Introduction
Summary of clinical practice guidelines for the post-operative care of the kidney transplant recipient
Kidney Transplant Recipient (KTR): organisation of outpatient follow-up (guidelines 1.1–1.4)
Guideline 1.1 – KTR: clinic infrastructure
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A consultant-level health care professional should be available for every transplant clinic
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KTRs should be reviewed in a dedicated outpatient area
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The results of blood tests (including drug levels if possible) should be available within 24 h
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A formal mechanism should exist for results review by health care professionals within 24 h of a clinic appointment
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There should be access to a multidisciplinary renal team including pharmacist, dietician, social worker and psychologist
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Patient care should be planned along principles set out in the National Service Framework and “Kidney Health Delivering Excellence”
Guideline 1.2 – KTR: clinic frequency
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2–3 times weekly for the first month after transplantation
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1–2 times weekly for months 2–3
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Every 2–4 weeks for months 4–6
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Every 4–6 weeks for months 6–12
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3–6 monthly thereafter
Guideline 1.3 – KTR: patient access
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All patients should have the option of on-line access to their results via the “Patient View” service
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All patients should have open access to the renal transplant outpatient service and have an established point of contact for enquiries
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Patient information should be available in both written and electronic formats
Guideline 1.4 – KTR: chronic transplant care review
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A process should exist for patient review on an annual basis in a different format of clinic according to the “Care plan model”
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This should be a patient-centred clinic, facilitated by a health care professional
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It should address concerns in medical, social, psychological and sexual domains
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Access to a renal dietician, social worker, specialist renal pharmacist and/or psychologist should be readily available from this clinic
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This process should proceed in parallel with formal medical review
Kidney Transplant Recipient: Non-adherence (Guideline 2.1)
Guideline 2.1 – KTR: recognising non-adherence
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Factors associated with non-adherence should be identified
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An established interventional pathway should be in place for those at high risk of or with proven non-adherence
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Pathways should be in place for paediatric KTRs in transition and for adolescent KTRs
Kidney Transplant Recipient: immunosuppressive treatment (Guidelines 3.1–3.12)
Guideline 3.1 – KTR: immunosuppression regimen
Guideline 3.2 – KTR: induction immunosuppression
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Immunosuppressive drugs should be started before or at the time of renal transplantation (1B)
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Induction therapy with biological agents should be administered to all KTRs. In patients at low immunological risk this will generally involve an interleukin-2 receptor antagonist (IL2-RA). Recipients at higher immunological risk may be considered for T-cell (lymphocyte) depleting antibodies (TDAs) (1B)
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Induction therapy with TDAs may also be useful for lower immunological risk patients with the intention of either steroid or calcineurin inhibitor (CNI) avoidance (1C)
Guideline 3.3 – KTR: induction immunosuppression
Guideline 3.4 – KTR: maintenance immunosuppression
Guideline 3.4 – KTR: maintenance immunosuppression
Guideline 3.5 – KTR: maintenance immunosuppression
Guideline 3.5 – KTR: maintenance immunosuppression
Guideline 3.6 – KTR: maintenance immunosuppression
Guideline 3.7 – KTR: maintenance immunosuppression
Guideline 3.8 – KTR: maintenance immunosuppression
Guideline 3.9 – KTR: maintenance immunosuppression
Guideline 3.10 – KTR: maintenance immunosuppression
Guideline 3.11 – KTR: maintenance immunosuppression
Guideline 3.12 – KTR: maintenance immunosuppression
Guideline 3.13 – KTR: monitoring of immunosuppression
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Tacrolimus and ciclosporin levels should be monitored. The initial frequency should be 3 times a week. Levels should also be checked when any medication with possible interactions is prescribed, the dosage is changed, the formulation is changed, or when there is unexplained graft dysfunction (2C)
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Tacrolimus should be monitored by the trough (C0) level, while ciclosporin can be monitored by either C0 or 2-h post dose (C2) level (2C)
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Tacrolimus and ciclosporin levels should be available within 24 h of taking blood samples in the first 3 months after transplantation (2D)
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The utility of monitoring mycophenolic acid (MPA) C0 levels is uncertain (2D)
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Sirolimus should be monitored by the C0 trough level (2C)
Guideline 3.14 – KTR: prescribing and the use of generic agents
Guideline 3.15 – KTR: prescribing and the use of generic agents
Guideline 3.16 – KTR: prescribing and the use of generic agents
Guideline 3.17 – KTR: prescribing and the use of generic agents
Kidney Transplant Recipient: acute rejection (Guidelines 4.1–4.12)
Guideline 4.1 – KTR: diagnosis of acute rejection
Guideline 4.2 – KTR: diagnosis of acute rejection
Guideline 4.3 – KTR: diagnosis of acute rejection
Guideline 4.4 – KTR: diagnosis of acute rejection
Guideline 4.5 – KTR: diagnosis of acute rejection
Guideline 4.6 – KTR: diagnosis of acute rejection
Guideline 4.7 – KTR: treatment of acute rejection
Guideline 4.8 – KTR: treatment of acute rejection
Guideline 4.9 – KTR: treatment of acute rejection
Guideline 4.10 – KTR: treatment of acute rejection
Guideline 4.11.1 – KTR: treatment of acute rejection
Guideline 4.11.2 -KTR: treatment of acute rejection
Guideline 4.12 – KTR: treatment of acute rejection
Kidney Transplant Recipient: chronic allograft injury (Guidelines 5.1–5.7)
Guideline 5.1 – KTR: diagnosis of chronic allograft injury
Guideline 5.2 – KTR: detection of chronic allograft injury
Guideline 5.3 – KTR: diagnosis of chronic allograft injury
Guideline 5.4 – KTR: diagnosis of chronic allograft injury
Guideline 5.5 – KTR: diagnosis of chronic allograft injury
Guideline 5.6 – KTR: treatment of chronic allograft injury
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By withdrawal of calcineurin inhibitors if there is histological evidence of CNI toxicity or non-specific interstitial fibrosis and tubular atrophy (2C)
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By intensification of immunosuppression if there is evidence of ongoing immune injury (cellular rejection and/or humoral rejection) (2C)
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In a similar fashion to other patients with chronic kidney disease (CKD), following similar preventative strategies and with timely referral to low clearance services (2D)
Guideline 5.7 – KTR: renal biopsy in chronic allograft injury
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If there is a persistent unexplained elevation of creatinine or failure to return to baseline after an episode of biopsy proven acute rejection (BPAR) (1C)
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Every 7–10 days during delayed graft function (DGF) (2C)
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If expected renal function is not achieved within 4–8 weeks (2D)
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If sustained new onset proteinuria develops (PCR >50 mg/mmol or ACR >35 mg/mmol) (2C)
Kidney Transplant Recipient: cardiovascular disease and lifestyle (Guidelines 6.1–6.6)
Guideline 6.1 – KTR: hypertension
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Blood pressure should be recorded at each clinic visit (1C)
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Clinic blood pressure should be <140/90 mmHg in clinic (130/80 mmHg if PCR >50 or ACR >35) (2C)
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Home blood pressure recordings and 24-h ambulatory recordings may be helpful in some instances but lower BP targets should then be set (home and or ambulatory daytime measures <135/80 mmHg) (2D)
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There is no evidence that any antihypertensive agent is better than any other and effort should be focused on achieving absolute blood pressure control rather than the use of individual agents (2D)
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Inhibitors of the renin-angiotensin system may be more effective in the minimisation of proteinuria but should be used with caution in the first 3 months post-transplant (2C)
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Resistant hypertension may be due to transplant renal artery stenosis and should be investigated according to local practice (2D)
Guideline 6.2 – KTR: dyslipidaemia
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Fasting lipid levels should be measured on an annual basis in renal transplant recipients (2C)
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Treatment targets should be the same as in the general population (2C)
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KTRs at increased primary or secondary cardiovascular risk receive statin therapy to reduce the risk of coronary artery disease (2C)
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The choice and dose of statin should take into account concurrent immunosuppression. High dose simvastatin (≥40 mg daily) should be avoided in conjunction with ciclosporin and/calcium channel antagonists (2D)
Guideline 6.3 – KTR: diabetes mellitus
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Screening for the development of post-transplant diabetes mellitus (PTDM) by dipstick urinalysis and measurement of blood sugar level at each clinic visit (2C)
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Post-transplant immunosuppression should take into account risk factors for the development of diabetes (2C)
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The diagnosis of PTDM is made based on WHO criteria for the diagnosis of diabetes mellitus based on fasting or random blood, serum glycated haemoglobin (HBA1c) or oral glucose tolerance testing (1C)
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A diagnosis of PTDM is made once patients are established on stable maintenance immunosuppression (2D)
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Post-transplant diabetes should be managed in collaboration with specialists in diabetic medicine (2D)
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All units should have a protocol for the management of post-transplant diabetes (2C)
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KTR with diabetes (either prior to transplantation or PTDM) should undergo screening for diabetic complications (retinal screening, foot care, neuropathy) in line with guidelines for non KTR patients with diabetes (2D)
Guideline 6.4 – KTR: ischaemic heart disease
Guideline 6.5 – KTR: smoking cessation
Guideline 6.6 – KTR: lifestyle measures
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Maintenance of a healthy diet should be encouraged (2C)
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An ideal weight should be targeted (body mass index (BMI) ≤25 kg/m2) (2C)
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Weight management services should be available (2C)
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We suggest that KTRs participate in physical activity at a level similar to that recommended to age and co-morbidity matched counterparts from the general population (2D)
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Alcohol consumption should be within national guidelines (2D)
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Recreational drug use should be avoided (2D)
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The use of over-the-counter medications (without discussion with clinical staff) and non-proprietary medications (e.g. herbal medicines) should be discouraged (2D)
Kidney Transplant Recipient: neoplasia (Guidelines 7.1–7.4)
Guideline 7.1 – KTR: screening for cancer
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Screening should be similar to the general population for cervical, breast, colon and prostate cancer (2C)
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Screening is not recommended for renal cell carcinoma (2C)
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Patient education pre and post transplantation (1C)
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Patients should be aware of malignancy risk and encouraged to report symptoms which may represent de novo malignancy (e.g. breast or testicular lumps) (2D)
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Skin surveillance by a healthcare professional at least biannually up to 5 years post-transplant and annually from 5 years post-transplant (2C)
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Patients with cirrhosis should undergo an annual hepatic ultrasound and determination of serum alpha feto-protein (2C)
Guideline 7.2 – KTR: Non-melanoma skin cancer (NMSC)
Guideline 7.3 – KTR: Non-melanoma skin cancer
Guideline 7.4 – KTR: Non-melanoma skin cancer
Guideline 7.5 – KTR: Non-melanoma skin cancer
Guideline 7.6 – KTR: Non-melanoma skin cancer
Guideline 7.7 – KTR: immunosuppression in cancers
Guideline 7.8 – KTR: immunosuppression in cancers
Guideline 7.9 – KTR: immunosuppression in Kaposi sarcoma
Kidney Transplant Recipient: infection complications (Guidelines 8.1–8.9)
Guideline 8.1 – KTR: vaccination
Guideline 8.1.1 – KTR: vaccination
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Should be vaccinated with inactivated viruses as per the normal population (1D)
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Should receive annual influenza vaccination unless contraindicated (1C)
Guideline 8.1.2 – KTR: vaccination
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Should have hepatitis B surface antibody (HBsAb) levels rechecked annually and be revaccinated if antibody titres fall below 10 mIU/mL (2D)
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Should not receive live attenuated vaccines (2C)
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Should receive pneumococcal vaccine and a booster every five years (2D)
Guideline 8.2 – KTR: cytomegalovirus (CMV) disease
Guideline 8.2.1 – KTR: prophylaxis and treatment of CMV disease
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Prophylaxis should be continued for 3–6 months, until immunosuppression has been reduced to long-term maintenance level (1B)
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Treatment should be administered for 6 weeks after treatment with a TDA (1C)
Guideline 8.2.2 – KTR: prophylaxis and treatment of CMV disease
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All transplant units should be able to measure CMV serological status and quantify viral load (2D)
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Donor and recipient CMV status should be recorded at the time of transplantation (2D)
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Each unit should have a written protocolised CMV strategy based on prophylaxis or pre-emptive therapy (2D)
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For the treatment of mild and moderate CMV disease, oral valganciclovir and intravenous ganciclovir are of equivalent efficacy (2C)
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The first line treatment of life-threatening CMV disease is intravenous ganciclovir (2D)
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Treatment duration should be determined by monitoring viral load (2C)
Guideline 8.3 – KTR: Epstein Barr Virus (EBV) infection
Guideline 8.3.1 – KTR: EBV infection
Guideline 8.3.2 – KTR: EBV infection
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Both donor and recipient should have their EBV serology recorded at the time of transplantation (2D)
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All high risk (D+/R−) patients (including adults) should have EBV viral load measured immediately after transplantation, monthly for 6 months, and 3 monthly to 1 year (2C)
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EBV viral load should be monitored after the treatment of rejection (2C)
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Total immunosuppression should be reduced when EBV titres rise significantly (2C)
Guideline 8.4 – KTR: Varicella Zoster Virus (VZV) infection
Guideline 8.4.1 – KTR: VZV infection
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Primary infection (chickenpox) should be treated with intravenous aciclovir or oral valaciclovir until the lesions scab over (1C)
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Uncomplicated shingles should be treated with oral acyclovir or valaciclovir until the lesions scab over (1D)
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Disseminated (>2 dermatomes), ocular or invasive shingles should be treated with intravenous aciclovir until the lesions scab over, together with a reduction in immunosuppression (1B)
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Varicella-susceptible KTRs (i.e. VZV IgG negative) with primary exposure to VZV should receive intravenous immunoglobulin, ideally within 96 hours, but up to a maximum of 10 days following exposure. If unavailable or after 10 days, oral aciclovir should be prescribed for seven days (1D)
Guideline 8.4.2 – KTR: VZV infection
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Patients on the waiting list who are VZV IgG negative should be vaccinated prior to transplantation (2D)
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Immunosuppression should be reduced during primary infection (2D)
Guideline 8.5 – KTR: Herpes Simplex Virus (HSV) infection
Guideline 8.5.1 – KTR: HSV infection
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Superficial HSV infection should be treated with appropriate oral agents until the lesions have resolved (1D)
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Systemic HSV infections should be treated with intravenous aciclovir and a reduction in immunosuppression until a response occurs and oral medication should be continued for at least 14 days (1C)
Guideline 8.5.2 – KTR: HSV infection
Guideline 8.6 – KTR: BK virus (BKV) nephropathy
Guideline 8.6.1 – KTR: BK nephropathy
Guideline 8.6.2 – KTR: BK nephropathy
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Screening should also be carried out when renal function deteriorates in an unexplained fashion (2D)
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KTRs should be screened for BKV viral load or by performing urine microscopy for decoy cells or by polymerase chain reaction (PCR) on urine or serum (2C)
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Suspected BK nephropathy should be confirmed by renal biopsy, which should be stained for SV40. Two cores containing medullary tissue should ideally be examined (2D)
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Immunosuppression should be reduced when the serum BKV load exceeds 104 copies/ml (2C)
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There is no established specific treatment for BK nephropathy (2D)
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Re-transplantation can safely be considered in patients who have BK nephropathy diagnosed in an earlier graft (2C)
Guideline 8.7 – KTR: pneumocystis jirovecii infection - treatment and prophylaxis
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All patients with confirmation (microscopy or PCR) of Pneumocystis jirovecii in respiratory secretions should be treated for 14 to 21 days with co-trimoxazole orally or intravenously (15-20 mg/kg in three or four divided doses) (2B)
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Patients with contraindications to treatment with co-trimoxazole should receive pentamidine (4 mg/kg/day intravenously) (2B)
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Adjunctive glucocorticoid therapy may be considered in patients with severe disease (2D)
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All patients should receive 3–6 months of treatment with co-trimoxazole 480 mg daily for Pneumocystis jirovecii prophylaxis following renal transplantation (1B)
Guideline 8.8 – KTR: post-transplant infection prophylaxis
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All patients should receive 3–6 months of treatment with co-trimoxazole 480 mg daily (1B)
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Oral antifungal prophylaxis should be administered for 1 week after transplantation (2C)
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In selected patients, prophylaxis against mycobacterium tuberculosis with daily isoniazid (supplemented with pyridoxine) should be instituted for 6 months after transplantation (2C)
Guideline 8.9 – KTR: Hepatitis E Virus (HEV)
Kidney Transplant Recipient: bone and joint disease (Guidelines 9.1–9.4)
Guideline 9.1 – KTR: osteoporosis
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KTRs suffering from osteoporosis or at high potential risk should be considered for steroid-avoiding immunosuppression (2D)
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KTRs on long-term steroids or at high risk for osteoporosis should undergo DEXA scanning if eGFR >30 mL/min/1.73 m2 (2D)
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Treatment should be according to the Royal College of Physicians (RCP) guidelines for steroid-induced osteoporosis (2D)
Guideline 9.2 – KTR: tertiary hyperparathyroidism
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Severe hyperparathyroidism should be treated prior to transplantation (2D)
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Cinacalcet can be used in KTR (2C)
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Treatment should be the same as for other patients with CKD (2D)
Guideline 9.3 – KTR: gout
Guideline 9.3.1 – KTR: treatment of gout
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We recommend that neither allopurinol nor febuxostat should be administered with azathioprine (1C)
Guideline 9.3.2 – KTR: treatment of gout
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Hyperuricaemia should be treated when associated with gout, tophi or uric acid stones (2D)
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Non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided in KTRs (2D)
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Acute gout may be treated with brief a course of oral prednisolone. (2D)
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Colchicine is an effective treatment for gout in KTR (2D)
Guideline 9.4 – KTR: calcineurin inhibitor bone pain
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Reduction or withdrawal of CNIs should be considered in KTRs with intractable bone pain (2D)
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Dihydropyridine calcium antagonists also may be beneficial (2D)
Kidney Transplant Recipient (KTR): haematological complications (Guidelines 10.1–10.3)
Guideline 10.1 – KTR: anaemia
Guideline 10.2 – KTR: polycythaemia
Guideline 10.3 – KTR: polycythaemia
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Haemoglobin levels should be monitored at every clinic visit (2D)
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Treatment should be initiated if the haematocrit or packed cell volume exceeds 52% in men and 49% in women (2D)
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Venesection may be used in refractory cases.(2D)
Kidney Transplant Recipient (KTR): reproductive issues (Guidelines 11.1–11.5)
Guideline 11.1 – KTR: conception and contraception (female)
Guideline 11.2 – KTR: conception and contraception (female)
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KTRs should wait for 1 year after transplant and have stable function before attempting conception (2C)
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Counselling regarding fertility and reproduction should be offered to female KTRs and their partners either prior to transplantation or soon afterwards (2D)
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m-TORi should be stopped prior to conception and replaced as appropriate (2D)
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Pregnancy should be jointly managed with an Obstetrics department with experience of care of KTR (2D)
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KTRs receive aspirin 75 mg daily to reduce the risk of pre-eclampsia from 12 weeks gestation until birth of the baby unless there are contraindications (2C)
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The risks and benefits of breastfeeding should be discussed (2D)
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Contraception advice should be similar to the general population (2D)
Guideline 11.3 – KTR: conception and contraception (male)
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Male KTRs are advised that MPA containing compounds have theoretical teratogenic potential in men taking these agents (1D)
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KTRs should be advised that m-TORi reduce the male sperm count and counselled accordingly. (1C)
Guideline 11.4 – KTR: conception and contraception (male)
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All immunosuppressive drugs other than m-TORi can be used in male KTRs. Advice for MPA is as Guideline 11.3 (2D)
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The decision to continue MPA containing compounds in a male KTR wishing to conceive should balance the risk of theoretical teratogenicity against the risk of rejection on changing from MPA to azathioprine (2D)
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Men on m-TORi who wish to conceive should discontinue these agents prior to conception and replace them as appropriate (2D)
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Men who wish to maintain fertility should avoid m-TORi or bank sperm prior to starting these drugs (2D)
Guideline 11.5 – KTR: sexual dysfunction
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Specific enquiry should be made regarding sexual dysfunction, preferably at an annual review clinic (2D)
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Care pathways for dealing with sexual dysfunction should be established (2D)
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Close liaison with local andrology service is recommended (2D)
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Sildenafil is safe and effective in male KTR not taking nitrates (2D)
Summary of audit measures for the post-operative care of the kidney transplant recipient
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Proportion of blood results available for review, and reviewed, within 24 h
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Proportion of units with a written follow-up schedule available to all staff and patients
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Percentage of patients accessing their results through Renal Patient View
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Percentage of total patients assessed in an annual review clinic
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Recording “Did Not Attend” (DNA) rates for all patients
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Recording sub-therapeutic drug levels. Measuring within-patient variability of CNI levels
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Percentage of total patients receiving induction with ILRAs and TDAs
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Percentage of de novo KTRs receiving tacrolimus
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Percentage of de novo KTRs receiving MPA based immunosuppression
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Percentage of de novo KTRs receiving corticosteroid maintenance therapy
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Use of generic agents
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Severity of biopsy proven acute rejection (BPAR) recorded by Banff criteria
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Percentage of KTRs with BPAR in first 3 months and first 12 months
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Percentage of KTRs requiring TDAs to treat rejection in first year
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Complication rates after renal transplant biopsy
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The percentage of KTRs with BPAR in first 3 months and the first 12 months
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The percentage of KTRs with a donor specific HLA antibody at the time of biopsy
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The percentage of KTRs with positive C4d staining on biopsy
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Proportion of patients receiving a target blood pressure of 140/90 mmHg or 130/80 mmHg in the presence of proteinuria (PCR >100 mg/mmol or ACR >70 mg/mmol)
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Proportion of patients with proteinuria assessed by dipstix and, if present, quantified at each clinic visit
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Proportion of renal transplant recipients with an annual fasting lipid profile
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Proportion of RTR taking statins (including the type of statin) for primary and secondary prevention of premature cardiovascular disease
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Proportion of patients on other lipid lowering agents
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Proportion of patients achieving dyslipidaemia targets
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Incidence of post-transplant diabetes mellitus (PTDM) at 3 months and at annual intervals thereafter
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Proportion of patients who require insulin, and in whom remedial action is undertaken – minimisation of steroids and switching of CNIs
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The proportion of patients with PTDM enrolled in screening for extra-renal complications of PTDM
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Proportion of patients with ischaemic heart disease
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Proportion of patients suffering myocardial infarction
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Proportion of patients undergoing primary revascularisation
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Proportion of patients receiving secondary prevention with a statin, anti-platelet agents and renin angiotensin system (RAS) blockers
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Proportion of KTRs who smoke
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Proportion of cigarette smoking KTRs who have been given formal advice or offered help with cessation
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Proportion of patients who are obese (BMI > 30 kg/m2)
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Proportion of patients having screening procedures for neoplasia at the annual review clinic
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Incidence of CMV disease
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Rate of EBV infection and PTLD
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Completeness of records for EBV donor and recipient serology
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Rates of primary VZV and shingles infection
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Completeness of records for VZV recipient serology
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Rates and outcomes of HSV infections
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Rates of BK viral infection in screening tests
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Rates and outcomes of BK nephropathy
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Frequency of bisphosphonate use
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Incidence of fractures
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Incidence of hyperparathyroidism
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Incidence of parathyroidectomy
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Use of cinacalcet
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Frequency of hyperuricaemia and gout
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Prevalence of anaemia
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Prevalence of polycythaemia
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Pregnancy rates and outcomes
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Prevalence of sexual dysfunction
Rationale for clinical practice guidelines for post-operative care of the kidney transplant recipient
Kidney Transplant Recipient (KTR): organisation of outpatient follow-up (Guidelines 1.1 – 1.4)
Guideline 1.1 – KTR: clinic infrastructure
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A consultant-level health care professional should be available for every transplant clinic
-
KTRs should be reviewed in a dedicated outpatient area
-
The results of blood tests (including drug levels if possible) should be available within 24 h.
-
A formal mechanism should exist for results review by health care professionals within 24 h of a clinic appointment
-
There should be access to a multidisciplinary renal team including pharmacist, dietician, social worker and psychologist
-
Patient care should be planned along principles set out in the National Service Framework and “Kidney Health Delivering Excellence”
Guideline 1.2 – KTR: clinic frequency
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2–3 times weekly for the first month after transplantation
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1–2 times weekly for months 2–3
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Every 2–4 weeks for months 4–6
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Every 4–6 weeks for months 6–12
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3–6 monthly thereafter
Guideline 1.3 – KTR: patient access
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All patients should have on-line access to their results via the “Renal Patient View” service if they wish
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All patients should have open access to the renal transplant outpatient service and have an established point of contact for enquiries
-
Patient information should be available in both written and electronic formats
Guideline 1.4 – KTR: chronic transplant care review
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A process should exist for patient review on an annual basis in a different format of clinic according to the “Care plan model”
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This should be a patient-centred clinic, facilitated by a health care professional
-
It should address concerns in medical, social, psychological and sexual domains
-
Open access to a renal dietician, social worker, specialist renal pharmacist and/or psychologist should be readily available from this clinic
-
This process should proceed in parallel with formal medical review
Kidney Transplant Recipient (KTR): Non-adherence (Guideline 2.1)
Guideline 2.1 – KTR: recognising non-adherence
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Factors associated with non-adherence should be identified
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An established interventional pathway should be in place for those at high risk of or with proven non-adherence
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Pathways should be in place for paediatric KTRs in transition and for adolescent KTRs
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Recording “Did Not Attend” (DNA) rates for all patients
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Recording sub-therapeutic drug levels
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Measuring within-patient variability of CNI levels
Kidney Transplant Recipient (KTR): immunosuppressive treatment (Guidelines 3.1 – 3.17)
General concepts
Risk Type | Low | Medium | High | Possible Strategy |
---|---|---|---|---|
Immunological | 0-DR mismatch First graft Unsensitised Recipient >60 | 1-DR mismatch Afro-Caribbean recipient Historical DSAs NDSAs DGF Older donor [45] | 2-DR mismatch Previous early immunological graft loss DSAs ABO-incompatible Sensitised (high CRF/PRA) Preoperative anti-ATIIR Abs [117] | Increase total immunosuppressive load |
Metabolic | Low BMI Age <40 Normal pre-Tx GTT | Positive family history ADPKD | Impaired GT BMI >35 HCV positive Age >60 Previous CVD Race | Avoid/minimise steroids and tacrolimus |
Neoplastic | Age <40 | Pre-malignant lesion | Previous cancer Hereditary syndrome e.g. VHL | Consider low immunosuppression load or sirolimus |
Ischaemia-reperfusion injury | Living donor Deceased donor <40 | CIT >12 h Donor aged 50–60 | DCD CIT > 24 h Extended criteria donor | Reduce CNI exposure |
Non-adherence | Poor RRT compliance Age <20 Transition from paediatric to adult | Education Simple drug regime alemtuzumab or belatacept |
Guideline 3.1 – KTR: immunosuppression regimen
Guideline 3.1 – KTR: induction immunosuppression
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Immunosuppressive drugs should be started before or at the time of renal transplantation (1B)
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Induction therapy with biological agents should be administered to all KTRs (1B). In patients at low immunological risk this will generally involve an interleukin-2 receptor antagonist (IL2-RA). Recipients at higher immunological risk may be considered for T-cell (lymphocyte) Depleting Antibodies (TDAs; e.g. anti-lymphocyte preparations [antithymocyte globulin (ATG) or alemtuzumab])
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Induction therapy with TDAs may also be useful for lower immunological risk patients with the intention of either steroid or CNI avoidance (1C)
Guideline 3.2 – KTR: induction immunosuppression
Guideline 3.3 – KTR: maintenance immunosuppression
Guideline 3.4 – KTR: maintenance immunosuppression
Guideline 3.5 – KTR: maintenance immunosuppression
Guideline 3.6 – KTR: maintenance immunosuppression
Guideline 3.7 – KTR: maintenance immunosuppression
Guideline 3.8 – KTR: maintenance immunosuppression
Guideline 3.9 – KTR: maintenance immunosuppression
Guideline 3.10 – KTR: maintenance immunosuppression
Guideline 3.11 – KTR: maintenance immunosuppression
Guideline 3.12 – KTR: maintenance immunosuppression
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Percentage of de novo KTRs receiving tacrolimus
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Percentage of de novo KTRs receiving MPA-based immunosuppression
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Percentage of de novo KTRs receiving corticosteroid as part of maintenance therapy
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short duration of increasingly expensive trials
-
convergence of outcomes with many different regimes for short term surrogate endpoints (e.g. rejection rates and graft function)
-
restrictions on trial recruitment which exclude many real world patients
Guideline 3.13 – KTR: monitoring of immunosuppression
-
Tacrolimus and ciclosporin levels should be monitored. The frequency should be 3 times a week immediately after the transplant. Levels should checked when any medication with possible interactions is prescribed or when there is unexplained graft dysfunction (2C)
-
Tacrolimus should be monitored by the C0 trough level, while ciclosporin can be monitored by either trough (C0) or 2-h post dose (C2) level (2C)
-
Tacrolimus and ciclosporin levels should be available within 24 h of taking blood samples (2C)
-
The utility of monitoring mycophenolic acid (MPA) C0 levels is uncertain (2D)
-
Sirolimus should be monitored by the C0 trough level (2C)
Guideline 3.14 – KTR: prescribing and the use of generic agents
Guideline 3.15 – KTR: prescribing and the use of generic agents
Guideline 3.16 – KTR: prescribing and the use of generic agents
Guideline 3.17 – KTR: prescribing and the use of generic agents
-
The use of generic agents should be monitored and audited
Kidney Transplant Recipient (KTR): acute rejection (Guidelines 4.1-4.12)
Guideline 4.1 – KTR: diagnosis of acute rejection
Guideline 4.2 – KTR: diagnosis of acute rejection
Guideline 4.3 – KTR: diagnosis of acute rejection
Guideline 4.4 – KTR: diagnosis of acute rejection
Guideline 4.5 – KTR: diagnosis of acute rejection
Guideline 4.6 – KTR: diagnosis of acute rejection
-
Severity of biopsy proven acute rejection (BPAR) recorded by Banff criteria
-
The percentage of KTRs with BPAR in first 3 months and the first 12 months
-
The percentage of KTRs requiring TDAs to treat rejection within the first year
-
Complication rates after renal transplant biopsy
-
The percentage of KTRs with a donor-specific HLA antibody at the time of biopsy
Guideline 4.7 – KTR: treatment of acute rejection
Guideline 4.8 – KTR: treatment of acute rejection
Guideline 4.9 – KTR: treatment of acute rejection
Guideline 4.10 – KTR: treatment of acute rejection
Guideline 4.11.1 – KTR: treatment of acute rejection
Guideline 4.11.2 - KTR: treatment of acute rejection
Guideline 4.12 – KTR: treatment of acute rejection
Kidney Transplant Recipient (KTR): Chronic Allograft Injury (CAI) Guidelines 5.1-5.)
Guideline 5.1 – KTR: Diagnosis of Chronic Allograft Injury (CAI)
Guideline 5.2 – KTR: Detection of Chronic Allograft Injury (CAI)
Guideline 5.3 – KTR: Diagnosis of Chronic Allograft Injury (CAI)
Guideline 5.4 – KTR: Diagnosis of Chronic Allograft Injury (CAI)
Guideline 5.5 – KTR: Diagnosis of Chronic Allograft Injury (CAI)
-
Severity of CAI recorded by BANFF criteria
-
The percentage of KTRs with positive C4d staining on biopsy
-
The percentage of KTRs with a donor specific HLA antibody at the time of biopsy
Guideline 5.6 – KTR: treatment of chronic allograft injury
-
By withdrawal of calcineurin inhibitors (CNIs) if there is either histological evidence of CNI toxicity or non-specific interstitial fibrosis and tubular atrophy (2C)
-
By intensification of immunosuppression if there is evidence of ongoing immune injury (cellular rejection and/or humoral rejection) (2C)
Banff code | Descriptive term | Pathophysiology | Interpretation | Treatment |
---|---|---|---|---|
i | Interstitial inflammation | Infiltration of interstitium by mononuclear cells | Linked with cellular rejection but also viral infection | Intensification of immunosuppression –often pulsed intravenous steroids |
t | Tubulitis | Infiltration of renal tubules by mononuclear cells | Linked with cellular rejection but also viral infection | Intensification of immunosuppression –often pulsed intravenous steroids |
g | Glomerulitis | Margination of inflammatory leukocytes in the glomerular capillary loops | Marker of humeral rejection | Intensification of immunosuppression if not too much chronic damage |
v | Arterial inflammation | Inflammation of arterial wall with infiltration of mononuclear cells | Marker of either severe cellular rejection or humeral rejection | Intensification of immunosuppression ifnot too much chronic damage |
ptc | Peritubular capillaritis | Margination of inflammatory cells in the peritubular capillaries | Marker of humeral rejection | Intensification of immunosuppression if not too much chronic damage |
ci | Interstitial Fibrosis | Interstitial structure replaced by fibrosis | Marker of chronic damage | Poor prognostic sign – may prompt reduction in CNI |
ct | Tubular atrophy | Interstitial tubules involuted | Marker of chronic damage | Poor prognostic sign – may prompt reduction in CNI |
cg | Transplant glomerulopathy | Interposition of mesangium and thickening of GBM | Associated with proteinuria and development of DSAs – End lesion of CAMR | Poor prognosis – no known treatment but intensification of immunosuppression often practiced |
mm | Mesangial matrix expansion | Increase of thickness of mesangial matrix | Marker of microvascular damage to glomerulus | Usually interpreted in association with other findings |
cv | Arterial fibrointimal thickening | Expansion of intima between endothelium and media | Marker of chronic damage – non-specific | Poor prognostic sign – vascular protective measures |
ah | Arteriolar hyalinosis | Nodular deposition of hyaline | CNI toxicity but non-specific (e.g. HT, DM, lipids) | Reduction or withdrawal of CNI |
Guideline 5.7 – KTR: renal biopsy in chronic allograft injury
-
If there is a persistent unexplained elevation of creatinine or failure to return to baseline after an episode of biopsy proven acute rejection (BPAR) (1C)
-
Every 7–10 days during delayed graft function (DGF) (2C)
-
If expected renal function is not achieved within 4–8 weeks (2D)
-
If sustained new onset proteinuria develops (PCR >50 mg/mmol or ACR >35 mg/mmol) (2C)
-
The percentage of KTRs with positive C4d staining on biopsy
-
The percentage of KTRs with a donor specific HLA antibody at the time of biopsy
Kidney Transplant Recipient (KTR): cardiovascular disease and lifestyle (Guidelines 6.1-6.6)
Guideline 6.1– KTR: hypertension
-
Blood pressure should be recorded at each clinic visit (1C)
-
Clinic blood pressure should be <140/90 mmHg in clinic (130/80 mmHg if PCR >50 or ACR >35) (2C)
-
Home blood pressure recordings and 24-h ambulatory recordings may be helpful in some instances but lower BP targets should then be set (home and or ambulatory daytime measures <135/80 mmHg) (2D)
-
There is no evidence that any antihypertensive agent is better than any other and effort should be focused on achieving absolute levels rather than the use of individual agents (2D)
-
Inhibitors of the renin-angiotensin system may be more effective in the minimisation of proteinuria but they should be used with caution in the first 3 months post transplant (2C)
-
Resistant hypertension may be due to transplant renal artery stenosis and should be investigated according to local practice (2D)
-
The proportion of patients receiving a target blood pressure of 140/90 mmHg or 130/80 mmHg in the presence of proteinuria PCR > 100 or ACR > 70)
-
Proportion of patients with proteinuria assessed by dipstick and, if present, quantified at each clinic visit
Guideline 6.2 – KTR: dyslipidaemia
-
Fasting lipid levels should be measured on an annual basis in all renal transplant recipients (2C)
-
Treatment targets should be the same as in the general population (2C)
-
KTRs at increased primary or secondary CV risk receive statin therapy to reduce the risk of coronary artery disease (2C)
-
The choice and dose of statin should take into account concurrent immunosuppression. High dose simvastatin (≥40 mg daily) should be avoided in conjunction with ciclosporin and/calcium channel antagonists (2D)
-
Proportion of renal transplant patients with measure of lipids
-
Proportion of renal transplant patients taking statins for primary and secondary prevention of cardiovascular disease
-
Proportion of transplant patients receiving other lipid lowering treatments
-
Proportion of patients achieving dyslipidaemia targets
Guideline 6.3 – KTR: diabetes mellitus
-
Screening for the development of post transplant diabetes mellitus (PTDM) by dipstick urinalysis and measurement of blood sugar level at each clinic visit (2C)
-
Post transplant immunosuppression should take into account risk factors for the development of diabetes. (2C)
-
We recommend that diagnosis of PTDM is made based on WHO criteria for diagnosis of diabetes mellitus based on fasting or random blood, serum HBA1c or oral glucose tolerance testing (1C)
-
We suggest that a diagnosis of PTDM is made once patients are established on stable maintenance immunosuppression (2D)
-
We suggest that post-transplant diabetes should be managed in collaboration with specialists in diabetic medicine (2D)
-
All units should have a protocol for the management of post-transplant diabetes (2C)
-
KTR with diabetes (either prior to transplantation or PTDM) should undergo screening for diabetic complications (retinal screening, foot care, neuropathy) in line with guidelines for non KTR patients with diabetes (2D)
-
Incidence of post transplant diabetes mellitus (PTDM) at 3 months and at annual intervals thereafter
-
Proportion of patients who require insulin, and in whom remedial action is undertaken – minimisation of steroids and switching of CNIs
-
The proportion of patients with PTDM enrolled in screening for extra-renal complications of PTDM
Guideline 6.4 – KTR: ischaemic heart disease
-
We suggest that KTRs receive standard treatment for ischaemic heart disease including thrombolysis, revascularisation, and secondary prevention (2C)
-
Proportion of patients with ischaemic heart disease
-
Proportion of patients suffering myocardial infarction
-
Proportion of patients undergoing primary revascularisation
-
Proportion of patients receiving secondary prevention with a statin, anti-platelet agents and RAS blockers
Guideline 6.5 - KTR: smoking cessation
-
Proportion of KTRs who smoke
-
Proportion of cigarette smoking KTRs who have been given formal advice or offer help with cessation
Guideline 6.6 KTR: lifestyle measures
-
Maintenance of a healthy diet should be encouraged (2C)
-
An ideal weight should be targeted (body mass index (BMI) ≤25 kg/m2) (2C)
-
Weight management services should be available (2C)
-
We suggest that KTRs participate in physical activity at a level similar to that recommended to age and co-morbidity matched counterparts from the general population (2D)
-
Alcohol consumption should be within national guidelines (2D)
-
Recreational drug use should be avoided (2D)
-
The use of over-the-counter medications (without discussion with clinical staff) and non-proprietary medications (e.g. herbal medicines) should be discouraged (2D)
-
Proportion of patients who are obese
Kidney Transplant Recipient (KTR): neoplasia (Guidelines 7.1-7.3)
General concepts
Relative risk | KTR Common cancers |
---|---|
High RR >5 | Kaposi’s sarcoma |
Eye | |
Lymphoma | |
Kidney | |
Non-melanoma skin | |
Lip | |
Thyroid | |
Medium RR 1-5 | Melanoma |
Cervix | |
Vulvovaginal | |
Bladder | |
Colon | |
Lung | |
Stomach | |
Oesophagus | |
Oropharynx and Larynx | |
Myeloma | |
Anus | |
Leukaemia | |
Hepatobiliary | |
No increase | Breast |
Prostate | |
Ovary | |
Uterus | |
Pancreas | |
Brain | |
Testis |
Guideline 7.1 – KTR: screening for cancer
-
Screening should be similar to the general population for cervical, breast, colon and prostate cancer (2C)
-
Screening is not recommended for renal cell carcinoma (2C)
-
Patient education pre and post transplantation (1C)
-
Patients should be aware of malignancy risk and encouraged to report symptoms which may represent de novo malignancy (e.g. breast or testicular lumps) (2D)
-
Skin surveillance by a healthcare professional at least biannually up to 5 years post-transplant and annually from 5 years post-transplant (2C)
-
Patients with cirrhosis should undergo an annual hepatic ultrasound and determination of serum alpha feto-protein (2C)
-
Proportion of patients having screening procedures for neoplasia at the annual review clinic
Guideline 7.2 – KTR: Non-Melanoma Skin Cancer (NMSC)
Guideline 7.3 – KTR: Non-Melanoma Skin Cancer (NMSC)
Guideline 7.4 – KTR: Non-Melanoma Skin Cancer (NMSC)
Guideline 7.5 – KTR: Non-Melanoma Skin Cancer (NMSC)
Guideline 7.6 – KTR: Non-Melanoma Skin Cancer (NMSC)
Guideline 7.7 – KTR: immunosuppression in cancers
Guideline 7.8 – KTR: immunosuppression in cancers
Guideline 7.9 – KTR: immunosuppression in Kaposi’s sarcoma
Kidney Transplant Recipient (KTR): infection complications (Guidelines 8.1–8.7)
Guideline 8.1 – KTR: vaccination
Guideline 8.1.1 – KTR: vaccination
-
Should be vaccinated with inactivated viruses as per the normal population (1D)
-
Should receive annual influenza vaccination unless contraindicated (1C)
Guideline 8.1.2 – KTR: vaccination
-
Should have HBsAb levels rechecked annually and consider revaccination if antibody titres fall below 10mIU/ml (2D)
-
Should not receive live attenuated vaccines (2C)
-
Should receive pneumococcal vaccine and a booster every 5 years (2D)
Inactive Vaccine | Live Attenuated Vaccine |
---|---|
Inactivated Influenza | Varicella Zoster |
Hepatitis A | Mumps |
Hepatitis B | Rubella |
Inactivated Polio | Measles |
Diptheria | BCG |
Tetanus | Smallpox |
Meningococcal | Yellow Fever |
Pneumococcal | Oral Salmonella |
Human Papilloma Virus | Oral Polio |
Rabies | |
Anthrax | |
Intramuscular Salmonella | |
Japanese encephalitis | |
Inactivated intravenous cholera vaccine |
Guideline 8.2 – KTR: cytomegalovirus disease
Guideline 8.2.1 – KTR: prophylaxis and treatment of CMV disease
-
Prophylaxis should be continued for 3–6 months, until immunosuppression has been reduced to long-term maintenance level (1B)
-
Treatment should be administered for 6 weeks after treatment with a TDA (1C)
Guideline 8.2.2 – KTR: prophylaxis and treatment of CMV disease
-
All transplant units should have the ability to measure CMV serological status and the detection and quantification of viral load (2D)
-
Donor and recipient CMV sero-positivity should be recorded at the time of transplantation (2D)
-
A written protocolised strategy based either on prophylaxis, or pre-emptive therapy, or both should be implemented (2D)
-
For the treatment of mild and moderate CMV disease, oral valganciclovir and intravenous ganciclovir are of equivalent efficacy (2C)
-
Treatment of life-threatening CMV disease should be initiated with intravenous ganciclovir (2D)
-
Treatment duration should be determined by monitoring viral load (2C)
-
Incidence of CMV disease.
Guideline 8.3 – KTR: Epstein Barr virus infection
Guideline 8.3.1 – KTR: EBV infection
Guideline 8.3.2 – KTR: EBV infection
-
Both donor and recipient should have their EBV serology recorded at the time of transplantation (2D)
-
All high risk (D+/R-) patients (including adults) should have EBV viral load measured immediately after transplantation, monthly for 6 months, and 3 monthly to 1 year (2C)
-
EBV viral load should be monitored after the treatment of rejection (2C)
-
Total immunosuppression should be reduced when EBV titres rise significantly (2C)
-
Rates of EBV infection and PTLD amongst KTRs
-
Completeness of records for EBV donor and recipient serology
Guideline 8.4 – KTR: Varicella Zoster Virus infection
Guideline 8.4.1 – KTR: VZV infection
-
Primary infection (chickenpox) should be treated with intravenous aciclovir or oral valaciclovir until the lesions scab over (1C)
-
Uncomplicated shingles should be treated with oral acyclovir or valaciclovir until the lesions scab over (1D)
-
Disseminated (>2 dermatomes), ocular or invasive shingles should be treated with intravenous aciclovir until the lesions scab over, together with a reduction in immunosuppression (1B)
-
Varicella-susceptible KTRs (i.e. VZV IgG negative) with primary exposure to VZV should receive intravenous immunoglobulins, ideally within 96 h, but up to a maximum of 10 days following exposure. If unavailable or after 10 days, oral aciclovir should be administered for seven days (1D)
Guideline 8.4.2 – KTR: VZV infection
-
Patients on the waiting list who are VZV IgG seronegative should be vaccinated prior to transplantation (2D)
-
Immunosuppression should be reduced during primary infection (2D)
-
Annual rates of primary VZV and shingles infection
-
Completeness of records for VZV recipient serology in KTRs
Guideline 8.5 – KTR: Herpes Simplex Virus infection
Guideline 8.5.1 – KTR: HSV infection
-
Superficial HSV (1 or 2) infection should be treated with appropriate oral agents until the lesions have resolved (1D)
-
Systemic HSV infections should be treated with intravenous aciclovir and a reduction in immunosuppression until a response occurs and oral medication continued for at least 14 days (1C)
Guideline 8.5.2 – KTR: HSV infection
-
Rates and outcomes of HSV infections
Guideline 8.6 – KTR: BK nephropathy
Guideline 8.6.1 – KTR: BK nephropathy
Guideline 8.6.2 – KTR: BK nephropathy
-
Screening should also be carried out when renal function deteriorates in an unexplained fashion (2D)
-
KTRs should be screened for BKV viral load or by performing urine microscopy for decoy cells or by PCR on urine or serum (2C)
-
Suspected BK nephropathy should be confirmed by renal biopsy, which should be stained for SV40. Two cores containing medullary tissue should ideally be examined (2D)
-
Immunosuppression should be reduced when the serum BKV load exceeds 104 copies/ml (2C)
-
There is no established specific treatment for BK nephropathy (2D)
-
Re-transplantation can safely be considered in patients who have BK nephropathy diagnosed in an earlier graft (2C)
-
Rates of BK viral infection in screening tests
-
Rates and outcomes of BK nephropathy
Guideline 8.7 – KTR: pneumocystis jirovecii infection- treatment and prophylaxis
-
All patients with confirmation (microscopy or PCR) of Pneumocystis jirovecii in respiratory secretions should be treated for 14 to 21 days with co-trimoxazole orally or intravenously (15–20 mg/kg in three or four divided doses) (2B)
-
Patients with contraindications to treatment with co-trimoxazole should receive pentamidine (4 mg/kg/day intravenously) (2B)
-
Adjunctive glucocorticoid therapy may be considered in patients with severe disease (2D)
-
All patients should receive 3–6 months of treatment with co-trimoxazole 480 mg daily for Pneumocystis jirovecii prophylaxis following renal transplantation (1B)
Guideline 8.8 – KTR: post-transplant infection prophylaxis
-
All patients should receive 3–6 months of treatment with co-trimoxazole 480 mg daily (1B)
-
Oral antifungal prophylaxis should be administered for 1 week month after transplantation (2C)
-
In selected patients, prophylaxis against mycobacterium tuberculosis with daily isoniazid (supplemented with pyridoxine) should be instituted for 6 months after transplantation (2C)
Guideline 8.9 – KTR: Hepatitis E Virus
Kidney Transplant Recipient (KTR): bone and joint disease (Guidelines 9.1-8.7)
Guideline 9.1 KTR: osteoporosis
-
KTRs suffering from osteoporosis or at high potential risk should be considered for steroid-avoiding immunosuppression (2D)
-
KTRs on longterm steroids or at high risk for osteoporosis should undergo DEXA scanning if eGFR >30 ml/min/1.73 m2 (2D)
-
treatment should be according the RCP guidelines for steroid-induced osteoporosis (2D)
-
Prevalence of KTRs on corticosteroids
-
Frequency of bisphosponate usage amongst KTRs
-
Incidence of fractures amongst KTRs
Guideline 9.2 KTR: tertiary hyperparathyroidism
-
Severe hyperparathyroidism should be treated prior to transplantation (2D)
-
Cinacalcet can be used in KTRs (2C)
-
We suggest treatment should be the same as for other patients with CKD (2D)
-
Incidence of hyperparathyroidism
-
Incidence of parathyroidectomy
-
Usage of cinacalcet
Guideline 9.3 gout
Guideline 9.3.1 treatment of gout
Guideline 9.3.2 –KTR: treatment of gout
-
Hyperuricaemia should be treated when associated with gout, tophi or uric acid stones (2D)
-
Non steroidal anti-inflammatory drugs (NSAIDs) should be avoided in KTRs (2D)
-
Episodes of gout may be treated with brief courses of oral prednisolone (2D)
-
Colchicine is an effective treatment for gout in KTRs (2D)
-
Frequency of gout and hyperuricaemia amongst KTRs
Guideline 9.4 –KTR: calcineurin inhibitor bone pain
-
Reducing or withdrawing CNIs should be considered in KTRs with intractable bone pain (2D)
-
Dihydropyridine calcium antagonists also may be beneficial (2D)
Kidney Transplant Recipient (KTR): haematological complications (Guidelines 10.1–10.3)
Guideline 10.1 –KTR: anaemia
-
Prevalence of anaemia amongst KTRs
Guideline 10.2 – KTR: − polycythaemia
Guideline 10.3 – KTR: − polycythaemia
-
Haemoglobin levels should be monitored at every clinic visit (2D)
-
Treatment should be initiated if the haematocrit or packed cell volume exceeds 52% in men and 49% in women (2D)
-
Venesection may be used in refractory cases (2D)
-
Prevalence of post transplant erythrocytosis amongst KTRs
Kidney Transplant Recipient (KTR): reproductive issues (Guidelines 11.1-11.5)
Guideline 11.1 – KTR: conception and contraception (female)
Guideline 11.2 – KTR: conception and contraception (female)
-
KTRs should wait for 1 year after transplant and have stable function before attempting conception (2C)
-
Counselling regarding fertility and reproduction should be offered to female KTRs and their partners either prior to transplantation or soon afterwards (2D)
-
m-TORi should be stopped prior to conception and replaced as appropriate (2D)
-
Pregnancy should be managed jointly with an Obstetrics department with experience of care of KTRs (2D)
-
We suggest that KTRs receive aspirin 75 mg daily to reduce the risk of pre-eclampsia from 12 weeks gestation until birth of the baby unless there are contraindications (2C)
-
The risks and benefits of breastfeeding should be discussed (2D)
-
Contraception advice should be similar to the general population (2D)
Guideline 11.3 – KTR: conception and contraception (male)
-
Male KTRs are advised that MPA containing compounds have theoretical teratogenic potential in men taking these agents (1D)
-
KTRs should be advised that m-TORi reduce the male sperm count and counselled accordingly (1C)
Guideline 11.4 – KTR: conception and contraception (male)
-
All immunosuppressive drugs other than m-TORi can be used in male KTRs. Advice for MPA is as Guideline 11.3 (2D)
-
The decision to continue MPA containing compounds in a male KTR wishing to conceive should balance a the risk of theoretical teratogenicity against the risk of rejection on changing from MPA to azathioprine (2D)
-
Men on m-TORi who wish to conceive should discontinue these agents prior to conception and replace them as appropriate (2D)
-
Men who wish to maintain fertility should avoid m-TORi or bank sperm prior to starting these drugs (2D)
-
Pregnancy rates and outcomes should be monitored
Guideline 11.5 – KTR: sexual function
-
Men should be counselled about the possible risks of impotence following transplantation surgery that involves the internal iliac artery (2D)
-
Specific enquiry should be made regarding sexual dysfunction, preferably at an annual review clinic (2D)
-
Care pathways for dealing with sexual dysfunction should be established (2D)
-
Sildenafil is safe and effective in male KTRs not taking nitrates (2D)
-
Prevalence of sexual dysfunction in the transplant clinic