inhibitors until good kidney function has returned

Readmissions

Medical Kidney Transplant Issues:

All kidney transplant recipients that are readmitted for medical reasons are admitted under a Medicine Team Attending.

These patients are all treated the same; the Transplant Fellow sees each patient daily and rounds with the Transplant Team on these patients.

The Transplant Fellow must be in close contact with the Medicine Team and vice versa. If either team writes any new orders they must let the other team know.

Discharges:

Medicine Interns write discharge orders, and along with the medicine team case manager, arrange homecare home PT/OT, IV antibiotics, and prescriptions.

With a newly transplanted patient who has many changes in their medicines, the Transplant Coordinator will be involved with the discharge.

With a patient who has not been transplanted recently, the Coordinator may not be directly involved.

Surgical Kidney Transplant Issues:

These patients are usually admitted under Urology/Transplant (Dr.Gritsch, Singer, Veale, and Lipshutz) and are followed closely by the Urology team.

Transplant Fellow sees these patients daily and rounds with the Transplant team on these patients.

Pancreas Transplant Issues:

These patients are always under Dr.Lipshutz and are usually on 8 North. These patients are followed by the Liver Team as well.

Transplant Fellow sees these patients daily and rounds with the Renal Transplant team on these patients.

Fellows usually do not write any orders on these patients unless discussed with Dr.Lipshutz or Liver Team.

STANDARD STEROID IMMUNOSUPPRESSIVE PROTOCOL

FOR DIURESING, LOW IMMUNOLOGIC RISK,

KIDNEY ALONE ORGAN, FIRST TRANSPLANT RECIPIENTS

Corticosteroids have been an essential part of the immunosuppressive regimen since transplantation began more than 40 years ago. However, the chronic use of steroids has been associated with significant complications such as hypertension, glaucoma, cataracts, peptic ulcer disease, osteoporosis, obesity, hyperlipidemia, glucose intolerance, and impaired wound healing.

The following rapid steroid withdrawal protocol is to be used for all patients scheduled to receive a primary kidney allograft from a deceased or living donor.

Please note high-risk patients (e.g., patients with prior transplant history, dual organ transplant, anticipated DGF, High PRA, African American descent) will remain on steroids, 20mg QD, and dose of steroids to be lowered at the discretion of transplant attending.

This protocol will be the routine for low risk (simple and uncomplicated) patients, with the exclusion criteria as follows:

• Patients with high-risk of rejection (e.g., patients with the most recent panel reactive antibody (%PRA) >20%, patients of African American descent).
• Known hypersensitivity to Sirolimus and its derivatives
• Cold ischemia time of donor kidney greater than 24 hours.
• Delayed graft function (DGF) anticipated
• Patients with a screening/baseline (or within 96 hours of the transplant) total WBC count ≤3000/mm³; PLT count ≤100,000/mm³; fasting triglycerides ≥400 mg/dL (≥4.6 mmol/L); fasting total cholesterol ≥300mg/dL (≥7.8 mmol/L); Fasting Lipid levels within 3 months prior to transplant for patients on lipid lowering therapy or one year prior to transplant for untreated patients.

Standard Steroid 5 day taper:

Peri-op 500mg IV in OR

Day 1 250mg IV

Day 2 125mg IV

Day 3 65mg PO

Day 4 30mg PO

Day 5 no steroids or 20mg PO QD

Ensure adequate RAPA / FK / CYA levels at time of last anticipated Steroid dose. “Zero” Steroid day can be delayed if necessary.

STANDARD IMMUNOSUPPRESSIVE PROTOCOL

FOR DIURESING, LOW IMMUNOLOGIC RISK, FIRST TRANSPLANT RECIPIENTS

CYCLOSPORINE (Neoral) TACROLIMUS SIROLIMUS MYCOPHENOLATE

DAY DOSAGE OR DOSAGE DOSAGE OR DOSAGE

Preop 2 mg/kg x 1 dose* PO 0.05mg/kg x 1 dose* PO none none

Immediate Post op 2 mg/kg PO Q 12 hr as soon 0.05mg/kg PO Q Day none none

as pt takes PO. If NPO > 12 hr, (split dose in BID)

consider IV at 4 mg/kg.

Post op day 1 as above as above 10 mg PO (loading dose) none

Post op day 2 adjust dosage to keep level adjust dosage to keep level 10 mg PO 1 gm PO Q 12 hr as

200-300 for first 4 weeks 8-12 (kidney) and 12-18 **soon as pt is tolerating

after transplant (pancreas) for 4 wks after txp. solid food**

Post op day 3 as above as above 6 mg PO as above

Post op day 4 as above as above as above as above

Post op day 5 as above as above administer daily until as above

Post op day 6 as above as above Sirolimus trough level as above

Post op day 8 as above as above is available – adjust as above

Post op day 9 as above as above dosage to keep level as above

Post op day 10 as above as above of 8 –15 (month 0-5) as above

and 6 –12 (month 6-12)

* In conjunction with the above immunosuppressives, please see additional immunosuppressive standard steroid protocol.

** The principle of immunosuppression with FK vs. CYA will be based on clinical assessment of patient (e.g., cosmetic, development of diabetes).

*** For all living related and living unrelated recipients, give 1 dose of preop cyclosporine/tacrolimus: a dose pretransplant.

**** For 2 haplotype matched living related recipients, may not need additional Mycophenolate.

1. Tacrolimus and Sirolimus levels are to be drawn daily prior to the morning dose.

2. Measuring Cyclosporine 2 hour peak levels (C2) or Cyclosporine trough levels will determined by Transplant Attending.

2. Cyclosporine IV must be infused slowly over, not less than, 4 hrs when it is not the initial dose.

3. Cyclosporine and Tacrolimus should not be started or stopped on any transplant recipient without the approval of the Transplant Attending.

4. Any questions should be directed to the Renal Fellow or Transplant Attending.

5. For guidelines for Cyclosporine and Tacrolimus levels after the first 2 weeks, see attached chart.

6. Ensure adequate RAPA / FK / CYA levels at time of last anticipated Steroid dose. “Zero” Steroid day can be delayed if necessary.

SOLUMEDROL PULSE THERAPY PROTOCOL

1. IV Solumedrol is used for the first line treatment of acute rejection

2. Dose to be prescribed by the attending physician. (usually 5mg/kg)

3. Mix Solumedrol in 100ml 0.9% sodium chloride for infusion.

4. Patient’s blood pressure must be checked before and after infusion of Solumedrol.

5. Infuse over 30 to 60 minutes.

6. Diabetic patients should be instructed to monitor blood sugars more frequently during pulse therapy. Diabetic patients will need insulin adjustments to treat high blood sugars.

7. Discharge on appropriate prophylaxis. Consult with Transplant Pharmacist

MANAGEMENT OF DIABETIC TRANSPLANT RECIPIENTS

1. Day of surgery

a. fasting glucose

b. half of usual dose of intermediate acting insulin

c. monitor fingerstick blood glucose every 4 hours:

if glucose is < 250 mg/dl give no insulin, for every 50 mg over

250 mg/dl, give 5 units of Regular insulin

2. From Recovery Room to re-establishment of oral feedings

a. replace insensible loss with D5 W

b. replace other output with D5 1/2 NS

c. either continue the sliding scale as above or start an insulin drip of 100 units Regular insulin in 1000 D5 W (if patient is oliguric, increase the concentration of the insulin infusion)

3. Following re-establishment of oral feedings

a. return to patient’s usual maintenance insulin dose or initially give 1/2 and 1/2 BID

b. monitor fingerstick blood glucose 4 times a day, before meals and at bedtime

c. remember that a patient’s insulin requirement is frequently increased with:

1) improvement in renal function

2) steroid therapy

3) re-establishment of oral intake

4) infection

4. Consult the Diabetic Teaching Team:

Rosemary Healy (#98673) or

Nancy Lee (#91664)

as soon as you are aware the patient is diabetic so she can follow him/her.

It is recommended that discharge insulin coverage be NPH bid, and novolog meal/sliding scale coverage. This will provide more flexibility in the immediate post-operative period.

The patient will be transitioned to longer acting insulin coverage later in the outpatient clinic.

CMV PROPHYLAXIS PROTOCOL

For CMV (-) recipients of a CMV (-) organ

Acyclovir 400 mg QHS only for herpes prophylaxis

CMV DNA q 2 wks x 3 months

For CMV (-) recipients of a CMV (+) organ

During antibody treatment: Gancyclovir 2.5 mg/kg IV QD, then

following thymoglobulin: Valcyte 900mg PO QD for 6 months

If no thymoglobulin: Valcyte 900mg PO QD for 6 months

adjusted to renal function*

CMV DNA q 2 wks x 3 months

For CMV (+) recipients of a CMV (-) organ:

During antibody treatment: Gancyclovir 2.5 mg/kg IV QD, then

following thymoglobulin: Valcyte 900mg QD for 3 months

adjusted to renal function*

If no thymoglobulin: Acyclovir 400 mg QHS

CMV DNA q 2 wks x 3 months

For CMV (+) recipients of a CMV (+) organ

During antibody treatment: Gancyclovir 2.5 mg/kg IV QD, then

following thymoglobulin: Valcyte 900mg QD for 6 months

adjusted to renal function*

If no thymoglobulin: Acyclovir 400 mg QHS,

CMV DNA q 2 wks x 3 months

*Adjusted to renal function

Creatinine clearance 70 or greater give Gancyclovir 5mg/kg QD

Creatinine clearance 50-69 give Gancyclovir 2.5mg/kg QD

Creatinine clearance 25-49 give Gancyclovir 1.25mg/kg QD

Creatinine clearance 10-24 give Gancyclovir 0.625mg/kg QD

Creatinine clearance <10 give Gancyclovir 0.625mg/kg TIW after Dialysis

Creatinine <1.5, give Valcyte 900mg PO QD

Creatinine > 1.5< 2.0, give Valcyte 450mg PO QD

Creatinine > 2.0, consult the Transplant Pharmacist for Valcyte dose

HIV Positive Recipient Guidelines

· Dr. Ardis Moe will be consulted for all recipients. She will be prescribing antiretroviral therapy.

· Stop all HIV antiretroviral therapy 3 days before the scheduled transplant.

· HIV meds will be on hold for two weeks post-transplant and will be started in the post transplant clinic. No-one should receive Viread (tenofovir) or Truvada (emtricitabine/tenofovir).

· Tacrolimus/cyclosporine levels should be checked at least 3 times/week for the first week after restarting the antiretroviral therapy.

· Because of the transient drop in CD4 cells, HIV+ patients should take azithromycin 1200mg a week for 3 months post-transplant, unless there is a history of MAC. In that case they should take azithromycin for the life of the transplant.

· HIV+ patients with a history of Cryptococcus need to take fluconazole (Diflucan) for the life of the transplant.

· HIV+ patients with no history of CMV disease do not need to take Valcyte (valgancyclovir) unless otherwise indicated by transplant protocols.

· PCP prophylaxis should be given for the life of the transplant (Bactrim, Mepron or Dapsone)

Banff Classification of Rejection

Rejection Treatment Protocol

Acute Cellular Rejection:

· Treatment is typically IV Steroid Pulse( see Solumedrol Protocol)

· May be given in Post Transplant clinic( open Monday through Friday mornings)

· Any patient that receive Steroid Pulse must be given prophylactic antibiotics:

o Bactrim ss 1 tab daily for one year

o Nystatin 100,000 u/ml: 4mls QID pc for 1 month

· If kidney function does not improve with steroids, Thymoglobulin may be administered

Vascular Rejection Type 2:

· Treatment is typically Thymoglobulin (see Thymo Protocol)

· Patient is hospitalized for any Thymo infusion

· Daily dose usually for 7-10 days

· After treatment, pt must receive proper prophylaxis:

o Bactrim SS, 1 tab po Qhs x one year

o Valcyte 900 mg po qhs X 6 months

o Nystatin 5ml S/Sw QID x 1 month

o These doses are adjusted if GFR is impaired

Humoral Rejection (C4D pos):

· Treatment is typically IVIG (see IVIG Protocol)

· Patient is hospitalized for any post transplant infusion

· Donor Specific Antibodies (Single Antigen Antibody ID Class 1 and Class 2) should be drawn before IVIG is given and repeated one month after treatment.

· Plasmapheresis may also be used if rejection is severe or if kidney function does not improve with IVIG

· Sucrose Free IVIG should only be used in kidney transplant recipients

Sulfonamide Drug Allergy Protocol

For those with a sulfa allergy, the following are alternatives for prevention coverage of Pneumocystis Carini:

Dapsone

Dapsone is best alternative to Bactrim per ID (Dr.Pegues).

G6PD level must be checked before starting Dapsone due to possibility of hemolytic anemia.

Dosage: Dapsone 100mg PO QD.

Atovaquone

Because of the high cost, Atovaquone is second choice.

Dosage: Atovaquone 1500mg PO QD (dispensed as 750mg/5ml).

Pentamidine

Pentamidine inhalation is third choice.

1. Fellow to fill out :

a. RT order form

b. Antibiotics order form

c. MD orders:

Pentamidine 300 mg by hand held nebulizer (HHN) Q month X 3 doses

Patient must be in private or isolation room for treatment

First dose to be given prior to discharge

2. All Pentamidine treatments must be scheduled with Respiratory Therapy.

PROTOCOL FOR ANTI-THYMOCYTE GLOBULIN

(THYMOGLOBULIN) ADMINISTRATION

Anti-thymocyte globulin is indicated for the treatment of kidney transplant acute rejection or induction therapy, in conjunction with concomitant immunosuppression and maybe administered for 4 to 14 days, under the direction of Transplant Attending. Induction therapy cases will include patients with anticipated Delayed Graft Function (DGF) and patients deemed “high risk” (e.g., high PRA, 2^nd transplant when 1^st transplant was lost to early rejection). In induction cases the Anti-thymocyte globulin protocol will be administered for a minimum of 4 to 7 days. The duration of IV therapy will be determined when adequate levels of cyclosporine, tacrolimus or sirolimus is achieved.

Anti-thymocyte globulin is a purified, pasteurized, gamma immune globulin obtained by immunization of rabbits with human thymocytes. This immunosuppressive product contains cytotoxic antibodies directed against antigens expressed on human T-lymphocytes. In patients, T-cell depletion is usually seen within a day from initiating therapy. Anti-thymocyte globulin has not been shown to be effective for treating antibody (humoral) mediated rejections.

1. Labs: Daily CBC with platelet count (review before dose is given)

Daily electrolytes, BUN and Creatinine

Weekly full chemistry panel

2. Cyclosporine or Prograf dose will be determined by the Transplant Attending, and may be cut in half or held, during the infusion of Anti-thymocyte globulin. Prior to the completion of treatment therapy, Cyclosporine and Prograf should be returned to a full dose to ensure adequate immunosuppression on the last day of treatment.

3. Mycophenolate may be stopped during Anti-thymocyte treatment, check with Attending MD on service.

4. Prednisone should be maintained according to schedule.

5. Patients should receive appropriate prophylaxis therapy: Valcyte 900 mg po Q day x 6 months, Cotrimoxazole SS 1 tab daily x 1 year, and Mycostatin 500,000 units (5cc) swish & swallow PC & HS for one month.

6. Patients must receive standard pre-meds with each dose of Anti-thymocyte globulin. Orders should include pre-meds to be given a minimum of 30 minutes prior to therapy:

Methylprednisolone 30 mg IVPB

(Attempt to give daily Prednisone dose in the form of the pre-med)

Diphenhydramine 50 mg slow IVP

Acetaminophen 650 mg PO and repeat in 4 hours

7. Dose is 1.5 mg/kg to be mixed in 50 ml NS for each 25 mg Anti-thymocyte globulin. The total daily dose is rounded to within 25mg.

Reduce dose by ½ for WBC 2,000 - 3,000 or PLT CNT 50,000 - 75,000 or ANC <1200

Hold if WBC < 2,000 or PLT CNT < 50,000 or ANC < 80

8. Anti-thymocyte globulin is administered through a dedicated, high flow central IV line. First dose should infuse over a minimum of 6 hours & maximum of 10 hours; subsequent doses over 4 hours to prevent/minimize adverse effects.

*Please note, the order for Thymoglobulin needs to be written very early in the day!

9. The patient should be closely observed for side effects including anaphylaxis. Monitor vital signs as follows: BP, T, HR, RR every 15 minutes for the first hour,

then every hour for the remainder of the infusion if no change.

10. Anti-thymocyte globulin is usually given daily for 7 days.

11. Check daily CBC with differential and LDH to evaluate effectiveness of the treatment.

Adjust doses for renal impairment:

Valcyte:

Creatinine > 1.5 < 2.0, give 450 mg po daily

Creatinine > 2.0, consult Transplant Pharmacist

Bactrim:

Creatinine > 1.5 < 2.0, give one tablet every other day

Creatinine > 2.0, consult Transplant Pharmacist

IVIG PROTOCOL

IVIG is a human immune globulin that contains the various IgG antibodies. It is used in the treatment of humoral rejection (C4D+). It maybe used to reduce preformed antibodies in pre transplant patients in an attempt to achieve a negative crossmatch with potential donor. It is also used to treat known donor specific antibodies

All immunosupression should be continued.

2. Patients must receive standard premeds with each dose of IVIG. Orders should

include Premeds: to be given 30 minutes prior to therapy.

Methylprednisolone 30mg IVPB

Diphenhydramine 50 mg slow IVP

Acetaminophen 650mg PO and repeat in 4 hours

Dose is 1gm/kg daily x 2 days (total 2 gm/kg). Total dose may be given as 1 infusion per Attending. Total max dose 144gm.

· Sucrose free IVIG must be used in kidney transplant recipients to prevent possible kidney function impairment.

· Start 50cc/hour, increase by 25cc/hour every 30 minutes until 150cc/hour.

• The patient should be monitored closely for side effects. Monitor vital signs every 15 minutes for the first hour then hourly until infusion completed.

• Due to required dilution volume, IVIG is usually given in two divided doses.

PROTOCOL FOR RITUXIMAB ADMINISTRATION

Rituximab is used in transplant for several reasons:

- In an attempt to decrease preformed anti HLA antibodies

- To facilitate living donor transplant with positive crossmatch or ABO incompatibility

- To treat humoral rejection

- To treat PTLD

Dosing:

- 375mg/m² [http://www.halls.md/body-surface-area/bsa.htm] once weekly for 4 weeks (at discretion of Attending)

- Premed : Tylenol and Benadryl

- Administration Infuse at an initial rate of 50 mg/hour, increase (50 mg/hour increments) as tolerated every 30 minutes, to maximum of 400 mg/hour. Subsequent infusions may be administered at an initial rate of 100 mg/hour, increase (100 mg/hour increments) as tolerated every 30 minutes, to a maximum of 400 mg/hour

- Dosage Forms Injection: 10 mg/ml; 100mg and 500mg vials

Adverse reactions:

- Infusion related reactions: Chills, fever, rigors, dizziness, hypertension, myalgia, nausea, pruritus, rash and vomiting (usually occurs with 1^st dose)

- Adverse effects in order of decreasing frequency: Fever, chills, weakness, nausea, headache, abdominal pain, night sweats, rash, pruritus, cough, rhinitis, angioedema.

- Others: Dizziness, hypotension or hypertension, diarrhea, vomiting, back pain, myalgia, arthralgia, peripheral edema, urticaria, bronchospasms, dyspnea, sinusitis, anxiety, flushing, paresthesia, agitation, depression.

- Laboratory abnormalities: Lymphopenia, leukopenia, neutropenia, thrombocytopenia, anemia, hyperglycemia, hypoglycemia, increased LDH.

Candida Pyuria

Per ID (Dr. Pegues): must treat if pyuria (UA with WBC’s and Candida) and/or stent

Treatment:

1st option: Fluconazole: 200mg QD x 7days and pessaries (Monistat vaginal suppositories x 3 days).

2nd option (if 1^st unsuccessful): Voriconazole: 200mg Q12H X 7 days

works against all “non” albicans candidas

No pyuria and no stent: no need to treat urine (treat only if local source)

No need for Amphoterecin bladder washes but if Attending decides it is needed:

Amphoterecin Bladder Washes

Indications:

Used to treat Candida Glabrata in urine

Dosing:

50mg/liter of sterile water or NS

Infuse into 3 way Foley catheter at 42 cc/ hr continuous

Daily for a total 3 days (may be as long as 5 days)

DO NOT USE INFUSION PUMP, MUST FLOW BY GRAVITY

Protocol for Dosage Adjustments of Sirolimus (Rapamune)

1. The first dose of Sirolimus should be given within 24 hours of kidney transplant as follows:

Day 1: Dose 3 mg

Day 2: 3 mg, administered daily until Sirolimus

trough level is available.

(Rapamune® oral solutions may be administered by a NG tube for up to 7 days post transplant if clinically necessary.)

2. Our standard is for Sirolimus dose to be taken with the morning Cyclosporine or Tacrolimus dose. Because the Sirolimus levels will be higher if it is taken at the same time as Cyclosporine, it is important to adjust the Sirolimus dose accordingly.

3. Sirolimus has a long half-life; trough levels should not be drawn any sooner than 3 to 5 days after initiation or change in dosage.

4. The target trough level is: Month 0 – 5 levels of 8 – 15 ng/ML

Month 6 – 12 levels of 6 – 12 ng/ML

5. If the trough level falls outside this range, change in dosage is based on this formula: new dose (mg)=[(current dose,mg) X (20/current srl trough level {ng/ml})]

Other considerations: female pts of childbearing age should use contraception; monitor for leukopenia, thrombocytopenia, and hyperlipidemia. It is recommended that the maintenance dose of Sirolimus be reduced by approximately 1/3 in patients with hepatic impairment. Patients must also be placed on antimicrobial prophylaxis with Bactrim SS for PCP prophylaxis for 1 year.

Protocol for Conversion to Sirolimus and Withdrawal of Calcineurin Inhibitor

Initiation: Discontinue MMF or AZA Loading dose of SRL 15 mg po Then SRL 5 mg QD

Day 7—obtain SRL trough level

SRL level >10 ng/ml: --reduce CSA/FK by 50% --adjust SRL dose if outside target range

5 to 7 days later

If SRL level < 10 ng/ml at any

point: no change in CSA/FK

SRL level > 10 ng/ml: --reduce CSA/FK to 25% original dose --adjust SRL if outside target range

5 to 7 days later

SRL level > 10 ng/ml: --discontinue CSA/FK --adjust SRL level if outside target range

Check SRL level 5 to 7 days later and adjust

ADMINISTRATION OF IV FERRLECIT

(Sodium ferric gluconate complex)

All kidney transplant recipients will have iron, total iron binding capacity, and ferritin levels drawn on admission. Living donor recipients will have these labs drawn prior to admission. Patients with Fe/TIBC < 20% or ferritin < 300 may require IV iron infusion.

The infusion should be completed in the hospital to avoid the inconvenience of outpatient scheduling.

1. Vital signs should be taken before, mid, and after infusion or as specified in physician’s orders.

2. Test dose of Ferrlecit 2ml (25mg elem. iron) diluted in 50ml 0.9% sodium chloride IV over 60 minutes.Test dose is not mandatory for Ferrlecit.

3 .Give Ferrlecit 250mg in 250 cc NS over 2 hours x 4 doses.

4. Potential adverse reactions include chest pain, hypotension, tachycardia, flushing, urticaria, rash, abdominal pain, nausea, vomiting, diarrhea, arthralgias, headache, fever, dyspnea, and hematuria.

Cytogam

Cytogam is a human immune globulin (IgG) containing a standardized amount of antibody to CMV.

It has several indications with regards to transplant:

- prophylaxis and treatment of CMV

- reduces HLA antibodies in highly sensitized patients

- used in conjunction with plasmapheresis which rapidly depletes anti HLA antibodies, Cytogam blocks resynthesis of anti HLA antibodies

- treats humoral rejection

Dosing

- Usual dosage 100mg/kg per infusion (maximum total dosage 150mg/kg)

- Duration of treatment at discretion of Attending- usually one dose only.

- Cytogam and plasmapheresis may be continued until anti HLA antibodies are no longer detected

- Initial dose: 15mg/kg/hr, after 30min increase to 30mg/kg/hr, after 30 minutes increase to 60mg/kg/hr. Not to exceed 75mg/kg/hr

- Premed at the discretion of the Attending but not required

Monitoring:

- Vital signs pre-infusion, mid-infusion and post-infusion

Adverse Reactions:

- chills, fever

- nausea/vomiting

- wheezing

- muscle cramps, arthralgia

- acute renal failure, ATN

INPATIENT PENTAMIDINE ADMINISTRATION

1. For patients with a sulfa allergy, for prophylaxis coverage of Pneumocyctis Carinii

2. Fellow to fill out :

a. RT order form

b. Antibiotics order form

c. MD orders:

Pentamidine 300 mg by hand held nebulizer (HHN) Q month X 3 doses

Patient must be in private or isolation room for treatment

First dose to be given prior to discharge

3. All Pentamidine treatments must be scheduled with Respiratory Therapy.