- Welcome to the Renal Unit
- Outcomes for the Nephrology rotation
- The Working Week
- Duties and information for registrars.
- Acute haemodialysis. Hepatitis B testing.
- Patients for surgery
- Renal biopsies
- Transplant protocols
- CAPD protocols
- Suggested reading
Updated January 2010
WELCOME TO THE RENAL UNIT
We hope your stay with us will be a pleasant and productive one.
The Renal Unit provides a comprehensive service at Tygerberg Hospital including:
MEET THE STAFF
- Renal transplantation.
- Chronic haemodialysis of patients at Tygerberg Hospital, with satellite units at Worcester Hospital, Vredenburg Hospital and Hermanus Hospital. We also have a Private-Public Initiative with the Paarl National Renal Care Unit.
- Continuous ambulatory peritoneal dialysis (CAPD) service.
- Referral service for Tygerberg in-patients and telephonic referrals from surrounding hospitals and private physicians.
- Acute dialysis therapies for acute renal failure or poisonings.
- Plasma exchange.
- Renal biopsy service.
- Outpatient clinics for CAPD, transplants and general nephrology patients.
- Academic activities including research and the teaching of medical students, medical registrars, nephrology trainees, dieticians and clinical technologists.
The Renal Unit has a large staff contingent and it is your interest to know the main role players and their function within the system.
NURSING MEDICAL TECHNOLOGY HOUSEKEEPING
HEADS: Mr Francis Prof Davids Mr Fransman
Secretary: Mrs Marinda Barnard
Social Worker: Mrs Marietjie Swart
Dietician: Ms Nazeema Fanie
Transplant coordinators: Srs Bertha Bailey and Cecelia Gidlin
Clerks: Mr Matthew Thys
We also work very closely with Dr Andre van der Merwe and his registrars in the Division of Urology as well as with Prof Danie du Toit and his team at Vascular Surgery.
OUTCOMES FOR THE ROTATION IN NEPHROLOGY
At the end of your rotation in Nephrology we expect that you will have acquired the following knowledge and skills:
- An understanding of the normal anatomy and function of the kidney, and to use this knowledge to recognise and distinguish normality from disease
- The ability to assess aspects of renal function by performing and/or interpreting the urine dipstix, microscopy of the sediment, urine chemistry, tests of GFR and renal imaging.
- An understanding of the indications for performing a renal biopsy. Trainees should be aware of the contra-indications, preparation required before and monitoring required after the procedure.
- In-depth knowledge of the common causes, pathophysiology, diagnostic work-up and management of acute renal failure (ARF). This includes ARF in the ICU and ARF associated with pregnancy. A focus on the prevention of ARF and a good grasp of the medical (non-dialysis) management of ARF is essential.
- An understanding of the indications for dialysis in ARF and acute poisonings. An appreciation of the limitations, complications and costs of dialysis in this setting. An awareness of the different dialysis modalities available.
- The ability to establish temporary vascular access for haemodialysis by inserting dialysis catheters via the internal jugular, femoral and (when unavoidable) the subclavian routes.
- In-depth understanding of the pathophysiology and management of fluid, electrolyte and acid-base disorders. This includes the correct use of fluid and diuretic therapy.
- An understanding of the normal physiology and the management of disorders of calcium, magnesium and phosphate.
- An in-depth knowledge of the pathophysiology, complications and management of essential and secondary hypertension including a sound knowledge of the drugs used in therapy.
- An understanding of the pathophysiology and the management of common primary and secondary glomerular diseases and interstitial diseases. The trainee must be able to distinguish between nephrotic and nephritic syndromes and know the correct use of biochemical and serological tests as well as the renal biopsy in the diagnostic work-up and follow-up of such patients. Trainees should be familiar with the mechanisms of action and side-effects of the drugs used to treat these patients.
- In-depth knowledge of the common causes, diagnostic work-up and principles of management of chronic kidney disease (CKD). A sound grasp of strategies to retard the progression of CKD is required as is an appreciation of the importance of timeous referral to a nephrologist.
- An in-depth understanding of the epidemiology, pathophysiology and management of diabetic nephropathy with an emphasis on preventing nephropathy in diabetics with microalbuminuria and retarding progression in patients with overt nephropathy.
- An understanding of the pathophysiology, complications and management of autosomal dominant polycystic kidney disease.
- An awareness of the different options available for renal replacement therapy when the patient has end-stage renal disease (ESRD). An appreciation of the costs involved and the ethical issues resulting from a limitation of resources in the public health sector is required.
- An understanding of the principles of dialysis and how these are achieved with haemodialysis and peritoneal dialysis respectively. Trainees must have experience with both peritoneal and haemodialysis including the management of complications of chronic renal failure and dialysis such as anaemia, bone disease, dialysis catheter sepsis and peritonitis.
- An understanding of drug-induced renal disease, including nephrotoxicity related to the use of aminoglycoside antibiotics and non-steroidal anti-inflammatory agents, and drug-induced allergic interstitial nephritis. The trainee must also be familiar with the effects of renal disease on the handling of drugs and the modifications required when prescribing drugs to patients with renal disease.
- Knowledge of the causes and a good approach to the diagnostic work-up of a patient with vasculitis.
- Experience with managing patients who are heavily immunosuppressed – this includes post-transplant patients and patients being treated for immune-mediated renal diseases.
- An understanding of the pathophysiology and management of renal stones, urinary tract infection and urinary tract obstruction.
- Be able to recognise and take care of patients that are potential organ donors. Be confident in their ability to diagnose brain death.
- An understanding of basic principles of pharmacology and the pharmacology of drugs commonly used in renal medicine including immunosuppressive agents.
NB: Be sure to use these outcomes to guide your learning in nephrology! Use them as a checklist and work through them by the end of you rsecond month with us.
THE WORKING WEEK
08h00: Meeting at Department Internal Medicine, Medical School. Compulsory!
09h00: A7 ward round (ward registrar). Transplant clinic (transplant registrar)
10h30: Applied basic sciences discussion (see roster).
11h30: Clinical case discussion.
12h00: Teaching round (all new referrals seen since previous Thursday).
16h00: Departmental pathology meeting (H10).
08h00: A7 round (ward registrar).
08h30: Meeting with urologists in seminar room - all.
08h45: CAPD Clinic (PD registrar, tx clinic registrar, others as soon as they are available).
A7 round (Ward registrar with consultant). Haemodialysis meeting (HD registrars with Prof Davids)
10h30: Journal Club (see roster).
11h30: Patient Assessment Meeting.
13h00: Basic Sciences meeting – A10 Seminar Room
13h30: Renal biopsies at ultrasound department – assist with your own patients.
08h00: Ward registrar round in A7. Transplant clinic (transplant registrar).
09h00: Ward registrar - A7 round with consultant.
10h15: Nephrology outpatients. Please start outpatients on time!! Outpatients gets priority over all other duties. At the end of the clinic we review the folders of all the patients seen. Inform the on-call consultant if you are going to be late or if you have to leave before the clinic is finished.
08h00: Ward registrar round in A7.
08h30 - 10h00: A7 teaching round. All doctors attend.
10h30: General working ward round, starting A7. All doctors.
13h30: Renal biopsies under ultrasound – assist with your own patients.
16h00 - 18h00: Departmental meetings, medical school – compulsory!
08h00: Ward registrar round in A7. Transplant clinic (transplant registrar).
08h30: A7 round with consultant.
10h30: Nephrology outpatients. Please start on time!!
12h00: Renal biopsy meeting with Dr Bates, Pathology Dept.
14h15: General Internal Medicine Grand Round – A5 West – all attend except if seeing referrals on call.
SATURDAY, SUNDAY, PUBLIC HOLIDAYS
A7 and hospital in-patient referral ward round (registrar on call). Inform the Ward sister when you have done your round and are leaving the hospital. Be sure to follow up on blood results sent off in the morning.
REGISTRARS DUTIES AND INFORMATION
Maintain a sense of humour and don’t take life too seriously!
Registrars covering the haemodialysis units: Check in at the unit to sort out any problems at the start of the morning and afternoon sessions (08h00 and 13h00). Make notes of all problems and update the incident list if any major event occurs. Inform the consultant of any major problems and any problems with patients involved in clinical trials. All HD patients must be examined every 3 months and a typed summary made. Use electronic summary template. The dialysis unit sister will arrange dates for you. Focus on vascular access, anaemia, and bone disease. See comments below.
- Registrar covering A7 inpatients (Ward registrar): NB: See ward patients, especially problem patients, before your round with the consultant. Get results (U+E, ciclosporin levels, renograms, sonars etc.) back the same day and tailor management accordingly. Do a round at ~16h00 with consultant and hand over to the person on call. Admission criteria for A7 :
- All transplant and CAPD patients, whatever their problem, are seen in A7 by the transplant/CAPD clinic registrar and admitted to A7 should this be required.
- Patients electively admitted for renal biopsies or making of AV fistulas can be admitted to A7 if beds are available; otherwise admit to Internal Medicine.
- All other patients go to general medical or surgical wards, including chronic haemodialysis patients.
- Summaries are to be completed within 24 hrs of discharge and handed to
- Mrs Barnard for typing!!
- Registrar covering CAPD: See and, if necessary, admit all PD patients presenting in A7 with an acute problem. PD clinic is done on Tuesdays from 08h45 - 10h00. NB: You need to review all the files of patients seen at PD clinic (by all doctors) on a weekly basis before the next clinic, checking and responding to results. Discuss problems with PD consultant, Dr Adeniyi and then brif the clinic Sr-in-charge.
- Registrar covering the transplant clinic: Clinics are on Mondays, Wednesdays and Friday mornings. Only emergencies to be dealt with on Tuesdays or Thursdays. Start early!! Check with Sr. September/Staff-nurse Varrie each morning whether there are any patients who need to be seen. They will also contact you during the course of the day should any other problems arise.
- All referrals must be seen on the same day and be presented to the consultant as soon as possible. Read up on the conditions you see,preferably BEFORE presenting your patient.
- Open a renal folder for all new referrals. If patient has an old renal folder (kept at OPD Clinic), continue notes in old folder. Complete the registration form inside the brown nephrology folder.
- Summarise the problem and state the management plan clearly in the Nephro folder before discharge – then hand folder to Mrs Barnard. Make any follow-up appointment at Nephro Clinic yourself – book pt as a follow-up and not a new patient.
- Keep a record of all referrals (incl. follow-up ward visits). Referrals/statistics for the week must be reported to the ward clerk by 10h00 Thursdays.
- All your patients in peripheral wards must be seen daily. Make daily notes in nephrology folder. Major decisions / recommendations must be personally communicated to the patient's registrar.
- Registrar-on-call must come out at night to see all new referrals or inpatients with an acute problem. No patient is to be admitted to A7 at any time without first being seen by the doctor-on-call (except for PD patients with clear-cut peritonitis).
- Complete dialysis instructions form before dialysis each day - or even previous afternoon. See these patients as early as possible and inform the staff whether patients will need dialysis ASAP.
- The acute referral remains the responsibility of the doctor who first saw the patient. This includes replacement of catheters etc.
- Social assessment: All patients with advanced renal failure (creatinine >500) who may require chronic dialysis must be referred timeously to our social worker (Mrs M Swart) for assessment. All requests for disability grants etc. must also be referred to the social worker. All discussions at the Assessment Meeting are strictly confidential!
- Renal journals are mainly available online via the SU library system. Contact your consultant if you are unable to access a particular journal.
- Good Clinical Practice (GCP): Please document in the patients’ notes any and all complaints, findings and alterations or additions to medication. This is especially crucial in patients on clinical trials. Ensure that all your notes contain an assessment of the problem, followed by a plan that follows logically from that assessment. Ensure that every page of notes has the patient’s sticker, or write the name at the top of the page. Update the problem list daily. Check the meds daily – stop drugs whenever possible. Make sure that you re-write full scripts timeously – especially before the weekend.
- Outpatients: Outpatient clinics take priority over any other duties. Start the clinic as early as you can, but no later than 10h30. We expect to be done by 13h00 on Wednesday and before 12h00 on Friday. Inform the consultant on call if you cannot start on time or if you have to leave before all the patients are seen. Patients are seen in the order in which they arrive – do not pick out folders of patients you have seen before, see the patient next in line! We make no distinction between new patients or follow-ups except that you need to discuss new patients with a consultant. You are likely to learn more by seeing a new patient than by seeing follow-ups where the diagnosis is already established. After the clinic on a Wednesday we review all the patients we’ve just seen. If in doubt, please ask.
- Renal registars are expected to assist the transplant coordinator in the care of potential organ donors.
Inform Haemodialysis Sister immediately you have a new patient requiring acute dialysis. Contact technologist on-call once patient is ready for dialysis.
No acute dialysis/plasmapharesis is to be undertaken without a HbsAg and HIV result! Confirm the telephonic results of Hep B and HIV tests with a computer printout ASAP.
CONTINUOUS RENAL REPLACEMENT THERAPIES (CRRT)
- Insert dialysis catheters well before the patient is due to be dialysed.
- Use internal jugular or femoral vein catheters and avoid the subclavian vein at all costs - very high incidence of venous thrombosis and stenosis.
- The patient must be haemodynamically stable (systolic BP 100 mmHg or above) for intermittent haemodialysis, otherwise use SLED if patient is in an ICU.
- If patient is bleeding or has a pericardial friction rub, heparin-free dialysis is attempted.
- When initiating dialysis, ultrafiltrate first and then dialyse – to avoid dialysis disequilibrium.
- Most patients have some fall in blood pressure - correct with saline, blood, or SHS/Haemacel; ± inotropes.
- Acidosis worsens initially on dialysis - severely acidotic patients (pH <7.10, HCO3 <10) often need NaHCO3 supplementation. These patients are often hypocalcaemic and require prophylactic iv Ca gluconate before NaHCO3 is given.
- The registrar must be available within 15 min for complications arising from starting the first dialysis, unless the patient is in an ICU. Acute dialysis prescription must be completed in before each dialysis. Assess all acute patients each day as soon as possible, so dialysis may be commenced if indicated. Delays in starting means overtime and extra costs.
CVVH(D)/SLED: Double lumen venous catheter (or 2 single lumens) required - for hypotensive patients. Lots of heparin used with CVVHD - about 30000u/day.
Paediatric patients needing dialysis are seen and managed by Dr Nourse or the paediatric nephrology registrar.
Plasma exchange (if requested by Neurology/Haematology) is arranged only through the renal consultant. Two single lumen catheters or double-lumen needed. Renal registrar inserts catheters, thereafter Neurology/Haematology registrar takes responsibility for patients.
Poisoning: HD or charcoal haemoperfusion can be done if indicated - see blue book (poisons index). Haemoperfusion requires two venous lines.
Untoward reactions on dialysis - consider electrolyte abnormalities in dialysate, incorrect dialysate temperature, bacterial or toxin contamination of dialysate (do cultures and endotoxin assays on blood and dialysate), air emboli, complement activation by dialyzer and arrythmias or ischaemia.
URGENT HEPATITIS B SURFACE ANTIGEN (HBsAg) TESTING
Two categories of service: (a) "Same day". (b) "Urgent".
(a) Same day service. Indications: All renal failure patients who might need dialysis in the next 24 - 48 hours. "Same day service" to be stated clearly on laboratory request form. Specimens must reach lab by 12h00 on weekdays and by 08h00 on Saturdays / Public holidays. Late specimens will be held over to the next working day.
(b) Urgent service. Indications: Acute haemodialysis. Arranged telephonically with duty virologist (phone 6234 or 6210 between 07h45 and 16h45 or bleep 589 after hours). "Urgent" to be stated on laboratory request form. Working hours - blood delivered by hand to lab (student or doctor, NOT porter) or by tube. Virology technologist will personally collect specimen, so be clear about where the specimen is being left e.g. fridge in F1, A7 transplant unit etc. Results should be phoned through to you or to ward A7.
THE HBV & HIV RESULTS ARE REQUIRED BEFORE HAEMODIALYSIS IS STARTED
Arrange all biopsies with Sr Cloete, A7 West.
(Ultrasound - telephone 5641.)
Patient needs -
- Radiology form filled in – U/S form or X-ray form;
- Renal biopsy data forms filled in in duplicate;
- Diastolic BP under 95 and systolic under 160;
- No evidence of UTI;
- Normal INR, PTT, PLT count within 48hrs of biopsy. Results to be in folder;
- Consent (by nephrology registrar);
- Pre-med written up: Pethidine 50-100 mg imi, Phenergan 25 mg imi 1hour before procedure.
- Stop asprin 1 week before biopsy (many transplant patients receive aspirin).
All above to be done personally or supervised personally by renal Registrar. You should accompany your patient and observe the biopsy procedure.
PATIENTS FOR ELECTIVE SURGERY
We have space on the Urology slate on Thursdays.
Patients are to be admitted by 10h00 on Wednesday.
Preparation of the patients for surgery is ultimately the responsibility of the registrar admitting the patient, but you should do as much of this work-up as possible on your patient BEFORE ADMISSION.
Avoid transfusions as far as possible. Give blood only if severely symptomatic (angina, heart failure etc.) or if required pre-op. All transfusions must be cleared with the consultant-on-call. Only use filtered red cells in patients who are potential transplant recipients.
Our patients who require parathyroidectomies are in a surgical ward, but are looked after by the Renal Unit.
- Continue usual PO4 binders.
- One-Alpha 4 mg/d po x 3 - 4 days pre-op (last dose on morning of the surgery)
- Check Ca and PO4 levels directly pre-op.
- Check Ca 6-hourly for first 48 hours, thereafter once daily (once Ca level normalizes)
- Aim for corrected Ca 2.1 – 2.5 mmol/L.
- Continue oral calcium supplements between meals
- Continue One-Alpha 2-4 mg/d post-operatively (and decrease if Ca >2.4mmol/L)
- Check Mg.
- IV Replacement if Ca ≤1.8mmol/L OR patient is symptomatic (NB: Use large peripheral vessels or central line as IV calcium causes tissue necrosis if it extravasates – Ca-gluconate is preferred to Ca-chloride – use cardiac monitoring to assess for arrhythmias).
- In emergency situation 10-30mls 10% Ca-gluconate ivi as slow push over 10-15minutes
- Otherwise 100ml (10 amps) 10% Ca-gluconate in 150mls 5% dextrose water starting at 20 – 40ml/hr according to 6-hourly Ca level. [Karen Bronn – Dec 2009]
CHRONIC HAEMODIALYSIS PROTOCOLS
Be sure to check in at the HD unit to sort out any problems at the start of the morning and afternoon sessions (08h00 and 13h00).
Make notes of all problems and update the incident list if any major event occurs. Inform the consultant (Dr Adeniyi or Prof Davids or Consultant-on-call) of any major problems and any problems with patients involved in clinical trials. Make sure that your notes includes the dose and duration of any treatment prescribed.
All HD patients must be examined every 3 months and then presented to Dr Adeniyi after which your summary must be handed to Mrs Barnard for typing. Liase with the dialysis unit sister and Natasha Stegmann (Senior Technologist) to arrange dates for examining the patients. Focus especially on the following -
- Vascular Access: all patients should be dialysed through an AV fistula. Any patient being dialysed through a temporary catheter should be on the surgical waiting list for a new access.
- Anaemia: the target Hb for our HD patients is 10-12 g/dl. Follow a step-wise approach to correct anaemia. See below:
- Ensure that there is no Fe deficiency – TSAT must be 20-50% AND ferritin 200-500. Begin by using oral FeSO4 2 tds or 6 nocte and repeat after 1 month. If still Fe deficient on oral Fe then use intravenous Fe sucrose (Venofer 3 x 100mg amps over 1 hour) with each dialysis for a total of 900 -1200 mg.
- Once Fe stores adequate and still anaemic, start synthetic erythropoetin – usual starting dose 2000u 3 x wkly
- Always look for other causes of anaemia – GI bleeding, chronic inflammation or infection etc.
- Avoid blood transfusions (use only filtered RBC) – discuss with consultant first!
- Bone disease: you should know the different types of renal bone disease.
- Hyperparathyroidism is a common problem – we aim for levels 3 x the usual upper limit of normal i.e. around 20. We use CaCO3 (2 tds with meals) as a phosphate binder and involve the dietician as well to help compliance with a low phosphate diet. Hyperparathyroidism is also treated by suppressing PTH release with vitamin D (One alpha 0.25 ug/d) and raising Ca levels. Beware of causing hypercalcaemia and a high Ca-P product! Parathyroidectomy is considered if these measures fail and there is evidence of bone disease (high ALP, X-ray changes etc).
- Aluminium-induced osteomalacia is another cause of bone disease – blood levels are checked by the technologists 6 monthly.
- Dialysis adequacy and general well-being: Base this important assessment on your overall clinical impression, serum albumin level, and only then on markers of adequate dialysis like a urea reduction ratio of >65% and KT/V of >1.2.
- Cardiovacular disease: remember that the main cause of death in our patients is cardiovascular disease, so pay attention to all the usual risk factors and also non-traditional risk factors like chronic fluid overload, anaemia, inflammation (check CRP) and malnutrition.
NB: Your summary must clearly state whether the patient is fit for transplantation and also how you plan to address problems like these listed above.
Definitions and notes
Screening for anaemia should be done at least yearly in patients with CKD.
Assessing iron status - serum ferritin target should be 200-500 ng/ml and TSAT 20-50%.
Iron deficiency is present if ferritin <200 or TSAT <20%.
Iron therapy – start with oral FeSO4 6 nocte for 1 month, and change to intravenous Fe therapy if still Fe deficient. This will be necessary for most patients as oral Fe is often poorly absorbed and poorly tolerated.
Target Hb is 11-12 g/dl.
Most patients will require EPO therapy to maintain target Hb. Higher doses are used during the initial correction phase, and during the maintenance phase the EPO should be titrated by the attending nephrologist to the lowest effective dose. Subcutaneous administration is most cost-effective.
A poor response to EPO treatment may be caused by inadequate dialysis, inflammation or malnutrition. These problems are usually association with a low serum albumin and/or a high CRP level. Hyperparathyroidism or aluminium toxicity may also cause EPO resistance.
RENAL TRANSPLANT PROTOCOLS
The likelihood of a successful outcome for the transplant recipient is greatly influenced by the quality of care of the organ donor.
The transplant co-ordinator is primarily responsible for overall management of the potential donor, but registrars may be asked for medical support.
GOALS OF OPTIMAL DONOR MANAGEMENT:
(Zaroff et al, Circulation 2002; Wood et al, NEJM 2004)
- Volume status: CVP 6 – 10 mmHg
- Maintain mean arterial pressure ³ 60 mmHg
- First choice agents are dopamine 5-10 mg/kg/min and dobutamine £ 10 mg/kg/min: Thus, for a 70 kg patient…Dopamine 200 mg in 200 ml saline: titrate upwards to maximum ± 40 ml/h, Dobutamine 250 mg in 200 ml saline: titrate upwards to maximum ± 35 ml/h
- Add adrenaline infusion 20 mg in 200 ml saline
- If adrenaline ³ 0.05 mg/kg/min (i.e. ³ 2 ml/h of 20 mg in 200 ml) required, then give bolus methylprednisolone 15 mg/kg. Repeat in 24 hrs.
- pO2 > 10 mmHg or Sats > 95%; pC02 4 – 5 mmHg
- pH 7.40 – 7.45. Bolus doses of sodabic may be required
- Hb ³ 10 (or hct ³ 30%) to improve tissue oxygenation. Use filtered RBC
- Maintain core temperature > 35°C. Warm blankets and warm replacement fluid.
- Correct electrolyte abnormalities: U&E 4 - 6 hly. Hyper Na+ due to diabetes insipidus: give DDAVP 4 mg 1-2 times dly
- Maintain normoglycaemia by IV insulin infusion, e.g.: 50 Units actrapid in 50 ml saline,
Do hourly HGT:
3 – 6 0
6 – 8 1 ml/h
8 – 10 2 ml/h
10 – 12 3 ml/h
12 – 14 4 ml/h
³ 15 5 ml/h
PRE-OPERATIVE ASSESSMENT OF THE KIDNEY TRANSPLANT RECIPIENT
- Cause of renal failure
- Recent infections
- Dialysis history
- Ischaemic heart disease
- Previous transplant history
- Peripheral vascular disease
- Urine output per day while on dialysis
- Urinary tract problems
Recipient blood group, tissue typing and virology (CMV, HIV, HBV, HCV)
Donor age, cause of death, ischaemic time, blood group, tissue typing, virology
(Transplant co-ordinator will provide the information)
- Mass compared to dry weight Fluid status.
- Evidence of infection Peripheral pulses and bruits
- Cardiac murmurs and extra-sounds Abdomen – scars
ANY FINDINGS FROM THE HISTORY OR EXAMINATION THAT MAY HAVE IMPLICATIONS FOR THE PROCEDURE MUST BE DISCUSSED WITH THE NEPHROLOGY CONSULTANT AND THE TRANSPLANT SURGEON
- U&E, Ca, glucose
- Baseline LFT’s
- PTT, INR
- Blood group & save
- CMV IgG
- HIV, HBV
- Tissue typing
Gastroscopy for patients with dyspeptic complaints
- Haemodialysis only if absolutely necessary – usually only for hyperK+. Discuss with the consultant on call.
- CAPD - continue dialysis as normal - empty abdomen just before theatre.
- Diabetics - sliding scale and 5% Dextrose drip once NPM.
- “Routine” anti-hypertensives are taken as usual pre-operatively, except ACE-inhibitors, ATII receptor blockers and diltiazem.
- Omit diuretics, NSAID’s, warfarin
Methylprednisolone pulse, plus
Ciclosporine-based triple therapy
- Ciclosprine 4mg/kg 12 hourly
- Trough(C0) level first 6 months Trough(C0) level after 6 months
- 260-350 ng/mL 150-250 ng/mL
- C2-level first 6 months C2-level after 6 months
- 800-1100 ng/mL 600-900 ng/mL
- Prednisone 30 mg daily
- Weeks 0-4 - 30mg
- Weeks 5-6 - 25mg
- Weeks 7-8 - 20mg
- Weeks 9-10 - 15mg
- >=10 weeks- 10mg
- Azathioprine 50 mg daily
[Azathioprine 1mg/kg/d (i.e. 75-100 mg/d) for patients at high risk of rejection]
Patients with a high risk of acute rejection:
1. Current panel reactive antibodies > 50%
2. More than one previous transplant
3. Previous episodes of acute rejection
MODIFICATIONS OF THE STANDARD PROTOCOL
- IL2-receptor monoclonal antibodies added to induction therapy in high risk patients (see later)
- Tacrolimus-based triple therapy
Superior to ciclosporin-based triple therapy, but costly. May consider as first-line therapy in medical aid patients.
Tacrolimus 0.1 mg/kg 12 hourly
- Trough level first 6 months - 10-15 ng/mL
- Trough level after 6 months - 5-10 ng/mL
- Mycophenolate mofetil (MMF)
Consider substituting azathioprine with MMF in patients at high risk of rejection who have medical aid.
MMF 1g 12 hourly with ciclosporin
MMF 500mg 12 hourly with tacrolimus
- Sirolimus – see later
ROUTINE INDUCTION PROTOCOL
Thorough clinical evaluation
CMV IgG, HIV, HBV
Solumedrol 500 mg IV (post dialysis)
Ciclosporin 4 mg/kg
CXR to check CVP position
Monitor CVP & urine output hourly
Maintain CVP between 8-10 cm H2O:
§ >10: Rehydration fluid 30 ml/hr
§ 8-10: Rehydration fluid 30 ml/hr PLUS
§ <8: Rehydration fluid 30 ml/hr PLUS
urine output PLUS boluses
normal saline / colloid
Morphine 2-4 mg/hr/IV prn
40% O2 facemask
Solumedrol 500 mg IV
Ciclosporin 4 mg/kg 12 hrly
(2.5 mg/kg 12 hrly IV if vomiting)
Azathioprine 50 mg daily
Prednisone 30 mg daily
Ulsanic 1g 12 hrly
Aspirin 150 mg daily
Ampho B lozenges 1 tablet 6 hrly
Bactrim 2 tablets daily
CVP removed if stable – all lines removed under Cefzol 1 g IV cover
Solumedrol 250 mg IV
Solumedrol 125 mg IV
Remove Portovac under antibiotic cover once drainage <50 ml/d
Ciclosporin levels Mondays, Wednesdays, Fridays – adjust dose same day:
Target trough level 260-350 ng/mL*
Remove urinary catheter (Zinacef cover) unless patient polyuric
Ciclosporin 12 hrly
Azathioprine 50 mg daily
Prednisone 30 mg daily
Bactrim 2 tablets daily (1 year)
INH 300 mg daily (1 year)
Pyridoxine 25 mg daily (1 year)
*If ciclosporin level >500 ng/mL, omit one dose and reduce by 50 mg 12 hourly
Dose adjustments usually 25-50 mg 12 hourly
Therapeutic ciclosporin levels must be achieved within the first week.
INDUCTION WITH IL2-RECEPTOR MONOCLONAL ANTIBODIES
(Not routinely available at Tygerberg Hospital – consider in selected cases)
1. Risk of delayed graft function (cold ischaemia > 24 hrs, donor ATN, donor given inotropes, donor age > 50 yrs)
2. Panel reactive antibodies > 50%
3. Previous transplant (particularly if previous rejection)
4. Black patients
Basiliximab (Simulect® - Novartis) 20 mg IV pre-op in theatre before reperfusion and 20 mg IV on day 4
Daclizumab (Zenepax® - Roche) 1 mg/kg IV pre-op in theatre before reperfusion and 1 mg/kg on day 5 (more cost effective than the 5 dose regimen)
All other immunosuppression will be given as usual, but ciclosporin may be withheld in patients with delayed graft function until Creatinine < 300 µmol/L.
Alternatively, initially start with lower ciclosporin doses, e.g. 100-150 mg 12hly (less urgency to achieve therapeutic levels rapidly).
Induction with lymphocyte depleting polyclonal antibodies is more effective than IL-2 monoclonal antibodies at preventing acute rejection in high risk patients. Depleting antibodies pose a greater risk of death from infection or malignancy and therefore we do not recommend its use as induction therapy in our population.
TREATMENT OF ACUTE REJECTION
CicloHexal® [Hexal Pharma (SA)] 25 mg and 100 mg soft gelatin capsules – generic drug currently used at Tygerberg Hospital
Neoral® (Novartis) 25 mg, 50 mg and 100 mg soft gelatin capsules most widely used
- Gingival hypertrophy
- Raised AST/ALT
- Acute pancreatitis
- Increased urate
- Skin thickening
- Brittle nails
- Kaposi sarcoma
- Burning sensation in limbs
- High turnover osteoporosis
Ciclosporin is metabolized by the cytochrome P450 system in the gut wall & liver and the metabolites are eliminated in the bile. Renal failure and dialysis do not influence the levels.
P450 inhibitors increase CsA levels
P450 inducers reduce CsA levels
St. John’s wort
Drugs with additive nephrotoxicity
Ciclosporin enhances the risk of statin induced rhabdomylosis.
Use potassium sparing diuretics and potassium supplements with caution – risk of hyperkalaemia.
Prograf® (Adcock Ingram for Fujisawa) 0.5 mg, 1 mg and 5 mg capsules
Tacrolimus 0.1 mg/kg 12 hourly:
- Trough level first 6 months- 10-15 ng/mL
- Trough level after 6 months - 5-10 ng/mL
Dose adjustments by 1-2 mg per dose.
Do levels 2-3 times per week until stable.
Switching ciclosporin to tacrolimus: divide total daily ciclosporin dose by 30 to determine total daily dose of tacrolimus.
Very similar to ciclosporin, but less hirsutism, gingival hypertrophy, hypertension and hyperlipidaemia.
Also nephrotoxic and neurotoxic.
Much greater risk of post transplant diabetes mellitus than ciclosporin – particularly a problem in South African black patients.
Tacrolimus is also metabolized by the cytochrome P450 system and therefore blood levels are influenced similarly to ciclosporin (see list under “Ciclosporin”).
Tacrolimus itself has an inhibitory effect on CYP3A4 of the cytochrome P450 system. Tacrolimus may therefore enhance the potency of other drugs metabolised by CYP3A4 dependant pathways:
- Dose of MMF reduced when prescribed with tacrolimus (MMF 500 mg 12 hourly vs. MMF 1 g 12 hourly with ciclosporin)
- Never prescribe ciclosporin with tacrolimus. The first dose of tacrolimus should be administered 24 hours after the last dose of ciclosporin when switching from ciclosporin to tacrolimus.
- An enhanced potency of steroids partly explains the increased risk of post transplant diabetes mellitus with tacrolimus-based triple therapy.
Imuran® 25 mg and 50 mg tablets
Generic equivalent by Hexal Pharma (SA) 25 mg and 50 mg
We use low dose (50 mg daily) azathioprine as part of triple therapy immunosuppression.
The conventional dose of 1-2 mg/kg (i.e. 75-100 mg) daily may be considered for patients at high risk of acute rejection.
- Bone marrow
- Reduced WCC , reduced PL, reduced Hb (macrocytic)
- May necessitate azathioprine dose reduction
- Stop if WCC <3.0 and restart at lower dose once WCC >3.0
- Acute pancreatitis
- Fragile, thin skin
Allopurinol inhibits the metabolism of azathioprine and may cause fatal neutropaenia.
Preferably avoid allopurinol. When indicated, reduce the dose of azathioprine by 50% and titrate allopurinol upward slowly from a low dose. Monitor FBC frequently.
MYCOPHENOLATE MOFETIL (MMF)
CellCept® (Roche) 250 mg capsules and 500 mg tablets
MMF 1g 12 hourly with ciclosporin
MMF 500mg 12 hourly with tacrolimus (1g 12 hourly with tacrolimus only for the first 2 weeks after transplantation)
Blood level monitoring not required
- Bloating, abdominal pain, diarrhoea, vomiting
MMF is usually taken on an empty stomach, but GIT side effects may improve if taken with food
- Bone marrow
- Decresed WCC , decreased PL, decreased Hb
- Small increase in CMV disease cf. Aza
Low incidence of PCP – MMF has anti-Pneumocystis carinii activity
MMF potentiates activities of acyclovir and ganciclovir
Rapamune® (Wyeth) 1 mg tablets
Trough levels on Tuesdays or Thursdays. Blood must reach UCT lab before 10H00.
Trough level 8-12 ng/mL
Reduce ciclosporin total daily dose by 25% per week over 4 weeks
Reduce azathioprine to 50 mg/day immediately
Reduce MMF to 500mg 12 hly immediately
Steroid dose remains unchanged
Start Sirolimus 3 mg daily.
Trough levels 2-weekly: 8-12 ng/mL
Dose adjustments by 1-2 mg.
Note: Allow at least 7 days after dose adjustment before the next trough level is performed.
Indication: calcineurin inhibitor induced HUS/neurotoxicity
Stop calcineurin inhibitor.
Loading dose Sirolimus 15 mg on day 1. Then start 5 mg daily on day 2.
Trough level on day 7 or 8.
Aim for higher trough level 10-15 ng/mL
At Tygerberg Academic Hospital, sirolimus will be considered in selected cases as substitute to a calcineurin inhibitor in the following situations:
1. Calcineurin inhibitor induced HUS/TTP
2. Calcineurin inhibitor induced neurotoxicity
3. Unacceptable calcineurin inhibitor cosmetic changes (provided the patient is stable > 6 months post-transplant)
4. Nephrotoxicity due to calcineurin inhibitors
5. Chronic allograft nephropathy: creatinine < 300µmol/L
Bone marrow suppression – most commonly a mild thrombocytopaenia
Hyperlipidaemia – usually responds to statins
Arthralgia (often transient)
Hyperglycaemia, abnormal LFT’s
Sirolimus is metabolized by the cytochrome P450 system and therefore blood levels are influenced similarly to ciclosporin (see list under “Ciclosporin”).
OUTPATIENT SURVEILLANCE OF TRANSPLANT PATIENTS
Creatinine Clearance mL/min
5mg/kg 12 hly
25 – 50
125 – 225
2.5mg/kg 12 hly
10 – 25
226 – 400
0 – 10
*IV in 100 mL saline over 1 hour
Usual treatment for 14 days, but may be prolonged to 21 days in severe CMV disease.
Monitor FBC daily: reduce the dose (50%) if neutropenia occurs. Stop therapy (temporarily) when neutrophil count < 500 cells/ mm3
Men and women should use contraception during, and for 90 days following, treatment.
Patients cannot do CAPD if they -
- have no access to running water inside their homes;
- live under overcrowded, unhygienic circumstances;
- work in dirty/dusty environments.
- are totally unmotivated.
Housewives are ideal candidates for this form of replacement treatment.
COMMENCEMENT OF CAPD
- (a) Patients should be seen by the CAPD sister as soon as the decision is made that the patient qualifies.
- (b) The Tenckhoff catheter is inserted into the peritoneal cavity under general anaesthesia by our surgeon or under local anaesthesia in the ward by the renal senior registrar in suitable patients. Arrangements for this should be made with the relevant surgeon (Tuesday meetings) and the patient prepared for surgery before admission. See that the patient is fit for a general anaesthetic, that a recent CXR and ECG are available, that electrolyte abnormalities are corrected and that the Hb is >8 g/dl. This preparation may include haemodialysis and transfusion. Wherever possible arrange for the patient to have bowel preparation before the procedure as constipation may compromise flow through the catheter.
- (c) We prefer to have the patients nursed in A7 ward. They are admitted on the day before surgery and are clerked by the registrar on for the ward.
- (d) For the first three days after the insertion of the TC, the peritoneal cavity is simply flushed with Dianeal once daily. Heparin 1000U is added to the bag if it is very bloodstained or if there are clots present.
- After the first three days, regular exchanges four times daily are done: Initially with 500 ml x three days, then increasing by 500 ml every three days till the patient is on full 2l exchanges. The patient may require haemodialysis till he is at least on 1l exchanges. So do not remove venous catheters for dialysis till the patient is on 1l exchanges.
- (e) Training: While the patient is in hospital, CAPD training will be commenced by the CAPD sister. This takes an average of 7 - 10 days.
MAINTENANCE OF CAPD
- (a) The fluid routinely used for PD is 1,5% Dianeal.The 1.5% refers to the dextrose content. 4,25% Dianeal is used to remove fluid from overloaded patients. Use as infrequently as possible. 2.5% Dianeal is used in hypertensive patients. It contains less Na than the other two solutions. Because it is more effective at ultrafiltration be alert to the possibility of causing dehydration.
- (b) All patients should get supplements of water soluble vitamins: Vit B Co ii/d, Vit C 100 mg/d, Folate 5 mg/d and oral iron sulfphate 6 tabs/d (for anemia management see hemodialysis protocol).
- (c) Diet
- (i) Because a large amount of protein is lost from the peritoneal cavity with CAPD (8 - 10 g/d, more with peritonitis), patients are encouraged to maintain a diet with about 1,2 g/kg of protein.
- (ii) Phosphate binders are used routinely and vitamin D when required for secondary hyperparathyroidism.
- (d) Problems:
- (i) Peritonitis
- It is recognised by - cloudy effluent, abdominal pain, with tenderness, rebound, fever, and nausea/vomiting/diarrhoea. Send a specimen to Microbiology for an urgent gram stain. A dipstiix may confrm WBC in the effluent. The diagnosis is confirmed by the finding of >100 WBC/ml of effluent (send to haematology) or a positive culture.
Our empric regimen for treating peritonitis depending on the gram stain result is Vancomycin 1g ivi over 1 hr in 200ml saline and Ciprobay 250mg po bd.
The antibiotic regimen is adjusted when the culture and sensitivity results become available. Most patients can be treated on an outpatient basis and only those patients with severe symptoms, temperatures >38.0°C and signs of septicaemia should be admitted. Additional intravenous antibiotics may be necessary in these patients (see clinic for details). Continue both if the gram stain reveals no organism.
Heparin may be needed for thrombi caused by the peritonitis.
If peritonitis is caused by a staphylococcus, Bactroban should be given daily at exit of the Tenkhoff catheter and weekly intranasally.
Treat all patients for 3 weeks.
- (ii) Exit site and tunnel infections
Exit site infection is recognised by redness around the wound and tunnel infection by tenderness over the catheter tunnel. Initial management consists of taking a pus swab and commencing on erythromycin or flucloxacillin. For unresponsive infections, Vancomycin 1 g ivi stat may be given. If there is no response, consider removing the Tenckhoff catheter.
- (iii) Catheter removal
Indicated for: Recurrent episodes of peritonitis, no response to appropriate antibiotics, persistent exit site or tunnel infection, one-way obstruction, fungal peritonitis, Pseudomonas peritonits.
These patients are temporarily transferred to haemodialysis before a new catheter is inserted. Patients with Pseudomonas peritonitis are maintained on HD.
- (iv) Fluid overload
Because CAPD is more efficient at fluid removal than haemodialysis, patients are allowed to be more liberal with fluid. Patients who come in fluid overloaded occasionally, can be treated effectively by doing 1-2 exchanges with 4,25% Dianeal for a maximum dwelltime of 2 hours.
- (e) Follow up
Patients are seen at the CAPD Clinic at 6-8 week intervals. At these visits, blood is drawn for FBC, U&Es, LFTs, iron studies and PTH.
Learning is going to be your main pursuit while rotating through the Renal Unit and will generally take precedence over other activities. In order to benefit fully from this experience will require commitment from your side. It is expected of you to participate in all the academic activities arranged in the Unit and Department at a postgraduate level. In order to facilitate the learning experience access to the Internet is available in the Registrars’ office in A7. This allows access to a wide range of reading material including renal and general medicine journals. It is there for your benefit – so please make full use of it.
In your learning, focus on key concepts and NOT on fine detail. Select books and articles which read easily, NOT those which are most comprehensive. Work as a team – learn from each other. Learning must be active – read up, make your own concise summaries – and this is easiest if done on the same day after you see a particular patient or after a discussion on the rounds.
In the course of you rotation through the Renal Unit, you will receive ongoing informal feedback on your performance. However, midway through and at the end of your rotation you will receive a formal formative assessment. The final assessment will consist of:
1. Objective written test (1.5 to 2 hours)
2. Clinical case
3. Feedback from consultants
Please ensure that your logbook is kept updated.
SUGGESTED READING FOR POST-GRADUATE NEPHROLOGY
- ‘Mini-Halperin’ – available at Jenny Stopforth @ R80.
- Fluid, Electrolyte & Acid-Base Physiology by Halperin & Goldstein.
- “Masterclasses” series of articles in the Quarterly J Medicine by Halperin et al.
- Website: www.integrativephysiology.com
- House Officer Series. NEPHROLOGY – 3rd Edition. Tisher and Wilcox
- A Primer on Kidney Diseases - Arthur Greenberg (Editor)
- Up-To-Date website: www.uptodate.com
- Urine microscopy: www.sin-italia.org/imago/sediment/sed.htm
- Schrier’s Atlas: www.kidneyatlas.org
- REFERENCE BOOKS
- Oxford textbook of Medicine – Cameron
- The Kidney – Brenner and Rector
- The Principles and Practice of Kidney Transplantation – Morris
JOURNALS – most are available online via SU Library website
- Kidney International, Current Opinions in Nephrology & Hypertension, American Journal of Kidney Diseases, Journal of the American Society of Nephrology, etc.
- New England Journal of Medicine, QJM, BMJ, Lancet, etc.
Each registrar will have a pigeon-hole for mail in the secretary’s (Mrs Barnard’s) office. Please check regularly for any correspondence.
Please complete the patient summaries as soon as possible after patients’ discharge. Also complete the PATIENT REGISTRATION form.
Please complete any requests for leave ASAP. Discuss with your co-registars and Dr Brönn.
The photostat machine may be used for copying nephrology literature. The number of copies made must be recorded. Use both sides of the paper.
Finally, as consultants we are here to teach and guide you; we wish this experience to be rewarding and enjoyable. Feel free to speak to any of us should there be anything that we can assist you with at any time. We wish you well during your stay with us!
Profs Davids, Moosa and Drs Nel & Adeniyi.