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 Table of Contents  
CLINICAL QUERIES
Year : 2017  |  Volume : 15  |  Issue : 2  |  Page : 88-89

Clinical questions: Responses to clinical queries from readers: Renal transplant


Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication18-May-2017

Correspondence Address:
Anna Valson
Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-4651.206545

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How to cite this article:
Valson A. Clinical questions: Responses to clinical queries from readers: Renal transplant. Curr Med Issues 2017;15:88-9

How to cite this URL:
Valson A. Clinical questions: Responses to clinical queries from readers: Renal transplant. Curr Med Issues [serial online] 2017 [cited 2017 Dec 12];15:88-9. Available from: http://www.cmijournal.org/text.asp?2017/15/2/88/206545

Question 4

What are the annual (or periodic) follow-up checkups/investigations needed in a renal transplant patient? One of my patients has crossed 20 years after transplant (unrelated). What are the special precautions to be taken by the patient?

Answer


A kidney transplant recipient needs to be closely followed up by the parent transplant center, especially in the 1st year after transplant when the immunosuppression dosage requires frequent adjustment based on the results of therapeutic drug monitoring, and the risk of rejection and infection is highest. As per the guidelines on “care of the kidney transplant recipient” given by the Kidney Disease: Improving Global Outcomes Transplant Work Group,[1] during the immediate posttransplant period, a patient should visit the parent transplant center 2–3 times a week in the first 1 month, weekly for months 2 and 3, every 2 weeks for months 4–6, and once a month from months 7–12.

After the first posttransplant year, the following investigations should be done to monitor kidney function and general health.





  1. Weight: Each clinic visit (and in children, height as well)
  2. Serum creatinine: Every 2–3 months
  3. Estimation of glomerular filtration rate using the chronic kidney disease epidemiology collaboration (creatinine)-based equation: Every 2–3 months
  4. Blood pressure: At every clinic visit, with target blood pressure being <130/80 mm Hg in adults and <90th percentile for age, gender, and height if<18 years
  5. 24 h urine protein excretion: Once a year
  6. Therapeutic drug monitoring: The concentration of immunosuppressive medication in the patient's blood needs to be monitored, the frequency of which varies depending on the time since transplant and the kidney function. Typically, beyond the first 1 year of transplant, the 12 h trough levels (C0) of tacrolimus and 12 h trough (C0) and 2 h postdose (C2) level of cyclosporine are measured at least once a year
  7. Liver function tests once in 6 months, and alpha fetoprotein and ultrasound abdomen (to screen for cirrhosis or hepatocellular carcinoma) once a year in patients who had hepatitis B virus or hepatitis C virus infection before transplant.
  8. Fasting and postprandial plasma glucose: Annually (for diabetic patients, glycated hemoglobin, fasting, and postprandial plasma glucose should be monitored at least once in 3 months)
  9. Lipid profile: Annually
  10. Complete hemogram: Annually.


In addition, though not specifically stated in the guidelines, the following investigations are performed by most transplant centers at least once a year for all kidney transplant recipients on long-term follow-up.

  1. Urine microscopy
  2. Serum uric acid
  3. Serum electrolytes (sodium, potassium, bicarbonate)
  4. Serum calcium and phosphorus (fasting)
  5. Urine culture for patients with pyuria on urine microscopy or history of recurrent urinary tract infections in the past.


If a patient's investigations reveal a rise in serum creatinine or proteinuria from baseline, he/she should immediately be referred to the parent transplant center for further evaluation which may include a biopsy of the transplanted kidney.


  Precautions to Be Followed by Kidney Transplant Recipients Top


  1. Follow a healthy lifestyle with a balanced diet and regular exercise
  2. Take medications, at the correct time and in the correct dosage, as prescribed by the parent transplant unit. Nonadherance to medication is a very important cause for acute rejection of the transplanted kidney
  3. Report to the parent transplant unit for regular follow-up as instructed
  4. Avoid contact with individuals who have an active infection
  5. Avoid live vaccines
  6. Do not smoke or use tobacco products
  7. Abstain from alcohol
  8. Avoid excessive weight gain and maintain body mass index in the normal range
  9. Avoid the use of nephrotoxic medications such as nonsteroidal anti-inflammatory drugs (including Cox-2 inhibitors) and aminoglycosides.
  10. Before starting any new drug, confirm with the treating physician whether it is safe to use and whether there is the potential for drug interaction with transplant medications
  11. All drugs should be dosed based on the patient's glomerular filtration rate
  12. Female kidney transplant recipients should wait at least 1 year after transplant before becoming pregnant and must plan conception only after a thorough evaluation of kidney function and risk for rejection by the parent transplant center. Some medications such as mycophenolic acid and mTOR inhibitors (sirolimus, everolimus) need to be substituted with alternative immunosuppressive agents such as azathioprine before conception is planned and it is desirable that kidney function is stable, proteinuria is <1 g/day, and blood pressure is well controlled before conception.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant 2009;9 Suppl 3:S1-155.  Back to cited text no. 1
    




 

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