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You & Your New Kidney: A Manual for the Kidney Transplant Recipient Dr. Shamik H. Shah MB BS, MD, DNB (Nephrology), ISN Fellow Critical Care & Transplant Nephrologist


Dr. Shamik H Shah

This

patient guide has been written so that you be-

come acquainted with information that is vital after your kidney transplant. You and your family should read it so you all become familiar with the follow-up care after the transplant.

This

guide may answer many of your questions. This guide is not meant to replace the relationship you have with your Doctors or transplant coordinators.

You

will have to perform daily self-monitoring skills, keep accurate records of your vital signs, weight, urinary output and medication dosages. often dicult to keep track, it down.

It is

so please write

Read this book carefully.

Always

ask questions and share your concerns with us.

Good luck with your new kidney !!

1


Contents 1 Introduction

6

1.1

How the Kidneys work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

1.2

Symptoms of Kidney Disease

6

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2 Kidney Transplantation 2.1

Why a Transplant is Necessary

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

History of Kidney Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

Types of Kidney Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9

2.2.1

Living Donor Kidney Transplantation

. . . . . . . . . . . . . . . . . . . . . . . . . . .

9

2.2.2

Cadaveric Kidney Transplantation

. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9

The Kidney Transplant Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

2.3.1

Transplant Nephrologist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

2.3.2

Transplant Surgeon

10

2.3.3

Transplant Coordinator

2.3.4

Floor or Sta Nurse

2.3.5

Psychologist / Psychiatrist

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

2.3.6

Social Worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

2.3.7

Pharmacists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

Pre Transplant Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

2.4.1

Histocompatibility Laboratory Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

2.4.1.1

Tissue Typing

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

2.4.1.2

Panel Reactive Antibody (PRA) . . . . . . . . . . . . . . . . . . . . . . . . .

12

2.4.1.3

Crossmatch testing

13

2.1.1 2.2

2.3

2.4

8

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2


Dr. Shamik H Shah

CONTENTS

2.4.1.4 2.4.2

2.5

Other tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Clinical Laboratory Tests

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

2.4.2.1

Blood Typing

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

2.4.2.2

Viral Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

The Kidney Transplant Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

2.5.1

The day you are admitted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

2.5.2

The Day of Surgery

14

2.5.3

The day after your surgery

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

14

2.5.4

Daily Hospital Routines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15

2.5.4.1

Vital Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15

2.5.4.2

Weight

15

2.5.4.3

Fluid Intake and Urine output

2.5.4.4

Daily Activity

2.5.4.5

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15

Lab Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16

3 Going Home 3.1

13

18

General Information

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18

Your Post-Transplant Diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18

3.1.1.1

Helpful hints about salt

. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18

3.1.1.2

Food Safety & Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19

3.1.1.3

Alcoholic Beverages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19

3.1.1.4

Smoking & Tobacco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19

3.2

Vital Signs and Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20

3.3

Resuming Normal Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

3.3.1

Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

3.3.2

Play . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

3.3.3

Sexual Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

3.3.3.1

Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22

3.3.3.2

Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22

3.3.4

Skin & Hair Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22

3.3.5

Driving, Vacation & Travel

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23

3.3.6

Pets at Home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24

3.1.1

3


Dr. Shamik H Shah

CONTENTS

4 Transplant Medications

25

4.1

General Medication Information

4.2

Medication Guidelines

4.3

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25

4.2.1

Before taking medications:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26

4.2.2

General Guidelines for Storing Your Medications . . . . . . . . . . . . . . . . . . . . .

26

4.2.3

Important Medication Tips

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26

4.2.4

Warnings

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26

Medications you may be taking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26

4.3.1

Tacrolimus

26

4.3.2

Mycophenolate Sodium or Mycophenolate Mofetil

4.3.3

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27

Prednisolone

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27

4.3.4

Cyclosporine

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27

4.3.5

Azathioprine

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28

4.3.6

Sirolimus (Rapamycin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28

4.3.7

Lymphocyte Immune Globulin

28

4.3.8

Sulfamethoxazole/Trimethoprim (Bactrim

4.3.9

Acyclovir

速)

. . . . . . . . . . . . . . . . . . . . . .

29

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29

4.3.10 Valganciclovir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29

4.3.11 Pentamidine

29

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4.3.12 Herbal Preparations

4.4

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30

4.3.13 Syringes & Needles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30

Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

31

4.4.1

Immunization you must not receive . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

31

4.4.2

Immunization you may receive

31

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5 Post-Transplant Complications 5.1

5.2

Rejection

32

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5.1.1

Symptoms & Signs of rejection

5.1.2

Treatment of Rejection

Infections 5.2.1

32

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

32

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33

Viral Infections: 5.2.1.1

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Cytomegalovirus (CMV)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

33 33


Dr. Shamik H Shah

CONTENTS

5.2.2

5.2.1.2

Herpes-simplex virus type I and II

. . . . . . . . . . . . . . . . . . . . . . .

33

5.2.1.3

Herpes zoster (shingles) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34

Fungal Infections: 5.2.2.1

5.2.3

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Candida (yeast)

Bacterial Infections: 5.2.3.1

34

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34

Wound infections

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34

5.2.4

Other Infections: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34

5.2.5

Avoiding Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34

5.3

Acute Tubular Necrosis

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35

5.4

Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35

5.5

High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35

6 Normal Blood Test Values

36

7 Denitions

37

5


Chapter 1

Introduction 1.1

How the Kidneys work

Normal functioning kidneys serve the body in several very important ways. They:

The kidneys are two bean-shaped organs located toward the back of the body on either side of the spine near the waistline. They are about the size of a st

ˆ

Clean your blood and remove waste products

ˆ

Balance water and salt to control uid in the body

and are protected by other organs and two of the lower ribs.

ˆ

Control blood pressure

ˆ

Help make red blood cells and strong bones

ˆ

Control the amount of potassium, calcium, magnesium and phosphorus in the blood

1.2

Symptoms of Kidney Disease

Failing Kidneys can cause a variety of disturbances in the body. Some of the common symptoms of kidney failure are:

Figure 1.1: The Normal Kidneys

6

ˆ

Decreased urine output

ˆ

Shortness of breath

ˆ

Swelling of legs and face

ˆ

Decreased appetite

ˆ

Nausea & Vomiting

ˆ

Headache


1.2.

Dr. Shamik H Shah

SYMPTOMS OF KIDNEY DISEASE

ˆ

Easy fatiguability

ˆ

High blood pressure

ˆ

Change in mental status

ˆ

Abnormal blood and urine tests

7


Chapter 2

Kidney Transplantation 2.1

Why a Transplant is Neces-

 the immediate results were excellent the child died about 2 weeks later.

sary ˆ

While such transplants did successfully produce

A number of diseases can directly damage the kid-

urine, they lasted only for about an hour before

ney. Damage to the kidney can seriously aect the

ceasing to function.

removal of water and waste products, production of

ˆ

red blood cells, regulation of blood pressure and bal-

Scientists of the time believed kidney transplants were possible, but their success was lim-

ance of electrolytes such as potassium, calcium and

ited by unknown  biochemical barriers, which

phosphorus.

prevented long-term kidney survival.

If the damage is severe enough, transplantation may be necessary. A transplant provides a patient with a kidney that can keep up with the demands of a full,

1933 - The rst human-to-human kidney transplant

active life.

was performed

ˆ

2.1.1 History of Kidney Transplantation

Unknown to doctors at the time, there were mismatches in donor and recipient blood groups and the donor kidney never functioned

Transplantation is a recent phenomena. Many of the

1940's - Sir Peter Medawar at the University of Lon-

big developments in this discipline have taken place

don experimented with the immunologic basis of or-

within the past 40 years. This time line gives a brief

gan rejection.

outline of how transplantation progressed through this century.

Early 1950's - Cortisone-like medications were used to

1902 - The rst successful experimental kidney trans-

suppress the human body's self-defense system (im-

plants were performed at the Vienna Medical School

mune system), resulting in some kidney transplant

in Austria with animals.

success.

1909 - The rst kidney transplant experiments were 1954

- Joseph E. Murray and his colleagues at Pe-

ter Bent Brigham Hospital in Boston performed the

performed in humans in France using animal kidneys.

rst truly successful kidney transplant from one twin

ˆ

A surgeon inserted slices of rabbit kidney into

to another. This was done without any immunosup-

a child suering from kidney failure. Although

pressive medication. 8


2.2.

Dr. Shamik H Shah

TYPES OF KIDNEY TRANSPLANTATION

Blood type

Can Donate to

Can receive from

O

A, B, AB, O

O

A

A, AB

A, O

B

B, AB

B, O

AB

AB

A,B, AB, O

Table 2.1: Blood type & Compatibility

can be tested thoroughly prior to transplantation.

ˆ

Figure 2.1: Kidney Transplant at Boston 1954

Living donor kidneys last longer.

Half of liv-

ing donor kidneys transplanted today will still be functioning 25 years from now, whereas half

ˆ

of cadaveric kidneys will fail in the rst 10 years.

Scientists predicted that immune system reactions should be minimal between identical twins

ˆ

(because their organs were indistinguishable to

mediately. The waiting time for a cadaveric kid-

each other's immune systems).

2.2

The living donor kidney can be transplanted imney ranges from two to ve years.

ˆ

Types of Kidney Transplan-

Most living donor kidneys function immediately after transplantation, while many cadaveric kidneys do not function well initially.

tation

2.2.2 Cadaveric Kidney Transplantation

There are two types of kidney transplants. The difference between the two is determined by the source of the donor kidney. One is known as

In this case, the kidney is obtained from a person who

2.2.1 Living Donor Kidney Transplantation

has died suddenly, usually as a result of an accident or stroke. This person might have previously expressed to their families a willingness to donate their organs. Alternatively, the family might come forward to do-

In this type of transplant, someone who has a very

nate the organs of their loved one. After the cadaveric

close relationship to the patient donates a kidney.

donor has been declared legally brain dead, the kid-

Usually this person is a parent, sibling, child or

neys are surgically removed, placed in a sterile uid,

spouse. This type of transplant requires planning and

and kept cold until a suitable recipient can be found.

is scheduled in advance for a time when the involved people are in optimal health and it is convenient for

The Cadaveric Transplant Registry picks the recip-

both the donor and the recipient.

ients based on blood group and waiting time.

I emphasize living donor kidney transplants as the best option for patients.

As

is pretty obvious, the recipient of a cadaveric transplant can expect to wait several years for a kidney to

Living donor organs oer

become available.

many advantages including:

Whenever a kidney becomes available, patients may

ˆ

The living donor kidney is the best quality kid-

receive calls informing them that they are being put

ney that a patient can receive because the donor

on a Final Crossmatch as a Back up. This means 9


2.3.

Dr. Shamik H Shah

THE KIDNEY TRANSPLANT TEAM

1 year survival

5 year survival

Live-related Donor

95%

80%

Cadaveric Donor

80-85%

65%

there are people whose names will be ahead of yours, and if they are compatible, they will get the kidney. However, due to unforeseen circumstances, sometimes the back up person may be oered the kidney.

Table 2.2: Statistical survival rates

You can avoid missing out on potential kidneys by staying as healthy as possible,

keeping us updated

about your address, phone numbers and insurance de-

2.3

ble and most importantly, we must be able to contact you at all times.

The

Kidney

Transplant

Team

tails, completing all required tests as quickly as possi-

Kidney Transplantation is a team eort involving sev-

Because the wait time for a kidney can be lengthy,

eral dierent individuals with dierent areas of exper-

it is our policy to complete annual testing on you to

tise. Some of the key individuals in your transplant

ensure you remain an acceptable candidate. We will

team are:

contact you when it is time to repeat testing. Please keep in mind that your wait time is not predictable. We must, repeat, must be able to reach you at all times.

It is imperative that you repeat calls from

the Transplant Coordinator immediately (no matter what time of day or night) to avoid being passed over for a kidney. Most donor calls come in the middle of the night so do not turn o your phones !! If you have diculty hearing or communicating, please identify a close family member or friend who can reach you at a moment's notice to help us communicate with you.

2.3.1 Transplant Nephrologist A transplant physician monitors all non-surgical aspects of patient care.

A transplant patient will see

this doctor often. The transplant physician will perform examinations, check test results, and adjust medication as needed. A patient should not be shy in asking questions and alerting his physician regarding changes in the way he feels, no matter how insignicant it may seem.

If you are called for a kidney, but are actively ill,

Your Transplant Nephrologist, Dr. Shamik Shah has

have an open wound or infection, or have a signicant

a vast experience in dealing with Kidney transplant

change in your medical condition, we cannot consider

patients. A university rank holder and gold medal-

you for a transplant at that time. Your name would

ist from his medical school days, he has trained at

simply be passed over around that time.

some of the best centers in the world. He was a Post-

You may

also turn down a kidney for personal reasons if you

Doctoral Scholar at the University of California, San

feel it is not in your best interests at the time you

Diego. He has many publications in textbooks and

are called. If you turn down kidneys, we may change

International Journals to his name. He is the recipi-

your status to inactive until you feel you are ready to

ent of prestigious awards like Young Investigator by

proceed with a transplant.

the International Society of Peritoneal Dialysis and ISN Fellow by the International Society of Nephrol-

The advantages of Cadaveric Transplantation are:

ˆ

ogy.

Provides a better quality of life for the recipient than Hemodialysis or Peritoneal Dialysis

ˆ

2.3.2 Transplant Surgeon

Provides a survival advantage over patients re-

The transplant surgeon performs the actual trans-

ceiving Hemodialysis or Peritoneal Dialysis

plantation procedure and monitors a patient's condition, during surgery. He or she will assess the quality 10


2.4.

Dr. Shamik H Shah

PRE TRANSPLANT EVALUATION

of the donor's kidney before surgery. He or she will

it will make in a transplant patient's life. The psy-

also check the incision to make sure it is healing prop-

chologist or psychiatrist can oer insight and support

erly.

along every step of the way.

2.3.3 Transplant Coordinator

2.3.6 Social Worker

This team member, will have the following key re-

The social worker will link the patient to services and

sponsibilities:

people in the community who can help with his recovery after leaving the hospital. If the patient needs

ˆ

First, he or she will coordinate all the events

transportation, help at home, or a hand when he goes

leading up to and following surgery. These may

back to school or work, the social worker will help

include scheduling pre transplant testing, locat-

arrange it. The social worker can also advise about

ing donor kidney, testing for donor compatibil-

insurance coverage, as well as helping with psychoso-

ity, contacting the patient once a kidney has

cial and family matters.

been found, and making sure that the patient

2.3.7 Pharmacists

has proper follow-up care.

ˆ

Second, the coordinator will teach the patient how to take care of himself before and after

During your hospital stay, a pharmacist will teach

transplantation, including how to take medica-

you about your medications either in a group class or

tion and when to return to the transplant center

individually as necessary. It is very important that

for follow-up visits. He or she can put the pa-

you understand your medicines well by the time of

tient in touch with community services that will

your discharge.

make life easier for him and his family.

ˆ

Makes

all

communications

between

patients,

hospital, clinics and doctors.

2.4

Pre Transplant Evaluation

Pre transplant tests, as well as giving a clear picture

2.3.4 Floor or Sta Nurse

of the patient's overall health status, help in identifying potential problems before they occur.

They

This nurse will help coordinate the activities of the

also help in determining whether transplantation is

transplant patient's other caregivers, as well as tend-

truly the best option.

ing to the patient's needs during his hospital stay

of success.

and preparing him for discharge. The sta nurse will also keep the lines of communication open between the patient and the other members of the transplant

The following procedures help in evaluating a patient's health status:

team.

ˆ

Complete medical and surgical history

-

Determines what additional tests may need to

2.3.5 Psychologist / Psychiatrist

be done.

ˆ

A patient and his family members may nd it helpful Frank discussion may help cope

with the transplant experience and with the changes 11

Physical exam

- Gives the doctor an overall

picture of the patient's conditions.

to talk about their feelings with a professional before and after surgery.

This increases the likelihood

ˆ

Chest x-ray - Determines the health of the patient's lungs and lower respiratory tract.


2.4.

ˆ

Dr. Shamik H Shah

PRE TRANSPLANT EVALUATION

Electrocardiogram (EKG or ECG) - Deter-

0%.

mines how well the patient's heart is working and

blood transfusion, pregnancy, a previous trans-

may reveal heart damage that was previously un-

plant or a current infection.

suspected.

ˆ ˆ

Ultrasound with Doppler examination

ˆ -

Determines

if

the

patient

(CMV), Epstein-Barr (EBV), or acquired im-

Blood tests - The patient's blood count, blood

mune deciency syndrome.

ˆ ˆ

performed.

Blood typing

Mammogram - X-ray of a woman's breast that can detect signs of breast cancer.

blood tests for certain infectious diseases will be

Pap smear

- Cells collected from a woman's

cervix that are microscopically analyzed for signs - Every person is a blood type

of cancer.

A, B, AB or O. The donor's blood type does

ˆ

not have to be the same as the recipient's blood match testing).

Pulmonary function test

Echo cardiogram - Reveals any abnormalities in the heart.

type, but it must be "compatible" (see Cross-

ˆ

-

Determines the quality of the iliac vessels.

and tissue type, blood chemistries, and immune

ˆ

Viral testing

has been exposed to hepatitis, cytomegalovirus

system function will all be checked. In addition,

ˆ

An immune system may be active from

ˆ

Dental Evaluations - You need to have a den-

- The patient will

tal check-up before you will be listed for trans-

be asked to breathe into a tube attached to a

plant. Your dentist must tell us that your teeth

measuring device, which will reveal how well his

and gums are healthy. You will also need to be

lungs are working and determine his blood's ca-

checked by your dentist every year while you are

pacity to carry oxygen.

waiting for your transplant.

Upper gastrointestinal (GI) series

ˆ

- This

Other tests - Any special tests or doctor visits that might be needed for the transplant workup.

will show whether the patient's esophagus and stomach are disease free.

ˆ

Lower GI series - Ensures that the

patient is

free of intestinal abnormalities.

ˆ

Renal function studies

- Urine may be col-

lected from the patient for 24 hours in order to determine if the kidneys are working correctly. Blood tests such as serum creatinine are also performed to measure kidney function.

ˆ

Tissue typing - This test is done on white blood cells. White blood cells have special "markers"

2.4.1 Histocompatibility Laboratory Tests 2.4.1.1 Tissue Typing This test is done on white blood cells.

The white

blood cells have special "markers" that tell your "tissue type". You inherit tissue type from your mother and father.

This test is used to match a kidney

and/or pancreas to you.

that distinguish "tissue type", which are used to nd a matching kidney.

ˆ

Panel Reactive Antibody (PRA)

2.4.1.2 Panel Reactive Antibody (PRA) - A way

of measuring immune system activity within the

This test shows how active your immune system is.

body. PRA is higher when more antibodies are

It is easier for you to get a kidney if your immune sys-

being made. It is easier to acquire a kidney if a

tem is calm or measures 0%. Blood will be drawn at

recipient's immune system is calm or measures

your dialysis center and sent to our laboratory. Your

12


2.5.

Dr. Shamik H Shah

THE KIDNEY TRANSPLANT SURGERY

immune system may be active from blood transfu-

2.5

sions, pregnancy, a previous transplant or a current

The

Kidney

Transplant

Surgery

infection.

2.5.1 The day you are admitted

2.4.1.3 Crossmatch testing

Your rst day in the hospital will be very busy. You

This test is done when a donor kidney is available. Your blood is mixed with the donor's blood. If there is no reaction (negative Crossmatch) it means you are "compatible" with the donor. If there is a reaction (positive crossmatch), the kidney will not work for

will be admitted one day prior to your surgery. You will be assigned a room on the transplant unit. Since many patients request private rooms, we will make every eort to honor that request or move you to a private room as soon as one is available. When you arrive in the unit, you will be interviewed

you because it is "incompatible".

and examined by both doctors and nurses. They will ask many questions about your illness, your allergies,

2.4.1.4 Other tests

your diet, your medications, and the availability of your family.

If you are unsure of the names and

dosages of your medicines, please bring them with The transplant doctors will ask for any special tests

you.

they think you will need. For example, people with Your

The nurses will weigh you, check your blood pres-

transplant coordinator or dialysis doctor can help you

sure, and take your temperature. At this time, you

diabetes will need more tests for their heart.

should inform the nurse if you have any valuables or

make arrangements for these tests.

money with you. We encourage you to leave jewelry and valuables with your family; you should keep only enough money to buy newspapers, magazines, etc.

2.4.2 Clinical Laboratory Tests

Your admission blood tests and chest X-ray will be done during the early part of your stay. You will also

2.4.2.1 Blood Typing

have an EKG (heart tracing) done. All of these are routine.

There are four dierent blood types.

They are A,

B, AB and O. Every person has one of these blood types. The donor's blood type does not have to be the same.

However, it must be "compatible" with

your blood type for you to receive the kidney.

See

table 2.1 on page 9

If you are able to urinate, we will ask you for a routine specimen as well as a "clean catch" specimen. If you have never collected "clean catch" urine, the nurse will explain how to do it. You will be dialyzed on the day prior to surgery. This is to make sure that your Urea, Creatinine, Potassium and other electrolytes are in acceptable range. Blood

2.4.2.2 Viral Testing

will be collected from your veins early morning to run these tests.

It is important for us to know if you have been ex-

You will be given two enemas the evening before your

posed to hepatitis, cytomegalovirus (CMV), Epstein-

operation. This is necessary because the surgeon will

Barr virus (EBV), or acquired immune deciency

be working very close to your intestines.

syndrome (AIDS). We will test you for these when

not be able to eat or drink anything after midnight

you are seen by your Transplant Nephrologist.

before surgery. You will be shaved from your chest 13

You will


2.5.

Dr. Shamik H Shah

THE KIDNEY TRANSPLANT SURGERY

to your thighs, but this is not painful. It is done to eliminate bacteria, which cling to the hairs on that part of your body. You will be asked to shower twice using special soap. A member of our anesthesia sta will visit you before surgery. He or she will explain the type of anesthesia that will be used during the operation and ask you about any allergies you may have and any medications you are taking.

He or she will be able to tell

you what time your surgery is scheduled. Prior to surgery you will be asked to sign a permission slip that gives the surgeon permission to do the transplant. You should read the permission carefully before signing it. We ask parents to sign for children who are under the age of 18.

Figure 2.2: The Kidney Transplant Surgery

2.5.2 The Day of Surgery

The operation will connect the new kidney to your bladder and blood vessels. It will be located under

You will be awakened early on the morning of your operation. At this time you should bath, shave, brush your teeth, and put on a hospital gown after your bath. At this time you should remove your jewelry and dentures. Please remember not to eat or drink anything.

an incision in either your right or left lower abdomen. The surgical team will place the donor kidney into the abdomen and connect the kidney's blood vessels to the recipient's iliac artery and vein. The surgeons will then connect the ureter to the bladder. A small drain, may be placed into the abdominal cavity to drain any excess uid.The kidney cannot be seen, but can

The attendant from the operating room will come

easily be felt by your doctors. Contrary to popular

get you with a stretcher.

belief, your native kidneys are not removed during

Members of your family

the transplant operation.

will be allowed to accompany you to the door to the crosswalk, but they may not go any further.

A Ureteric Stent, also called a Double J or DJ

During your surgery, your family should wait in the

stent is a small plastic tube that may be placed into

waiting room.

your ureter during transplant surgery. The ureter is

The doctor will inform your family Prior to going to

the tube that brings urine from the kidneys to the

the waiting room, a family member should remove

bladder. The stent prevents the ureter from kinking

when your surgery is completed.

all of your belongings from your room since you will

while everything heals.

be going to another room when you return to the

by a cystoscopy procedure usually on the 14th day of

transplant oor.

surgery.

Once in the operating room, you will be given medication that will make you go to sleep.

The doctor

will then place a central venous catheter (a large IV catheter) just under your collarbone or on the side

The stent will be removed

2.5.3 The day after your surgery When you wake up after your surgery, you will prob-

of your neck. This allows us to closely monitor your

ably be in the transplant ICU, a special room on the

uid intake and administer uids and medications.

transplant oor. This room has special monitors and

We can also use this catheter to obtain blood.

is staed by specially trained nurses. Usually you will 14


2.5.

Dr. Shamik H Shah

THE KIDNEY TRANSPLANT SURGERY

spend approximately 24 hours in here, being moni-

2.5.4 Daily Hospital Routines

tored very closely to make sure your new kidney is functioning well before you are transferred to your room.

These include the following procedures:

This is what the patient should expect:

ˆ

Some pain and discomfort, which medication will

2.5.4.1 Vital Signs

help to relieve.

ˆ

The patient will be asked to cough periodically to keep his lungs clear. If it hurts to cough, the

ˆ

During your post-surgery hospital stay, you will be involved in the daily routines of our transplant unit.

Your vital signs (blood pressure, pulse, and breath-

patient should ask someone to support his ab-

ing) may be measured every hour, or more frequently,

domen.

for the rst 24 hours you are in the transplant unit.

The patient will have an IV line in his arm or

After this, they will be measured every four hours.

neck under the collarbone, which will be used to give uids and medication for the rst few days after surgery.

ˆ

For several days after surgery, the patient will have a catheter in his bladder to drain urine. He may feel uncomfortable, and may feel that he has

2.5.4.2 Weight You will be awakened early every morning to get weighed.

to urinate constantly, but it is only temporary.

ˆ

During surgery, one drain may be placed in or near the incision. The drain will be removed 5

2.5.4.3 Fluid Intake and Urine output

to 10 days after surgery.

ˆ

We must have an accurate record of your uid intake Dialysis may still be needed to help clear excess

and urine output to determine if your new kidney is

uid and toxins in the body until the kidney re-

functioning adequately. You will also be given a cup

covers from the procurement process.

with markings on it to measure your urine; the cup is

We will notify your family as soon as you arrive in your room so they can visit you for a short time. After this rst visit, they must observe regular visiting hours. The nurses will measure your vital signs

marked in cc, and you should tell the nurse or record the amount you void each time on your I & O (Intake & Output) sheet. Your nurse will explain in detail how to do this.

every half hour. They will do this as quietly as possible, but the procedures may awaken you at night. The nurses will also frequently remind you to cough, breathe deeply, and turn in the bed to reduce your chance of getting pneumonia after surgery. You will not be able to eat or drink anything for about 24 hours after your surgery. It takes about that long for your stomach to begin to work well again. Intravenous uids will provide your nourishment during

2.5.4.4 Daily Activity While you still have a catheter, you may take a sponge bath; as soon as the catheter is removed, you may take a shower. After bathing, you may dress in comfortable pajamas

this time. When your doctor decides you are ready,

that do not rub or irritate your incision. You should

you may receive some clear liquids.

spend most of the day out of your room or with the

gradually be changed to solid food.

Your diet will

other patients as you choose. 15


2.5.

Dr. Shamik H Shah

THE KIDNEY TRANSPLANT SURGERY

2.5.4.5 Lab Tests

ˆ

Mg measures magnesium, which is necessary for normal functioning of muscles and for blood clot-

Every day you will have blood drawn.

ting.

These tests

help the doctors monitor the function of your new

ˆ

kidney. If for any reason someone does not draw your blood, please let your nurse know right away.

ˆ

A usual lab test monitors blood count, kidney functient's blood. Other tests may be ordered as neces-

ˆ

sary.

WBC tell if the patient's white blood cells have

Drug levels

measure Tacrolimus (TacloranÂŽ) or

Cyclosporine (NeoralÂŽ) in the blood. Tacrolimus or

increased (usually a sign of infection) or de-

Cyclosporine blood levels must be checked regularly

creased (indicating a lower defense against in-

to avoid levels that are too high or too low. High lev-

fection).

els could lead to toxicity or over-immunosuppression,

HCT measures the hematocrit, which is the per-

and low levels may lead to rejection.

centage of red blood cells in the blood.

ˆ

HCO3 measures bicarbonate, which helps maintain acid balance in the body.

Tests for Blood Count:

ˆ

Na measures sodium, which helps maintain the balance of salt and water in the body.

tion, electrolytes, and medication levels in the pa-

ˆ

K measures potassium, which is needed for normal heart and muscle function.

Red

NOTE: The desired level (normal range) will dier

blood cells carry oxygen to all parts of the body.

for each person, depending on the combination of im-

When a patient's HCT is low, he may feel tired

munosuppressive medications and the length of time

or have little energy.

since the transplant.

PLT

measures the level of platelets.

Additional tests and Procedures

Platelet

cells form a blood clot when the body is injured. Low platelet levels may cause someone to bruise easily and to bleed for a longer time when injured.

Tests for Kidney Function: Creatinine and Blood Urea or BUN tell how well the kidneys work by measuring levels of creatinine and blood urea, waste products normally removed from the blood by the kidneys.

The transplant team may perform one or more of the following tests and procedures to monitor a patient's transplant:

Ultrasound

- This test is performed to make sure

all the main blood vessels leading to the kidney are functioning normally. This test is also used to check for collections of uid, such as blood.

The proce-

dure consists of placing a cool gel on the patient's abdomen, over which a wand (transducer) is moved to transmit sound waves.

These are converted into

When these numbers rise, the cause may be rejection

images of the kidney and projected onto a television

or a side-eect of medications.

screen.

Kidney biopsy

Tests for Electrolytes (dissolved minerals): ˆ

Ca

to

measures calcium, which is necessary for

strong bones and teeth, blood clotting, and heart and nerve function.

ˆ

PO4

lems.

for

- This test is usually performed

rejection,

or

other

possible

prob-

This may be done in the hospital or in the

outpatient/short-stay unit. The patient will receive special instructions regarding the procedure. Before the procedure, the patient will receive a numbing in-

measures phosphate, which works closely

with calcium to strengthen bones.

check

jection (local anesthetic) on the right side of his abdomen.

16

Then a special needle will be inserted to


2.5.

Dr. Shamik H Shah

THE KIDNEY TRANSPLANT SURGERY

withdraw a small sample of kidney tissue that will be examined with a microscope.

Computerized tomography (CT) scan - This is a type of X ray that allows the physician to view the patient's kidney from many dierent angles to detect infections, uid collections, or other problems. The procedure requires that the patient drink a liquid that outlines his stomach and intestines and makes his kidney more visible; then he lies at for 1 hour while the machine takes X rays around him.

Magnetic resonance imaging (MRI) - This is another type of test that produces an image. Somewhat like a CT scan, it also allows a patient's kidney to be viewed from dierent angles and in three-dimensional images. An MRI shows soft tissues, such as the kidney, more clearly than a CT scan does.

Renal Scan - This is a test performed in the Department of Nuclear Medicine. It involves drawing blood and injecting material into your veins, which will be taken up by your kidney. A large machine will pass over you, taking pictures of your kidney and bladder to measure the amount of the material in your kidney. The only discomfort you will feel is the needle stick when the uid is injected.

Prior to this test

you MUST drink a lot of uid UNLESS your uids are restricted. The nurse will tell you when you are scheduled for a renal scan.

17


Chapter 3

Going Home 3.1

General Information

gain weight quickly. Some of the immunosuppressive medications can

3.1.1 Your Post-Transplant Diet

cause your cholesterol and triglycerides to become elevated, which is bad for your heart. Your blood tests

When your doctor allows you to eat solid foods, you

will be monitored closely to watch for any changes in

will be placed on a "Post-transplant 2gm Sodium

your lipid prole. Diet and lipid lowering agents are

(Na )" diet.

employed to maintain normal cholesterol and triglyc-

+

This diet limits fat, salt, and sugar

and encourages fruits,

vegetables,

lean meats or

meat substitutes, and low fat dairy products. Your food choices are very important to your health, and this diet will help minimize the side eects of your medicine and maintain optimal health.

Later on,

erides.

Too much sugar may increase your blood

sugar as well as your weight. Your dietitian will work with you individually on your diet as needed.

your dietary salt restriction will become less strict

3.1.1.1 Helpful hints about salt

and you will be allowed to eat a normal salt diet. Generally you do not have to avoid foods high in potassium, phosphorous, or protein after your transplant. At rst, you will need extra calories and protein to heal.

Later your calorie and protein needs

ˆ ˆ

140 mg or less.

foods to keep your bones strong.

ˆ

sodium

The medication (Prednisone)

used after transplant can cause hunger.

have a working kidney, you probably feel better, and

ˆ

more than you ate before your transplant, and it is essential that you limit your intake of fat and sugar and increase your exercise.

glutamate

(MSG),

18

benzoate,

Over the counter and prescription drugs may

ˆ

Avoid using salt at the table.

ˆ

Avoid using salt when preparing foods. spices to avor foods.

If you do not, you will

sodium

contain varying amounts of sodium.

food may even taste much better! Your appetite will increase as you feel better. You will soon want to eat

Sodium

sodium bicarbonate, etc.

It changes

the way your body uses fat and sugar. Now that you

Read the ingredients on food labels.

may be added to foods in the form of mono

much easier to gain unwanted weight (fat). There are several reasons why.

Read the Nutritional Content on food labels. Look for servings that contain approximately

will return to normal. You will also need extra dairy

As you may have heard, after a transplant it is often

2 Grams of sodium equals 2000 mg

Use


3.1.

ˆ

Dr. Shamik H Shah

GENERAL INFORMATION

4. Do not eat any raw food.

Foods highest in sodium that should be limited or avoided are: canned soups; salted breads and

5. Always drink pasteurized milk, juices, etc. Use

crackers; cheese spreads and processed cheeses;

cheese made from pasteurized milk only.

meat, sh and poultry that has been salted, canned, pickled or smoked; meat tenderizers; pickles, olives, potato chips and pretzels; salted

Other helpful tips

nuts and peanut butter; salt and seasoned salts

1. Don't buy foods in damaged containers,

like garlic, onion or celery; condiments  soy sauce, ketchup.

ˆ

i.e.

cracks in packages, dents in cans, or bulging lids. 2. Check dates, sell-by dates on all dairy, meat, sh

Canned vegetables and canned vegetable juices

and poultry.

3.1.1.2 Food Safety & Preparation

3. Refrigerate perishables as soon as you get them. Freeze meat, poultry and sh right away.

People with weakened immune systems (like trans-

4. Make sure the refrigerator temperature is 40 de-

plant patients) are at risk from diseases caused by

grees or lower and freezer temperature is 0 de-

contaminated food.

grees or lower.

How To Protect Yourself When Eating Out

5. Store canned foods in a cool dry place for no more than 1 year.

1. Never eat raw or undercooked food of animal

6. Wash sponges, towels, and kitchen washcloths

origin or sh. Do not eat uncooked meat like 35

frequently.

steak tartar, hamburger or roast beef.

7. If your water is from a well, you may use bottled

2. Avoid soft cheese like Feta, Brie, Camembert,

water or boil the water for 10 minutes.

Bleu, Mexican white cheese. 3. Avoid salad bars at restaurants. Avoid roadside stands and markets. 4. Foods should be well cooked and served to you hot (cooking food thoroughly destroys potentially harmful organisms).

Medications such as Tacrolimus, Cyclosporine, Azathioprine, and Co-Trimoxazole are broken down by the liver and, if combined with alcohol, could harm

Food should not be

the liver and eventually lead to abnormal blood lev-

left to stand longer than 2 hours.

els of these medications.

5. Avoid foods with raw or undercooked eggs like dressing in Caesar salad, etc.

This can compromise the

function of the kidney. Alcohol is dehydrating.

This is hard on your new

kidney and can cause problems in the function of the

How to Protect Yourself at Home

kidney.

1. Always wash your hands. Wash utensils, knives, cutting boards, etc. thoroughly.

3.1.1.4 Smoking & Tobacco Use of tobacco products is strongly discouraged.

2. Do not eat fruits with skin. 3. Thoroughly wash vegetables before consuming them.

3.1.1.3 Alcoholic Beverages

Chewing tobacco can lead to neck and mouth cancers. Smoking:

19


3.2.

Dr. Shamik H Shah

VITAL SIGNS AND WEIGHT

Take Blood Pressure

ˆ

Increases risk of cancers, especially lung cancer.

ˆ

Increases your surgical risk.

ˆ

Twice a day

Causes atherosclerosis (fatty deposits in your

ˆ

Preferably in the early morning and late after-

ˆ

noon.

blood vessels)

ˆ

How to take an accurate blood pressure reading

Increases risk of heart attack and stroke.

Marijuana can cause lung and brain fungal infections.

1. Do not smoke or ingest caeine for half an hour before the measurement.

If you need help quitting smoking or chewing tobacco, please get in touch with your Transplant Nephrolo-

2. Sit quietly for 5 minutes, keep bare arm sup-

gist.

ported at the level o your heart (on a table). 3. Feel for the brachial artery.

3.2

Vital Signs and Weight

This is found by

lightly pressing the crease on the inside of your elbow. You will feel a pulse. 4. Expel any air in the B/P cu and wrap evenly

It is important that you do the following things every day. Temperature, blood pressure, weight, intake,

with lower edge 1 to 2 above the strongest

and output should be taken and recorded on the Daily

brachial artery pulsation.

Patient Record. (See sample in your folder) Remem-

marking on the cu over the brachial artery.

ber to bring this record with you to each clinic visit.

Avoid contact with thick clothing, as this will

Take Temperature

reduce the sound.

Center the arrow

5. Place the stethoscope over the brachial artery

ˆ

Twice a day

ˆ

Early morning & late afternoon

and inate the cu to 200 mm Hg. 6. Slowly deate the cu. Listen for the rst sound and note the number on the dial. systolic pressure, or top number

If your temperature is 100 degrees Fahrenheit or

This is the

126/80.

7. Continue deating the cu and note the level

greater, call the transplant nurse. If you feel like you have a fever or the chills, take your temperature and

when you hear the last sound. This is the dias-

record it more often. If you have a fever of over 100

tolic pressure or bottom number 126/

degrees Fahrenheit after 3 months post transplant,

8. If your blood pressure is outside your regu-

call your doctor.

lar pattern, or less than 90/60 or more than 170/110, please notify the transplant Nephrol-

Here are Celsius and Fahrenheit equivalents:

0 0 0 0 38 C = 100.4 F 0 0 39 C = 102.2 F 0 0 40 C = 104.0 F

ogist.

37 C = 98.6 F

Weigh Yourself

80.

The ideal blood pressure for all kidney

transplant patients is 120/80. If you have a digital blood pressure machine please follow the directions that came with your machine. If you are having a problem accurately taking your blood pressure please bring your blood pressure machine to clinic with you and the nurse / transplant coordinator will check your blood pressure equipment

ˆ

Before breakfast each day

for accuracy and assist you. 20


3.3.

Dr. Shamik H Shah

RESUMING NORMAL ACTIVITIES

3.3

Resuming

Normal

Activi-

ˆ

ties

ˆ

Pain or pressure in the chest, neck, or jaw Excessive fatigue that is not related to lack of sleep

Activity restrictions following transplant are few. We want you to resume your past level of activity and lead an active life. Restrictions in general include:

ˆ

ˆ

Unusual shortness of breath

ˆ

Dizziness or light-headedness during or after ex-

Do not lift weights more than 5 kg. till 6 weeks

ercise

of transplantation.

ˆ

Do not lift weights more than 10 kg. 6 and 12 weeks of transplantation.

ˆ

between

Persistent rapid or irregular heart rate, new since the transplant, during or after exercise.

No lifting

restrictions after 3 months of transplantation.

ˆ

No jogging or running on hard surfaces like cement or asphalt for 3 months after transplantation.

ˆ

dominal muscles, becoming weak.

This is due par-

tially to not using them, and to the side eects of prednisone. Excellent ways to improve the strength

Avoid activities that cause you to bounce, like horseback riding or riding motorcycles for 3 months after transplantation.

ˆ

You may notice your muscles, especially leg and ab-

of leg muscles include walking, bike riding and swimming. After three months, sit-ups and other abdominal exercises will improve the tone of your abdominal muscles. Also avoid contact sports like football. Due

Avoid swimming and bathing in tubs or Jacuzzis

to taking immunosuppressive medications, you may

till your incision has healed.

be at greater risk for infection if you are injured or require surgery.

3.3.1 Exercise After transplant surgery, exercise is critical to mental health and physical well-being.

3.3.2 Play

Physical activ-

ity is also very important in helping decrease the ef-

Use common sense as your guide to any activity af-

fects of prednisone, which causes muscle weakness.

ter transplant. As you gain strength and endurance,

A daily exercise routine is essential to avoiding the

your amount of physical activity will also increase.

muscle and total-body weakness that often occurs

If you have any questions, please call the Transplant

after a long illness or period of connement.

Nephrologist.

The

program should be a progressive one in which the patient builds or increases his levels of exercise. In this way, you will obtain the full benets of exercise without causing strain or serious injury to your body. Before starting on any exercise program, you should remember to check with your transplant team. They will give you advise regarding an exercise routine that

3.3.3 Sexual Activity Your new kidney is well protected.

Sexual activity

will not harm your transplanted kidney. As with any major surgery, waiting a period of six weeks before

will best meet your needs.

engaging in sexual intercourse is a good idea. This

WARNING: If a patient experiences any of the fol-

time will allow the incision and muscles to heal. It

lowing symptoms, he should stop or delay exercise

is even more important to take precautions against

until he consults his physician:

sexually transmitted diseases after a transplant. 21


3.3.

Dr. Shamik H Shah

RESUMING NORMAL ACTIVITIES

3.3.3.1 Men

ˆ

In general, we recommend waiting about 2 years after transplant before becoming pregnant.

Most men are potent after transplant and regain sexual desire and function often lost during kidney fail-

The decision to have a child is a personal one, but we

ure and dialysis. The status of kidney function and

hope you will feel free to talk with us. We want you

certain medications, such as those used to treat high

to make an intelligent choice based on all available

blood pressure, will sometimes aect sexual function

information.

after transplant. If you notice a change in your sexual

Although the odds are with you for a successful preg-

ability, do not hesitate to ask for advice about what

nancy, there are some special risks to mother and

might be done to improve the situation. Men should

child. About 30 percent of mothers will develop high

discuss family planning with the transplant doctors.

blood pressure with protein in their urine, and in ap-

It is recommended that men do not father children

proximately 10 percent of cases this can be accom-

while on certain immunosuppressive medications.

panied by a decrease in kidney function. There is a 30 percent risk of premature birth and prenatal care is essential for successful outcome. The risk of ma-

3.3.3.2 Women

jor congenital malformations of the baby is approximately 5% if the mother has had a kidney transplant,

Most women are fertile after transplant. Menses (periods) resume anywhere from one to several months after transplant. You may be ovulating even though

and about a 4 percent chance of an abnormal baby if the father has had a transplant.

you do not have a regular period. Many women have

Plan to have a routine gynecological exam every year

become pregnant and delivered healthy children after

close to your birthday. It must include a Pap smear and a breast examination.

a kidney transplant. We recommend the following regarding pregnancy:

ˆ

had breast cancer. If you are not planning to become pregnant, you

Kidney function must be good if a pregnancy is planned.

ˆ

velop acne or dry skin. Generally, you should shower

You will probably need more frequent lab testing

or bathe as often as necessary to keep your skin clean. Most soaps are appropriate.

Immunosuppressive drugs (prednisolone,

aza-

thioprine, cyclosporine) doses should be at a low level.

ˆ

3.3.4 Skin & Hair Care You will not need any special skin care unless you de-

with pregnancy.

ˆ

Acne:

Prednisone can cause acne on the face, chest,

shoulders, or back. Cyclosporine can make the skin

Although, you may require higher doses

more oily. If acne develops, the patient should wash

of Tacrolimus or Cyclosporine to maintain this

the area three times per day with a mild soap, scrub-

level.

bing gently with a clean, wet washcloth. Rinse the

Women on Mycophenolate who are pregnant or considering pregnancy must consult the transplant physician.

Mycophenolate increases the

soap completely from the skin to leave the pores open and clean.

Ways to control Acne:

risk of birth defects.

ˆ

Women over

30 should have mammograms if a female relative has

should use a reliable form of birth control.

ˆ

If you are over 40, you

should have an annual mammogram.

ˆ

Keep hands away from the face and avoid rub-

No other medical problems should be present

bing the aected area.

that would add to the risk of the pregnancy.

not pick or touch the acne. 22

To avoid infections, do


3.3.

ˆ ˆ

ˆ

Dr. Shamik H Shah

RESUMING NORMAL ACTIVITIES

Unwanted hair growth

Do not use cosmetics.

- If facial hair increases,

use a hair-removal cream (depilatory). Be sure to folAvoid the use of medicated hypoallergenic cos-

low directions carefully to avoid eye or lip irritation.

metics intended to cover acne. Wearing makeup

An alternative is to bleach extra hair growth with a

will prevent acne from going away.

50% peroxide solution.

The patient might consider

waxing or electrolysis to remove extra hair. Do not rub or scrub the skin vigorously.

This

can irritate the skin.

Even

if hair growth is excessive, do not alter medication. Contact the transplant team.

Avoid soaps that contain creams and oils, be-

Sun exposure

cause they will aggravate acne.

creased chance of developing skin and lip cancers.

ˆ

Do not use lotions for dry skin.

always protect his skin from the ultraviolet rays of

ˆ

If the skin becomes very dry, stop washing those

ˆ

- Transplant patients have an in-

Since the risk increases with time, the patient must the sun that cause skin cancers. areas temporarily so the skin can recover its nat-

ˆ

ural moistness.

ˆ

Avoid midday (10 am to 3 pm) sun, when ultraviolet rays are strongest.

Do not use RETIN-AÂŽ (tretinoin cream) on the

ˆ

skin without consulting a physician, because it

Wear a hat, long sleeves, and slacks when outdoors unless using a sunscreen.

will increase the sun sensitivity caused by pred-

ˆ

nisone

Use a sunscreen lotion with sun protective factors (SPF) rated at least 15.

WARNING: Remember that severe or infected acne

ˆ

Use a sunscreen lotion and lip balm every day

must be treated by a dermatologist. If acne remains

(rain or shine) and apply to exposed areas, es-

a problem, a member of the transplant team should

pecially face, neck, and hands.

be contacted for advice.

Dry skin care - For problems with dry skin, use a mild soap and apply body lotion after bathing

Cuts and scratches

-

Wash

minor

cuts

and

scratches daily with soap and water. For treatment of large cuts, contact a physician immediately.

Skin growths - The transplant team should be noti-

3.3.5 Driving, Vacation & Travel After your kidney transplant it is recommended that you do not drive for at least 2-2½ weeks.

Your re-

exes, judgment and vision may be aected by the medications you are taking. Do not drive if you feel any of these are impaired. Have a licensed driver with

ed if the patient discovers any unusual skin growths,

you the rst time you get behind the wheel. Always

rash, or discoloration.

wear your seat belt. It will not hurt your new kidney!

Hair care

- Prednisolone will probably aect the

Live vaccines should not be taken after transplanta-

condition of hair. Permanent hair dyes, tints, wave

tion. If planning a trip to a foreign country that re-

lotions, and bleach may cause hair to become brittle

quires immunization for smallpox, measles, German

and to break.

It is recommended that the patient

measles, or any other vaccine containing a live virus,

waits until the prednisone dosage is lower than 10

the patient should ask the transplant team to send

mg per day before having a permanent or coloring

a letter to his local passport bureau stating that he

the hair. The patient's hairdresser should be advised

cannot receive these vaccines. Because he is not im-

that the patient is taking prednisone and to use a

munized, however, travel to these countries may not

good conditioner on the patient's hair.

be safe. 23


3.3.

Dr. Shamik H Shah

RESUMING NORMAL ACTIVITIES

3.3.6 Pets at Home

The following are some tips for healthy traveling:

ˆ

1. Obtain the name and telephone number of a

How-

adopt pets should note the following concerns

2. Make arrangements for any needs such as a spe-

and responsibilities:

cial diet or a wheelchair.

ˆ

3. Take a written list of your medications and your

Be sure to adopt your pet from an animal shelter, reputable pet store or breeder.

dosages. We can provide Transplant letterhead

ˆ

for you to use.

Have your new pet checked out by a veterinarian right away.

4. Keep the medications in their original bottles

ˆ

that are labeled.

Take your pet to the veterinarian for regular vaccinations, worm treatments, and check ups.

5. Carry your medications with you at all times. Do

ˆ

not pack them in a suitcase that will be checked. Your suitcase may be lost or delayed.

ˆ

6. Take several extra days worth of medications in

Give your pet a balanced diet. Your pet's living area must be cleaned weekly. Litter boxes must be cleaned daily. It is best if

case your return is delayed.

the transplant patient does not clean up animal feces.

7. When changing time zones, gradually adjust the times of your medications until you get to the

ˆ

schedule that you are following at home. Consult

Wash your hands with soap and water after handling or cleaning up after animals.

with one of the coordinators for assistance.

ˆ

8. Drink canned or bottled beverages and water. Avoid ice.

Most pets can remain in the household.

ever, transplant patients who own or wish to

transplant center close to your destination.

Treat your dog or cat for eas and ticks, which are a potential source of infection.

In certain areas with questionable

ˆ

sanitation, avoid coee or tea made with tap wa-

Always wash your hands after handling reptiles,

ter. If in doubt, use bottled water to brush your

(snakes, lizards and turtles) as they may carry

teeth.

salmonella.

Reptiles are not recommended as

pets.

9. Avoid foods such as raw vegetables; salads, especially those prepared with mayonnaise; undercooked meat and sh; and unpasteurized dairy

You and your pet should avoid contact with wild an-

products.

imals, which can carry deadly diseases, such as ra-

Whole fruits that are washed and

peeled by you are generally safe as are foods that

bies.

have been cooked thoroughly and still hot. Al-

Ticks can transmit Rocky Mountain Spotted Fever

Rodents can transmit plague and hantavirus.

ways order meats well done. Once served, make

and lyme disease. To discourage wild animals from

sure the meat, poultry and sh has been thor-

nesting near your home, keep your house clean, keep tight-tting lids on food and garbage containers, and

oughly cooked. 10. Avoid eating foods that were purchased from a street vendor.

do not leave food or garbage containers outside your home when they are not in use. Chlamydia and other infections can be transmitted

11. If you develop traveler's diarrhea, physician.

consult a

by birds. Transplant patients should not have birds

Or if your doctor agrees, you may

as pets, should not care for chickens or pigeons in

be able to carry a lled prescription for CiproÂŽ

coops, and should avoid contact with bird feces.

500mg to be taken twice a day for 3 days.

24


Chapter 4

Transplant Medications 4.1

General

Medication

Infor-

any changes you are requested to make on your medication list. Always take your medication according

mation

to your medication list. Destroy any old lists when you are given new ones.

After you have received your new kidney, you will be required to take a combination of medications each day for the life of your new kidney.

These medica-

tions are essential to prevent kidney rejection. You can never stop or miss these medications, or you risk rejecting your new kidney. It may also be necessary to take other medications.

It is extremely important that you take your medications at the correct time each day.

You may set

your schedule around meals and bedtime. It is easy to forget whether you took your pills or not.

You

may nd it helpful to use the medication pages in your transplant manual, or to set up a check system of your own.

Approximately three days after your transplant your nurse or pharmacist will explain the  self-medication program and what you will be expected to do. We want you to actively participate in your medication therapy and become responsible for it while you are in the hospital. The medications and medication list will be set up at your bedside. You will learn what the medications look like, what amounts to take, what they are for, and what side eects they may cause. Your inpatient nurse must always check your medications after you have set them up and before you take them.

Explanations of specic medications you may be taking are on the following pages. It is important that you become familiar with common side eects that may occur from the medications you are taking. It is also important for you to know that not all side eects or problems related to each medication are included.

Only those that commonly occur in the

transplant patient are listed. Also, please remember that you will not necessarily develop all of the side eects mentioned.

Feel free to call the Transplant

Team to discuss any problems you feel you may be having with any of the medications you are taking.

The Transplant Nephrologist will always manage your immunosuppression medications.

If your pri-

mary care physician wants to make any changes to your immunosuppression medications, please have him or her contact the Transplant Nephrologist.

4.2

Medication Guidelines

You are responsible for taking the medications that

The doses of your medications will change frequently.

have been prescribed for you.

After you are home, the medication changes may be

your physician, pharmacist, transplant nurse, and/or

called to you over the phone. Be sure you write down

coordinator to understand fully:

25

You should talk to


4.3.

Dr. Shamik H Shah

MEDICATIONS YOU MAY BE TAKING

ˆ

The name and purpose of each medication

ˆ

Keep all medications away from children.

ˆ

When to take each medication

ˆ

Do not store medications in your car.

ˆ

How to take each medication

ˆ

How long to continue taking each medication

ˆ

Principal side eects of each medication

ˆ

ˆ

What to do if you forget to take a dose

ˆ

ˆ

4.2.3 Important Medication Tips

When to order more medication so it doesn't run

ˆ

Take Tacrolimus or Cyclosporine AFTER the lab draws blood for a level.

ˆ

How to order or obtain medications

ˆ

What to avoid while taking medications

ˆ

Bring the medication with you and take it after your blood has been drawn.

ˆ

Never change your dose of immunosuppressants with-

Bring all of your medications to your rst clinic appointment.

out discussing it with the Transplant Team.

4.2.4 Warnings

4.2.1 Before taking medications: Ask the nurse, coordinator, or pharmacist to help in selecting the best times to take medi-

There are many possible drug interactions between your post transplant medications and herbs or over the counter dietary supplements. Do not take herbs

cations.

ˆ

Take your Tacrolimus or Cyclosporine doses 12 hours apart.

out

ˆ

Take Tacrolimus on an empty stomach.

or dietary supplements before consulting your trans-

Try to take each medication at the same time

plant physician.

every day.

take medications or herbs intended to  boost their

ˆ

Follow a written schedule.

make changes to your kidney drugs (immunosuppres-

ˆ

DO NOT cut or crush a tablet unless advised to

immune systems. Only the Transplant Team should

do so.

sion medications). If any of your other doctors want to make changes, please have them contact the transplant team.

4.2.2 General Guidelines for Storing Your Medications ˆ

Transplant patients should never

4.3

you

may

be

taking

Keep all of your medications in the original container.

Medications

4.3.1 Tacrolimus

ˆ

Make sure the cap is on tightly.

ˆ

Store the medication containers in a cool (<80°

What is it used for?

F), dry place away from direct sunlight.

This medication is used to prevent or treat acute kid-

Â&#x2C6;

Do not store medications in the bathroom - moisture can cause medications to lose their strength.

ney rejection.

How is it given?

26


4.3.

Dr. Shamik H Shah

MEDICATIONS YOU MAY BE TAKING

This medicine is given orally or intravenously, depending on the condition being treated.

What else do I need to know? It is important that you tell your doctor if you are

When do I take it?

taking any over-the-counter iron tablet supplements. Report excessive diarrhea to your doctor. This medi-

Tacrolimus is given twice daily, 12 hours apart, in the morning and at night. Take Tacrolimus at the same times each day and consistently with or without food.

What side eects might I expect? This medication may cause headache, tremors, muscle cramps, diarrhea, nausea, high blood pressure and kidney problems.

cation may be taken with or without food, but please be consistent.

4.3.3 Prednisolone What is it used for?

What else do I need to know?

Prednisone is used to prevent and treat acute kidney

Take with food to prevent nausea. Do not stop taking Tacrolimus unless you are told to do so by your

How is it given?

doctor. Tacrolimus levels are measured using blood

Prednisone is given orally in the morning.

tests. Do not take your Tacrolimus in the morning

When do I take it?

rejection.

until after the blood tests have been drawn on days they are due. Avoid grapefruit/grapefruit juice and mandarins, they will make the level of medication in

Prednisone is given once daily for lifetime or as determined by your doctor.

your blood rise too high.

What side eects might I expect?

4.3.2 Mycophenolate Sodium or Mycophenolate Mofetil

Diculty sleeping, mood changes, nervousness, increased appetite, and indigestion.

What else do I need to know?

What is it for?

Take with food to prevent nausea. Do not abruptly

Mycophenolate is an immunosuppressive drug that

stop taking prednisone unless you are told to do so

may be used before and after kidney transplant. My-

by your doctor.

cophenolate may also be used to prevent further re-

time as prednisolone.

Do not take antacids at the same

jection after a rst rejection occurs.

How is it given?

4.3.4 Cyclosporine

This medicine is given orally or intravenously, de-

What is it for?

pending on the condition being treated.

When do I take it?

Cyclosporine is an immunosuppressive agent used to

It is given twice daily and in most patients will continue throughout the lifetime.

What side eects might I expect?

When do I take it? Cyclosporine is typically on the day of transplant. In most cases it is continued for a lifetime. It is given

Possible side eects that you may experience include nausea, vomiting, loss of appetite, diarrhea and stomach cramps.

prevent kidney rejection.

once or twice a day.

How is it given?

27


4.3.

Dr. Shamik H Shah

MEDICATIONS YOU MAY BE TAKING

Most commonly, it is given orally in the form of

This medication is used to prevent or treat acute kid-

pills.

ney rejection.

Cyclosporine is sometimes initially given in-

travenously. In that case, after a few days, patients are usually switched to liquid or pills.

What side eects might I experience?

How is it given? This medicine is only given orally.

Cyclosporine may cause kidney problems, high blood

When do I take it?

pressure, leg cramps, gum tenderness/inammation,

Sirolimus is given once daily for lifetime or as deter-

and tremors.

mined by your doctor.

What else do I need to know?

Take Sirolimus at the same

time each day and consistently with or without food.

Avoid grapefruit and grapefruit juice, they will make

What side eects might I expect?

the level of medication in your blood rise too high.

This medication may cause low white blood cell and

Cyclosporine levels are measured using blood tests.

platelet counts and high cholesterol.

Do not take your cyclosporine in the morning until

What else do I need to know?

after the blood test has been drawn on days they are due.

If you take the oral solution, mix it with milk, chocolate milk or orange juice to make it taste better. Stir

4.3.5 Azathioprine

it well and drink it all at once. Also, only mix it in a glass container (not plastic), and rinse the container

What is it for?

to make sure you get the full dose. Do not stop taking Sirolimus unless you are told to do so by your doc-

Azathioprine is an immunosuppressive drug that may

tor. Sirolimus levels are measured using blood tests.

be used before and after kidney transplant.

Do not take your Sirolimus in the morning until af-

How is it given?

due. Cholesterol should be monitored while on this

Azathioprine is given orally or intravenously, depend-

medication.

ter the blood tests have been drawn on days they are

ing on the condition being treated.

When do I take it? It is given once daily and in most patients will continue for life.

What side eects might I expect?

4.3.7 Lymphocyte Immune Globulin What is it for? ThymoglobulinÂŽ is an anti lymphocyte serum used

Possible side eects that you may experience include low white blood cell count and hair thinning.

to cause immune suppression or stop an immune response, such as acute rejection.

When do I take it?

What else do I need to know? It is important that you tell your doctor if you are

ThymoglobulinÂŽ is used during kidney transplanta-

taking Allopurinol (a medicine sometimes used to

tion to suppress the immune system or after trans-

treat gout.)

plant if rejection occurs that doesn't respond to prednisone treatment.

4.3.6 Sirolimus (Rapamycin) What is it used for?

How is it given? ThymoglobulinÂŽ is given intravenously for 1 to 14 days. 28


4.3.

Dr. Shamik H Shah

MEDICATIONS YOU MAY BE TAKING

When do I take it?

What side eects might I experience? Fever, chills, rash, low white blood cell count, joint

Acyclovir is started around the time of transplant

and muscle aches, low platelets, headache, shortness

and continued for two weeks after the transplant. It

of breath, skin rashes, and low blood pressure are the

is given 2-5 times daily depending on where you are

most commonly reported side eects.

in the course of your treatment.

What else do I need to know?

How is it given?

Before each ThymoglobulinÂŽ dose you will be given

Acyclovir can be given either orally or intravenously.

paracetamol, antihistaminics and possibly other medications to help prevent side eects. The nurse will

What side eects might I experience?

monitor you closely for side eects but you should

Headache, nausea, and vomiting are the most com-

let the nurse know if you have any trouble breathing,

monly reported side eects.

throat tightness, itching, or any unusual side eects.

4.3.8 Sulfamethoxazole/Trimethoprim (Bactrim ) What is it for?

ÂŽ

BactrimÂŽ is an antibiotic that is used to prevent or treat Pneumocystis carinii Pneumonitis (PCP) and bladder infections.

BactrimÂŽ is given three times a week (Monday, Wednesday and Friday) after kidney transplant.

A photo sensitivity reaction (a sunburn like reaction when exposed to sunlight,) rash, and diarrhea are commonly reported side eects.

What else do I need to know?

Valganciclovir

is

used

to

prevent

and

treat

cy-

How is it given? Valganciclovir may be given by IV or orally.

Headache, nausea, low white blood cell and platelet counts.

What else do I need to know? Always take valganciclovir with food,

BactrimÂŽ should be taken with a full glass of water.

Virus (HSV or  cold sores .)

What is it used for?

What side eects might I expect?

What side eects might I experience?

Acyclovir is used to prevent or treat Herpes Simplex

4.3.10 Valganciclovir

Valganciclovir is given 1-2 times daily.

BactrimÂŽ is given either orally or intravenously.

What is it for?

be taken with or without food.

When do I take it?

How is it given?

4.3.9 Acyclovir

While taking acyclovir, drink plenty of uids. It can

tomegalovirus (CMV).

When do I take it?

Drink plenty of uids while taking BactrimÂŽ.

What else do I need to know?

and drink

plenty of uids.

4.3.11 Pentamidine What is it for? Pentamidine is used to prevent Pneumocystis carinii Pneumonia (also called PCP).

How is it given? 29


4.3.

Dr. Shamik H Shah

MEDICATIONS YOU MAY BE TAKING

Pentamidine is inhaled into the lungs using a machine

fungal, or parasitic infections. Some herbs have

called a nebulizer.

been reported to contain pesticides and metals

When do I take it?

such as lead and mercury.

Pentamidine is given once a month for four months.

What side eects might I expect?

3. Some herbs have been found to produce serious toxic eects to the liver, kidneys, and heart,

Nausea, vomiting, dizziness, headache, cough, rash,

causing organ failure and even reports of deaths.

abdominal pain, diarrhea, and shortness of breath.

They have been known, especially when taken

What else do I need to know?

with other medication, to cause serious changes in blood pressure, blood sugar and potassium

If you are not able to tolerate this medicine, another

levels; increased risk of bleeding; transplant re-

one may be ordered.

jection.

4.3.12 Herbal Preparations

4. Dosages may vary from pill to pill, manufacturer to manufacturer or from what is stated on the

Alternative therapies have gained a great deal of pop-

label.

ularity over the last few years. Many people use them

plant team recommend that you avoid the use of

on a regular basis for everything from prevention and

any herbal preparation.

treatment of many diseases to weight loss.

tions regarding herbs speak with a coordinator

Herbal

products are advertised as being  all natural ,  or-

To be safe, the members of the transIf you have any ques-

or physician.

ganic or  wholesome which gives the public a false sense of comfort and security. Herbs are readily available to the public in health food stores, but the also can be found in local drug stores, supermarkets and on the Internet.

Not only are they available as a

single preparation, they are now contained in teas,

4.3.13 Syringes & Needles

soft drinks, multivitamins and even items like cough drops and potato chips.

After transplant, you may be prescribed a medication

There are very few scientic studies that have been done with herbs to prove whether they are eective, have side eects, or interfere with prescribed medications, other herbs or food. Use of these products can have a serious impact on patients who have renal failure, take medications or who have had a transplant.

that is taken with a needle and syringe. If you take Insulin, Erythropoietin or Neupogen and give this medicine to yourself at home, you will need to properly dispose of the needle and syringe. Do not discard the needle and syringe directly into the garbage unless it is properly contained.

The following are areas of concern about the use of After your injection, place the uncapped needle in

herbs:

a puncture proof container such as a coee can or 1. There may be interactions between herbs and medications that may reduce the eectiveness of the prescribed drugs for transplant.

a bottle made of rigid plastic (bleach or soda bottle).

Do not use a glass container as it may break

in the garbage. When the container is full, put the lid on and tape around the container to prevent the

2. Herbs may not be pure because of inadequate

lid from coming o. Use duct tape or masking tape

purication and sterilization procedures. Herbs

for extra strength. Put the taped container inside of

are made from plants that may cause bacterial,

your garbage bag.

30


4.4.

Dr. Shamik H Shah

IMMUNIZATION

4.4

Immunization

4.4.1 Immunization you must not receive ˆ

Smallpox

ˆ

Measles

ˆ

Mumps

ˆ

Rubella

ˆ

Oral polio

ˆ

Chicken pox

You must not receive the above immunizations because they contain live organisms. There is a chance you could contract the actual disease since your immune system is suppressed.

4.4.2 Immunization you may receive ˆ

Injectable polio

ˆ

Diphtheria/Tetanus booster (every 10 years)

ˆ

TB skin test

ˆ

Inuenza A & B

ˆ

Pneumococcal

31


Chapter 5

Post-Transplant Complications 5.1

5.1.1 Symptoms & Signs of rejection

Rejection

Rejection is what happens when your body recog-

A rejection episode is not very common and can be

nizes that the transplanted kidney is not part of it's

reversed most of the time. Your body's signs of re-

own self. The transplanted kidney is attacked by the

jection are very important for you to know.

body's natural defense system. This can occur at any

notice any of the following signs, call the transplant

time after you receive the kidney transplant, however,

team immediately.

it is most likely to occur in the rst three months post transplant.

1.

Therefore, it is essential that you have your

- happens when the body

blood tests done on schedule so that a rejection

immediately destroys the new kidney, this is rare be-

can be detected early.

cause of the Crossmatch testing used before transplant.

2.

time after the transplant, most often it happens during the rst several months. This can be treated by

3.

4.

as an outpatient if it is recognized early.

Rejection itself

is not life threatening and does not

generally mean you will lose your kidney. Rejection

A temperature of 100

0

F or more. This

Tenderness or pain in the transplanted kidney : The kidney may seem swollen or you it.

years after the transplant. This type of rejection is resistant to treatment with current medications. This

Fever:

may have a sensation of pain when you push on

- this may happen months or

will cause your new organ to slowly stop working.

A gain of more than one kilo-

can mean either rejection or infection.

giving you higher doses of medication by mouth or by intravenous infusion. You may get this treatment

Weight Gain:

gram in one day or two kilograms in seven days.

Acute rejection - although this can happen at any

Chronic rejection

Occasionally this

may be the only sign of a rejection episode.

There are several types of rejection:

Hyperacute rejection

Rise in Serum Creatinine:

If you

5.

Decreased urine output:

by half the volume.

(For example your intake is about 2000 cc in a day and your output drops to 1000cc).

Your

urine output should be nearly equal to your in-

can occur at any time and you may feel perfectly well.

take.

That is why it is very important to have your lab tests

per 24-hour period, your urine output should be

performed regularly, at intervals recommended by the

about 2000cc. (A 300 to 400 cc dierence is ex-

Transplant Team.

pected). 32

If you are drinking 2000 cc or 2 Liters


5.2.

6.

7.

Dr. Shamik H Shah

INFECTIONS

Fluid retention:

Moderate swelling in face,

porary dialysis may be necessary.

If you obtain two blood pres-

may remain in place unless you become sick (fever, pain, swelling, vomiting, etc.). If this occurs it may

5.1.2 Treatment of Rejection

be necessary to have the rejected kidney removed surgically.

The new medications you are taking help to prevent rejection.

The transplant team will discontinue your

immunosuppressive medications.

If we think you are having a rejection

episode, you may need:

5.2

ˆ

An examination by the Transplant Nephrologist

ˆ

An ultrasound

ˆ

A kidney biopsy

ˆ

More frequent blood tests

Infections

Because

immunosuppressive

medications

interfere

with a patient's natural immune system, you are more likely to get infections.The following are some of the most common infections:

There are several treatments for rejection. The transplant team will decide which one is best for you. You doctor may want to biopsy the new kidney.

If the

rejection is severe, you may need a period of dialysis.

CMV is one of the viral infections that occur most frequently in transplant patients. The risk of CMV

The rejection may be treated with one or more of the

is highest in the rst months after transplanta-

following:

tion. Signs include fatigue, high temperature, aching

Intravenous Steroids:

joints, headaches, visual disturbances, and pneumo-

You may be given IV

nia. Treatment may include hospitalization.

Solu-Medrol for 3 to 5 days

Increase in the dose of Prednisolone:

Your

prednisone may be increased for ve to nine days.

5.2.1 Viral Infections: 5.2.1.1 Cytomegalovirus (CMV)

may need to be readmitted to the hospital, and the

The transplant team will tell you how

much to take. Usually this treatment does not

Thymoglobulin / OKT3 :

This drug is given

by IV over four hours every day for 7 days. You doses. You will need more frequent lab monitoring during this treatment.

closporine

Of

These viruses most often infect the skin but can also I typically causes cold sores and blisters around the

must be in the hospital for the rst and second

Dose reduction:

5.2.1.2 Herpes-simplex virus type I and II occur in other areas such as the eyes and lungs. Type

require you to be admitted to the hospital.

4.

If these methods of treatment are not successful you will return to chronic dialysis. The rejected kidney

170/100.

3.

If your kidney is not working well and

Blood Pressure:

sure readings taken 1 hour apart outside of your

2.

Dialysis:

your Blood Urea and creatinine are high, tem-

normal range or less than 90/60 or more than

1.

5.

Feet, hands, ankles and/legs

mouth, and type II causes genital sores.

Herpes is

an infectious disease and can be transmitted sexually.

Herpes infections in transplant patients, how-

ever, were not necessarily transmitted sexually. Most herpes-simplex infections are mild, but occasionally they can be severe. Although there is no cure for her-

Tacrolimus

or

Cy-

pes, it can be treated. Depending on the severity of the infection, the treatment is either topical, oral, or

33


5.2.

Dr. Shamik H Shah

INFECTIONS

intravenous (IV). A patient should contact the trans-

5.2.4 Other Infections:

plant team immediately if he believes he has herpes. Symptoms of herpes include feeling weak and having

Pneumocystis carinii is a germ similar to a fungus,

painful uid-lled sores in the mouth or genital area.

and it is normally found in the lung. In people whose

Women should also be aware of any unusual vaginal

immune systems are suppressed, it may cause a type

discharge.

of pneumonia (PCP). Early in the illness, a mild, dry cough and a fever may occur. If a patient suspects that he has a cold or u like illness, he should contact

5.2.1.3 Herpes zoster (shingles)

his physician immediately.

Shingles appear as a rash or small water blisters, usually on the chest, back, or hip. The rash may or may not be painful. A patient should notify the transplant oce if such a rash occurs.

5.2.5 Avoiding Infections You need to protect yourself consciously from infections by taking the following precautions:

5.2.2 Fungal Infections:

ˆ

Wash hands often.

5.2.2.1 Candida (yeast)

ˆ

Keep hands away from face and mouth.

Candida is a fungus that can cause a variety of in-

ˆ

fections in transplant patients. It usually appears in the mouth and throat but may also be in the surgical wound, eyes, or respiratory and urinary tracts. Candida is most severe in the bloodstream.

If in-

ˆ ˆ

areas), pain or tenderness, a white lm on the tongue,

ˆ

ach) or, in women, the vagina.

If you have a wound and must change your own

Wash hands after coughing or sneezing, and throw tissues into the trash immediately.

and diculty swallowing. Candida can also infect the esophagus (the tube from your mouth to your stom-

Ask friends to visit only when they are well.

dressing, wash hands before and after.

fection occurs in the mouth or throat, it is called thrush. Thrush produces white, patchy lesions (raw

Stay away from people with colds or other infections.

ˆ

If someone in the patient's family becomes ill

Vaginal infections

with a cold of u, have that individual follow nor-

usually produce an abnormal discharge that may be

mal precautions (use separate drinking glasses,

yellow or white. A patient should notify the trans-

covering their mouths when coughing, etc.)

plant oce if a Candida infection occurs.

ˆ

transplant. Thereafter, wear gloves.

5.2.3 Bacterial Infections:

ˆ

Avoid handling animal waste and avoid contact with animals who roam outside.

5.2.3.1 Wound infections

Do not clean

bird cages or sh or turtle tanks or cat litter. The cat litter box should be covered and taken

Bacterial wound infections occur at the surgical site.

out of a patient's home before it is changed.

If a patient has a fever or notices redness, swelling, tenderness, or drainage at the incision, he should notify the transplant team.

Avoid working in the soil for 6 months after the

After a wound culture (a

ˆ

Avoid vaccines that consist of live viruses, such as Sabin oral polio, measles, mumps, German

test for bacteria) is taken, an antibiotic will be pre-

measles, yellow fever, or smallpox. The live virus

scribed if infection is present.

can cause infections. If a patient or any family 34


5.5.

Â&#x2C6;

Dr. Shamik H Shah

HIGH BLOOD PRESSURE

member intends to receive any vaccinations, they

Blood sugar can be reduced through weight loss, care-

should notify the transplant team or local physi-

ful diet, and exercise. An oral diabetes drug or insulin

cian.

injections may be necessary.

Take good care of your teeth by brushing two

If a patient develops diabetes, he will receive special-

times a day and seeing the dentist twice a year

ized teaching about how to deal with this problem.

for cleaning and checkup

Do not use face masks to prevent infections. Stud-

5.5

High Blood Pressure

ies have shown that face masks become colonized with bacteria within 10 minutes.

These colonies

High blood pressure and heart disease are common

then grow because of the moist environment. When

disorders that become more frequent as people grow

you inhale, these bacterial colonies go inside your

older.

nose and lungs and can cause serious infections like

some medications.

pneumonia.

medication to control his blood pressure.

High blood pressure is also a side eect of A patient may need to take a

There are many dierent types of drugs available to

5.3

control high blood pressure.

Acute Tubular Necrosis

A patient may need

to try several dierent medications. The transplant team or local physician will select the one that works

This is a condition when the kidney doesn't work right away after transplant. ATN is usually temporary. It can be caused by a long organ storage time on ice before transplant or by medications.

best for each specic patient. A diuretic (water pill) may also be prescribed to lower blood pressure, increase urine output, and remove extra uid.

The symptoms are treated in two ways:

1. By limiting the salt, protein, potassium in your diet, and uid intake, or by dialysis. 2. The transplant team will look at the lab results, your weight, your limiting uid intake, urine output, and vital signs to decide which treatment you will need.

5.4

Diabetes

Diabetes is an increased level of sugar in the blood. Some of the immunosuppressive medications may cause diabetes. Symptoms of diabetes may include: increased thirst, increased frequency of urination, blurred vision, and confusion.

A patient should notify his transplant

team or local physician if he experiences any of these symptoms. 35


Chapter 6

Normal Blood Test Values Every lab has slightly dierent normal ranges. The normal values given below are intended to be used only as guidelines.

Your own lab results will natu-

rally vary, or they may be slightly above or below the normal values given here. We will help you interpret your results. Often labs will run additional tests along with the tests below. If you learn a test result is abnormal, please inform the transplant team. Test

Normal Value

Comment

Glucose

65-110

The value of sugar in your blood

Urea

15-40

The level of a protein waste product in your blood

Creatinine

0.5-1.2

The level of a muscle waste product in your blood. Kidney transplant patients will have their own normal range

Potassium

3.8-5.2

Phosphorous

2.2-4.2

A mineral needed for proper functioning of muscles, including heart muscle A mineral that works with calcium to form bone; a small amount is found in the muscles

Calcium

8.5-10.5

A mineral needed for proper functioning of muscles,nerves, heart, blood clotting and maintenance of strong bones and teeth

Cholesterol

< 200

A necessary building block of tissue and hormones. Excess cholesterol in your blood stream can cause deposits in the blood vessels causing heart attack and stroke.

W.B.C.

4000-10000

Special blood cells that help the body ght infections.

Hematocrit

36.1-46.1

The percentage of red blood cells in your blood. The red cells carry oxygen

Platelets

2.5-4 lakhs

Special blood cells that are important in helping your blood clot.

and carbon dioxide throughout the body.

Table 6.1: Normal blood test values

36


Chapter 7

Denitions Acute

A chemical that is excreted by the liver in the bile.

Short, relatively severe.

Bladder

Analgesic

The organ that receives and stores urine from the kidneys until it is urinated out of the body.

Pain medicine.

Blood Urea Nitrogen

Anemia

A waste product excreted by the kidney.

A low number of red blood cells.

Cadaveric Donor

Anesthetic Medication that dulls sensation in order to reduce

A recently deceased organ donor.

pain.

Catheter

Acute Tubular Necrosis (ATN)

A soft rubber tube that is inserted into the bladder

Temporary non-functioning of the kidney transplant due to the kidney's storage time prior to transplantation.

to drain urine.

CellCept An immunosuppressive drug used to limit or reverse

Antibody

rejection.

A part of the immune system that ghts infection or

Cholesterol

foreign organisms or tissue.

A kind of fat that is necessary for bodily function,

Antigen

but that in excess can cause heart disease.

The  marker that starts antibody production.

Chronic

Arteriosclerosis

Persisting over a long period of time.

A hardening of the arteries that blocks blood ow to

Chronic Renal Insuciency

the kidneys.

Bacteria

Permanent damage to both kidneys, treated by dialysis or transplantation.

Germs that can cause disease or infection.

Coagulopathy

Bilirubin

Abnormal blood clotting. 37


Dr. Shamik H Shah

Electrocardiogram

Creatinine An indicator of kidney function, produced by mus-

A test that uses electrodes placed on the chest to

cle metabolism. The higher the creatinine level, the

measure the heart rhythm and look for injury to heart

lower the kidney function.

tissue.

Crossmatch

Electrolyte

A

test that determines the compatibility of the

A dissolved mineral, such as magnesium or potas-

donor's blood with that of a potential recipient.

sium.

CT Scan

Endoscope

A 3-dimensional x-ray of internal organs.

A small telescope-like instrument that is used to ex-

Cyclosporine

amine the esophagus, stomach and small intestine.

Endotracheal Tube

A powerful immunosuppressive drug.

A tube inserted through the mouth and into the

Cyst

windpipe to aid a person in breathing during surgery.

End Stage Renal Disease

A sac-like structure that contains uid and matter.

Cytomegalovirus (CMV)

When chronic renal failure progresses to the point

A common viral infection that can be harmful to

at which the kidneys are permanently functioning at

transplant recipients if contracted after transplant.

less than 10% of their capacity.

Diabetes

Enzyme

A disease characterized by high levels of blood sugar.

Diabetic Nephropathy

The tract between the mouth and the rectum, includ-

Dialysis

ing the intestines and stomach.

A process by which blood is cleaned to restore chemical balance.

Glucose

The bottom number when the blood pressure is measured. This is the pressure on the arteries between heart beats.

Echocardiogram A test that uses beams of ultrasonic waves to mea-

hands or legs, due to retention of excess uids.

Sugar found in the blood or urine.

Graft A transplanted tissue or organ, such as a kidney or

sure the motion and position of the heart and nearby

Swelling of a specic area of the body, such as the

Glomerular Filtration Rate (GFR) A test that determines the level of kidney function.

Diastolic Blood Pressure

Edema

stances.

Gastrointestinal (GI)

Kidney failure as a result of diabetes.

tissue.

A bodily protein that can break down other sub-

pancreas.

Helper T-cell The white blood cell that tells the immune system to ght infection or foreign substances, such as transplanted tissue.

Hematocrit 38


Dr. Shamik H Shah

The measure of the number of red-blood cells in the blood.

Kidney Organs located on both sides of the spine at waist

Hepatitis

level that rid the body of waste materials via the production of urine.

Liver inammation, usually caused by a virus.

Kidney Failure- Acute

Herpes A family of viruses that can cause lip, genital sores, or other symptoms.

Rapidly diminished kidney function that can be reversed.

Kidney Failure- Chronic

Human Leukocyte Antigens (HLA)

Diminished kidney function over time that is irre-

Genetic markers, inherited from one's parents.

versible.

Human Leukocyte Antigen (HLA) CompatiLeukocyte bility A test done on the donor and the potential recipient

A white blood cell that helps ght infection.

to determine how actively the recipient's cells would

Nephrectomy

attack the graft.

The removal via surgery of one or both kidneys.

Hypertension

Nephrologist

High blood pressure.

Hypotension

A physician who specializes in diagnosing and treat-

Low blood pressure.

Noncompliance

ing kidney disease.

Immune System

Failure to follow health care instructions regarding

Complex ghting mechanism of the body that re-

taking medications and treatments, getting tests on

sponds to foreign organisms or tissues that enter or

time, and taking vital signs.

are placed in the body.

shortens the lifetime of the transplanted organ(s).

Immunosuppression

Orally

Decrease of the body's immune response, accom-

By mouth

plished through the use of certain drugs, in order to

Panel Reactive Antibody (PRA)

help prevent or control a rejection following a trans-

Noncompliance often

plant.

A laboratory process in which a patient's blood is

Insulin

mixed with a panel of human blood in order to de-

A hormone produced by the pancreas that regulates blood sugar levels.

to foreign blood and tissue.

A score of 0/42 or 0%

sensitized is best, a score of 42/42 or 100% sensitized

Intravenous (IV)

is worst. Causes of sensitization can include pregnan-

Refers to uids or medications administered to patients directly into a vein via a needle or catheter.

Jaundice

cies, blood transfusions and previous transplants.

Phlebotomy Removal of approximately one pint of blood through

Yellowish discoloration of the skin and eyes indicating an excess of bilirubin in the blood.

termine the overall level of sensitization of the patient

a vein.

Platelet

39


Dr. Shamik H Shah

Stenosis

A small blood cell necessary for clotting.

Pneumocystis Carinii Pneumonia (PCP)

Narrowing of a passage in the body. (also known as

A type of pneumonia that is mostly contracted by individuals with suppressed immune systems.

Polycystic Kidney Disease (PKD)

Systolic Blood Pressure The top number when the blood pressure is measured.

A hereditary disease that causes cysts to grow in

This is the pressure when the heart muscle

contracts.

place of normal kidney tissue.

Symptoms

Potassium A mineral.

 stricture )

Things you feel, such as pain, dizziness or fatigue. High potassium levels can irritate the

heart and is a problem often associated with poor

T Cells

kidney function.

White blood cells that play a major part in rejection.

Red Blood Cells

Thrombosis

The part of the blood that transports oxygen to body

The development of a blood clot.

tissues.

Thrush

Rejection

A fungal infection found in the mouth.

When the immune system attacks what it thinks is a foreign substance (such as a transplanted kidney.)

Tissue Typing Identifying a person's major antigens used to evaluate

Renal

the match between a donated organ and a potential recipient via a blood test.

Anything regarding the kidneys.

Toxins

Sepsis

Waste products in the blood that are poisonous to

A severe infection that has spread to the blood

the body in high concentrations.

stream.

Ultrasound

Shingles A herpes virus infection that usually aects a nerve, causing localized pain.

A method of picturing internal organs using sound waves. Often used to detect masses, abscesses, organ size, or blood ow to a transplanted organ.

Signs

Ureter

Things you or someone else can see that are deter-

One of a pair of tubes that carries urine from the

mined by measurement, such as in increase in tem-

kidney to the bladder for elimination.

perature or blood pressure.

Urethra

Sleepy Kidney

The tube from the bladder which carries urine out of

An expression for the temporary delay in kidney

the body.

function that sometimes follows transplantation (also

Urinary Tract

known as ATN.)

Sodium

The body system that produces, transports, stores

The main salt that is found in blood.

kidneys, ureters, bladder and urethra.

and eliminates urine. The urinary tract includes the

40


Dr. Shamik H Shah

Virus A small germ that causes infection.

White Blood Cells The part of the blood that ghts infection.

41


Transplant Recipient Manual