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 di cult 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 De nitions
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
Clean your blood and remove waste products
Balance water and salt to control uid in the body
and are protected by other organs and two of the lower ribs.
Control blood pressure
Help make red blood cells and strong bones
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
Decreased urine output
Shortness of breath
Swelling of legs and face
Decreased appetite
Nausea & Vomiting
Headache
1.2.
Dr. Shamik H Shah
SYMPTOMS OF KIDNEY DISEASE
Easy fatiguability
High blood pressure
Change in mental status
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 a ect 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 su ering 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 o er
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 o ered 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 e ort involving sev-
Because the wait time for a kidney can be lengthy,
eral di erent individuals with di erent 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 di culty 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 insigni cant 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 signi cant
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 o er 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.
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.
Ultrasound with Doppler examination
-
Determines
if
the
patient
(CMV), Epstein-Barr (EBV), or acquired im-
Blood tests - The patient's blood count, blood
mune de ciency syndrome.
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
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-
-
Determines the quality of the iliac vessels.
and tissue type, blood chemistries, and immune
Viral testing
has been exposed to hepatitis, cytomegalovirus
system function will all be checked. In addition,
An immune system may be active from
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
- 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.
Lower GI series - Ensures that the
patient is
free of intestinal abnormalities.
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.
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.
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 e ort 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 di erent 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 de ciency
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 sta ed 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:
Some pain and discomfort, which medication will
2.5.4.1 Vital Signs
help to relieve.
The patient will be asked to cough periodically to keep his lungs clear. If it hurts to cough, the
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.
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.
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.
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 di er
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-e ect 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 di erent 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 di erent 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 pro le. 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 e ects 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 ca eine 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 in ate the cu to 200 mm Hg. 6. Slowly de ate 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 de ating 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 e ects 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 con nement.
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 bene ts 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 a ect 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 a ected 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 a ected 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 a ect 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 co ee 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 e ects they may cause. Your inpatient nurse must always check your medications after you have set them up and before you take them.
Explanations of speci c medications you may be taking are on the following pages. It is important that you become familiar with common side e ects that may occur from the medications you are taking. It is also important for you to know that not all side e ects 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 e ects 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 e ects 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 e ects 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 e ects might I expect?
4.3.2 Mycophenolate Sodium or Mycophenolate Mofetil
Di culty 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 e ects 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 e ects 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 e ects 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/in ammation,
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 e ects 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 e ects might I expect?
4.3.7 Lymphocyte Immune Globulin What is it for? ThymoglobulinÂŽ is an anti lymphocyte serum used
Possible side e ects 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 e ects 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 e ects.
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 e ects. The nurse will
What side e ects might I experience?
monitor you closely for side e ects but you should
Headache, nausea, and vomiting are the most com-
let the nurse know if you have any trouble breathing,
monly reported side e ects.
throat tightness, itching, or any unusual side e ects.
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 e ects.
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 e ects might I expect?
What side e ects 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 e ects might I expect?
3. Some herbs have been found to produce serious toxic e ects 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 scienti c studies that have been done with herbs to prove whether they are e ective, have side e ects, 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 co ee can or 1. There may be interactions between herbs and medications that may reduce the e ectiveness 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
puri cation 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
Smallpox
Measles
Mumps
Rubella
Oral polio
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
Injectable polio
Diphtheria/Tetanus booster (every 10 years)
TB skin test
In uenza A & B
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 di erence 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
An examination by the Transplant Nephrologist
An ultrasound
A kidney biopsy
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 o ce 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:
Wash hands often.
5.2.2.1 Candida (yeast)
Keep hands away from face and mouth.
Candida is a fungus that can cause a variety of in-
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-
areas), pain or tenderness, a white lm on the tongue,
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 di culty 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.
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 o ce if a Candida infection occurs.
transplant. Thereafter, wear gloves.
5.2.3 Bacterial Infections:
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
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 e ect of A patient may need to take a
There are many di erent types of drugs available to
5.3
control high blood pressure.
Acute Tubular Necrosis
A patient may need
to try several di erent 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 speci c 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 di erent 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
De nitions 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 Insu ciency
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 speci c 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 in ammation, 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 a ects 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