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Care of the transplant recipient in a primary care setting

In 2011-12, 3,960 solid organ transplants were performed. These comprised a combination of kidney, pancreas, liver, small bowel, heart and lung transplants. Recipients may have more than one organ transplanted simultaneously from the same donor - the most common combinations are kidney and pancreas, small bowel and liver or a full mutliversceral transplant comprising of liver, small bowel, stomach and pancreas. The majority of solid organ transplants are from deceased donors, although there are also a growing number of live kidney and partial liver donations now occurring in the UK, either from living related or altruistic donors.1

Follow-up of these recipients will be lifelong, until the graft fails or is removed.2 Post-transplant patients are discharged home once the transplanted solid organ (graft) function is satisfactory, and will have regular outpatient appointments at their transplanting centre or referral centre to monitor their health and graft function. Depending on the organ transplanted, the recipient may be discharged anything from day six post transplant, in the case of an uncomplicated kidney transplant, to many months following a mutliversceral transplant. 

As a primary care nurse you may be asked to provide agreed shared care for transplant recipients and/or care for them as part of their primary healthcare team.

What to look out for post transplant

Rejection 

The most common type of rejection is acute cellular rejection, occurring in 20-25% of transplant patients, usually within the first six months post transplant. Recipients may first present to you stating that they don't feel 'right,' or with an unexplained deterioration of graft function depending on the organ transplanted. 

They may present with symptoms of:

 - Increased or new pain.

 - A skin rash.

 - Diarrhoea.

 - Jaundice.

 - Fever.

 - Flu-like symptoms.

 - Breathlessness.

 - Reduced urine output.

 - Reduced exercise tolerance.

 - Deranged blood sugars.

The recipient should be referred to the transplant centre immediately to be seen and assessed by their team where they will be treated immediately if necessary. Most (80-90%) episodes of acute cellular rejection are amenable to treatment with intravenous corticosteroids. 

Chronic rejection or progressive graft function may begin months or years post transplantation. The transplanting team will review graft function and may decide to alter the immunosuppressant agents or change doses. These patients and their families will benefit from emotional support and compliance to immunosupressants should be assessed and encouraged at every contact.

If rejection is not managed and doesn't respond to treatment, it can lead to the recipient losing the graft. For some this may mean a re-graft; for others it may ultimately end their life. 

Post-transplant infections

After transplantation the recipient will receive immunosuppressant drugs to prevent organ rejection. Although these drugs help to protect the new organ from the recipients' own immune system, immunosuppressents also bring with them the complication of increased susceptibility to infection. 

In the first few months, the transplant recipient's immunosuppressant level will be kept relatively high and therefore the recipient is at particular risk of infection. Infections can be caused by viruses, bacteria and fungi. Some susceptibility will also depend on the viral exposure of the recipient pre-transplant and the donors' viral status. Recipients will be on a combination of antiviral and anti-fungal prophylaxis and some antibiotics post transplant for approximately 200 days. Because of their immunocompromised status, infection or reactivation of any of the below organisms can be extremely dangerous and even fatal to a transplant recipient:

 - Cytomegalovirus (CMV).

 - Shingles and herpes zoster (VZV).

 - Herpes simplex virus (HSV).

 - Epstein-Barr virus (EBV).

 - BK virus.

 - Candida.

 - Pneumocystis jiroveci.

 - Aspergillus.

 - Methicillin-resistant staphylococcus aureus (MRSA).

 - Vancomycin-resistant enterococci (VRE).

 - Protozoal.

 - Toxoplasma.

It is important that regular screening blood samples are taken as requested to monitor for viruses, and that if a patient is pyrexic, feels flu-like, or has any other symptoms associated with infection that they are assessed and referred back to the transplant centre immediately.

Wound infections/dehiscence

If a recipient presents to your clinic with any of the usual signs of infection such as fever, redness around the wound, tenderness, visible pus or exudates, swab the wound and notify the transplant centre and ask for their advice. The recipient may need treatment with systemic antibiotics and possibly surgical drainage of any collections. Wound dehiscence is usually treated with a vacuum dressing or surgical repair.  

New-onset diabetes after transplant

Transplant recipients are at risk of developing glucose intolerance and those on Tacrolimus are particularly at risk of developing new onset diabetes after transplant (NODAT). Recipients will be screened at each hospital visit for NODAT however please be vigilant and if a patient is exhibiting signs of NODAT that has not been detected, refer them back to their transplanting centre immediately. When a patient has been diagnosed with NODAT they will need help and support as with any other newly-diagnosed diabetic patient.    

Post-transplant malignancy

One of the major complications of taking immunosuppressants over a prolonged time is the increased risk of malignancy, particularly those driven by oncoviruses such as human papillomavirus (HPV) and Epstine-Barr virus (EBV) which is associated with post-transplant lymphoproliferative disease (PTLD), presenting signs may include: 

 - Localised swelling.

 - Abdominal pain.

 - Shortness of breath.

 - Fevers.

 - Night sweats.

 - Weight loss. 

Immunosuppressants also inhibit the body's natural tumour surveillance abilities and potentiate the effects of other carcinogens such as ultraviolet (UV) light therefore increasing their incidence of skin cancers. Recipients will be educated about the importance of sun screen, keeping sun exposure to a minimum and checking their own skin regularly for any changes. 

Remind transplant recipients about sensible skin care, and if they do present any skin changes that concern you, ask them to contact their transplant centre who will refer them to a dermatologist for assessment.   

Care required 

Vaccinations

Most recipients will have had their viral immunity checked and had a full course of vaccinations as part of their pre-transplant work-up. Post transplant, due to their immunocompromised status, the recipients:

 - Will require annual flu vaccines, as will their close family members.  

 - Should not receive live attenuated vaccines.

 - Should receive pneumococcal vaccine and one booster every five years. 

 - Should have hepatitis B antibody levels rechecked annually and revaccination carried out if antibody titres fall below 10mIU/ml.

Lifestyle advice 

Advice on healthy lifestyle should form a routine part of post-transplant care for all transplant recipients, and when the opportunity arises the following should be discussed:

 - Maintenance of a healthy diet.

 - An ideal weight should be targeted (BMI≤25).

 - Maximising activity for a healthy lifestyle.

 - Alcohol consumption should be within national guidelines.

 - Smoking cessation (if continuing to smoke). 

 - Contraception as per guidelines2 or as advised by transplant centre.

 - Sun exposure and sun cream usage - factor 50 is recommended, hats and regular skin checks by a trained healthcare professional.

 - Recreational drug use should be avoided.

 - The use of over-the-counter medications (without discussion with clinical staff) and non-proprietary medications (eg. herbal medicines) should be discouraged. 

Medication and compliance

Transplant recipients will be on lifelong drug regimes and their compliance to these will have a great effect on the longevity and function of their graft. Compliance with medication and follow-up regime is vitally important and has been shown to be significantly linked to mortality rates. Teenage recipients are known to be particularly at risk of non-compliance. The transplanting centre will advise on medication changes and any dosages. Please encourage the recipient to:

 - Take their medication as they have been prescribed, which normally means at regular intervals and exactly as they have been instructed to do so by their transplant doctor or pharmacist.

 - Normally every 12 hours (morning and evening) unless it is a 'prolonged release' version of Tacrolimus which is only taken once a day, usually in the morning.

 - Avoid grapefruit or grapefruit juice when taking Tacrolimus or Ciclosporin as the fruit can affect the levels of medication reached in the blood. It is thought that cranberry juice may have a similar effect so this should also be avoided.

 - Avoid St John's wort (hypericum perforatum) or any other herbal products or supplements, especially potassium products. 

 - Inform their transplanting centre if they have diarrhoea as this may effect levels of immunosuppressant in their blood.  

 - Check with the transplanting centre before taking any additional medications including certain antibiotics, antifungals, epilepsy treatments, antihypertensives and statins. 

Psychological issues 

For many, transplantation will bring with it recipient psychological issues that they may want to discuss and explore with you. These may include:

 - Donor guilt. This is well-documented3 and can present itself post transplant as depression. 

 - Change in body image may be dramatic post transplant, such as after the formation of a stoma post bowel transplant, steroid-induced cushingoid features or large incision scars. 

 - Change in health status.

 - Change in home life, routine and work. 

There are support groups for transplant recipients and families4 including organ-specific groups that meet at the transplanting centre or national organisations that you can signpost your patients to (see Resources). 

Communication 

The transplant recipient will have a transplant co-ordinator, transplant nurse specialist or transplant clinic nurse at the transplanting hospital that helps co-ordinate their follow-up care and they should be used as a point of contact if you have any concerns or questions about a transplant recipient's care or health in office hours. Out-of-hours, recipients and other healthcare professionals are encouraged to call the transplant ward or bleep a member of the transplant team via hospital switch. It is universally acknowledged that transplant recipients health can deteriorate rapidly and every centre would prefer to be contacted sooner rather than later if you have any concerns about a recipient. 

Blood samples

Transplant recipients are monitored regularly using blood samples, not only to check that the organ is functioning correctly and not rejecting, but also to check that their levels of immunosuppressants are within therapeutic range and to monitor for viruses. The recipient may ask for specific timed appointments, as early as possible during morning clinic, particularly for their blood test to check immunosuppressant levels. This is because a trough level is used to gauge whether the correct dose is being taken.

Conclusion 

With the number of solid organ transplants every year in the UK it is inevitable that you will have transplant recipients attending your practice at some point in time and therefore it is advisable to have a practice policy in place in preparation. This should include:

 - Establishing contact details for the patients' recipient transplant co-ordinator or alternative point of contact as soon as they are referred to you post transplant, to aid good communication.

 - Be vigilant for signs of infection or rejection and always highlight any concerns you have about a recipient or their graft function quickly to a member of the transplant team. Acting speedily may save their graft and ultimately their life. 

 - Take opportunities to discuss healthy eating and lifestyle choices and offer strategies and counselling where appropriate.

 - Enquire about and encourage good medication compliance at every opportunity, particularly with teenagers and young adults.

 - Check any suggested changes in medication that have not been initiated by the transplanting unit. 

 - Be aware that blood samples may need to be taken first thing in the morning to test immunosuppressant trough levels. 

 

Resources

British Transplantation Society

Efficacy and Safety of Prescribing In Transplantation

NHS Organ Donation and Transplantation

The Renal Association

 

References

1. NHSBT. UK Transplant Activity Report 2011/2012

2. The Renal Association. Post-operative Care of the Kidney Transplant Recipient. 2011.  

3. Griva K, Ziegelmann JP et al. Quality of life and emotional responses in cadaver and living related renal transplant recipients. Nephrology Dialysis and Transplantation 2002;17:2204-11.

4. Transplant Support Network