ORIENTATION TO KTU
Contents
Page
Overview of Service and Team Members …..………………………………………………………….…………………….……… 2
Admissions for Cadaveric Transplants ………………………………………………………………………………………….…….. 9
Admissions for Living Donor Transplants ………………………………………………….……………………………….…... 12
Other Admissions ………………………………………………………………………………………………….…………………………………. 15
Discharges ……………………………………………………………………………………………………………………………………………..…… 17
Daily Management of Patients …………………………………………………………………………………………………….………… 21
KTU Routines ………………………………………………………………………………………………………………….……………………. 21
Labs, Cultures, and IVs ……………………………………………………………………………………………………………………. 21
Imaging Studies …………………………………………………………………………………………………………….………………….. 23
Foleys and Bladder Function …………………………………………………………………………………….……………………. 24
Consults and Nontransplant-related Procedures ……………………………………………………………………… 25
Immunosuppressive Medications ……………………………………………………………………………….…………………… 25
Other Medications …………………………………………………………………………………………………………….………………… 26
Posttransplant Fluid Management ……………………………………………………………………….…………………………. 28
Attached Readings

Surgical Techniques of Renal Transplantation*

Early Course of the Patient with a Kidney Transplant* (Required reading)

Pathology of Kidney Transplantation*

Simultaneous Pancreas-Kidney Transplantation: An Overview of Indications, Complications,
and Outcomes (written by Chris Freise, Peter Stock, and other UCSF MDs)

The Early Management of the Pancreas Transplant Recipient (by Dr Peter Stock, UCSF)


Immunotherapeutics of Solid Organ Transplantation (a quick reference)
Solid Organ Transplantation Immunosuppressants (A quick reference)

Immunosuppressive Medications for Renal Transplantation: A Multiple Choice Question (an
in-depth discussion of how immunosuppression is chosen)

UCSF’s Immunosuppression Protocols for Kidney Transplantation

UCSF’s Immunosuppression Protocols for Pancreas (or Simultaneous Pancreas/Kidney)
Transplantation

UCSF Protocols for Prophylactic Antibiotic Therapy

Immunsuppressive drug interactions with anti-infective agents

The Laparoscopic Donor Nephrectomy
* From “Kidney Transplantation: Principles and Practice,” 5 th Edition, edited by Peter J. Morris
1
OVERVIEW
The KTU is on 9 Long, sharing the 36 bed unit with the LTU (Liver Transplant Unit). The
transplant services are unique in that they have both medical and surgical patients. The
patient population is primarily adult.
As of May 2007, UCSF has performed more than 8000 kidney transplants (more than any
other center in the world) and about 400 pancreas transplants. In mid 2006, Kaiser closed
its transplant program and UCSF again began doing transplants on their patients. In 2007,
UCSF is expected to perform about 380-400 kidney transplants and 25-30 pancreas
transplants. About half of the recipients have living donors, related or unrelated. Living
donation is encouraged because the waiting time is currently about 5 years, even 6-7 yrs for
type “O” patients. The UCSF waiting list for kidneys now has about 7000 patients.
Most pancreas transplants at UCSF are done with simultaneous kidney transplants. A few
are being done after a successful kidney transplant and a very few are being done in
patients with decent native kidney function. All of these patients are followed by the KTU
service while in-house. (Patients who receive livers with their kidneys are followed by the
liver transplant service and the nephrologists will consult.)
About 3000 post transplant patients are followed as outpatients, with about 125 outpatient
visits a week. There are outreach clinics in Fresno, the South Bay and the East Bay where
pre and post transplant patients are seen. UCSF is now running the outpatient transplant
clinic at Kaiser as well (located at the San Francisco Kaiser facility).
Other procedures frequently performed by the KTU surgeons include, of course, the donor
nephrectomies (almost all laparoscopic), native nephrectomies on pre and post transplant
patients, transplant nephrectomies, an occasional autotransplant (usually as a consulting
service to urology), and placement of hemodialysis vascular accesses and peritoneal dialysis
catheters. KTU is the consulting service for pediatric transplants: Peds Renal service
writes all immunosuppression orders etc. Transplant fellows rotate call for organ
procurement at other facilities (donor runs) even though UCSF does not always receive the
organs.
Typically, the inpatient team has one attending nephrologist, one attending surgeon, a
second attending surgeon to cover pancreas if the first one does not do pancreas
transplants, a transplant surgical fellow, a transplant nephrology fellow, a general
nephrology fellow, one 2nd or 3rd year resident, one to two interns, the inpatient nurse
coordinator, and the transplant pharmacist. In addition, the KTU service has its own social
workers and shares a case manager with the LTU.
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Physician Rotations onto the Service
Attending nephrologist……………………… …Typically covers 1 week at a time, changing on Friday.
Also covers outpatient calls when the clinic is closed.
Deb Adey
Bill Amend (retired)
Steve Tomlanovich (medical director)
Flavio Vincenti
Julie Yabu
Attending Surgeon………………………………….Usually change on Mondays
Nancy Ascher (Chief of Surgery, does not do pancreas tx)
John Roberts (Chief of Transplant Services, does not do pancreas tx)
Sandy Feng
Chris Friese (Does most of the dialysis accesses and laparoscopic nephrectomies)
Ryo Hirose
Sang-Mo Kang (Also does laparoscopic nephrectomies)
Andrew Posselt (Also does laparoscopic nephrectomies, pancreatic islet transplant,
and bariatric surgery)
Peter Stock (Director of Pancreas Transplant, PI for Pancreatic Islet Transplant,
and Director of Pediatric transplant)
Transplant Nephrology Fellow…….……… A new position since Jan 2004, the transplant
Brian Lee (till 6/08)
nephrology fellow rotates between kidney transplant
clinic and the in-pt service. In addition, general
nephrology fellows rotate onto the service a month at
a time, usually changing on the first of the month.
Transplant Surgery Fellow……………………Usually on service several months at a time, starting
on the first of a month. When not on KTU, the
fellows rotate to the LTU or into the research lab.
Matt Levine
Todd Brennan
Bruce Gelb
2nd and 3rd year residents……………………..Change on the first of the month. These residents
may not have been on KTU before. KTU and LTU are
also rotations for Fresno surgical residents.
Intern……………………………………………………….. Changes on 21st of each month. Interns in the urology
program may rotate onto KTU more often than
others.
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Nonphysician Team Members Usual Schedules
Inpatient Coordinators………………………….Work 10 hr shifts (app 0900-1930), opposite days,
together covering 6 days a week most weeks. Do not
usually work Sundays and major holidays.
Joan McElroy RN, MSN
Nancy Fong-Hom RN, BSN
353-1490, pgr 443-4937
353-1490, pgr 443-0416
Transplant Pharmacist………………………… Monday through Friday, 0900-1700.
Terrie Nghiem Pharm D.
353-1335, pgr 443-3451
Post transplant Nurse Practitioner…..
Sue Robertson RNP
Sees recipients and donors in kidney clinic 353-8373
(covers patients M-Z)
Melanie Macaraig RNP
Sees recipients and donors in kidney clinic 353-8376
(covers patients A-L)
Cely Hynson RNP
Sees pancreas recipients in pancreas clinic 353-1508
Social Workers………………………………………..Monday through Friday, 0830 –1630.
Julie Schlesinger LCSW (inpt) 353-2345, pgr 443-3964
Laura Griffin LCSW (outpt)
353-2791
Wendy Kahn LCSW (donors and pancreas recipients) 353-8963, pgr 443-0997
Case Manager…………………………………………. Mon, Tues, Thur, Fri
Jennie Crossfield RN
353-8908, pgr 443-4117
9 Long Nurse Managers……………………………….…… Mon-Fri 0830-1700
Margarita Ilumin Nurse Manager for 9 Long
Agatha Ekeh, Assistant Nurse Manager for 9 Long
Call schedules
At the beginning of each month, each group of people puts out their call schedule. This
includes the pretransplant coordinators who are involved in making cadaver transplants
happen. The call schedule is available on-line. The in-pt coordinators will print the schedule
and post it at the nurses station. Residents’ schedules will not be on it: KTU residents will
need to post their call schedule after consulting with the moonlighting residents who will be
sharing coverage with them.
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TEAM MEMBER RESPONSIBILITIES
Inpatient Transplant Coordinators
In addition to assisting the physicians as described later, the inpatient coordinators

Assist the transplant pharmacist in getting all discharge meds ready for the patient.
This includes verifying insurance as needed, calling insurance for prior authorization for
drugs, sending the list of DC meds to the outpatient pharmacy patient will use, and
updating the DC med list as needed. The bedside nurses teach the patient most of the
med-related info, but the coordinators and pharmacist will instruct the patients on
issues regarding outpatient meds, refills, etc.

Facilitate communication with the kidney transplant clinic and pancreas coordinator.
This involves completing a form the coordinators created called “Inpatient Admission
Summary,” also called a profile. It is a summary of the pretransplant workup, previous
transplant history and antigen match, summary of the hospital course, and discharge
plan. This form, along with copies of the pt's med card and the flow sheet kept up
during the hospital stay, is faxed to the clinic at the time of discharge. These papers
are kept in the coordinators’ office indefinitely for reference in case the patient is
readmitted. (For pts transplanted from 2001 or later. Only limited info available on pts
transplanted earlier.)

Notify the case manager and/or social worker about discharge needs or planned
transfers to other facilities.

Assist the coordinators for the research protocols (JoAnn Zlatunich, Esterlina Gurion,
and Clarina Mendoza) by making sure protocols are adhered to and the proper study labs
drawn, as well as consenting patients for the studies if necessary.

Assist patients and MDs with outpatient appointments, outpt lab work, and readmissions.
These are the appointments the KTU service knows about when the patient is on the
inpatient service. If there are appointments and admissions planned by the outpatient
clinic staff, the outpatient clinic staff sets them up.

Complete reporting forms on donors and recipients for UNOS (United Network for
Organ Sharing). Complete ESRD Medical Evidence Form (HCFA 2728) on certain
patients.

Orient housestaff to KTU protocols.

Keep all KTU protocols and preprinted orders up to date. Will be updating orders for
computerized order entry, due to be implemented late in 2008.

If there is no coordinator on Monday through Friday for any reason, the transplant
pharmacist is the person covering her.
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Transplant Pharmacist
 The pharmacist usually has a pharmacy student working with her and is responsible for
supervising this student. When the transplant pharmacist is not available for some
reason, the inpatient coordinator will supervise the pharmacy students’ work on
discharge meds.

Along with the inpatient coordinator, the pharmacist makes sure the KTU and study
protocols are adhered to and makes suggestions as to drug substitution, dose
adjustment, etc.

The pharmacist has primary responsibility for getting the discharge meds ready for the
patient. This includes all the insurance issues etc that may be involved, as mentioned
above under the coordinator responsibilities. For patients using the UCSF Transplant
Pharmacy, she will fill and bring the meds up from that pharmacy and give them to the
patient.

The pharmacist follows up on all medication errors on KTU patients.

Periodically, the pharmacist will work in the transplant clinic to assist with prescriptions,
and in the transplant pharmacy to fill prescriptions. At these times, she is available by
pager for questions, but may not be able to help out on KTU.

When the pharmacist is on vacation, the discharge meds will be handled by the inpatient
coordinators. The liver transplant pharmacist, David Quan, will cover anything else.
Attending Surgeons and Nephrologists
Have the ultimate responsibility for the care of all patients admitted to the service.
Specific responsibilities include
 Decisions on whether to admit or discharge patients from the service.
 Decisions about obtaining consults from physicians outside the kidney transplant service.
 Choosing which immunosuppressive drugs to use (When a patient is first transplanted, the
surgeon has the final word on immunosuppression. Pancreas patients are still followed by
the surgeons after discharge, however the kidney-only patients are primarily managed by
the nephrologists after discharge.)
 Dictating daily progress notes on all transplant patients, as well as ESRD patients they are
following for dialysis management.
 Running one set of rounds per day.
 Teaching fellows and residents.
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 Choosing which patients to approach for enrollment in investigational protocols.
 Clearing potential donors and recipients for surgery.
 Communicating with patients’ outside physicians.
Transplant Surgery Fellow
 Oversees the care of all patients admitted to the service, including most of those who are
really more medicine than surgery. May be less involved in the care of patients admitted
for overnight stays who are primarily medicine patients.
 Conducts AM/PM work rounds with housestaff.
 Supervises housestaff and medical students.
 Serves as liaison to pediatric renal service.
 Presents cases at complications conferences.
 May make dose changes in current immunosuppressive regimen if OK with attending MD.
 Assesses clinic patients when surgeon is needed.
 On call for “donor runs” to other hospitals to surgically remove organs from donors.
Transplant Nephrology Fellow and General Nephrology Fellow
 The general nephrology fellow has just completed a residency in general medicine and
wishes to pursue a specialty in nephrology. The transplant nephrology fellow has already
completed a general nephrology fellowship and now wishes to pursue further training in
transplant medicine. The transplant nephrology fellow shares workload and call with the
attending nephrologist. The general nephrology fellow rotates evening and weekend call
with other nephrology fellows and may cover other nephrology patients on other services
when on call. Together, they will follow all patients on the KTU service, providing a
nephrology consultation on all patients. The responsibilities below will be divided up such
that the transplant nephrology fellow will do more advanced procedures and concentrate
more on transplant medicine.
 They will both make every attempt to be on rounds, though the need to see patients while
on dialysis sometimes makes this impossible. They will also write all hemodialysis and
peritoneal dialysis orders for patients on KTU service except on patients followed by
private nephrologists at UCSF.
 Complete H&P, admission orders, discharge orders, and PDP (Physician’s Discharge Plan) on
all patients admitted as “ONB*” stays for biopsy of the transplanted kidney. Share
responsibility for H&Ps, admission orders, discharge orders, PDPs, and dictation of
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discharge summaries on readmitted transplant patients, especially when the primary
reason for admission is medical.
*“ONB” means outpatient needing a bed. It is generally used when the patient must
be in a hospital bed for a few hours. However, if an “ONB” patient stays overnight,
the hospital is not reimbursed for any of the nursing care on the inpatient unit.
“OBS” refers to observation status. It can be for as long as 72 hours. It is still
considered an outpatient stay, but the implication is that the patient needs to be
observed, though no other procedures are planned.
ONB and OBS patients are admitted to the LSU (Limited Stay Unit) whenever
possible. If they need to stay longer than a night, they are admitted to 9 Long.
The UCSF standard of care for a patient requiring a biopsy of the transplanted
kidney or pancreas is to observe the patient overnight for complications including
bleeding at the biopsy site, hematuria, and creation of an A-V fistula between
vessels in the organ. (This results in a diversion of blood flow within the organ,
which may need to be repaired in Interventional Radiology using coil embolization to
restore normal flow.) However, technically speaking, the biopsy patients do not
meet the Medicare criteria for “OBS” status. To avoid Medicare fraud, these
patients are admitted as “ONB,” then after the biopsy, the order must be written to
change the status to “OBS.” A progress note must be written documenting the need
for observation, (i.e., at high risk for bleeding because uremic or whatever is
appropriate). If a patient is admitted directly to Ultrasound and has a biopsy
before getting to the floor, the post-biopsy/admission orders can say “admit to 9
Long as OBS.” The The LSU staff of the inpt KTU coordinators will make the call to
bed control to get the status changed.
If there are post biopsy complications requiring treatment, or if there is rejection,
the order needs to be written to change the patient to inpatient status.
Residents
Being the lone intern on the service can be overwhelming at times, so the 2 nd and 3rd year
residents share most of the work the intern does. However, the more senior residents may
be in the OR more, and are more frequently called to assist on donor runs than the interns.
Depending on the service and the transplant fellow running it, the resident’s responsibilities
may be divvied up slightly differently from time to time. However, there are resources
available to the KTU housestaff that are unique to the service. Resident responsibilities
are described on the following pages, with the person(s) who can help when it gets too busy.
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ADMISSIONS FOR CADAVERIC TRANSPLANTS
FYI: UCSF, Stanford, and California Pacific Medical Center are the transplant centers in
the region’s OPO (organ procurement organization). The OPO has one common waiting list.
UCSF alone has over 7000 people waiting for kidney transplants. Organs are offered first
to the patient with a 6 Antigen match who has been waiting the longest in the nation. If no
one matches, the organs are offered first within the OPO the donor’s hospital is in, then
regionally, then nationally. Because there are so many people waiting for a transplant in our
OPO, it is very unusual for no one to be able to use the organs that become available in our
area.
Patients near the top of the waiting list are put “on the trays.” This means they send blood
every month to the UCSF Immunogenetics and Transplantation Lab (ITL, located at Davies
Hospital elsewhere in San Francisco). This blood is used to perform a lymphocyte
crossmatch with every ABO compatible donor that is offered to our OPO. This way the
crossmatch can be performed before any patients are offered the organ. This saves time,
money and frustration. If the crossmatch is positive, the patient has preformed antibodies
against the donor and the organ will not be offered to him. If the crossmatch is negative,
the transplant can proceed. If several potential recipients have negative crossmatches, the
patient with the longest waiting time is offered the organ. However, several things can
make it necessary to pass up a patient, such as infection or inability to get to the transplant
center within a reasonable time.
There may be times when a patient is called in even though no crossmatch has been done.
For example, the family of a person who died may know of someone they wish the organs to
be given to. This would be a "directed donation." However, the potential recipient may not
have been fully evaluated yet or may not have been on the waiting lost long enough to get
"on the trays." It is also possible that one of our patients is getting a 6 Antigen or “zero
mismatch” kidney but he was not close enough to the top of the waiting list to be on the
trays. Another scenario is when the patient may have had a blood transfusion or infection
since the last crossmatch specimen was sent to ITL, and so needs repeat crossmatching. In
all these cases, the crossmatch is drawn on admission and the results take a few hours. If
the crossmatch is positive, the organ is offered to someone else.
There will be rumors about CRT(cadaver renal transplant) admissions, but until the
pretransplant coordinator gives the name of the recipient to the charge nurse on 9 Long,
don’t assume too much. The pretransplant coordinator also notifies the transplant fellow,
the OR, and admitting. Most pretransplant coordinators are also paging the intern on call.
The attending surgeon on call already knows about the patient because he or she accepted
the organ and reviewed the potential recipient with the coordinator. The inpatient
transplant coordinators are not usually on the list of people to be notified except by email,
which may be several days later.The pretransplant coordinator also tells the charge nurse
the ETA, what kind of dialysis the patient is on, when last dialyzed, age, and whether a final
crossmatch is needed. They may also say the patient needs his serologies drawn. This is the
set of hepatitis, RPR, HIV, CMV, and EBV labs that need to be reasonably current at the
9
time of transplant. Occasionally, the patient may be in need of a cardiac or other consult
and the coordinator will tell the charge nurse if the consulting MD has already been called.
Some patients are due for dialysis about the time they are called in for transplant. The
attendings may decide to have the patient go right to dialysis as soon as the patient is
admitted. Pre-op labs can be drawn by the dialysis nurse. If the patient is on CAPD
(Continuous Ambulatory Peritoneal Dialysis), he is instructed to bring enough supplies for
three exchanges. In most cases, the patient will continue doing the exchanges per his usual
routine until the time he goes down to the pre-op area. The peritoneal cavity should be
drained before the transplant surgery begins.
INTERN/RESIDENT RESPONSIBILITIES for cadaveric
transplant admissions
WHO CAN HELP
When the transplant office in the ACC is open, the pretransplant
shadow chart will be sent over. If the office is closed, obtain this
chart from the cart in Rm M893. The key to this room is at the
9L nurses station on a very heavy piece of hardware. If the chart
is not in M893, make sure the surgeon does not have it. If not,
the chart will most likely be on the plaza level of the ACC (400
Parnassus). However, at this time, there is no key available for the
interns to use to get into the building after hours. Call the
attending surgeon if you are unable to locate the chart. The
attendings have keys. Finally, if the chart still cannot be found,
the inpatient coordinators can pull up most of the information on
their computer. The pretransplant coordinator may also be able to
help out as they have access to the computer program at home
that generates parts of the shadow chart and they can fax the
info.
Transplant fellow or inpatient
coordinator
Find out from charge nurse if final crossmatch specimen is
needed
Check with attending (Usually the attending nephrologist) to
determine immunosuppressive plan and eligibility for
investigational protocols
Inpatient coordinator
Obtain consent from patient to participate in research
study if indicated. (Attending nephrologist or research
coordinator can explain study to patient over the phone if
necessary. Residents would never be asked to do more than
witness patient’s signature.)
Transplant fellow or inpatient
coordinator
Determine which serologies are needed. This info is in
pretransplant chart and occasionally in STOR:
 If not done in the last year: HIV, HbsAg, HbcAb, HCVAb,
RPR, CMV Ab, EBV ab screen. (No need to draw CMV if
already +)
Inpatient Coordinator
10
Transplant fellow, inpt coord,
or transplant pharmacist
Obtain consent for HIV test if indicated. Use attending
surgeon’s name for person to whom report will be sent. Give
to secretary to clip to phlebotomy papers.
Inpatient coordinator
Write admission orders using the easy-to-follow preprinted
orders, available for kidney and pancreas recipients. . Check
box if order to be implemented. Follow investigational
protocols as needed.
Inpt coordinator,
transplant pharmacist
As for pt’s usual meds, do not give any ACE Inhibitors.
Almost all our recipients meet the criteria for perioperative
beta blockade. Check with attendings or transplant fellow
re other antihypertensive meds. Don’t worry about
phosphate binders, epogen, cholesterol meds, or vitamins.
Check with attending surgeon about plavix and ASA.
Complete AOS for any antibiotics ordered.
Complete Radiology and EKG requisitions (give to secretary).
The EKG is usually done by the phlebotomy team.
Inpt coordinator (however MD
must still sign).
Inpt coordinator
Draw labs if phlebotomy team not available (Rarely a
problem)
Inpt coordinator
H&P (Must include rectal exam and guiac) Report any
abnormality to attending nephrologist, attending surgeon, or
transplant fellow. The attending may decide if a consult is
needed.
Renal fellow, though H&P from
a surgeon will still be required
within 24 hrs
Follow up on results of EKG, CXR, and other imaging studies.
Transplant fellow, renal
fellow, attending nephrologist
(who prefers to see the EKG
anyway when possible)
Check gram stain on urine and peritoneal fluid. Check cell
count on peritoneal fluid. If the fluid's ANC >50, patient
may have peritonitis even if Gm stain and culture are
negative. (Nursing staff obtains all specimens from CAPD
systems.) Report any positive cell count or culture to
attending surgeon or fellow.
Inpatient coordinator
Check electrolytes: Notify nephrologist or renal fellow if
abnormal. K+ of 5.5 is usual max for anesthesiologist. Pt
may need dialysis before surgery for high K+ or fluid
overload. Do not give kayexalate or IV cocktail to lower K+.
Renal fellow, inpt coordinator
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Obtain consents for surgery, potential blood transfusion
For pancreas transplants: Check with attending surgeon or
transplant fellow for bowel cleansing regimen. What they
use depends on how long it will be before surgery and which
surgeon is doing the transplant.
Inpatient coordinator
ADMISSIONS FOR LIVING DONOR TRANSPLANTS
FYI: Recipients and their living donors are usually admitted the day of surgery. Pediatric
recipients are usually admitted the day before surgery. Cases can be scheduled Monday
through Friday usually at either 0730 or noon. AM cases are admitted directly to the
pre-op holding area on the 4th floor. Afternoon cases are instructed to arrive by 0800 to
admitting and hopefully admitted to 9 Long. It is common to have no empty beds to
accommodate them when they arrive. The nurses are not allowed to save beds overnight
for these patients if there are other patients who need a bed. When 9 Long doesn’t have
a bed, the nurses staffing the discharge lounge on the first floor have an area in which
they can draw blood, start a Hep Lock IV, or do an EKG after about 1030 AM. The 9 Long
charge nurse and the Pre-op staff will coordinate the pre-op placement of the patient.
The chart needs to brought to the discharge lounge if the pt starts there. After
surgery, if there are not enough beds, priority is given to recipients. Donors may be
boarded on other units.
Except for most pediatric recipients, all donors and recipients have their pre-op work-up
done prior to admission. This is done mostly through UCSF’s PREPARE program. The workup is usually completed within a week of surgery.
DONE in PREPARE:
EKG (A donor may have an EKG from the time of an earlier part of the donor evaluation.
If that EKG is normal, it probably does not need to be repeated.)
CXR (Again a donor may have an acceptable film from an earlier phase of the evaluation.)
Labs CBC with diff, BUN, Cr, lytes, Ca, Mg, Ph, Glu, LFTs, PT/PTT, Alb, hepatitis
serologies (if not done in last year), CMV Ab (if negative and not done in last year),
EBV antibody screening (if not done in last year), RPR (if not done in
last year). Note: Donor does not need Ca, Ph, LFTs, Alb if done within last 3
months, and does not routinely need Mg checked at all.
Type and Crossmatch for 2 units PRBCs will be done in Prepare, though if surgery is
more than 72 hours away, only a Type and Screen may be drawn. Check STOR for
expiration date of the crosasmatch specimen.
UA with micro. Donor needs C&S with Gm stain only if UA positive. Recipient needs
12
DONE in PREPARE continued…
culture and Gram stain regardless of UA results. (Note: recipients of deceased
donor kidneys do not get pre-op urine cultures because it will be redone anyway in
the OR when the foley is placed.)
Recipients on peritoneal dialysis need a cell count, gram stain and culture of the
effluent. In most cases, this is completed by the patient’s dialysis unit within a
reasonable time before surgery.
Guiac: In most cases, patients bring a card with them from home and it is tested in
our lab or by the nephrologists.
H&P
Done by an anesthesiologist or nurse practitioner.
Surgical consents, transfusion consents, and advance directive information may or may not
be completed during the PREPARE appointment. This is because the surgeon doing the case
may not be available to speak with the patient that day.
All results are reviewed by the pretransplant coordinator and an attending nephrologist.
High potassiums are treated with kayexalate and/or dialysis. (Patients on hemodialysis are
supposed to arrange to have a treatment at their units the day before admission if that is
not their usual day anyway.) Antibiotics may be started if the urine cultures are positive.
Further work-up may be needed. Patients on hemodialysis often have difficult schedules to
work around, so the case could get postponed if additional studies are necessary.
The pretransplant coordinator will write admission orders on a regular physician’s order
sheet and they are signed by the attending nephrologist. These orders will include stat
lytes for the recipients, and fluid boluses and thrombus preventive measures for the donor.
Type and Cross is added if not done in PREPARE. There may be other individualized orders
as well. Please do not add any more labs to the pre-op orders unless there is a new
problem. (Insurance may not cover repeat studies that were just done a few days
before.)
ABO compatibility forms are completed by the pretansplant coordinators. The white top
copy is placed in the progress notes section of the recipient's inpatient chart. The yellow
carbon copy is kept with the pretransplant shadow chart.
Patients eligible for research protocols are usually approached on the PREPARE day to see
if they are willing to participate. Some refuse or sign immediately, others take the consent
home and give their answer when they are admitted. The research coordinators will follow
up and write study-specific pre-op orders if necessary.
When everything is ready, no later than the evening prior to surgery, the pretransplant
coordinator sends the pretransplant workup chart over, along with the inpatient charts
started by the PREPARE staff. These charts are sent to Joan and Nancy’s office. (The
charts started by PREPARE may be in the usual hard blue binder, a plastic orange binder, or
they may just be in a manila folder.) After reviewing the chart, Joan or Nancy will send the
charts to Pre-op the evening before for early AM cases, and when the pre-op staff calls for
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other cases. The cardboard (blue or brown) chart with the pretransplant evaluation
should not go to the OR!
Whenever possible, Joan and Nancy will review the charts to make sure everything has been
done. If something was missing from the labs, they will either add it on to the specimens in
the lab or add it to the admission orders. They will also check with the research
coordinators to find out if any research studies are possible, and may add protocol-specific
labs to the admission labs. If they notice the patient is sulfa allergic, they will add a G6PD.
(Dapsone is given for PCP prophylaxis in septra-allergic patients, but only if they are not
G6PD deficient.)
INTERN/RESIDENT RESPONSIBILITIES for Living
Donor Transplants
Review pre-op work-up. If studies appear to be missing,
discuss with inpt coordinator, transplant fellow, or
attendings. If the recipient's admission lytes are abnormal,
notify nephrologist immediately
WHO CAN HELP
Inpatient Coordinator
H&P, even though done by Prepare staff. You will note their
physical rarely includes an examination of the abdomen, for
example. This H&P can be done anytime within 24 hrs of
the admission.
Make sure all consents are signed
Determine immunosuppression plan based on enrollment in
research protocols, whether patient is high risk/sensitized,
and surgeon preference.
Inpatient Coordinator,
Transplant Pharmacist,
Attending Nephrologist,
Transplant Fellow
Write immuno and any other additional orders as needed.
Note: No preprinted orders are used pre-op for recipients
or donors who go through Prepare.
Inpt coord, but MD sig needed
14
OTHER ADMISSIONS
FYI: For the most part, transplant patients are admitted to KTU no matter what the
admission diagnosis is. They may be transferred to another service, such as ortho or
vascular, and then only the nephrologist and renal fellow will follow them. If admitted
within 3months of transplant, the patient is supposed to be admitted to the attending
surgeon (Medicare rules). However, many patients admitted for bx during this time are
admitted to the nephrologist and worked up by the renal fellow.
Surgical problems prompting readmission include lymphocele, wound infection or leakage,
occasional urine leak, and hernias. Medical reasons for readmission include rejection,
cardiovascular issues (including dehydration, thrombophlebitis), GI problems, and infection.
Some of the admissions are direct admits from home, some are sent from the pancreas or
kidney transplant clinic, and some are transferred to UCSF from outside facilities. Not
many of the transplant patients actually present to our Emergency Department, but when
they do, the attending nephrologist should be notified right away. If residents get a call
from the ER to come and see the patient, check with the transplant fellow or an attending
physician first. (The ER is supposed to call the attending physician first anyway.)
The charge nurse might not notify the inpt coordinator or housestaff of an admission until
the patient has arrived. However, a name in green on the patient board means that patient
is soon to be admitted, so check the board frequently if you want to know ahead of time
what’s going on. (The blue names are KTU patients, the red names are LTU patients, and
anything else is a patient on another service. The color scheme changes from unit to unit.)
Ideally, patients admitted for surgical problems would be worked up by the surgical
resident, and patients admitted for medical problems would be worked up by the nephrology
fellow. However, the unpredictable nature of the transplant service makes it impossible to
be rigid about this. Teamwork is a requirement. When the renal fellow is in clinic and
unable to get to his/her biopsy (of the transplanted kidney) admissions, the inpatient
coordinator will get things going by checking coags, writing admission orders, scheduling the
biopsy in ultrasound, and putting the consent and pathology papers together in the chart.
She’ll do the same for surgical admissions (except for scheduling cases in the OR). The
renal fellow and the resident can help each other with H&Ps.
Labs
In addition to patient-specific admission orders, the following labs are usually ordered on
KTU patients:
Q AM
CBC, BUN, Cr, lytes, Glucose
Tacrolimus level Q AM if pt is on Prograf.
Cyclosporine level Q AM if pt on Neoral, Gengraf, or Sandimmune.
For all pancreas patients, add amylase.
For a pt with a bladder-drained pancreas, add spot Urine amylase Q AM.
For all pts on anticoagulants: PT, PTT
Starting in AM, sirolimus level Q week if patient on Rapamune
15
The following labs are not routinely done every day and if ordered daily for no good reason,
the coordinators are likely to request they be dc'd. But these labs may be worth adding to
the admission labs on the first day:
Ca, Mg, Ph, ALT, AST, Alk Phos, Total Bili, Alb
For pancreas pts admitted for possible pancreas problems, add lipase
For patients undergoing an invasive procedure, add PT, PTT
Type and Crossmatch for 2 units if going to the OR or having a pancreas
biopsy (4 units for bilateral native nephrectomies and sometimes for
transplant nephrectomies), Type and Hold for other invasive
procedures.
About ordering patient meds:
Most patients, especially newer ones, should have their list of medications with them. The
med card the nurses give them is usually green (pink for large print). If the patient doesn’t
have his card and doesn’t know his meds, but has been hospitalized at UCSF recently, the
inpatient coordinator may have a copy of the card that was given to the patient at
discharge.
To get updates to the med list:
Med information for pancreas patients is in the pancreas transplant nurse practitioner’s
office at 350 Parnassus, 8th floor. Her phone number is 353-1508 and she is in the office
Monday through Friday.
If the patient is within 8 weeks of a kidney-only transplant, call Sue Robertson NP, who
follows the patient closely during those first two months. Her phone number is 415 3538373. Pager 443-9593.
Other kidney patients’ med information is at the kidney transplant clinic, 400 Parnassus, 3 rd
floor. The MD phone there is 74910. The clinic is open Monday through Friday, 0800 to
about 1600.
Many patients are enrolled in drug studies involving experimental drugs. Others are in
studies looking at newer protocols using meds already FDA approved, but their supply may
be provided by the study or there may be placebos. If the patient’s med card says anything
about a drug being a study medication, this info must be written on the admission orders
when the med is ordered. Otherwise, pharmacy and the nurses will not provide the correct
drug to the patient. Specifically, write the name of the study, write that the drug is to be
taken from patient's study supply and specify the times of administration (in case they are
different than the usual times nursing will give the drug). If the patient did not bring his
study supply, his nurse can call the pharmacy to let them know. The inpt pharmacist can
page the investigational pharmacist if nececessary. The transplant pharmacist, inpatient
coordinator, or attending nephrologist can provide more details.
16
DISCHARGES
Discharge Summaries
In general, surgical housestaff dictate discharge summaries on most of the patients on the
service. The renal fellow does the discharge summary on the biopsy patients and a few
others. The same goes for the PDP (Physician’s Discharge Plan). All patients, even those
admitted as 23 hr stays, must have a PDP completed. Dictated discharge summaries are
required on all patients who stay 48 hrs or more. Dictations and PDPs must be completed
immediately: The chart is picked up by medical records the next day.
Meds and Prescriptions
The discharge prescription form is actually an extension of the PDP. This means it must
include all meds the patient will be taking, not just the new ones or the ones that need a new
prescription. On KTU, the transplant pharmacist or the inpatient coordinator will write this
list. This is may be done several days before discharge so it can be sent to the patient’s
outside pharmacy, often a mail order pharmacy. The list is revised and updated by the time
of discharge to reflect new dosages, insurance substitutions, etc. The pharmacist and
coordinators leave notes on the discharge med list for each other and for anyone
discharging the patient on Sunday or holidays, in case there are any loose ends to wrap up
concerning the meds or how the patient is going to get them. The patient’s nurse makes
sure the patient’s med card matches this final list.
Incidentally, a few years ago, UCSF closed its outpatient pharmacy to all but transplant
patients. This pharmacy is now called the Transplant Pharmacy and it is located in the
basement, just next to the Moffitt elevators. It is like any other retail pharmacy in that
the patient’s insurance must allow the patient to use it. (Just because an insurance allows a
patient to get a transplant here does not necessarily mean they allow the patient to get
outpatient meds from the Transplant Pharmacy. ) The Transplant Pharmacy is open Monday
through Friday, 9-5. It will ship prescriptions to patients unable to pick them up. Patients
are instructed to allow a week for a new or refill order to be processed and shipped.
Transfers to other facilities:
A stat discharge summary should be dictated and the transcriptionist should be asked to
fax it to 9 Long before the patient is transferred. The fax number on 9 Long is 353-1954.
The hard copy should be reviewed and signed before it goes into the envelope of transfer
papers.
The intern or resident should also complete the form, “Interfacility Physician Orders.”
Because there is very little room for the list of medications on this form, it is OK to write
“See attached list,” meaning the usual discharge prescription page. The nurse, social
worker, and any physical or occupational therapist complete another form for transfer that
outlines their respective plans of care and other information.
Although the social worker will find the skilled nursing facility or rehab center and set up
transportation, there must be physician-to-physician communication when transferring from
17
one acute facility to another. In most cases, the attending nephrologist will take care of
this but the housestaff or transplant fellow will be the ones to speak with the doctor at
Laguna Honda when patients are transferred back there after dialysis access surgery or
other overnight stays. Transfers back to Laguna Honda must happen before noon, before
the weekend, and will not be accepted unless the doctor there has been contacted.
Follow-up appointments
KTU arrangements for post-discharge care can be rather confusing. Fortunately, the inpt
coordinators or their AA will schedule the appts and give pts their paperwork, including all
necessary lab requisitions. Appt info is written in the bottom right corner of the big
flowsheets used during rounds. In general, pancreas recipients are followed by the
pancreas surgeons, even if those patients also have transplanted kidneys. Patients with a
kidney transplant only are followed by the nephrologists. Unfortunately, the two groups of
doctors do not share the same clinic space. So here is how it works:
Patients with just a kidney transplant:
New kidney transplant recipients are closely followed for the first 2-3 months by Sue
Robertson N.P. They are followed in the “8 Week” or “Acute” clinic. This is physically the
same space as the regular kidney transplant clinic, but the staff are focused on the new
patients.
On the day of discharge, the attending nephrologist or inpatient coordinator will tell the
patient what day to return to clinic. For new patients, the first visit is usually on a Monday,
Tuesday, or Thursday. The inpt coordinator will make the appt and give the pt the
information. Thereafter, the patient needs to call the clinic and make the appointment
himself.
The coordinators fax information about the patient to the clinic and facilitate transfer of
the patient to the outpatient service.
The kidney transplant clinic is located at 400 Parnassus, Room 333.
Hours: Technically, the clinic is open 0800-1600 Monday through Friday, closed holidays,
including university holidays. . For urgent problems off hours, patients are instructed to
call the transplant answering service.
Phone Numbers:
Main KTU clinic
353-8377
353-4183
74910
Number pts can call to make appt
fax
direct line to nurse practitioner
18
Patients with a pancreas or pancreas/kidney transplant
The pancreas surgeon who operated on the patient, or the pancreas surgeon on call, tells the
patient what day to come to pancreas clinic. It will almost always be a Tuesday because
that is the only day there is a pancreas clinic. Cely Hynson, the post pancreas transplant
coordinator, will give the patient a more specific time. The inpatient coordinators will
contact Cely regarding appointment times and will give the patient this information.
Cely is also the person pancreas patients should call if they have any questions or problems.
Her phone number is 353-1508 and her fax number is 353-2558. She is generally available
Monday through Friday, 8-5. If patients have problems at other hours, they should call the
kidney transplant answering service (415) 353-1551 and be sure to mention they had a
pancreas transplant.
Cely’s office is in the kidney transplant service’s offices at 350 Parnassus, 8 th floor. This is
where she keeps clinic charts she is working on. However, the pancreas clinic is located
within the liver transplant clinic, at 400 Parnassus, 6th floor. Do not call the liver transplant
clinic to make an appointment for a pancreas clinic visit. Call Cely. However, it is unlikely
you will need to worry about this as the coordinators take care of it.
If a kidney pancreas recipient loses his/her pancreas or has major medical issues like
severe HTN, the care may be transferred to the kidney transplant clinic.
Donors
Donors are usually instructed to follow-up in the “8 Week” clinic in 7-14 days. This usually
coincides with their recipients’ first or second clinic visit.
Before the surgery, donors are given a booklet of discharge instructions specifically written
for them.
The donor’s discharge meds are filled by the inpatient pharmacy. That way, the cost can be
included with the charges for the hospitalization, which is usually covered by the recipient’s
insurance. Once the donor is discharged, he will have to pay for his meds. Discharge meds
provided by the hospital will include pain meds, colace, and anything else needed as a result
of the nephrectomy. Although anti-ulcer meds are given during the donor’s hospitalization,
they are not usually continued after discharge. If the donor was on other meds prior to
admission, these meds will be provided while the patient is in the hospital, but no supply will
be issued at discharge.
Appointments in other clinics:
If physicians from other services do not give the patient a specific appointment, the patient
should be given the name and phone number of the clinic to call. If there are scheduling
difficulties, such as a need to coordinate several appointments, the inpatient coordinators
will usually help the patient.
All stent removals (except those requiring the OR) will be scheduled for 6-8 weeks after
the stent is placed, unless other instructions are given. The inpatient coordinators schedule
19
the procedure with Dr Marshall Stoller, unless otherwise instructed. They will give the
patient information about the procedure and will order three doses of antibiotic for
prophylaxis (usually Cipro 500 mg) to be taken at the time of stent removal.
Foleys can be removed by Sue Robertson in the transplant clinic. The inpt coordiantors will
arrange this.
Labs
If labs are needed before the next visit at UCSF, the inpatient coordinators will give the
patient a requisition. Note: Kaiser patients are given a Kaiser lab requisition that is
preprinted with UCSF specific information.
Home Care
Joan and Nancy (inpatient coordinators) notify Jenny (case manager), who will contact
outside agencies and arrange home care. This can rarely be done on weekends. Even if
planned on a Thursday, many agencies have already assigned all their staff and are unable to
service the patient. Please anticipate home care needs as early as possible.
Scheduling Readmissions
If, at the time of discharge, there are plans to readmit a patient, the inpatient
coordinators will do the admission reservation and start the admission orders. If the
decision to admit is made after the patient has been to clinic, the clinic receptionist will
schedule the admission.
Patients who have received a pancreas transplant alone (PTA) or have a bladder-drained
pancreas transplant) may be readmitted for routine surveillance pancreas transplant
biopsies 6 weeks after the transplant. The coordinators will set this up.
20
DAILY MANAGEMENT OF PATIENTS
FYI
Routines:
0600-0800
0800-0900
0900-1000
1000-1030
1030-1200
Afternoon
Afternoon
Housestaff prerounds
Breakfast and/or grand rounds. Liver and Kidney transplant complications
conference is on Friday at 0800.
Inpatient coordinator and pharmacist write labs onto flow sheets and check
that new patients’ immunosuppression doses are written in.
Multidisciplinary rounds with Attending MD, Pharmacist, Social Worker,
Independent Donor Advocate, Physical Therapist, Nutritionist, Staff RN,
Case Manager-Home Care Liaison, and Transplant Coordinator.
Rounds with attendings, housestaff, in-pt coordinator, and pharmacist.
Other nurses are welcome to join. (These rounds are usually at 0800 on
weekends and major holidays)
Tacrolimus and cyclosporine levels back. The in-pt coordinator will review
them with attendings and/or transplant fellow.
Review the list* with the team. The coordinator and pharmacist should be
included.
* The list, updated continuously by the housestaff, is used by several people not usually
present on rounds. This means that when copies are made for 10 AM rounds, plan on
making 12-15 copies. Also, please include the patient's visit number, as this is needed
for dictation.
Labs, cultures, and IVs
 The coordinators will add missed labs and cancel unnecessary ones as they see the need.
 On all transplant recipients, labs are done QD, as outlined in. If a patient is very stable,
lab frequency can be reduced after a discussion on rounds.
 All routine and stat labs, including peripheral blood cultures, can be done by the
phlebotomy team, but they must have a written order. If a test can be added to blood
already in the lab, please specify in the order “add to this AM’s labs,” or whatever. If
the lab cannot be added, please consider whether the test will even be run before the
next AM draw. If not, please write the order specifying to be drawn with next AM’s
labs. Your patients will greatly appreciate your thoughtfulness in avoiding unnecessary
needlesticks.
 If the phlebotomy team is unsuccessful, the RNs will attempt the stick or draw from a
central line, if there is one. If the dialysis fistula is the only option, an RN trained in
sticking the fistula may use it. However, Joan McElroy, the dialysis nurses, and Pete
21
Calixto (9 Long staff nurse) are the only RNs who are trained. If all the attempts by
RNs fail, the MD is responsible for obtaining the specimens.
 IVs are placed by the nursing staff. If they are unsuccessful, the MDs are responsible
for getting the line in. For patients with access issues, consider a PICC line. At UCSF,
there are RNs who insert these catheters and others similar to them. They have a
voicemail on which to leave the order. They work Monday through Friday 8-4. If
unsuccessful, Interventional Radiology will try.
 MDs remove all central lines, including PICCs. The inpatient coordinators can also do this
when the MDs are in the OR and the patient needs to leave. Please check with nursing
before removing a central line. The nurses may want to give one last IV med before the
line is removed, especially if the patient has poor peripheral access. If there is no
specific reason to DC the catheter (i.e., the WBCs are not elevated and the patient is
afebrile), the nurses may need the line to draw labs.
 Coming very soon: preprinted orders specifying how to flush the various catheters. These
will need to be completed on every patient with any kind of IV.
 Cultures may be reviewed by the inpatient coordinators and the pharmacist, but it remains
the residents’ responsibility to follow them. When ordering antibiotics, keep in mind
that most antibiotics ending in “mycin” or “azole” will greatly increase the levels of
calcineurin inhibitors (tacrolimus and cyclosporine) and sirolimus. If these antibiotics
are necessary, the immunosuppression doses may need to be decreased. (See article
elsewhere in this orientation packet.) An AOS (Antibiotic Order Sheet) must be
completed for all new antibiotics or when an antibiotic is changed from IV to po (or po
to IV), but not when there is a dose change. The top sections of the form must be
completed or the med will not be continued for more than 24 hours, if it is sent at all.
 If a patient is suspected of having C-diff (or any other communicable condition), please
inform the charge nurse so the patient can be instructed on the proper precautions.
 CMV infection is usually suspected in patients who are febrile, especially if the WBC is
low. To check for CMV infection, order a CMV antigen. If you just order CMV culture,
the wrong test may be done (such as CMV antibody). The specimen for the CMV Antigen
(one large lavender top tube) must be in microbiology by 1400 Monday through Friday or
it will not be run, even the next day. The patient will have to be stuck the next weekday
morning. Results are usually back by the next weekday.
 When deciding whether to obtain blood cultures on a febrile patient, keep in mind we are
more likely to treat low grade infections in our immunocompromised patients. However,
also keep in mind that fever is a common side effect of thymoglobulin and even more
common with OKT3.
22
Imaging procedures
 Physicians are responsible for completing the requisitions for imaging studies. The reason
for the exam must be included, along with the pager number of the ordering MD. Leave
the requisition in the patient’s chart. The secretary will schedule the chest xrays, but
the physicians and coordinators must schedule all other procedures with the appropriate
departments. Please tell the secretary and the patient’s nurse (or the charge nurse) if
a patient will be going anywhere.
 If a patient is an outpatient, the ICD-9 code must be written on the requisition. For a
patient with a kidney transplant, the code is V42.0. If a patient has a pancreas
transplant, the code is V42.8. If a patient has both a kidney and a pancreas, both codes
must be written.
 For any procedure, there must be an order that clears the patient for transport off the
floor. (i.e., “OK for pt to leave 9 Long for CXR.”)
 A renal transplant ultrasound (usually with doppler) is usually done when
 there is no apparent function right after a transplant,
 there is a rise in the creatinine after it had been falling steadily after transplant,
 there is a sudden rise in creatinine in a patient who had been doing well,
 the patient complains of unusual pain in the abdomen
 A perinephric or other nearby fluid collection is suspected
 Localization is needed for percutaneous biopsy of the transplanted kidney
Interpretation of renal ultrasound:
The US of the transplanted kidney evaluates 5 areas
1. +/- swelling
2. sinus (pelvic fat)
3. medullary pyramids
4. +/- pelvi-infundibular wall thickening
5. resistive index
The resistive index (RI) is determined by a flow Doppler analysis of the arcuate
arteries in the transplant and is expressed as a percentage
Peak systole - end diastole
RI% = _____________________________ X 100
Peak systole
Normal: No dilation of pelvis or ureters, may have small perinephric fluid collections
(seroma, hematoma), normal appearing sinus fat and corticomedullary junction. The
RI is usually < 70%. This is also seen with CSA toxicity, tacrolimus toxicity, ATN,
and chronic transplant nephropathy.
Acute rejection: (Note: The following changes are seen when creatinine elevation is
greater than 1.0 mg%) Swelling of the allograft, reduced sinus fat (from
23
compression), prominent medullary pyramids, pelvi-infundibular thickening, and RI >
70%.
Obstruction: Dilated collecting structures (either intra-ureteral obstruction or
peri-ureteral obstruction, secondary to lymphocele, also seen on US). These
changes are normally followed up with antegrade pyelogram, decompression of the
kidney via nephrostomy tube, stenting of the ureter if indicated, and possibly
surgery.
Ureteral obstructions several months after surgery may be associated with polyoma
virus infection. This BK virus is omnipresent and harmless in the immunocompetent
patient, but is now emerging as a major cause of graft loss. Blood and urine samples
may be sent for BK virus quantification by PCR.
 A pancreas transplant ultrasound, usually with doppler, is generally done when
 Rejection of the pancreas is suspected
 Fluid collections around the pancreas are suspected or need to be monitored
 The pancreas needs to be localized for a biopsy
 A nuclear medicine “Mag 3” scan is usually done to
 R/O urine leak, suspected when the patient has abdominal pain, especially if the pain is
associated with urination. (As isotope is excreted, it should follow the urinary path,
showing up in the ureter, then the bladder, then the foley or urethra. Deviations
from this path, especially those that look like little blips or sprays near the ureterovesicular junction are suspicious for urine leaks.)
 Assess renal blood flow (severe reduction of isotope uptake in the kidney would be
consistent with very poor renal blood flow.)
 A CT of the abdomen (and maybe pelvis) is ordered when the US is inconclusive. It is
usually the better study for assessing wound dehiscence, abcesses, and assessment of
PTLD (post transplant lymphoproliferative disorder). If renal function is marginal,
check with attending for OK on whether to give contrast. For all patients, regardless of
renal function, mucomyst is usually given because one small study implied it has a
protective effect on the kidney. The dose is 600mg po BID X 4 doses. Ideally, the
first two doses would be given prior to the procedure.
Foleys and Bladder Function
 All transplant recipients will have a foley for at least three days after transplant. The
surgeon who did the transplant will be responsible for informing the housestaff if the
foley must remain in place any longer than three days.
 All patients who have undergone a ureteral reanastomosis or had a tiny urine leak treated
only with a foley, will have the foley in for at least 2 weeks.
24
 Foleys may be removed somewhat sooner if the bladder is left intact by doing a ureteroureterostomy (nicknamed "U to U") instead of a neocystotomy. However, the attending
surgeon must decide.
 When a recipient’s foley is removed, he will be instructed to void Q 1 hour. The nurses
will do a PVR after the first three voids, using the bladder scanner. If the PVR is high
despite the patient’s attempts at double voiding, the foley is usually reinserted. If the
patient’s BP can tolerate it, Hytrin or Flomax may be started (though Flomax often not
covered by the pt's insurance once he is discharged). If bladder function is expected
to return very soon, the foley may be removed the next day. The Q hour voids and
bladder scans are repeated. If the patient is still unable to void and is otherwise ready
to go home, he will be discharged with the foley. The nurses will teach him how to use a
leg bag during the day. Foley removal will be scheduled in the transplant clinic. Once
the patient is able to empty his bladder efficiently, he will be instructed to void Q 1-2
hours for a few more days, gradually increasing the time between voidings if the patient
tolerates it.
 All donors also have foleys, but they can usually have the foley removed within 24-48 hrs.
Donors do not need to void Q hour, but should be encouraged to void within 4 hours.
Donors do not need the bladder scanned unless they continue to have problems voiding.
Consults and procedures not related to transplant
1. All consults must be approved by the attending physicians. For liver biopsies and consults,
the liver transplant service is used. For endoscopy, colonscopy, etc, the GI service on
call in the hospital is usually used. For urology, the first choice is usually Dr Marshall
Stoller. For simple consults, the inpatient coordinator can initiate the call to the
consulting MD.
 UCSF may only be authorized to provide transplant related care for the patient. If a
problem is discovered that is not transplant-related and not urgent, check with the
inpatient coordinator or case manager before ordering tests and consults for that
problem.
Immunosuppressive Medications
 See immunosuppression protocols for guidelines on the use and dosing of specific
medications. A few general points to remember:

All antibody preparations (Thymoglobulin, OKT3, Zenapax® (daclizimab), Simulect®
(basiliximab), and a few others not yet FDA approved) are given IV, either centrally
or peripherally. Peripheral thymoglobulin requires a different dilution and has
heparin and hydrocortisone added to the bag. There is a preprinted order sheet to
use for the first dose of Thymoglobulin or OKT3.
25

Steroids are given IV as Solumedrol (methylprednisolone) during induction and until
the patient can tolerate po. It is also given IV when given as a three day pulse for
treatment of rejection. Otherwise, steroids are given po as prednisone, rounding
off to a mg to mg conversion from methylprednisolone. PO doses over 100 mg per
day can be divided.

All other immunosuppressants currently used, including tacrolimus (Prograf®),
modified cyclosporine (Neoral®, Gengraf®), mycophenolate mofetil (CellCept®),
mycophenolic acid (Myfortic®) and sirolimus (Rapamune®), are given po except in
rare instances when IV administration is more appropriate. (Sirolimus does not yet
come in an injectable formula.) Although IV CellCept® is the same dose as po
CellCept®, the dosing of IV tacrolimus or cyclosporine is very different than po.
The attending MD will decide if IV dosing of these immunosuppressants is indicated.

Outside the hospital, insurance dictates which of the modified cyclosporine generics
the patient will receive. Both Gengraf® and Neoral® are available at UCSF, so when
this drug is given in the hospital, the brand the patient will have at home is the
brand used in the hospital as well. The pharmacist and inpatient coordinators will let
the team know which one to write for.
Other medications

All new transplant recipients need prophylaxis against PCP, CMV, and candida
infections. See the handout elsewhere in this orientation packet for more
information. By six months post transplant, these are no longer considered
necessary, though pancreas recipients receive PCP prophylaxis for life. However, if
a patient receives thymoglobulin or OKT3 for treatment of rejection, the
prophylactic meds are recyled. They are all given po.

All new transplant recipients need ulcer prophylaxis. Because of the high doses of
steroids and the high potential for GI irritation from CellCept® and calcineurin
inhibitors (especially Prograf®), H2 blockers are not considered strong enough.
Proton pump inhibitors are preferred. Protonix® (pantoprazole) is the one UCSF
currently has on its formulary. Once the patient is discharged, insurance dictates
which PPI is covered, so patients may come in on Aciphex® (rabeprazole), Prilosec®
(omeprazole), or Prevacid® (lansoprazole). It is OK to switch them temporarily to
whatever is on UCSF’s formulary unless the patient had a specific problem with it.

Blood pressure management involves avoiding hypotensive episodes, including
significant orthostatic changes, as well as treatment of excessively high pressures.
In the early post-op period, it is common to allow the patient to have a pressure
slightly higher than normal. The nephrologists will fine-tune the meds when they
follow the patients in clinic. ACE inhibitors and angiotensin II blockers are not
given just before or for some time after the transplant as they can cause acute
renal failure if there is any problem with the renal artery. ACE inhibitors, however,
are often very effective in lowering the Hct later in patients who develop posttransplant polycythemia. Verapamil is avoided because it interferes with the
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metabolism of cyclosporine, tacrolimus, and sirolimus, causing the levels of these
drugs to be significantly higher.

Electrolyte and mineral abnormalities should be corrected by diet if possible. This is
particularly true for hypokalemia and hypophosphatemia: ESRD patients are often so
accustomed to restricting potassium and phosphorus that just telling them to eat
foods high in these substances is enough to fix the problem. If dietary changes are
not enough, use po meds when possible:
Calcium: Calcium carbonate comes in 500 mg (TUMS) or 1250 mg. As a
calcium supplement, it should be given between meals. If given with meals, it
will bind up phosphorus. It will also bind Cellcept, so it should not be given
within 2 hrs of Cellcept.


Magnesium: At UCSF, magnesium po supplements come as Mag Complex 300
mg tabs. A typical dose might be one tab TID for a magnesium  1.2 mg/dl.
Outside UCSF, magnesium is commonly available as mag oxide in 400 mg tabs.
To make it easier for patients, we just tell them to take the same number of
pills as they did for mag complex. Note: It is not usually considered necessary
to supplement Magnesium in the transplant patient unless the magnesium is
<1.2. These patients are chroncially wasting magnesium secondary to
calcineurin inhibitor therapy.

Phosphorus: There are several po phophorus supplements available. The have
the same amount of phosphorus in each pill or packet (250 mg) and they have
confusingly similar brand names, but they vary greatly in the potassium
content.
o
o
o
K-Phos Neutral (tablet) has 1.1 meq of K per 250 mg Phosphorus. This
is the preferred preparation on KTU.
Neutrophos has 7 meq of K per 250 mg of Phosphorus. This is a large
capsule of powder that is opened and mixed in water.
Neutrophos-K has 14 meq of K per 250 mg of Phosphorus. This comes
in a packet to be opened and mixed in water.
Pharmacy techs often fill the patient’s med drawer with the wrong
preparation. To avoid this, the pharmacists suggest the order be written to
include the amount of potassium desired and the word “tab” in the directions
for K-Phos Neutral.

When replacing potassium by IV, a maximum of 10 meq/hr may be given
without having the pt on a monitor. Pharmacy provides each 10 meq in a 100 ml
bag, but keep in mind that if it is to be given peripherally, this will burn a
great deal. Most patients complain of burning when the concentration is any
higher than 10 meq in 250 ml diluent. If peripheral administration is the only
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IV option, it may take a lot of fluid and/or time to replace potassium.
Consider giving at least part of the supplement po.

In most cases, it is OK to resume pre-op meds such as hormone replacements,
dilantin, ophthalmic medications, etc, but check with the attending
nephrologist before resuming cholesterol-lowering meds, ASA, coumadin,
Epogen, and gout meds.
Post Transplant Fluid Management
The goal here is to ensure good perfusion of the kidney and or pancreas without putting the
patient into pulmonary edema or CHF. For the first 24 hrs, careful assessment of renal
function is required. This includes Urine output, CVP, and Serum Cr (drawn in PACU, again 6
hrs later, and QD)
Immediate Renal Function:
Defined by:
 UO ≥ 1 cc/kg/hr and/or
 Serum Cr decrease by 25% from PACU serum Cr value
In PACU
1.
No Lasix drip
2.
No dopamine drip
3.
Straight rate ½ NS @ 200 cc/hr (living donor recipient)
100 cc/hr (cadaveric recipient)
Inadequate Urine Output
Defined as < 1 cc/kg/hr
1.
Determine CVP (if available)
a.
< 10: Give 500 cc NS bolus until CVP ≥ 10. (Max 1 Liter, then physical
reassessment)
b.
≥ 10: No bolus
2.
Once CVP ≥ 10: Add lasix and/or/dopamine
3.
If no response with increased urine output, decrease IV rate to ½ NS 50 cc/hr.
4.
If urine output increases to ≥ 1 ml/kg/hr,then ½ NS at 100 cc/hr.
(Updated 7/02/08)
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