Frequently Asked Questions

Erik L. Lum

Natalie Bjelajac

Meena Parakkal

Michele Pena

Suggestions provided for frequently asked questions in this chapter are opinion based, and practice may vary among centers and countries. Both kidney transplant recipients and their primary health care providers should have access to the “mother” transplant center at time of need.

Pretransplant blood transfusion
- Assess risk and benefit: Human leukocyte antigens (HLAs) expressed on the surface of donor leukocytes can induce anti-HLA antibody production (also referred to as allosensitization). Blood transfusion in patients awaiting a kidney transplant should be avoided unless benefit outweighs risk.
- If blood transfusion is deemed necessary, consider use of leukocyte-reduced blood products. However, it should also be noted that leukocytes and red blood cells carry a large HLA antigen load, thus residual leukocytes and/or red blood cell HLA may not prevent or reduce allosensitization to any significant degree (blood transfusion in the posttransplant period is discussed in chapter 10).¹
Preservation of vascular access
- All transplant patients should be treated as chronic kidney disease (CKD) patients because most, if not all, allografts will eventually fail. The United Network for Organ Sharing (UNOS) database showed that the 10-year graft failure rates for transplants performed in 2005 for deceased and living donor transplants were 52.8% and 37.3%, respectively.² Hence, maintaining vascular access integrity is essential to provide future dialysis in the event of graft failure.
- Peripherally inserted central catheter (also known as PICC line) and midline catheter can cause local injury and thrombosis to the vessels and render them unviable for future arteriovenous (AV) access creation. Placement of a small-bore central catheter into the right internal jugular vein is preferred over a PICC unless options are limited.
- Central venous catheters that are intended for long-term use (defined as more than 7-10 days) should be placed using a subcutaneous tunnel.
Activities in the early posttransplant period: Frequently asked questions the first 3 months after transplant are shown in Table 20-1.

Return to work precautions

Routine work-related precautions or exposure

Work-specific precautions

Outdoor (construction, farming, gardening): See “gardening, yard work” in the following text.

TABLE 20-1 Frequently Asked Questions the First Three Months After Transplant

When can I?	Recommendations are for stable kidney transplant recipients
Exercise, lift weight	After hospital discharge: may begin routine walking for exercise and walking up and down the stairs. Exercise intensity can be increased as tolerated. The first 6 wk after transplant: no lifting more than 5 lb or straining of abdominal muscles including mowing the lawn or vacuuming
Drive	3-4 wk after transplant
Have sexual intercourse	3-4 wk after transplant (see “contraceptive methods and pregnancy after transplantation”)
Return to work	2-3 mo after transplant
Travel abroad	3 mo after transplant (see chapter 13 for travel vaccinations)

Weight lifting: Patients with a functioning AV fistula or AV graft should avoid lifting more than 10 lb in the ipsilateral arm.
Construction workers can return to work after 3-6 months without weight restriction

Gardening, yard work
- Soil can contain bacteria and fungi that can cause serious or life-threatening infection in immunocompromised kidney transplant recipients: shoes, socks, and gloves recommended
- Wear a mask for heavy dusty work or when soil is being stirred up because microscopic spores of fungus and bacteria can be released.
- Wear gloves when working with indoor plants.
- Avoid changing water of indoor cut flowers.
Contacts with pets and animals
- Wash hands after touching pets.
- Contacts with dogs and cats are safe. Keep their vaccination up-to-date.
- Avoid
  - Contacts with birds and bird droppings
  - Handling turtles, their water, or tank (increased risk of salmonella infection)
  - Cleaning cat litter

Repatriation of patients

In the United States, patients are commonly repatriated to the referring or community nephrologists 3 months after transplant.
Patients should be seen by their primary care provider monthly the first year, every 2 months the second year, and every 3 months thereafter or at the discretion of the clinician. Suggested infectious disease screening and preventive health care guidelines³,⁴,⁵ for kidney transplant recipients are shown in Table 20-2.
Follow-up visits at the transplant center every 3 months until the end of the first year and annually thereafter are typically recommended. Community physicians may vary with respect to the degree of comfort in assuming the care of a kidney transplant recipient. Some transplant centers maintain control of the immunosuppression dosing for the life span of the allograft.
Patients should return to the transplant center for assessment of any significant changes in kidney function and of any new comorbidity.
If an allograft biopsy is required, it is preferred that this be performed at the transplant center because of the proximity of pathology expertise and a broad range of therapeutic options.

TABLE 20-2 Suggested Infectious Disease Screening and Preventive Health Care Guidelines

Infectious disease screening and preventive health care	Screening frequency (as applicable)	Comments
CMV surveillance after prophylactic therapy (monitor plasma CMV DNA by PCR)	For patients at increased risk for postprophylaxis CMV disease (R−/D+): CMV DNA weekly for 8-12 wk after the end of prophylactic therapy^a For R+/D− or R+/D+: screening after the end of prophylactic therapy as clinically indicated^a,^b For R−/D−: screening when clinically indicated or when exposed to large volume blood transfusions^a	Avoid transfusion-transmitted CMV infection in R−/D−: Consider leukocyte-reduced or CMV-seronegative blood products. The Third International Consensus Guidelines on the management of CMV in solid organ transplantation advocate both “CMV prophylaxis” and “preemptive therapy” strategies (see chapter 13).
BK surveillance following transplant (monitor plasma BK DNA by PCR)	Monthly × 6, then month 9, month 12, and then annually up to 5 y posttransplant	Management of BK viremia is discussed in chapter 13.
Screening for skin cancer (opinion-based)	Annual dermatology surveillance Regular (monthly) self-skin examination Patients should be advised to avoid excessive sun exposure, use sunscreen, and wear protective clothing.	Patients with history of actinic keratosis, precancerous skin lesions, or skin cancers: Screening frequency may vary from every 3 to 6 mo depending on cancer types and single vs multiple episodes. Close dermatology follow-up is mandatory.
Screening for other malignancies	Anogenital cancer screening Women >18 y of age should have annual pelvic exam and Papanicolaou test because anogenital cancer is common after transplantation. Colorectal cancer screening^c,d Consider colonoscopy every 5-10 y. If last screening colonoscopy >5 y before transplant, consider repeat colonoscopy in the first 1-2 y after transplant. For patients <50 y of age at transplant First colonoscopy screening at age 50 y or At age 40 y, if comorbid conditions are present (diabetes, obesity, smoking history, or alcohol use) Screening for breast and prostate Follow local guidelines for the general population.	The KDOQI guidelines suggest an individualized screening plan for kidney transplant recipient, considering the individual’s past medical and family history, tobacco use, and competing risk for death.
Routine vaccinations	Recommended vaccinations in the posttransplant period are discussed in chapter 13. Live vaccinations are contraindicated posttransplantation.	Most centers restart vaccinations 6-12 mo after transplantation, 3 mo posttransplant for influenza during outbreaks.
Travel vaccinations	See chapter 13.
Drug-drug interaction	See chapter 2.	Clinicians must remain vigilant to drug-drug interactions between immunosuppressants and commonly used drugs.
Others	Encourage healthy diet and regular exercise.	Management of posttransplant cardiovascular disease, hypertension, diabetes/metabolic disease is discussed in chapter 14. Management of mineral and bone disorders is discussed in chapter 11.
Abbreviations: CMV, cytomegalovirus; D+, donor CMV seropositive; D−, donor CMV seronegative; KDOQI, Kidney Disease Outcomes Quality Initiative; PCR, polymerase chain reaction; R+, recipient CMV seropositive; R−, recipient CMV seronegative.
^aRecommendations based on the 2018 Third International Consensus Guidelines on the management of CMV in solid organ transplantation. Practice may vary among centers. ^bSigns and symptoms of CMV DNAemia and CMV disease are discussed in chapter 13. ^cPrenner and Levitsky Am J Transplant. 2017 (recommendations based on literature review). ^dFor increased risk patients (eg, family history of colon cancer in first-degree relative <60 y at diagnosis), follow pretransplant guidelines (see chapter 4).