Practical Protocols – experience and evidence based routines
Transcript of Practical Protocols – experience and evidence based routines
Practical Protocols – experience and evidence based
routines
Henrik Ekberg
Living Donor Kidney Transplantation - Protocols
Why do we need protocols?
• Every transplant centre needs to make decisions on their routine practice.
• The reason for this is that all patients should be given the best possible care.
• These protocols should be based on current transplantation research
• They should be updated at regular intervals.
• The objective is to reach the highest international standard of outcome after kidney transplantation.
How to make your own protocols
• The book is published in Chinese and in English.
• With the book you should find a CD.
• If you want to make a print out of the same text as in the book, use the pdf file.
• If you want to make your own protocols, similar to what we have suggested but with an update or with local application, use the Word file.
A message from The Transplantation Society
Professor Jeremy Chapman, President, TTS 2008-2010.
• “This book provides the practical elements needed for a modern transplantation programme.
• It is absolutely essential in today’s clinical transplant programmes that all the professional staff work as a unit.
• Without protocols covering the most important aspects of transplant care there is no cohesion or collaboration.
• These Practical Protocols provide all transplant units the opportunity to build their own protocols easily and on a sound basis of international best practice. “
Structure of the Transplant Centre
DirectorTransplant Centre
TransplantSurgery
Vice Director
Transplant Nephrology
Vice Director
Transplant Laboratories
Riskassessment Cardiology
TransplantCo-ordinator
Protocols
1. Kidney Recipient Work Up
2. Living Donor Work Up
3. Consent to Kidney Donation
4. Protocols for the Doctor: Admission of the Recipient Before Transplantation
5. Protocols for the Nurse: Admission of the Recipient Before Transplantation
6. Doctor’s Orders: Pre-operative Management in Kidney Transplantation
(1) Kidney Recipient work up
1. Cardiac evaluation
2. Parathyroid function
3. Glucose tolerance
4. APC resistance
5. Panel reactive antibodies
6. Dentist
7. Antibody screening (HIV, HBV, HCV, etc)
8. Vaccination
9. CT of iliac arteries
(2) Living Donor Work Up1. Informed consent2. Blood group test3. Electrocardiogram4. Clinical chemistry according to a specified list5. GFR6. Glucose tolerance test7. Echocardiogram8. Renal artery ultrasound9. Chest X-ray10. Myocardial scintigraphy (if > 50 yrs old)11. CT angiography of renal arteries12. Nephrologist’s decision13. Surgeon’s decision
More Protocols
7. Anaesthetist: Intra-operative Management in Kidney Transplantation
8. Post-operative Management After Kidney Transplantation
9. Routine Blood Samples After Kidney Transplantation For the Nurse in the Transplant Ward
10. Flow Chart of Events of Nursing After Kidney Transplantation
11. Flow Chart of Events of Nursing in Kidney Donation
12. Long-term Follow-up After Kidney Donation
13. Antibiotics and Kidney Transplantation
(14) Initial Immunosuppression After Kidney Transplantation
1. Normal risk patient (with basiliximab)
2. Normal risk patient (with no induction)
3. NODAT risk (steroid avoidance)
4. NODAT risk (low-dose steroids)
5. High risk (with basiliximab induction)
6. High risk (with ATG induction)
(14) Initial Immunosuppression After Kidney Transplantation
15 + 515 + 51010 for
1 week
then 0
15 + 515 + 5Prednisone
Mg/day
111111MMF g BID
543.5443.5Start dose
Mg BID for 70kg BW
0.070.060.050.060.060.05Start dose
Mg/kg BID
10 - 128 – 103 - 78 – 108 – 105 - 8Tac trough
ATGBasiliximabBasiliximabBasiliximabNoneBasiliximabInduction
High risk (2)
High risk (1)
NODAT (2)NODAT (1)Normal risk (2)
Normal risk (1)
(14) Initial Immunosuppression After Kidney Transplantation
15 + 515 + 51010 for
1 week
then 0
15 + 515 + 5Prednisone
Mg/day
111111MMF g BID
543.5443.5Start dose
Mg BID for 70kg BW
0.070.060.050.060.060.05Start dose
Mg/kg BID
10 - 128 – 103 - 78 – 108 – 105 - 8Tac trough
ATGBasiliximabBasiliximabBasiliximabNoneBasiliximabInduction
High risk (2)
High risk (1)
NODAT (2)NODAT (1)Normal risk (2)
Normal risk (1)
(14) Initial Immunosuppression After Kidney Transplantation
15 + 515 + 51010 for
1 week
then 0
15 + 515 + 5Prednisone
Mg/day
111111MMF g BID
543.5443.5Start dose
Mg BID for 70kg BW
0.070.060.050.060.060.05Start dose
Mg/kg BID
10 - 128 – 103 - 78 – 108 – 105 - 8Tac trough
ATGBasiliximabBasiliximabBasiliximabNoneBasiliximabInduction
High risk (2)
High risk (1)
NODAT (2)NODAT (1)Normal risk (2)
Normal risk (1)
(14) Initial Immunosuppression After Kidney Transplantation
15 + 515 + 51010 for
1 week
then 0
15 + 515 + 5Prednisone
Mg/day
111111MMF g BID
543.5443.5Start dose
Mg BID for 70kg BW
0.070.060.050.060.060.05Start dose
Mg/kg BID
10 - 128 – 103 - 78 – 108 – 105 - 8Tac trough
ATGBasiliximabBasiliximabBasiliximabNoneBasiliximabInduction
High risk (2)
High risk (1)
NODAT (2)NODAT (1)Normal risk (2)
Normal risk (1)
(14) Initial Immunosuppression After Kidney Transplantation
15 + 515 + 51010 for
1 week
then 0
15 + 515 + 5Prednisone
Mg/day
111111MMF g BID
543.5443.5Start dose
Mg BID for 70kg BW
0.070.060.050.060.060.05Start dose
Mg/kg BID
10 - 128 – 103 - 78 – 108 – 105 - 8Tac trough
ATGBasiliximabBasiliximabBasiliximabNoneBasiliximabInduction
High risk (2)
High risk (1)
NODAT (2)NODAT (1)Normal risk (2)
Normal risk (1)
(14) Initial Immunosuppression After Kidney Transplantation
15 + 515 + 51010 for
1 week
then 0
15 + 515 + 5Prednisone
Mg/day
111111MMF g BID
543.5443.5Start dose
Mg BID for 70kg BW
0.070.060.050.060.060.05Start dose
Mg/kg BID
10 - 128 – 103 - 78 – 108 – 105 - 8Tac trough
ATGBasiliximabBasiliximabBasiliximabNoneBasiliximabInduction
High risk (2)
High risk (1)
NODAT (2)NODAT (1)Normal risk (2)
Normal risk (1)
(14) Initial Immunosuppression After Kidney Transplantation
15 + 515 + 51010 for
1 week
then 0
15 + 515 + 5Prednisone
Mg/day
111111MMF g BID
543.5443.5Start dose
Mg BID for 70kg BW
0.070.060.050.060.060.05Start dose
Mg/kg BID
10 - 128 – 103 - 78 – 108 – 105 - 8Tac trough
ATGBasiliximabBasiliximabBasiliximabNoneBasiliximabInduction
High risk (2)
High risk (1)
NODAT (2)NODAT (1)Normal risk (2)
Normal risk (1)
Tacrolimus (target concentration 5 – 8 ng/mL)
MMF 750 mg x 2 (or azathioprine 75 – 100 mg x 1)
Prednisolone 5 mg at 8 am
Days 90 and after
Tacrolimus (target concentration 5 – 8 ng/mL)
MMF 750 mg x 2
Prednisolone 10 mg at 8 am
Days 60-90
Tacrolimus (target concentration 5 - 8 ng/mL)
MMF 750 mg x 2
Prednisolone 15 mg at 8 am
Days 30-60
Tacrolimus 0.05 mg/kg x 2 (target concentration 5 – 8 ng/mL)
MMF 1000 mg x 2
Prednisone 15 mg at 8 am and 5 mg at 8 pm
Day 4: basiliximab 20 mg IV
Every day after transplantation
(8 am and 8 pm) Days 1 – 30
Tacrolimus 0.05 mg/kg
MMF 1000 mg
Prednisolone 100 mg IV
In the evening(8 pm) of the day of transplantation
Methylprednisolone 500mg IV
Basiliximab 20 mg IV
At the start of transplantation in the operating room
Tacrolimus 0.05 mg/kg
MMF 1000 mg
Morning of the day of transplantation (6 am)
Tacrolimus 0.05 mg/kg (e.g. 3.5 mg)
MMF 1000 mg
Evening (8 pm) the day before transplantation
Final Protocols
15. Transplant Biopsy
16. Treatment of Acute Rejection
17. Long-term Follow-up After Kidney Transplant
18. Responsibilities of Surgeon and Nephrologist
19. The Gift of a Kidney
– Information for the Potential Donor
20. Further Reading
At your transplant center:
• Which protocols would you accept today as they are?
• Which protocols would you like to modify to make them applicable to your routines?
• Are there any protocols you would not use?
• Please, give me your comments and suggestions: