Purpose
Post-operative routines are focused upon close monitoring of the function of the transplanted kidney and close observation for complications or signs of rejection of the kidney. Your body sees the transplanted kidney as a foreign object and attempts to react against it as a natural response. The body does this by means of your immune system which forms antibodies or activates white blood cells against the kidney. This is called rejection. Medications called immunosuppressants are given to lessen the action of the immune system and to keep the body's natural defense mechanisms from attacking the foreign object, the transplanted kidney. When immunosuppressants are given, the body does not fight foreign tissue or harmful organisms as strongly.
Types of Rejection
There are several types of rejection. Hyperacute rejection occurs almost at the moment the kidney is attached to its blood supply. It becomes evident very quickly that there is no compatibility between the transplanted kidney and the recipient. When hyperacute rejection occurs, the kidney may be removed in the operating room. With current improved matching techniques, hyperacute rejection seldom occurs.
Accelerated acute rejection occurs within the first few days after surgery. With accelerated acute rejection, the kidney is usually lost to rejection and may never function. With the antibody screening technique, the frequency of accelerated acute rejection may be lessened, thus making it important for you to have the monthly antibody screens while you are waiting for a transplant.
Acute rejection usually is seen after the first week and can occur several months to years after the transplant. This type of rejection can be treated with medication. Chronic rejection can occur at any time, even years after the transplant, and results in slow loss of kidney function. Chronic rejection does not respond to medication.
It is not unusual for a person with a newly transplanted kidney to experience an episode of acute rejection. Close monitoring for signs of rejection allows for timely intervention and treatment of the rejection.
Signs of Rejection
Rejection can be detected by several means. Temperature, blood pressure, pulse, and respirations are measured routinely. Intake and output of fluids is measured daily. An elevated blood pressure, a fever, or a drop in urine output can be a sign that an episode of rejection is occurring. Weights are taken every day. An excessive weight gain can be a sign of an episode of rejection. Swelling and tenderness of the transplanted kidney may indicate that rejection is present. Blood samples are taken every day to follow the progress of kidney function. The level of creatinine in the blood tells us how well the kidney is working.
Laboratory Measurements
Creatinine is a by-product of normal muscle activity. When kidney function is normal, creatinine is removed from the body by the kidneys. When kidney function is not normal, the level of creatinine builds up in the blood because it is not being removed properly by the kidneys. After a transplant, a creatinine that approaches normal levels of 0.6 - 1.4 mgm% is an indication that kidney function is adequate. The BUN is also a measure of kidney function, but it is affected by changes in food intake and some medications so it is not as good of a marker of kidney function as is the creatinine level in the blood.
Each day someone will enter data on a flow sheet placed on your door. It will include temperature, blood pressure, intake and output, urine studies, blood studies, and medications taken. The data gathered together shows trends so that you will be able to follow the progress of the transplanted kidney.
A newly transplanted kidney may begin to function immediately, or may not function for some time. What happens as far as kidney function is concerned in the first few days after transplant has no direct bearing on how the kidney will work in the long run.
Ultrasound and Renal Scan
Sometimes the doctors will want to do an ultrasound and/or a renal scan. Both of these tests are done in the X-Ray Department. For an ultrasound, you lie on an exam table and the X-ray technician moves a special instrument over the skin over the kidney. This does not hurt. For a renal scan, you receive a special medicine in your vein and then lie on the scanner stretcher. The scanner picks up the special medication in the kidney and the bladder which shows up on an X-ray film. This does not hurt either.
Biopsy of the Transplanted Kidney
The most accurate way to tell whether or not rejection is present is to biopsy the kidney. This means that the doctor removes a small piece of the kidney with a special needle. If it is felt that a biopsy is necessary, it will be discussed with you at the time and you will be asked to sign a consent form like the form for transplant surgery. Most people dread the thought of a biopsy, but usually find that it is not as painful as expected. The information learned from a biopsy is very important in evaluating a problem with a kidney that is not working as well as expected. Biopsies are performed under local anesthetic in either the patient's room or the ultrasound room. Because a needle biopsy device is used, potential complications of bleeding and damage to adjacent organs are anticipated, but there is less than 1% risk of this happening.
Dialysis After Transplant
There is a possibility of needing dialysis after the transplant operation. There are two reasons for this. One reason is that the kidney may develop acute temporary changes between the time it is removed from the donor and transplanted to the recipient. This may be thought of as going into a state of "hibernation" and may take up to several weeks to resolve before the kidney "opens up" and begins to function. This condition is called acute tubular necrosis or ATN. If you have ATN, you will not receive some of your routine immunosuppressive medicines, cyclosporine (Sandimmune, Neoral) in particular, until the kidney begins to work well. You will receive a medicine called ATG instead. The other reason for dialysis is that during an episode of rejection, dialysis may be necessary to provide support while the kidney is not working. Dialysis is stopped when the kidney is working.
Diet
During the period of waiting for the kidney to function at a normal level, some diet restrictions of sodium, potassium, fluids, and protein may be necessary. When the kidney is functioning normally, these diet restrictions are usually lessened.
Medications
There are medicines that are given after a transplant for their immunosuppressive action. These medications will be taken for the life of the transplant. Their action is to suppress the natural body response of rejection of foreign tissue. Before your discharge from the hospital, you will be given a medicine card with your medicine instructions. You will also be taught about your medicines. The following is a brief description of the possible immunosuppressive medications you might be on:
Imuran works to prevent rejection by decreasing the white blood cell response. White blood cells are a natural body response to foreign tissue. The dose of azathioprine (Imuran) is adjusted according to weight and white blood count. Side effects of Imuran can include a white blood count that is too low and therefore makes the body less able to fight any infections. It can also cause temporary loss of hair, sores in the mouth, a tendency to bruise easily, nausea and vomiting, or hepatitis.
CellCept is similar to Imuran. Side effects may include abdominal pain, nausea, vomiting, diarrhea, and anemia.
Prednisone works to prevent rejection by reducing the body's natural inflammatory and allergic responses to foreign tissue. Prednisone is given initially at high doses. The dose is reduced over a period of several months to a maintenance level. During the time the prednisone dose is high, you are at a higher risk for infections such as colds, flu or other contagious diseases. This is not because you might "catch" something more easily, but because your body is less able to fight any infection once it is established.
Cyclosporine/Neoral acts upon the immune system by limiting the formation of cells which work against the kidney. Cyclosporine was released for general use in December 1983. Since its release, the percentage of kidney transplants that work has increased. It is in a liquid or capsule form. It can also be given through a vein.
FK506 is a more recent drug with side effects very similar to cyclosporine.
Side Effects of Prednisone
Prednisone, one of the steroid medications, has a number of side effects, some of which are more common than others. One person would not be expected to experience all of the side effects, but you should be aware of what they are. Side effects tend to occur more often if someone needs to receive large doses of steroids to treat rejection. The list of possible side effects include:
Prednisone is a medication which replaces and suppresses hormones made by the adrenal gland in the body. If prednisone needs to be discontinued, the dose should be gradually reduced and never suddenly stopped. Gradual tapering of the dose allows the balance between natural body production of adrenal gland hormones and prednisone taken as a medicine to be maintained and avoids any sudden shift in the level of steroids in the body. Sudden shifts in the steroid level can be dangerous.
Side Effects of Cyclosporine
The following is a list of possible side effects of cyclosporine. The UTMB Transplant Service utilizes the lowest dose possible that will give the needed immunosuppression. The side effects, when they do occur, are usually seen early after the transplant and tend to get better as the dose is decreased. One person would not be expected to have all of them, but you should be aware of what they are.
Treating Rejection
A large dose of the intravenous (IV) steroid drug called SoluMedrol is usually the first medication used to treat acute rejection when it occurs. Symptoms of acute rejection may be:
When the symptoms occur, a course of treatment of intravenous (IV) steroids given through the vein for several days may be used. This often is enough to reverse the rejection. The high doses of the steroids might make you have nightmares, have difficulty concentrating, or feel excessively restless, irritable, or emotional. If these symptoms should occur when you are receiving high doses of steroids, they will get better when the high doses are stopped.
Other medications which may be used to treat rejection are ATG, OKT3, FK506, and CellCept. These are given daily for 7 to 14 days. ATG and OKT3 are both given intravenously (IV). These medications can cause fever, chills, or joint pains. These symptoms tend to be worse with the first dose. FK506 and CellCept are oral medications and may be given instead of CSA and/or Imuran.
In spite of careful observation and treatment, some kidneys do not ever function well. The reason for careful monitoring of kidney function and the early recognition and treatment of acute rejection is to promote kidney function and to have the best possible transplant outcome. However, treatment of acute rejection is not continued to a point at which treatment is making you sicker than the rejection itself.
If the transplant is rejected, after a period of time for recovery, another transplant is usually possible. It is not necessary to remove a rejected transplanted kidney unless it is making you ill.
Monitoring for Infection
The careful monitoring while you are in the hospital is also to watch for any signs and symptoms of infection. Infection is the most common complication of a transplant. What is usually a mild infection to someone without a transplant may be overwhelming and life-threatening to a person with a transplant. The danger of infection is somewhat lessened when the dose of immunosuppression is lowered to the maintenance levels. However, as long as you take immunosuppressants, you must be alert for signs and symptoms of infection. Call your local doctor or the transplant center promptly if you think you have an infection. Some signs of infection are:
