Paediatric renal transplantation protocol

Publication: 04/03/2021  --
Last review: 01/01/1900  
Next review: 04/03/2024  
Clinical Guideline
CURRENT 
ID: 6880 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Paediatric renal transplantation protocol


Summary of guideline

This guideline has been developed for the multi-professional team to provide a safe and consistent approach to managing children and young people undergoing a renal transplant in the paediatric nephrology service

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Aims and objectives

Provide practical and easy to follow information for preparing patients for renal transplantation, intraoperative management and delivering consistent care in the immediate post-transplant period.

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Admission for transplant

All patients admitted for a renal transplant will need to be assessed and have investigations as outlined below:

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Clinical assessment

Full medical history including a full list of all current medications and allergy status

Specifically record recent illnesses, recent contact with infectious diseases, recent immunisations, native kidney function i.e. 24 hour urinary output, history of urinary tract infections, type of dialysis (if any)

Full examination including blood pressure (BP), examination of ears, nose and throat, as well as examination of the peritoneal dialysis (PD) catheter exit site and the exit site for any central venous lines looking specifically for infection

All children must have their height and weight documented in the clinical notes and entered into eMeds. Whilst eMeds uses and displays the surface area calculated using the Boyd formula; the renal transplant protocols built in eMeds use the preferred Mostellar formula (see below) to calculate the surface area and then drug doses. It is therefore essential to use the protocols when prescribing transplant medication.

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Investigations

Blood tests
To make the process easier “transplant packs” containing the necessary blood forms and bottles are prepared and stored on the renal ward (see below). Ensure that bottles are in date, particularly for transplant cross match samples.

The required forms can be printed using the quick tab “admission for renal transplant” on the paediatric nephrology requests page on ICE.

  1. FBC, coagulation screen


  2. Urea and electrolytes, calcium, magnesium, phosphate, bicarbonate, chloride, glucose and liver function tests



  3. Cross match 3 units of packed red cells



  4. HIV screen, Hepatitis B surface antigen, Hepatitis B core antibody, Hepatitis C screen


  5. Repeat serology only if previously seronegative and not done in the last month: CMV IgG, EBV IgG, HSV IgG, Toxoplasma serology (IgG), Syphilis serology, Human T-cell lymphotrophic virus (HTLV) antibodies



  6. Cross match bloods for tissue typing (not necessary for living related donor transplants as full investigations will have been performed prior to admission, according to the Transplant Immunology Laboratory Live Donor Protocol)

    Cross match blood for tissue typing should be sent urgently by taxi authorised by the site matron to Ward J49, Male Renal Unit, 1st Floor, Lincoln Wing, SJUH.

    Blood tubes for these tests will be in the transplant pack which can be found on the renal ward (speak to the nursing staff)

Other tests

  1. Urine dipstick and urine culture (if passing urine)
  2. Urine protein creatinine ratio (if passing urine)
  3. Chest radiograph if clinically indicated based on history and clinical assessment
  4. ECG
  5. Echocardiogram (if not done in the last 12 months, repeat requested by anaesthetist, severe hypertension or if there are concerns about cardiac function)
  6. Urgent PD fluid cell count, Gram stain and culture (if on PD)

The results of all investigations must be reviewed and discussed with the paediatric renal consultant on-call.

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Medications

Prescribe intraoperative and postoperative medication on the eMeds system and post-operative fluids on paper infusion charts before the patient goes to theatre (see medication and postoperative management below).

There are protocols on eMeds that must be used for prescribing transplant medication. The exact regime will be guided by the paediatric renal consultant on-call so please discuss.

The patient may not require many of their usual medication. Specific guidance for each medication will be provided by the paediatric renal consultant on-call.

The patient should be advised to stay on their usual fluid target/restriction either orally or intravenously depending on fasting instructions from the anaesthetist. Standard guidance for fasting is 6 hours for solids and 1 hour for clear fluid.

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Additional requirements

  1. Provide paediatric high dependency unit (HDU) with the patient’s details and inform them that the patient will require admission post operatively

  2. The transplant surgical team will enter the patient’s details on the appropriate theatre list and inform the theatre charge nurse and the paediatric anaesthetist on-call. Consent and skin marking will be performed by the transplant surgical team.

  3. A compatible crossmatch report (full or virtual crossmatch) must be received from the Transplant Immunology laboratory prior to commencement of transplantation surgery, for both living and deceased donor transplantation

Intra-operative medication

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Induction immunosuppression

Steroids
Intravenous Methylprednisolone should be administered intra-operatively:

Methylprednisolone 600mg/m2 (maximum 500 mg)

Basiliximab
Basiliximab is a monoclonal antibody used as induction immunosuppression in paediatric renal transplantation

The first dose should be given intra-operatively and the second dose on day 4 post transplant by intravenous injection

If patient <35kg, dose = 10mg
If patient >35kg, dose = 20mg

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Antibiotics

A single dose of intravenous Co-amoxiclav 30 mg/kg (max 1200mg) should be given after induction of anaesthesia.

If true penicillin allergy then replace with single doses of intravenous Ciprofloxacin 10 mg/kg (max 400mg) and Teicoplanin 10 mg/kg (max 400mg)

Post-operative medication

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Maintenance immunosuppression (for summary see appendix 1)

Immunosuppression regimes will be based on the clinical background of each patient (see table below). There may be specific regimes required for some patients so discuss with the paediatric nephrologist on-call prior to completing the eMeds prescription.

 

A
First transplant
(unless otherwise stated)

B
Highly sensitised or
second transplant

C
Early steroid withdrawal

Induction immunosuppression
(see above)

Methyl prednisolone
Basiliximab

Maintenance immunosuppression

Tacrolimus
Prednisolone
Azathioprine

Tacrolimus
Prednisolone
Mycophenolate Mofetil

Tacrolimus
Prednisolone (stops on day 4)
Mycophenolate Mofetil

Steroids
For postoperative steroids give oral Prednisolone or equivalent intravenous methylprednisolone as a single dose in the morning (5mg oral prednisolone = 4mg methylprednisolone)

Type A and B transplants:

Day 0

IV Methylprednisolone (given intra-operatively)

Day 1-2: 60 mg/m2 orally once daily (maximum 60 mg)
Day 3-7: 40 mg/m2 orally once daily (maximum 40 mg)
Day 8-14: 30 mg/m2 orally once daily (maximum 30 mg)
Day 15 –21: 20 mg/m2 orally once daily (maximum 20 mg)
Day 22 – 28: 10 mg/m2 orally once daily (maximum 10 mg)
Day 29-90: 10 mg/m2 orally on alternate days (max 10 mg)
Day 91 onwards 5 mg/m2 orally on alternate days (max 5 mg)

Type C transplants:

 

Day 0:

IV Methylprednisolone (given intra-operatively)
Day 1: 60mg/m2 orally (max 60mg)
Day 2: 40mg/m2 orally (max 40mg)
Day 3: 30mg/m2 orally (max 30mg)
Day 4: 20mg/m2 orally (max 20mg) and then stop

Azathioprine
Used for patients receiving a first kidney transplant (Type A). The initial dose should be given within 12 hours post-transplant.

2 mg/kg/day       orally/IV once daily (adjusted for leukopenia)

The dose should be rounded to the nearest tablet size (25mg and 50mg tablets)

Unless the patient is unable to tolerate enteral medication azathioprine should be given orally. If intravenous azathioprine is required it will be made by pharmacy aseptics in normal working hours (if it is anticipated that intravenous azathioprine will be needed out of hours, please inform the ward pharmacist as soon as possible to plan ahead).

Tacrolimus (Adoport or Modigraf)
The initial dose should be given within 12 hours post-transplant. All prescriptions for tacrolimus must include the brand name due to varying bioavailability of the different brands.

Weight <40kg: 150 micrograms/kg (max 5mg) orally twice daily
Weight > 40kg: 100 micrograms/kg (max 5mg) orally twice daily

For children that can swallow tablets use Adoport and round up the dose to the nearest capsule size (500 microgram or 1mg capsules). For children who are unable to swallow tablets use Modigraf granules which can be dissolved in water. Modigraf comes in 0.2mg and 1mg sachets so round up the dose to the nearest 0.2 mg. To dissolve Modigraf use 2mL water for each 1mg of Modigraf, administer the dose then rinse out the cup with the same volume of water and give this as well.

Subsequent dosing is based on 12 hour trough levels aiming for the following levels:

Time post-transplant

Tacrolimus level (µg/l)

0 - 2 months

8 - 12

3 - 12 months

5 - 8

> 12 months

individualise

Tacrolimus should be given at the same time each day (e.g. 8am and 8pm) particularly for school-age children. Tacrolimus should be given on an empty stomach (do not feed 1 hour pre and 1 hour post tacrolimus administration). Ideally do not give via feeding tube (adheres to tubing) however in some children it can be given via a gastrostomy if this is consistently used as the route of administration.

Mycophenolate mofetil
Used as an alternative to azathioprine for highly sensitised patients, recipients of second transplants or those on an early steroid withdrawal regime. The initial dose should be given within 12 hours post transplantation.

Type B transplants

300 mg/m2 (max 500mg per dose) orally twice daily

Type C transplants

Day 0-14 600mg/ m2 (max 1 g per dose) orally twice daily
Day 15 onward 300 mg/m2 (max 1 g per dose) orally twice daily

If the child can take tablets the dose should be rounded to the nearest tablet size. Mycophenolate mofetil is available as 250mg capsules, 500mg tablets or as an oral suspension (1 gram/5ml)

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Antimicrobials

Antifungal prophylaxis
Prophylaxis for fungal infections is with the use of nystatin.

Nystatin 100,000 units orally four times daily for 3 weeks post-transplant

With significant immunosuppression (e.g. plasma exchange) the on-call paediatric nephrologist may choose to treat with oral fluconazole instead which should be given for at least 3 weeks.

Fluconazole 3mg/kg once daily (max dose 200 mg)

Fluconazole interacts with tacrolimus so tacrolimus levels will need to be monitored closely especially when starting and stopping fluconazole.

Pneumocystis
Pneumocystis Jiroveci is an opportunistic pathogen in immunosuppressed patients. Renal transplant patients should receive prophylaxis as below for 6 months post-transplant.

Co-trimoxazole 240mg once daily < 6 years of age
Co-trimoxazole 480mg once daily 6 years of age and above

The dose may need to be reviewed if there is delayed graft function. Co-trimoxazole is available in 480 mg tablets and two suspensions of 240mg/5mL and 480 mg/5mL

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Anticoagulation

Low molecular weight heparin (LMWH)
Graft thrombosis is an important complication in renal transplant recipients. Following discussion with transplant surgeons patients should receive prophylactic LMWH for up to 1 week or until they are fully ambulant.

Enoxaparin 0.5 mg/kg subcutaneously twice daily (maximum 20 mg twice daily)

Doses should be rounded for ease of administration. If the estimated glomerular filtration rate (eGFR)* is <30ml/min/1.73m2 enoxaparin should be administered once daily rather than twice daily.

*eGFR is calculated using the Schwartz formula: eGFR (mL/min/1.73 m2) = [36.5 × height (cm)]/creatinine (micromol/L)

Unfractionated Heparin
The anticoagulant effects of LMWH are difficult to reverse so it may be unsuitable in patients where there is a significant risk of bleeding in the post-transplant period. These patients will be identified by the renal transplant surgeon and should receive prophylaxis with unfractionated heparin, which can be reversed more readily if required.

For prophylactic use of unfractionated heparin in this situation a bolus dose at initiation of therapy is not required. The infusion should be started as below following request from the renal transplant surgeons. Check the APTT four hours after starting the infusion to ensure levels are not unexpectedly high and again if there are clinical concerns but regular monitoring and targeting of APTT is not required when using unfractionated heparin in this context.

Unfractionated heparin 10 Units/kg/hour as a continuous infusion

If unfractionated heparin is used, try and administer it via a peripheral cannula so the central line can be used for sampling and APTT monitoring if there are concerns about over anticoagulation. If using the central line for APTT monitoring check there is no heparin in the sampling line (including Heplock).

To reverse the anticoagulant effects of unfractionated Heparin stop the infusion and consider using protamine sulphate. For more detailed information on the use and reversal of unfractionated heparin see “Guideline for the use of anti-thrombotic treatment in children” available on Leeds Health Pathway (LHP).

Any complex anticoagulation issues should be discussed with the paediatric haematologist on a case by case basis.

Aspirin
When the patient is mobile they should be switched from LMWH to Aspirin which is usually continued for 3 months post transplantation

Weight 10 - 25kg Aspirin 37.5mg once daily
Weight >25 kg Aspirin 75 mg once daily

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CMV prophylaxis

Valganciclovir is used as prophylaxis for CMV infection. Valganciclovir is mandatory for all patients where the donor is CMV IgG positive and the recipient is CMV IgG negative. Valganciclovir should be commenced between day 5-10 post-transplant and continued for 3 months.

Oral Valganciclovir is given once daily and the dosing is calculated using the following formula:

Valganciclovir (mg) = 7 × Body surface area × eGFR* (maximum 900mg once daily)
(Maximum eGFR for above formula is 75ml/min/1.73m2)  

*eGFR is calculated using the Schwartz formula:   eGFR (mL/min/1.73 m2) = [36.5 × height (cm)]/creatinine (micromol/L)

The commercially available valganciclovir preparations are 450mg tablets and a 50mg/mL oral solution. The dose should only be rounded down by a maximum of 10% to facilitate the use of the tablet form of the medication or a sensible volume e.g. in multiples of 25mg for liquid doses.

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Additional medication

Lansoprazole is available as dispersible tablets or capsules and used for gastric prophylaxis.

Children 10 - <15 kg 7.5 mg once daily
Children 15 - 30 kg 15 mg once daily
Children >30 kg 15-30 mg once daily

Prophylaxis can be stopped at 1 month. In the early steroid withdrawal group (Type C transplants) prophylaxis with lansoprazole can be stopped one week post-transplant.

Anaesthetic management

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Pre-operative considerations (in addition to usual pre-operative assessment)

  • What is the cause of renal failure? Are there co-morbidities? The patient may be small for age/have features of a syndrome associated with chronic renal failure
  • Is the patient on dialysis (haemodialysis/peritoneal dialysis)? When was the last session - if recently the patient may be intravascularly dry, if not the patient may be hyperkalaemic
  • What is the patient’s optimal weight? Is there a native urine output? Does the patient have a fluid restriction?
  • The patient may be hypertensive and on treatment. Are there any cardiac concerns? The patients have usually had an echocardiogram within the last 12 months and ECG on admission
  • Patient may have an arterio-venous (AV) fistula. If so use the other limb for access and plan to protect the fistula peri-operatively.
  • Check the recent bloods (Full blood count, clotting, electrolytes). Cross match of 3 units of packed red cells should have been requested
  • If a pre-medication is required use Midazolam 0.5mg/kg orally (maximum 15 mg). Ensure this is prescribed and ordered as soon as possible from pharmacy as it has a short shelf life, is not routinely kept on the renal ward and unavailability could delay the transplant

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Monitoring / access

  • IV access - establish at least two reliable large bore cannulae to give fluid including blood
  • Central venous line (CVL)

    Central access can be difficult (multiple previous lines in the past with scars on both sides of the neck). The patient may have had neck vessel imaging which may be helpful to review.

    Ideally a triple lumen line should be sited and is usually reserved for intra-operative central venous pressure (CVP) monitoring. Whenever possible the line position should be confirmed in theatre via image intensifier prior to starting the case as manipulation if inappropriately positioned could require a return to theatre.

    Some patients have dialysis lines in situ. Anaesthetists are strongly advised to avoid using the dialysis line. Infection or blockage can be life threatening on the rare occasion where the line is required for dialysis post-transplant.

    If the risks and consequences of attempting to insert another central line, or working without a central line outweigh the risks of using the dialysis line then the dialysis line can be used. Dialysis lines are locked with concentrated heparin and this MUST BE ASPIRATED prior to any use of the line.
  • Arterial lines are not always required. If needed avoid the femoral artery and non-dominant arm so those vessels are preserved for future AV fistulae
  • Urinary catheter - usually inserted by the surgeon
  • Nasogastric tube (leave in post operatively unless patient has gastrostomy) and oropharyngeal temperature probe. Use a warming mattress underneath and Bair hugger on top (patients are at particular risk of cooling because of their fragile pre-operative condition.

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Induction of anaesthesia

  • Anaesthetic agents, muscle relaxants and anti-emetics as routine
    The patient may require a smaller than usual endotracheal tube for intubation
  • Analgesia
    • Intravenous Paracetamol 15 mg/kg
    • Intravenous Morphine 0.1-0.3 mg/kg
  • Drugs from a transplant perspective (will be prescribed on eMeds by the renal team)
    • Intravenous Co-Amoxiclav 30 mg/kg (max 1200 mg) unless allergic (see page 4)
    • Intravenous Methyl prednisolone 600 mg/m2 (max 500 mg)
    • Intravenous Basiliximab (If patient <35kg, dose = 10mg If patient >35kg, dose = 20mg)

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Fluids

The patient is about to receive a kidney which is likely to be large for their body which will drop their systemic vascular resistance so be generous with fluid. The patient may be relatively under filled if dialysed that morning.

It is sensible to do a blood gas at the beginning of the case to assess acidosis and potassium levels to inform the decision on which type of fluid to use. Further potassium monitoring will be required with the use of Hartmann’s solution (contains 5mmol/L of potassium).

Aim for a CVP >10 cm of H2O. Monitor blood gases and if good oxygenation with normal ventilation in 30% inspired oxygen and the CVP has not increased significantly then overfilling is unlikely. Total volumes infused may exceed 100ml/kg

After implantation of the kidney, release of clamps and reperfusion of the donor kidney the patient may become tachycardic and hypotensive with a drop in CVP. Some of this will be due to reperfusion injury but also the physical act of filling the kidney. Inspect the kidney along with the surgeon and ask if it looks full and also if there is urine in the ureter as these are signs of good filling. Continue to give fluid at this point, reducing to more normal volumes when everything is looking good.

Dopamine is no longer used routinely post renal transplant but may be considered by the anaesthetist and renal transplant surgeon in patients who despite being adequately filled continue to have a suboptimal blood pressure.

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Additional medication

Additional drugs given during implantation of the kidney as the surgeon starts the venous anastomosis

  • Intravenous Mannitol 0.5g/kg given over 20 minutes

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Post operatively

Routinely give oxygen using a Hudson mask

Analgesia

  • Paracetamol 15mg/kg IV or 20mg/kg orally four times day, note time any doses given pre- or intra-operatively
  • Morphine infusion or patient controlled analgesia (PCA)
  • No contraindication to transversus abdominis plane (TAP) blocks or wound infusion catheters

Ensure fluids are running in recovery. If the patient appears under filled in recovery and they can tolerate more fluid consider giving a fluid bolus. This may be particularly relevant in patients who have received a living related kidney. The combination of Mannitol in theatre plus a well functioning new kidney can result in very high volumes of urine as the patient is waking up. Commence fluid as per renal protocol (see below). If the patient has good respiratory effort and is cardiovascularly stable it may be more practical to transfer the patient directly to HDU where the facilities for CVP monitoring etc. will be ready.

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Post-transplant

All patients will go to paediatric HDU (or paediatric intensive care (PICU) if unwell/deemed necessary by the paediatric anaesthetist) for at least 48 hours post operatively. All patients will have a urinary catheter, central venous line, wound drains and appropriate analgesia (e.g. PCA) commenced in theatre.

All patients should be reviewed by the ST4-8 on arrival in HDU and then discussed with the paediatric nephrologist on call.

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Monitoring

  1. In the immediate post-transplant period monitor:
    1. Daily weight (once practical to do so)
    2. Blood pressure hourly for the first 24-48 hours (unless arterial line in in situ)
    3. CVP for first 24-48 hours
    4. Urine output - hourly
  2. Imaging
    1. Chest radiograph - to check position of CVL (if not already done in theatre)
    2. Ultrasound scan (USS) of renal transplant in the first 24 hours to assess perfusion
  3. Bloods
    1. FBC, coagulation U&E, bicarbonate, calcium, phosphate, albumin, magnesium, LFTs and glucose should be done immediately post-transplant
    2. Monitor U&E, bicarbonate, calcium, phosphate, albumin, magnesium and glucose 4-6 hourly for at least 24-48 hours
    3. Reduce testing to 12 hourly when things are stable and continue for first 3 days. Renal function can then be checked daily dependent on graft function
    4. Monitor FBC 12 hourly for the first 24 hours and then monitor daily
    5. Tacrolimus levels daily ( 12 hour trough level)
    6. Monitor APTT as per table on page 7 if on unfractionated heparin
  4. Urine
    1. Daily urine dipstick until discharged
    2. Urine protein:creatinine ratio as clinically indicated
  5. Wound drain losses
    1. If drain losses are over 100 ml/hour for 2 consecutive hours contact the transplant surgeon

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Fluids and urine output

The main goal of fluid management is to maintain the patient in a relatively volume loaded state, with an adequate blood pressure to ensure good perfusion of the transplant kidney and to encourage primary graft function:

  1. Once the patient is in recovery intravenous fluids should be commenced immediately to maintain a volume loaded state. Intravenous fluids should be administered as
    1. insensible losses administered at a set hourly rate for at least the first 48 hours (400ml/m2/day or 17ml/m2/hour)
    2. replacement of urine output (ml for ml) every hour

Use alternate bags of 0.45% sodium chloride with 2.5% glucose (500mL) and 0.9% sodium chloride depending on serum sodium and blood glucose.

In very polyuric patients urine replacement may need to be increased to half hourly to prevent falling behind with fluid balance

  1. Aim to maintain central venous pressure (CVP) at 8-10cm of H2O for the first 24-48 hours*
  2. Aim for a minimum systolic blood pressure of 100-110mmHg*
  3. Aim for a minimum urine output of 2-4ml/kg/hour*
  4. Fluids - be generous with fluid administration. Use clinical assessment plus monitoring (low CVP, low blood pressure, low urine output) to anticipate hypovolaemia and if there are concerns administer

    0.9% Sodium Chloride 10ml/kg bolus

    OR

    4.5% (or 5%) Human Albumin Solution (HAS) at 5-10mL/kg (maximum 500ml per bolus)

    OR

    Packed red cells if the haemoglobin is less than 70g/L (discuss with consultant first)

Oligoanuria is usually because the child is under filled so do not be afraid to give large volumes of fluid. Administer repeat fluid boluses as required and do not delay administration of fluid if HAS is unavailable (e.g. use crystalloid)

If the patient remains oligoanuric despite adequate fluid replacement, or if they become suddenly oligoanuric, remember to check the urethral catheter is not blocked. Try flushing gently with 10 mL 0.9% sodium chloride under full aseptic technique and if no improvement in urine output then contact the on-call paediatric nephrologist and the transplant surgeons.

Do not deduct any fluid boluses from the fluid used to replace urine output.

Do not give diuretics to transplant patients without prior approval from the paediatric nephrology consultant on-call

Discuss with the paediatric nephrology consultant on-call if more than 2 fluid boluses are required or if the patient is persistently oligoanuric (i.e. <2ml/kg/hour for greater than 2 hours).

*different parameters may be required/set in certain clinical situations and will be advised by the paediatric nephrology consultant on-call or the transplant surgeons.

IF THERE ARE ANY CONCERNS THE ST4-8 SHOULD DISCUSS WITH THE PAEDIATRIC NEPHROLOGY CONSULTANT ON CALL.

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Blood results

Haematology
Transfuse if the haemoglobin < 70g/L, aiming to maintain the haemoglobin between 80-100g/L. Any transfusions should be discussed with the paediatric nephrology consultant on-call. Do not give diuretics with blood transfusions.

Biochemistry
The urea and creatinine should progressively fall. Any rise in a previously falling creatinine should prompt discussion with the on-call paediatric renal consultant.

Monitor blood glucose levels and change to non-dextrose containing fluids if the blood glucose is elevated. If patients are drinking also ensure that they are not drinking sugary fluids.

Hyperglycaemia can induce an osmotic diuresis. If there is hyperglycaemia (blood glucose >14 mmol/L), despite changing to 0.9% sodium chloride for at least 4 hours, check blood ketones and urine for glycosuria. If blood ketones are >0.6mmol/l speak to the on-call paediatric diabetes consultant before further intervention.

Consider commencing insulin sliding scale (see Appendix 3). This must be discussed with the paediatric nephrologist on-call with additional advice from the diabetes consultant if necessary.

Monitor serum phosphate and magnesium levels which are likely to fall post-transplant. Enteral/intravenous replacement should be initiated as outlined below.

Hypophosphataemia (<1mmol/l)

  1. Request dietetic review and encourage a phosphate rich diet
  2. Oral therapy should be commenced as outlined below. The dose should be adjusted based on serum phosphate levels. Oral therapy can cause diarrhoea.

    Child 1 month - 4 years: 2-3mmol/kg daily in 2-4 divided doses (max 48mmol/day)
    Child 5-17 years: 2-3mmol/kg daily in 2-4 divided doses (max 96mmol/day)

    Available as:
    • Phosphate Sandoz® (each tablet contains 16mmol phosphate, 20mmol sodium and 3mmol potassium)*
    • Joulies Solution (contains 1mmol phosphate and 0.78mmol sodium per ml). Dose should be expressed in mmol of phosphate*

*One dose of Joulies solution is approximately ten times the cost of one dose of Phosphate Sandoz®

  1. Parenteral administration can be used if phosphate levels are very low, the patient is symptomatic or dietetic/oral therapy is ineffective/not tolerated.

    Initial dose is 0.5 mmol of phosphate/kg/day infused at a rate of 0.05mmol/kg/hour
    (doses of up to 1 mmol/kg/day of phosphate can be used if required)

Usually administered using a 50ml Phosphate Polyfusor® (50 mmol phosphate, 81 mmol sodium, 9.5 mmol potassium in 500 mL)*

Run at   0.5 mL/kg/hour for 10 hours (which gives 0.5mmol/kg/day)

If patients have not responded to a 10 hour infusion or are symptomatic then continue the infusion for longer (maximum 20 hours/day which is 1 mmol/kg/day).

Where possible all phosphate infusions should be given via a CVL to decrease the risk of phlebitis.

*If patients are hyperkalaemic use neutral sodium phosphate (0.85mmol phosphate/mL and 1.5mmol sodium/mL)

Hypomagnesaemia (<0.5mmol/L)

  1. Oral therapy is usually sufficient to correct hypomagnesaemia but oral therapy can cause diarrhoea.

Give   0.5mmol/kg/day in 2-4 divided doses (maximum 20 mmol/day). Increase as necessary depending on levels and tolerability

Available as:

  • Magnesium glycerophosphate 4mmol tablets or magnesium glycerophosphate 1mmol/ml liquid
  • Magnesium oxide capsules 400mg (10 mmol) is used second line if patient unable to tolerate magnesium glycerophosphate. If required the capsules can be opened dispersed in water (disperse a 10mmol capsule in 10mL to give a 1 mmol/mL solution)
  1. Parenteral administration is usually required if the patient is failing to respond to/not tolerating oral therapy. It is usually given over 6 hours as this maintains a more continuous magnesium level*

Dose is   0.4 mmol/kg (max 8 mmol) over 6 hours given centrally/peripherally

Preparation:
Use intravenous magnesium sulphate 50% (2mmol/mL). Dilute to a maximum magnesium concentration of 0.4mmol/mL (100 mg/mL) with 5% glucose or 0.9% sodium chloride. The rate of administration should not exceed 0.04 mmol/kg/min (10 mg/kg/min)

*If a patient has acute or life threatening symptoms of hypomagnesaemia rapid intravenous magnesium replacement may be required. The same magnesium sulphate dose can be given by a slow bolus over 10 minutes (rate of infusion should not exceed 0.04mmol/kg/min).

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Lines and drains

Central venous line
Is used for sampling and administration of fluid/medication and usually remains in situ for 3-5 days.
Do not use the existing haemodialysis line for blood sampling or administration of fluids/medication.

Urinary catheters
The urethral catheter is usually removed after day 5. If there is a supra-pubic catheter in situ it is usually clamped on day 5 and removed on day 7 if the child is voiding appropriately.

Wound drain
This is usually removed when there is minimal or no drain loss for 24-48 hours after discussion with the transplant surgeon.

Peritoneal dialysis catheter or haemodialysis line
These are usually removed under anaesthesia along with the transplant ureteric stent at 6-8 weeks post-transplant. A referral letter should be sent to the paediatric urologists requesting removal of the peritoneal dialysis catheter or haemodialysis line AND the transplant ureteric stent on week 6 post transplant, prior to the patient being discharged from hospital.

Transplant ureteric stent
A ureteric stent is routinely inserted intra-operatively and is removed approximately 6-8 weeks post-transplant as a day case procedure. A referral letter should be sent to the paediatric urologists requesting removal of the ureteric stent (along with any permanent dialysis catheters - see above) on week 6 post transplant, prior to the patient being discharged from hospital.

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Assessment of allograft dysfunction

At any time post transplantation consider the following issues when asked to assess for allograft dysfunction e.g. rising creatinine or falling urine output

  • Hypovolaemia - see above section on fluid

  • Acute graft thrombosis - should be considered if there is a fall in urine output which is refractory to fluid therapy, especially if there is associated macroscopic haematuria. An urgent USS and doppler of the transplant kidney should be requested to exclude thrombosis and assess graft perfusion
  • Infection
    • Urine infection - urinalysis and urgent urine microscopy and culture
    • CMV infection - send blood CMV PCR
    • Polyomavirus - send blood BK virus PCR

  • Drug toxicity - is the tacrolimus level elevated or have any other nephrotoxic drugs been given?
  • Obstruction
    • Flush urinary catheter and discuss with transplant surgeons
    • Arrange an USS of the transplant kidney

  • Rejection - see below

  • Recurrence of primary renal disease e.g. FSGS

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Renal biopsy indications

A renal biopsy will be considered by the paediatric renal consultant if

  • Patients have delayed graft function of the transplant kidney, i.e. no reduction in serum creatinine by day 3, consider a biopsy on day 5-7
  • There is poor response and poor graft function e.g. an initial fall in the plasma creatinine but no continued fall to less than 100 -150µmol/l
  • All kidneys where there is an unexplained confirmed continued rise of greater than 10-20% over the previous creatinine.

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Treatment of acute rejection

Acute cellular rejection is diagnosed on a renal biopsy. It should be managed initially with:

Intravenous Methylprednisolone   600 mg/m2/day (max of 1 gram) for up to 3-5 days*

Oral steroids should be discontinued during intravenous therapy and recommenced at a dose recommended by the paediatric nephrology consultant on-call. The consultant may also consider changing maintenance immunosuppression from Azathioprine to Mycophenolate mofetil

Steroid resistant rejection/unresponsive vascular rejection may need treatment with other agents like Anti-Thymocyte Globulin (ATG). See ATG protocol available on LHP (guideline 6140).

The diagnosis of antibody mediated rejection (ABMR) is made on renal biopsy with the presence of donor specific antibodies (DSA) in the blood.

Treatment of ABMR will be dependent on individual patient circumstances but broadly speaking may include plasma exchange, intravenous immunoglobulin or Rituximab.

Post-transplant DSA requests may be made on any patient if there is a clinical suspicion of antibody mediated rejection. Monitoring at set time points is advised in higher risk cohorts, specifically: HLA incompatible transplants, patients with DSA in historic antibody profile, patients in whom donor specific immunity has been therapeutically modified prior to transplant or repeat HLA mismatches from a previous transplant. The requirements for DSA testing will be guided by the transplant immunology laboratory and paediatric renal consultant on-call.

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Discharge

The inpatient stay post renal transplant varies but on average is between 10-14 days.

Patients and their carers should be counselled regarding their medicines prior to discharge by the renal pharmacist or renal transplant specialist nurse. This should be initiated at least 72 hours before discharge to enable parents to practice giving medicines on the ward supervised by ward nurses before discharge. Please ensure the pharmacist or specialist nurse is informed of the expected discharge date at the earliest opportunity to avoid delayed discharge. This counselling should be documented in the patient’s medical notes. Those being counselled should also receive a hand-held card with a list of the medicines currently being taken, which should be updated when any medications are altered. The patient/carers will also receive a patient information leaflet explaining the importance of each of the medicines.

Patients and families should also receive safe diet advice from the renal dietician and general education and training from the transplant nurse specialist before discharge.

Discharge documentation should be completed and sent to the GP detailing all discharge medication. All patients should receive a 3 month supply of their medicines prior to discharge. There are shared cared guidelines supporting GP’s to take over providing medication beyond 3 months.

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Outpatient follow-up

All recipients should receive clinic appointments at the frequency below post discharge, unless discussed with the paediatric renal consultant.

Day 1 - 28 = 3 times a week
Month 2 = 2 times a week
Month 3 = once a week

Following this period follow up will be spaced out with patients being reviewed every 6-8 weeks in the long term.

Provenance

Record: 6880
Objective:
Clinical condition:

Renal transplantation

Target patient group: Paediatric patients undergoing renal transplants
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

Not supplied

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

Equity and Diversity

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