1. Practical Protocols – experience and evidence based routines Henrik Ekberg

3. Living Donor Kidney Transplantation - Protocols Why do we need protocols? Every transplant centre needs to make decisions on their routine practice. The reason for this is that all patients should be given the best possible care. These protocols should be based on current transplantation research They should be updated at regular intervals. The objective is to reach the highest international standard of outcome after kidney transplantation.

4. How to make your own protocols The book is published in Chinese and in English. With the book you should find a CD. If you want to make a print out of the same text as in the book, use the pdf file. If you want to make your own protocols, similar to what we have suggested but with an update or with local application, use the Word file.

5. A message from The Transplantation Society Professor Jeremy Chapman, President, TTS 2008-2010. “This book provides the practical elements needed for a modern transplantation programme. It is absolutely essential in today’s clinical transplant programmes that all the professional staff work as a unit. Without protocols covering the most important aspects of transplant care there is no cohesion or collaboration. These Practical Protocols provide all transplant units the opportunity to build their own protocols easily and on a sound basis of international best practice. “

6. Structure of the Transplant Centre Director Transplant Centre Transplant Surgery Vice Director Transplant Nephrology Vice Director Transplant Laboratories Risk assessment Cardiology Transplant Co-ordinator

7. Protocols 1. Kidney Recipient Work Up 2. Living Donor Work Up 3. Consent to Kidney Donation 4. Protocols for the Doctor: Admission of the Recipient Before Transplantation 5. Protocols for the Nurse: Admission of the Recipient Before Transplantation 6. Doctor’s Orders: Pre-operative Management in Kidney Transplantation

8. (1) Kidney Recipient work up 1.Cardiac evaluation 2.Parathyroid function 3.Glucose tolerance 4.APC resistance 5.Panel reactive antibodies 6.Dentist 7.Antibody screening (HIV, HBV, HCV, etc) 8.Vaccination 9.CT of iliac arteries

9. (2) Living Donor Work Up 1.Informed consent 2.Blood group test 3.Electrocardiogram 4.Clinical chemistry according to a specified list 5.GFR 6.Glucose tolerance test 7.Echocardiogram 8.Renal artery ultrasound 9.Chest X-ray 10.Myocardial scintigraphy (if > 50 yrs old) 11.CT angiography of renal arteries 12.Nephrologist’s decision 13.Surgeon’s decision

10. More Protocols 7. Anaesthetist: Intra-operative Management in Kidney Transplantation 8. Post-operative Management After Kidney Transplantation 9. Routine Blood Samples After Kidney Transplantation For the Nurse in the Transplant Ward 10. Flow Chart of Events of Nursing After Kidney Transplantation 11. Flow Chart of Events of Nursing in Kidney Donation 12. Long-term Follow-up After Kidney Donation 13. Antibiotics and Kidney Transplantation

11. (14) Initial Immunosuppression After Kidney Transplantation 1. Normal risk patient (with basiliximab) 2. Normal risk patient (with no induction) 3. NODAT risk (steroid avoidance) 4. NODAT risk (low-dose steroids) 5. High risk (with basiliximab induction) 6. High risk (with ATG induction)

12. (14) Initial Immunosuppression After Kidney Transplantation Normal risk (1) Normal risk (2) NODAT (1)NODAT (2)High risk (1) High risk (2) InductionBasiliximabNoneBasiliximab ATG Tac trough5 - 88 – 10 3 - 78 – 1010 - 12 Start dose Mg/kg BID 0.050.06 0.050.060.07 Start dose Mg BID for 70kg BW 3.544 45 MMF g BID111111 Prednisone Mg/day 15 + 5 10 for 1 week then 0 1015 + 5

13. (14) Initial Immunosuppression After Kidney Transplantation Normal risk (1) Normal risk (2) NODAT (1)NODAT (2)High risk (1) High risk (2) InductionBasiliximabNoneBasiliximab ATG Tac trough5 - 88 – 10 3 - 78 – 1010 - 12 Start dose Mg/kg BID 0.050.06 0.050.060.07 Start dose Mg BID for 70kg BW 3.544 45 MMF g BID111111 Prednisone Mg/day 15 + 5 10 for 1 week then 0 1015 + 5

14. (14) Initial Immunosuppression After Kidney Transplantation Normal risk (1) Normal risk (2) NODAT (1)NODAT (2)High risk (1) High risk (2) InductionBasiliximabNoneBasiliximab ATG Tac trough5 - 88 – 10 3 - 78 – 1010 - 12 Start dose Mg/kg BID 0.050.06 0.050.060.07 Start dose Mg BID for 70kg BW 3.544 45 MMF g BID111111 Prednisone Mg/day 15 + 5 10 for 1 week then 0 1015 + 5

15. (14) Initial Immunosuppression After Kidney Transplantation Normal risk (1) Normal risk (2) NODAT (1)NODAT (2)High risk (1) High risk (2) InductionBasiliximabNoneBasiliximab ATG Tac trough5 - 88 – 10 3 - 78 – 1010 - 12 Start dose Mg/kg BID 0.050.06 0.050.060.07 Start dose Mg BID for 70kg BW 3.544 45 MMF g BID111111 Prednisone Mg/day 15 + 5 10 for 1 week then 0 1015 + 5

16. (14) Initial Immunosuppression After Kidney Transplantation Normal risk (1) Normal risk (2) NODAT (1)NODAT (2)High risk (1) High risk (2) InductionBasiliximabNoneBasiliximab ATG Tac trough5 - 88 – 10 3 - 78 – 1010 - 12 Start dose Mg/kg BID 0.050.06 0.050.060.07 Start dose Mg BID for 70kg BW 3.544 45 MMF g BID111111 Prednisone Mg/day 15 + 5 10 for 1 week then 0 1015 + 5

17. (14) Initial Immunosuppression After Kidney Transplantation Normal risk (1) Normal risk (2) NODAT (1)NODAT (2)High risk (1) High risk (2) InductionBasiliximabNoneBasiliximab ATG Tac trough5 - 88 – 10 3 - 78 – 1010 - 12 Start dose Mg/kg BID 0.050.06 0.050.060.07 Start dose Mg BID for 70kg BW 3.544 45 MMF g BID111111 Prednisone Mg/day 15 + 5 10 for 1 week then 0 1015 + 5

18. (14) Initial Immunosuppression After Kidney Transplantation Normal risk (1) Normal risk (2) NODAT (1)NODAT (2)High risk (1) High risk (2) InductionBasiliximabNoneBasiliximab ATG Tac trough5 - 88 – 10 3 - 78 – 1010 - 12 Start dose Mg/kg BID 0.050.06 0.050.060.07 Start dose Mg BID for 70kg BW 3.544 45 MMF g BID111111 Prednisone Mg/day 15 + 5 10 for 1 week then 0 1015 + 5

19. Evening (8 pm) the day before transplantation Tacrolimus 0.05 mg/kg (e.g. 3.5 mg) MMF 1000 mg Morning of the day of transplantation (6 am) Tacrolimus 0.05 mg/kg MMF 1000 mg At the start of transplantation in the operating room Methylprednisolone 500mg IV Basiliximab 20 mg IV In the evening (8 pm) of the day of transplantation Tacrolimus 0.05 mg/kg MMF 1000 mg Prednisolone 100 mg IV Every day after transplantation (8 am and 8 pm) Days 1 – 30 Tacrolimus 0.05 mg/kg x 2 (target concentration 5 – 8 ng/mL) MMF 1000 mg x 2 Prednisone 15 mg at 8 am and 5 mg at 8 pm Day 4: basiliximab 20 mg IV Days 30-60Tacrolimus (target concentration 5 - 8 ng/mL) MMF 750 mg x 2 Prednisolone 15 mg at 8 am Days 60-90Tacrolimus (target concentration 5 – 8 ng/mL) MMF 750 mg x 2 Prednisolone 10 mg at 8 am Days 90 and afterTacrolimus (target concentration 5 – 8 ng/mL) MMF 750 mg x 2 (or azathioprine 75 – 100 mg x 1) Prednisolone 5 mg at 8 am

20. Final Protocols 15. Transplant Biopsy 16. Treatment of Acute Rejection 17. Long-term Follow-up After Kidney Transplant 18. Responsibilities of Surgeon and Nephrologist 19. The Gift of a Kidney – Information for the Potential Donor 20. Further Reading

21. At your transplant center: Which protocols would you accept today as they are? Which protocols would you like to modify to make them applicable to your routines? Are there any protocols you would not use? Please, give me your comments and suggestions: henrik.ekberg@med.lu.se