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
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
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
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.
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)
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 therapya
For R−/D−: screening when clinically indicated or when exposed to large volume blood transfusionsa
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.
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.
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.
See chapter 13.
See chapter 2.
Clinicians must remain vigilant to drug-drug interactions between immunosuppressants and commonly used drugs.
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.
a Recommendations based on the 2018 Third International Consensus Guidelines on the management of CMV in solid organ transplantation. Practice may vary among centers.
b Signs and symptoms of CMV DNAemia and CMV disease are discussed in chapter 13.
c Prenner and Levitsky Am J Transplant. 2017 (recommendations based on literature review).
d For increased risk patients (eg, family history of colon cancer in first-degree relative <60 y at diagnosis), follow pretransplant guidelines (see chapter 4).
Frequently Asked Questions
Frequently Asked Questions
Erik L. Lum
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.
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