Pediatric Kidney Post

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Pediatric Kidney Post-Transplant Protocol
Intra-op meds:
1. Mannitol (0.25 gm/kg)
2. Lasix (1 mg/kg)
3. Methylprednisolone, Thymoglobulin (in most cases, see below)
4. Cefazolin
Fluid Management:
1. Insensible Losses: D5W @ 20 ml/hr
2. Urine replacement: 0.45% NS + 20 meq NaHCO3/L @ ml/ml of urine losses

After initial post-operative period (24-48hr), change to fixed intake (PO + IV)
of 1.5x maintenance.

Long-term: Target enteral intake of 1.5x maintenance.
Immunosuppression:
1. For typical immune risk:
Thymoglobulin (rabbit polyclonal antithymocyte preparation)

Initiated intra-op, give 1 mg/kg IV over 6 hours, then daily (over 4 hours), for a
total of 5-6 doses

Premedicate with methylprednisolone, acetaminophen and diphenhydramine
OR if previous thymoglobulin and a high titer of anti-rabbit antibodies:
Alemtuzumab (Campath) is used
2.
Mycophenolate mofetil

300 mg/m2 PO BID while on Thymoglobulin, then 600 mg/m2 BID

Dose adjusted as needed based on WBC.
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3. Methylprednisolone/prednisone

Intra-op: 10 mg/kg

Post-op:
POD #1: 2 mg/kg IV - will serve as a premed for Thymoglobulin
POD #2-4: 1 mg/kg IV daily – will serve as a premed for Thymoglubulin

Subsequent early steroid taper (prednisone):
Post-op day

Dose per day (mg/kg)
5-6
0.6
7-8
0.5
9-10
0.4
11+
0.3
Eventual taper to low dose on an alternate day dosing schedule
4. Tacrolimus (Prograf)

~ 0.1 mg/kg/dose PO q 8hr if < 6yrs old, q 12hr if older

Target trough level of 10-12

First dose once renal function well established
Blood Pressure Management:

While in PCCU: Nifedipine 0.1 mg/kg/dose PO prn SBP > 99% for age & gender,
if pain well controlled

Transition to Amlodipine PO, BP target is 50% for age & gender

Stepwise use addition of atenolol and other antihypertensives as needed.
Prophylaxis:
1. Wound: Cefazolin IV intra-op
2. Candida: Nystatin suspension, starting POD #1
3. PCP & UTI: Bactrim PO nightly, starting POD #1
*If sulfa allergy: Dapsone & Macrodantin
4. CMV: If patient and/or donor is CMV +, treat with valganciclovir (Valcyte) PO daily
for 6 months. ( R- D+ / R+ D+ / R+ D- )
5. GI: Famotidine (Pepcid) IV q day, then PO BID
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Monitoring:
1. CBC/diff, BMP on arrival to PACU/PCCU
* then Hct, BMP q 6h x2
* CBC/diff/plts, BMP, Ca PO4, Mg q am
* daily FK trough levels once tacrolimus started
2. If temp >38.5, obtain blood cultures from appropriate lines, urine culture and CXR,
if indicated by clinical status.
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