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.
Ask about adherence to medication, additional new drugs, transplant pain, urine output and weight changes.
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.
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.
See GGC Guideline Renal Support: Renal transplant recipients for common transplant medication considerations.
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