Logistics - Kidney transplant

Immunosuppression primer

Schedule

   
M 8:30-12:00 AM - post-op kidney clinic
T

10:45-12:30 PM - kidney selection 
12:30 - PM - liver selection
W Living pair cases
Th 8:30-12:00 AM - post-op kidney clinic
2:00-3:00 PM - transplant didactics
F 8:30-9:30 AM - Kidney journal club/M&M
9:30-10:30 AM - kidney care conference
10:30-12:00 PM - desensitization, review living pairs
1:00-2:00 PM - peds liver care conf
2:00-3:00 PM - adult liver care
3:00-3:30 PM - turn down conf

Clinic

  • Interns go to kidney clinic (Boswell A1, code 0160) on M/Th
  • Can show up later if rounding with liver  
  • Leave the pre-transplant evals (Tuesday) to the fellows
  • Busque will have you dictate notes: area code is 75. First and last clinic letter note needs to be dictated letter to the patient’s outpatient/referring nephrologist (not transplant nephrologist). Other clinic notes can be dictated just as clinic notes.
  • Pham: OK to type or dictate; .trxkidneyclinicprog
  • Review BP/BG logs, ask about prograf toxicity (tremors/headaches), do normal post-op stuff, review labs to see if immunosuppression should be adjusted, adjust ppx dosing based on renal function (for DGF pts), if/when ureteral stent comes out, etc.

Conference/didactics

  • In 750 Welch Road (exit through front of Children's, cross street, door is on the R side of the building on the outside)
  • Th didactics and Fri journal club mandatory; go to selection meeting if possible

Rounds

  • Pre-round with fellow, pharmacy resident
  • Attending (multi-disciplinary) rounds usually ~ 1 PM after clinic - with transplant nephrology, pharmacy, social work, coordinator, etc.

Discharges

  • Kim Miller (coordinator) will order all discharge meds to be delivered to patient. Make sure at time of discharge to change the dosing/etc to match their final discharge regimen as they usually won't need all of the meds that are ordered (eg change sig to 'Do not take until instructed in clinic' or something). You put in the discharge order and discharge summary.

Consent

  • Usually every Tuesday you will admit a living donor pair (for OR on Wednesday); both need H&P (.kidneydonoradmit, .kidneytransplantadmit, .livertransplantadmit as created by Dr Pham) and consents (organ transplant consent form only found on C1 unit)
  • Admission orders - there is an order set, usually fellow will take care of it, but of note patients need both Admit to obs/pre-procedure (C1, for pre-op) and an Admit to Inpatient order (post-op)
    • "IP TRS Kidney Donor Preop"
    • "IP TRS Kidney/Pancreas Transplant Recipient Preop"
    • basically just check all the boxes if unsure...make sure they have T&S, and AM labs if they're pre-admitted (e.g. living recipient) to see if they will need dialysis in AM.
  • Donor: consent x 2
    • OR (laparoscopic, hand assisted, possible open, [Left vs Right] donor nephrectomy)
      • Usually take the L kidney because the renal vein is longer
    • Blood transfusion
  • Recipient: consent x 3 
    • Organ transplantation - find out from fellow if 'high risk' to check the box
      • CDC means patient engaged in high risk activities (IV drug use, multiple blood transfusions in past) that even though all the blood tests we have were negative, there still may be risk of bloodborne disease
      • DCD: deceased cardiac donor. Due to mode of death, these donors are slightly higher risk of non-functioning
    • OR (deceased/living donor kidney transplant [with possible PD catheter removal])
      • Risks of surgery to discuss with pts: delayed graft function (~20%) that may require additional dialysis while inpatient. Risk of blood clots, which if they occur in renal veins may require return to OR, risk of lifelong immunosuppression, risk of chronic graft non-functioning
      • If transplanted kidney immediately making good urine, may remove PD cath intra-op
    • Blood transfusion
  • Recipient H&P:
    • Etiology of ESRD
    • Dialysis status (since when, HD vs PD, schedule, amount of urine made)
    • Previous abdominal surgery
    • Pulse exam (femoral, DP/PT bilaterally)

Post-op (recipient)

    Comments
Neuro

POD 0-2: fentanyl PCA
POD 1: start PRN Norco

 POD 0-5: OnQ (bupivicaine) pump, only Busque uses it. Will last 5 days, may be discharged with it if needed. Remove in clinic
CV
  • Goal SBP 100-160 (< 100 can cause malperfusion, thrombosis)
  • CVP monitoring for 24 hrs post-op
  • PRN IV labetalol, IV hydral (IV hydral generally works better, up to 10-20 mg q1-2h PRN)
  • PO meds in order of preference: norvasc 5-10 mg qd, metop 25-100 mg BID, clonidine 0.1-0.2 mg TID (max out meds rather than adding new ones if possible)
  • Do not give ACEi/ARB (kidney), or diltiazem (raises prograf level)
 Thymo can cause hypotension esp. with first dose; if this happens then pause infusion, check CVP, call fellow
GI POD 1: CLD/full liquid diet, then ADAT  don't have to wait for return of bowel function for reg diet
FEN

POD 0 (for 24 hrs): D5 1/2 NS @ 100 cc/hr, plus D5 1/2 NS with sodium bicarb or NS to replete 75% of UOP 
POD 1: D5 1/2 NS with bicarb or NS @ 75 cc/hr (no more UOP replacement). 
POD 2: stop bicarb, wean mIVF as appropriate

 Can wean mIVF POD1 if good POD intake and wanting to diurese.
Renal

POD 3: remove Foley 

unless difficult bladder, then remove POD 5/7 

If DGF and not making urine, can remove earlier
Drains

Remove JP drain after Foley out if < 80 cc/d (may go home with it)

  
Endocrine

"Very Aggressive" sliding scale because will be on steroids

 Pharmacy helps to dose insulin
ID

If DDRTx, peri-operative zosyn x 48 hrs 

If LDRTx, peri-op Ancef

  If PCN allergic to Zosyn, can do vanc x 1 at time of surgery, then cipro x 48h
Prophylaxis
  • SQH (5000 U) q12h, 12h after surgery - not TID
  • Bactrim SS for PCP ppx - MWF; daily if donor is toxo+
  • Valcyte 450 mg for CMV ppx - MWF; daily if high risk (donor +, recipient -)
  • Fluconazole 100 mg qF for anti-thrush
 If poor renal function, dose bactrim/valcyte MTh (change it back when better)
Immunosuppression

Induction

  • If low PRA (< 20%) - may not need induction with ATG
  • Otherwise ATG 3 mg/kg
  • If high PRA (≥ 98%), will dose ATG 5 mg/kg with rituximab 500 mg at end. 

Goal prograf trough of ~10 (drawn 10-12h after last dose)

  • Envarsus is dosed daily instead of BID; try to switch to this if insurance covers

Cellcept at 500 mg BID if getting ritux, 1000 mg BID otherwise, titrate as necessary to side effects (e.g. diarrhea)

Life-long steroid taper; if diabetes then do rapid steroid taper to off

ATG/ritux - use order set "IP TRS Kidney/Pancreas Induction/Rejection medication"

  • Pre-med with tylenol, benadryl, steroid 1 hr before starting infusion
  • If on steroid taper, can use that day's dose for the pre-med instead
  • If giving ritux, must check the 'emergency meds' box

Discuss with fellow before adjusting!!!

Post-op (donor)

  • Donor Cr can peak at 2x baseline, usually around POD2, then will improve over week/month
     
POD 0 post-op labs 4-6 hrs after OR (check for bleeding)
fentanyl PCA
D5 1/2 NS @ 125 cc/h
CLD
SQH 5000 TID (unless bleeding)		  
POD 1 d/c PCA, transition to Norco
wean mIVF
Do not advance diet until return of bowel function (Busque discharges on full liquid diet)
Check iCa (Busque - replace IV; Gallo - Tums 1000 mg TID)
Foley catheter out if awake/mobile (Busque/Gallo - ambulate prior to d/c). If retention (no UOP in 6h), replace Foley (no straight cath) and try again next day.		 Melcher - toradol 15 mg q6h x 6 doses if no e/o bleeding
Gallo does TAP blocks
Check w fellow before giving toradol
POD 2 Discharge  

 

Kidney transplant calls that keep you up at night
  • "No UOP" Differential dx: Delayed graft function, arterial/venous thrombosis
    • "Prerenal" etiology: rule out hypotension, bleeding
    • Arterial/venous thrombosis: presents with pain at the graft site (deep abdominal pain), reduced UOP. Timeline is typically POD0-2
      • This warrants call to fellow RIGHT AWAY, as this requires takeback to OR or getting IR involved
      • First step: see patient, get vitals, get labs. Obtain kidney ultrasound
    • Delayed graft function: technical definition of DGF is if pt requires HD within 1 week of surgery. Up to 25-40% pts get this
      • This is less of an emergency. Get labs, consult nephrology if HD is warranted (rising K, rising BUN, etc). May end up getting kidney ultrasound.
      • DCD donor or cold ischemia time > 24 hrs = probably will expect more DGF
  • When patients get their induction immunosuppression (ATG, basiliximab, IVIG), there can be a cytokine release syndrome that accompanies this. Presentation of fevers, hypo (or hyper) tension, shaking. Basically looks like SIRs reaction
    • What to do: call rn to pause the infusion. Let the fellow/senior know. Usually the move is to give another dose of solu-cortef then restart the infusion at a slower rate (usually half)
author: admin | last edited: June 20, 2019, 4:12 p.m. | pk: 134