In Belfast the median length of stay for recipients is 9 days; most recipients from a living donor transplant go home 7 days after surgery. Patients are seen twice weekly at clinic for the first 6 weeks, then weekly for the next 6 weeks. Review interval gradually lengthens to a maximum of 4-6 months in those with stable long-term function.
There is a low threshold for re-admission to hospital in the early post-transplant period. The most common reasons are with infection, gastrointestinal symptoms, or following a rise in creatinine noted at out-patient clinic. We welcome discussion if there are concerns in primary care about any recent transplant patient. Options are contact via the renal transplant secretary (via Belfast City hospital switchboard 02890329241) who can then liaise with the particular consultant involved, or out of normal hours to contact the transplant ward (02895040719)
Standard immunosuppressive therapy initiated at the time of transplantation is with Prednisolone, Tacrolimus and Mycophenolate mofetil. This combination has been used in Belfast since 2002. Patients transplanted before this may be prescribed Azathioprine or Ciclosporin, and rarely Sirolimus is used. Ultimately patients end up on maintenance immunosuppression with monotherapy (Tacrolimus / ciclosporin), dual therapy, or triple therapy depending on their risk of rejection and how well they tolerate the different medications. The following points are the most salient:
- Brand prescribing: this is essential given the narrow therapeutic index for these medications. Too much and there is infection, too little and there is rejection. All patients (at time of writing in 2014) are discharged on Prograf (Tacrolimus) and Cellcept (mycophenolate mofetil). Some patients, usually for compliance reasons, will be switched to Advagraf which is a once daily preparation of Tacrolimus – mixing these up clearly is not good! Any switch in brand MUST be done in conjunction and under the supervision of the consultant nephrologist.
- Dose adjustment: in the first weeks and months after transplantation there will be frequent adjustments in doses of the immunosuppressive medications. Realistically the changes will be made more quickly than the letters detailing these changes will reach you. Although a hand-written script will be provided as often as possible, it is not infrequent for a patient to be telephoned in an evening after the clinic results are available and asked to make a dose adjustment. In the vast majority of cases the patients know what medications they are meant to be taking as they have several educational sessions about their drugs before discharge from hospital. In cases where there is uncertainty then dosset boxes, containing all medication except the Tacrolimus (which is likely to be changed more readily based on trough levels at clinic), are arranged.
- Supply of medication: clearly compliance with immunosuppressive medication is essential and patients cannot afford to miss any doses. All assistance for patients with supply and repeat prescription is very much appreciated.
- Monitoring: all patients will have full blood count, renal function and electrolytes, hepatic function, Tacrolimus trough levels and blood pressure checked at each clinic visit. The responsibility for safety monitoring is with the hospital as part of the shared care agreement. No additional testing is therefore required to be organised by the GP practice.
- Interactions: the most common error is co-prescription of clarithromycin or erythromycin without dose reduction in Tacrolimus. If possible, these antibiotics should be avoided but if there is no viable alternative then dose adjustment should be discussed with the transplant team (contact the Transplant secretary via Belfast City hospital switchboard 02890329241). The prescription of Allopurinol for someone taking Azathioprine (Imuran) may be tempting but is contraindicated unless there is dose reduction and careful monitoring are agreed with the hospital consultant.
Other medications commonly prescribed include co-trimoxazole for the first 6 months as PJP prophylaxis, monthly nebulised pentamide is arranged for those with allergy or intolerance to this. Valganciclovir is prescribed for those at high risk of CMV infection, but is dispensed by the renal pharmacists at Belfast City Hospital.