1. THE FIRST THREE MONTHS

2.  UTI in 40 to 70% of transplant patients within first 3 months  Increased risk of Klebsiella, enterococcus, pseudomonas  Gram positive organisms up to 40%  Prophylaxis of little benefit  15% of transplant recipients have reflux  Increased risk of pyelonephritis with or without reflux  Aggressive monitoring of U/A, C&S  Minimum 2 week course of treatment

3.  Hospital outpatient POD 2-4  Weekly clinic visit for 6 weeks  Biweekly clinic visit for 6 weeks  Routine visit labs: CBC, CMP, Mg, PO4, Prograf level, U/A

4.  Assessment of renal function  Assessment of patient understanding of medical regimen  Assessment of drug level  Assessment of drug toxicity  Assessment of UTI  Assessment of transplant site  Assessment of volume status  Assessment of blood glucose  Assessment of Mg, PO4  Assessment of serum K  Assessment of blood pressure  Assessment of everything else

5.  Volume depletion ( approx. 10% with Na wasting)  Calcineurin inhibitor toxicity  Acute cellular mediated rejection (highest risk within first 3 months)  3-7% incidence  Delayed appearing antibody mediated rejection  Acute tubular necrosis  Urine leak/urinoma (with or without obstruction)  Obstruction (hematoma, distal ureteral stricture. Prostate dz.)  Neurogenic bladder  Thrombotic microangiopathy related to calcineurin inhibitor  Drugs (NSAID’s, ACEI, ARB, contrast, AIN)  Recurrence of original disease  Post transplant lymphoproliferative disease (we actually had one at 2 months

6.  Calcineurin inhibitor history (drug level may be artificially low if not a true trough)  Drug intake history  Ultrasound  Renal Scan  Polyoma virus titers  Biopsy

7.  Make sure a true trough  Drugs that increase levels  Calcium channel blockers  Ketoconazole, fluconazole, itraconazole  Erythromycin  HAART drugs  Metoclopramide  Grapefruit juice  Make sure patient taking right dose 

8.  Rifampin, rifabutin  Barbiturates  Phenytoin  Carbamazepine  Not a true trough  Quit taking fluconazole  Severe gastroparesis

9.  Hair loss  Headache  Memory changes  Tremors  Nausea  Elevated Cr  Type IV RTA  Hypomagnesemia  Hypophosphatemia

10.  Neutropenia  Anemia  Thrombocytopenia  Nausea, vomiting  Diarrhea

11.  Hyperglycemia  Myopathy  Weight gain  Hypertension  Avascular necrosis

12.  Calcineurin inhibitor  Type IV RTA (obstruction, CNI, post transplant tubulopathy)  Renal insufficiency  TMP/SMX  Diet  Other meds

13.  40-60% of post transplant patients with HTN (seems like 90% in our population)  Steroids  Calcineurin inhibitor ( Na retention, renal and peripheral vasoconstriction)  Improved diet, increased Na intake  Renal insufficiency

14.  Mycophenelate mofetil  Azathioprine  CMV disease  TMP/SMX  Other viral infections  Valcyte

16.  Renal insufficiency  Gastrointestinal blood loss  Menorrhagia  Mycophenelate mofetil  B12 deficiency  Hypothyroidism  Folate deficiency  Iron deficiency  Parvovirus B19  Thrombotic microangiopathy

17.  Exacerbation of Hepatitis C  CMV  Drugs (fluconazole, MMF,Valcyte, other)  Proton pump inhibitors  Angiotensin receptor blockers

18.  Routine labs  CMV PCR  BK PCR  EBV PCR  Lipid panel  Parathyroid hormone  Vitamin D studies  D/C Valcyte if CMV D+/- R+  D/C Acyclovir if CMV D-/R-  D/C fluconazole  Adjust CNI upwards

19. PAN T CELL DEPLETING ANTIBODIES Alemtuzumab Thymoglobulin B CELL DEPLETING ANTIBODIES Rituximab NON DEPLETING ANTIBODIES Basiliximab Daclizumab COSTIMULATION BLOCKADE Belatacept

20.  Solumedrol 500mg IV in OR  250mg IV POD 1  100 mgIV POD2  Prednisone 50 mg po POD3  20mg po POD4 – 7  Thymoglobulin 1.5mg/kg IV in OR before revascularization  1.5 mg/kg IV POD 1-6 depending on graft function ( 3 doses for IGF, 5 doses for SGF, 7 doses for DGF)  Mycophenelate mofetil 500mg po bid (target 1000mg bid)

21.  Prednisone 15 mg po POD 7-14  10 mg po POD14-30  5mg po POD 31, thereafter  Tacrolimus 0.05 mg/kg every 12 hours starting POD3 or when Thymoglobulin complete. Target blood level 8-10.  Mycophenelate mofetil 1000mg po every 12 hours.

22.  Renal dysfunction requiring dialysis  Differential Diagnosis  Acute tubular necrosis  Technical issues (urine leak, vascular thromboses from anastamotic misadventures, etc…)  Antibody mediated rejection, cellular rejection (rare)  Cortical necrosis

23.  Transplant ultrasound with doppler interrogation Exclude obstruction, assess for urine leak Doppler’s assess flow, resistive indices Renal Scan Assess radioisotope uptake and excretion Good uptake, no excretion….ATN Delayed uptake, no excretion…Rejection, Severe ATN Percutaneous transplant renal biopsy

24.  <30% decline of Cr over 3 days  Differential diagnosis and evaluation basically the same as delayed graft function

25.  Mid 1990’s, infections exceeded rejection as leading cause for hospital readmission.  Transplant recipients at increased risk for post- operative bacterial infections  Lymphocyte depleting induction regimens increased dramatically risk of CMV  Though uncommon, pneumocystis, other fungal infections potentially catastrophic

26.  30-60% risk of infection/disease within first 3 months if no prophylaxis  Valcyte 450mg qod to daily for D+/R- for 6 months  Valcyte 450mg qod to daily for D+/- to R+ for 3 months  Acyclovir 400mg tid for D-/R- for 3 months  If R+ gets infected, 30% comes from recipient, 70% comes from donor  Valcyte qod dosing for GFR 30

27.  58%Reduction in CMV disease  39% Reduction in CMV infection  37% Reduction in all cause mortality  Decreased risk of herpes simplex, herpes zoster, bacterial infection and protozoal infections  RR 1.6 for acute rejection with CMV infection  RR2.5 for acute rejection with CMV disease  OR 1.5 for arrythmia, CHF, coronary occlusion with CMV disease  OR 4.0 for post transplant diabetes with CMV infection

28.  Low risk of fungal infection within first 3 months  Candida, Histoplasmosis, Aspergillosis, Toxoplasmosis most common in this area  Fluconazole 100mg daily until GFR>30, then 200mg daily  Give for 3 months  Adjust calcineurin inhibitor with discontinuation  Some centers do not provide

29.  Low risk  TMP/SMX SS daily for 6 months, then Tu/Th until 1 year  Dapsone 25mg daily for one year if sulfa allergic