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Management of Renal Transplant Recipients

Introduction

Renal transplant recipients are at an increased risk of infection, cardiovascular disease, drug interactions, various degrees of renal impairment and transplant rejection. Early discussion with 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.

Examination

  • Review patient observations. N.B. Pyrexia may be masked.
  • Examine for evidence of infection and transplant pain.
  • Assess fluid status.

Investigations

  • Check U&Es, LFTs, FBC, CRP and bone profile.
  • If relevant, check trough level of ciclosporin or tacrolimus (EDTA tube sent before morning medication).
  • If infection suspected, send at least one urine sample for culture, even in the absence of dipstick nitrates or leucocytes.

Management

General principles

  • Transplant patients must not miss doses of immune suppression medication unless a decision has been made to withhold drugs e.g. due to sepsis.
  • Be aware that multiple interactions exist between common acute prescriptions (e.g. antibiotics) and immunosuppression. Check for drug interaction risk in all newly prescribed medications.

Infection

Common infections may present atypically in immunosuppressed patients. All transplant patients presenting with a fever, nausea or general decline should be screened for infection with urinalysis, MSSU, blood culture and CMV / EBV PCR as baseline tests. Further investigations will be guided by the clinical presentation.

Consider pneumocystis pneumonia. Clinical suspicion should be raised by hypoxia (more marked following exertion), a relatively normal respiratory examination and bilateral infiltrates on CXR. Diagnosis requires induced sputum or BAL (bronchoalveolar lavage) and all cases should be discussed with the Renal Unit.

Urinary infection (UTI) is common and may present with transplant dysfunction. Urinalysis is not always informative; send a mid-stream urine for culture in all patients suspected of UTI.

In severe sepsis it is usually advisable to increase steroid dose, withhold antiproliferative medication (mycophenolate, azathioprine) and monitor, reduce or stop tacrolimus or ciclosporin.

N.B. Where reduction of immunosuppression is being considered in sepsis, all cases must be discussed with the Renal Unit.

Renal Dysfunction

Acute renal dysfunction in transplant recipients can occur for all the same reasons as those without a transplant. Refer to Management of Acute Kidney Injury (AKI). Unique considerations include: increased risk of infection, transplant drug toxicity, transplant obstruction, vascular abnormalities and rejection.

All cases of transplant function should be assessed as per Management of Acute Kidney Injury (AKI) with the addition of transplant ultrasound, ideally with vascular doppler, in those with significant (doubling in baseline serum creatinine) or slow to improve AKI (no improvement within 24 hours of treatment) and trough drug levels (ciclosporin, tacrolimus).

All cases of AKI in transplant recipients should be discussed with the Renal Team to allow rapid organisation of biopsy if necessary.

Drug Therapy / Treatment Options

Immunosupression

  • With the exception of severe sepsis, immunosuppression should continue uninterrupted during hospitalisation. Reductions must be discussed with renal on-call.
  • If nil-by-mouth, insertion of an NG tube and continuing enteral feeding is advised unless otherwise contraindicated.
  • If conversion to IV is required, discuss the case with a renal pharmacist (during working hours via the renal on-call phone and select option 1) for advice on dosing and monitoring.

See GGC Guideline Renal Support: Renal transplant recipients for common transplant medication considerations. 

Other Information

Contact 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.

 

Guideline reviewed: April 2023

Page last updated: June 2023