North Bristol NHS Trust

Blood group / ABO in-compatible renal transplantation

Author: Dr Rommel Ravanan

Version 1.0 March 2010 Revision due April 2011

2

Contents Chapter Page number 1. Introduction 3 2. Recipient selection 3 3. Roles & Responsibilities 4 4. Day -30 to discharge 6 5. Blood test protocol 16 6. Immunosuppression protocol 16 7. Appendix 1 – Blood Test protocol 15 8. Appendix 2 – Immunosuppression Protocol 16 9. Appendix 3 – Rituximab Prescription 17 10. Appendix 4 – Immunosuppression & Steroid Dosing 19 11. Appendix 5 - Fresh Frozen Plasma & Albumin requirements 20

12. Appendix 6 - DFPP prescription 21

13. Appendix 7 - DFPP treatment related information 22

3

Introduction Blood group or ABO in-compatible (ABOi) renal transplantation have been performed in Japan for more than 20 years and in Europe/US since at least 2001. Clinical protocols from centres in these countries have been refined over time with the availability of newer therapeutic agents. One and five year graft and patient survival for patients undergoing ABOi renal transplantation in these centres are comparable to blood group compatible renal transplantation. Recognising the growing acceptance of ABOi renal transplantation as an acceptable treatment option for selected patients with ESRD, BTS published ABOi renal transplant guidelines in 2006. ABOi renal transplantation needs to be considered in parallel with the other transplant options for the patient including waiting for deceased donor transplantation and paired/pooled live donor transplantation. The excess risks associated with ABOi transplantation are increased risk of infection (due to higher intensity immunosuppression / plasma exchange), increased risk of peri-operative bleeding (due to loss of clotting factors on plasma exchange) and possibly a slightly higher risk of graft loss till a mature ABOi program is in place. Recipient selection: Inclusion: [1] Aged 18 – 60 years [2] Medically fit to undergo renal transplantation / active on the national transplant

register [3] On dialysis or CKD with eGFR <15 mls/min or likely to be <15mls/min within

180 days [4] Able to provide full informed consent or consent provided by NOK/carer [5] Medically fit ABOi Living Kidney Donor [LKD] only available Exclusion: [1] Aged >60 years [2] Previous in-tolerance to monoclonal or polyclonal anti-T/B cell antibodies [3] Previous intolerance to Plasma Exchange [4] Native kidney disease of either MPGN type II or primary FSGS [with evidence

of graft loss due to recurrence in previous transplant] [5] Medically fit blood group compatible LKD also available [6] Patients in-tolerant of blood products for medical or religious reasons Relative contra-indications: [1] Blood stream or systemic infection within 60 days of planned operation date [2] Iso-agglutinin titres >1:256 Donor selection: Donor selection will follow BTS guidelines. Donor work up will be undertaken as previously at Bristol / Dorset / Exeter / Gloucester. Other than ensuring that there are no other ABO compatible potential donors available for the intended recipient, there will be no change to the process of the donor’s medical evaluation. All further steps in this protocol will refer only to the recipient unless specified other wise.

4

Roles & Responsibilities: LKD co-ordinator in Bristol (in conjunction with Exeter/Dorset co-ordinators) will: [1] Ensure no other blood group compatible potential LKD available for the

intended recipient [2] Ensure blood from donor and recipient are made available to tissue typing lab,

Bristol [LAB] for anti-A/B titre estimation at the same time as first & second tissue typing/cross match testing

[3] Ensure that donor and recipient nephrologists are aware of the planned ABO incompatible transplantation

[4] Liaise with recipient co-ordinator / nephrologist and ensure recipient is either active on the deceased donor transplant register or is in the process of being assessed to be declared medically fit for transplantation

[5] Co-ordinate review of the potential recipient by lead nephrologists in Bristol for the ABOi program before invasive investigations are completed for the donor i.e. prior to second crossmatch / titre estimation

[6] Provide recipient with information leaflet for ABOi transplantation [7] Ensure Independent Assessment process completed preferably at least before

day -14 of Expected Date of Operation [EDO] [8] Liaise with Renal Day Case Unit (RDCU) to arrange admission on day -30 for

Rituximab infusion as per protocol Lead Nephrologists for ABOi program ( RAR or CRKD unless stated otherwise) will: [1] Ensure no other blood group compatible potential LKD available for the

intended recipient [2] Ensure intended recipient is medically fit to undertake ABOi transplantation. If

necessary, he/she will arrange for appropriate investigations to prove fitness in liaison with the recipient’s nephrologist.

[3] Ensure recipient is aware of potential transplant choices and is aware of risks versus benefits of each option

[4] Ensure recipient is aware of logistics of pre-operative conditioning treatment including need for central venous access to enable plasma exchange [if usable AVF/permcath not already available.

[5] Inform named contact in North Bristol NHS Trust [NBT] blood bank re recipient/donor blood group details after second cross match.

[6] Liaise with LKD co-ordinator and lead ABOi transplant surgeon to agree on an EDO

[7] Liaise with lead nurse for the acute dialysis team to arrange a schedule for plasma exchange treatments prior to EDO

[8] Liaise with LKD coordinator to arrange for Rituximab infusion as per protocol Lead transplant surgeon for ABOi program will: [1] Ensure no other blood group compatible potential LKD available for the

intended recipient [2] Ensure recipient is surgically fit to undergo transplantation and arrange

appropriate investigations if necessary in liaison with the recipient’s nephrologist

[3] Ensure recipient is aware of potential transplant choices and is aware of risks of each option

Acute Dialysis Team lead nurse will: [1] Liaise with lead ABOi nephrologist/surgeon/LKD co-ordinator plus patient to

plan for and schedule plasma exchange treatments. [2] Co-ordinate with renal bed manager / ward staff for bed availability in case

patient requires admission for pre-operative plasma exchange or co-ordinate

5

with ward clerk for patient transport to enable pre-operative Plasma exchange [PEX] as an out-patient

[3] Liaise with lead ABOi nephrologist for securing appropriate venous access to enable plasma exchange

[4] Ensure PEX performed as per protocol / as prescribed [5] Ensure pre plasma exchange blood samples to estimate anti-A/B titres are sent

to LAB as per protocol* [6] Liaise with ward/CAPD/satellite HD unit staff to ensure patient undergoes

regular PD/HD in-between PEX sessions. *Unless stated otherwise to estimate anti-A/B titres, 6mls of blood collected in an EDTA tube will be required from recipient. Donor RBC can be stored for up to 6 weeks and if titre work is being repeated after that time interval, fresh 10 mls of donor blood needs to be collected in an EDTA tube.

6

Day -30: Day -30 will normally be 30 days prior to ‘Expected date of operation’ [see above]. Taking into account weekends, bank holidays etc, this can be +/- 4 days from day-30. Unless indicated for exceptional reasons, day 0/scheduled day of transplantation will be the Wednesday LKD transplantation slot. LKD co-ordinator will: [1] Arrange for final HLA cross match between donor and recipient before recipient

is given Rituximab. This is to avoid performing the final cross match during the week before transplantation as any residual Rituximab activity will result in a positive crossmatch result.

[2] Ensure anti A/B titre sample from recipient (6mls EDTA) and blood sample from donor (10 mls EDTA) sent to LAB

On-call renal SHO / registrar will: [1] Ascertain any history of acute medical illness during the 6 weeks preceding day

-30 and if positive history obtained to discuss with lead ABOi nephrologist. [2] Record basic clinical observations [Temperature, pulse and blood pressure] [3] Obtain peripheral venous access [4] Ensure FBC sample collected. [5] Obtain patient specific prescription for Rituximab [Appendix 2] signed by lead

ABOi nephrologist/surgeon. Ideally this prescription should have been obtained and delivered to the renal pharmacists before day-30

[6] If basic observations normal at the end of the infusion, patient can be discharged home. Arrangements to be made to admit or review the patient the patient on day -14 [see below].

[7] If patient is currently prescribed ACEI, to discuss with ABOi nephrologist with a view to consider stopping the drug prior to admission on day -14 [see below]. This is to reduce the risk of hypotension during PEX.

[8] Confirm re history of drug allergies, requirements for drugs especially immunosuppression preferred in syrup form as compared to tablets etc and if identified discuss same with renal pharmacists.

ABOi lead nephrologist will: [1] Review patient’s basic blood results and ensure haemoglobin >12gm/dl. If less

than <12gm/dl, will liaise with the recipient’s team to modify EPO/Iron dose as appropriate and aim to achieve higher haemoglobin by EDO.

[2] Will fill in FFP/albumin request form [Appendix 2] and deliver to contact in Blood bank.

[3] Arrange for permcath insertion prior to day-14 with renal access specialist nurse if suitable AVF not available for use

7

Day -14: Day -14 will normally be 14 days prior to ‘Expected date of operation’ [see above]. Taking into account weekends, bank holidays etc, this can be +/- 2 days from day-14. For most patients with ‘average’ antibody titres [=/< 1:128], admission on day -14 will be appropriate. If titres are significantly higher or lower than the average, date of admission will be modified as necessary. The target anti-A/B titre prior to transplantation is =/< 1:8 of IgG / AHG titre. Patient will have been scheduled to be admitted [if requiring admission for PEX]. If patient has chosen not to get admitted, Acute Dialysis Team lead nurse to ensure bed for PEX available during the scheduled PEX dates/times. Following arrival of patient on ward On call renal SHO will: [1] Clerk patient. If new/active medical symptoms or signs are elicited on

history/examination, to discuss with lead ABOi nephrologist urgently. [2] Continue with patient’s current prescribed medication including

alfacalcidol/EPO except ACEI, Clopidogrel and non-calcium containing phosphate binders

[3] Liaise with ABOi Nephrologist to confirm requirement for regular oral calcium supplementation / commencing calcium containing phosphate binders whilst undergoing PEX

[4] Commence patient on Mycophenolate Mofetil [MMF/Cellcept] 500mg twice daily (via out-patient or in-patient prescription as appropriate)

Acute dialysis team nurse will: [1] Ensure anti-A/B titre blood sample obtained and sent off to WTAIL [2] Check if useable AVF/permcath available for performing PEX. If none available,

in liaison with lead ABOi nephrologist arrange for appropriate central venous access. This will normally be a permcath inserted into the jugular vein. The permcath will be used exclusively for the purpose of PEX. In between PEX treatments, Heparin/Gentamicin based lock solution (as per protocol) will be used for the dialysis lumens.

[3] If patient is on CAPD to liaise with CAPD nursing staff to ensure prescribed dialysis regimen is followed. If on HD to liaise with RDU/satellite HD unit staff to ensure prescribed HD sessions are provided on non-PEX days.

[4] Commence first session of PEX [Appendix 3 for PEX instructions] [5] Arrange for alternate day PEX sessions with final session normally scheduled

for day -1/day prior to operation. PEX will normally happen on Tue/Thu/Sat in the morning. If necessary, the patient’s dialysis time slots need to be changed or dialysis unit site altered to dovetail with PEX sessions. If necessary both PEX and HD sessions will be provided by the acute dialysis team on Carrington ward/RDU.

[6] Arrange for anti-A/B titre samples to be collected and sent to LAB prior to commencement of each PEX session

Lead Nephrologist for the ABOi program will: [1] Review patient and ensure no active/current medical history to preclude

commencing PEX [2] Prescribe PEX sessions [Appendix 4] [3] Ensure appropriate access available for PEX

8

[4] Review patient’s biochemistry and prescribe oral calcium supplementation if PEX causes hypocalcaemia

[5] Follow up serial anti-A/B titre results and alter PEX prescriptions as appropriate NO BLOOD TRANSFUSIONS SHOULD BE ADMINISTERED TO THE PATIENT UNLESS AUTHORISED BY THE LEAD ABOi NEPHROLOGIST OR SURGEON

9

Day -7: Day -7 will normally be 7 days prior to the ‘Expected date of the operation’. Taking into account bank holidays, weekends this may be +/- 1 day from day -7. LKD co-ordinator will: [1] Obtain the anti-A/B titre results before the third/fourth plasma exchange [2] Results discussed with lead ABOi nephrologist/surgeon and decision regarding

proceeding to transplantation on day 0 or delaying transplantation date to be made.

[3] Inform donor of any change to ‘Expected date of operation’ ABOi lead nephrologist/surgeon will: [1] Review the patient to ensure tolerating PEX and prescription of oral

immunosuppression [2] Review PEX prescriptions according to titre values [3] Discuss any planned change in date of operation if appropriate [4] Ensure named contact in blood bank aware of donor and recipient blood groups

and EDO and arrange for donor compatible FFP for day -1 PEX session. NO BLOOD TRANSFUSIONS SHOULD BE ADMINISTERED TO THE PATIENT UNLESS AUTHORISED BY THE LEAD ABOi NEPHROLOGIST OR SURGEON

10

Day -2: Where the patient has not already been admitted on day-14, he/she will be admitted on day -2 prior to ‘Expected date of operation’. This will usually be on either Saturday or Sunday before the planned operation on the following Tuesday. On call renal SHO/Registrar will: [1] Clerk patient. If new/active medical symptoms or signs are elicited on

history/examination, to discuss with lead ABOi nephrologist urgently. [2] Ensure blood forms filled for the following 2 weeks. Needs daily renal profile,

magnesium, FBC, 3/week trough Tacrolimus level. [3] Prescribe drugs as below in-patient drug chart:

a. Tacrolimus 0.05mg/kg PO twice daily (dose as per Appendix 4). If allergic to Tacrolimus please discuss with lead ABOi nephrologist

b. Mycophenolate Mofetil [MMF/Cellcept] 1g PO twice daily. Where there is previous history of GI in-tolerance with MMF, consider continuing with MMF 500 mg bd.

c. Prednisolone PO once daily (dose as per Appendix 4) d. Adalat Retard 10mg PO bd [if systolic BP >130 mmHg] e. Co-Trimoxazole 480mg PO three times a week f. Nystatin oral suspension 100,000 units, PO four times daily [after

food] g. Confirm with lead ABOi nephrologist about requirement for oral

Calcium supplementation whilst undergoing PEX [4] Liaise with donor and recipient surgeon when results of anti-A/B titres are

available to ensure no contraindication for proceeding to transplantation on day 0.

Acute dialysis team lead nurse will: [1] Ensure final plasma exchange session planned for day -1. This will usually be

on the Tuesday morning before the planned day of operation on the Wednesday.

NO BLOOD TRANSFUSIONS SHOULD BE ADMINISTERED TO THE PATIENT UNLESS AUTHORISED BY THE LEAD ABOi NEPHROLOGIST OR SURGEON

11

Day -1: This will usually be the Tuesday before the planned operation on Wednesday / day 0 Acute dialysis team lead nurse / nurse will: [1] Ensure anti-A/B titres sent to LAB by 9am [2] Ensure final PEX session arranged as per protocol and needs to commenced

by 9am. Replacement fluid for final PEX session will be donor compatible standard FFP (15mls/Kg) instead of human albumin [see Appendix 2 + table below]

[3] Liaise with ward staff to arrange for HD session later in the same day if patient on HD or continue on CAPD as per prescribed regimen

ABOi lead nephrologist will: [1] Review patient with results of anti-A/B titres by 5pm and confirm final decision

to proceed to transplantation the following day [2] Ensure patient is well and no medical contra-indication to transplantation [3] Ensure drugs as above correctly prescribed FFP Selection table for ABO incompatible kidney transplants.

RECIPIENT ABO GROUP DONOR ABO GROUP FFP GROUP TO GIVE

O

A

A

O

B

B

O

AB

AB

A

B

AB

A

AB

AB

B

A

AB

B

AB

AB

12

Day 0: Ward registrar / SHO will: [1] Ensure pre-operative anti-A/B titre sample has been obtained and sent to LAB [2] Ensure necessary arrangements in place for urgent PEX if required in the

immediate post-operative period [3] Prescribe IV Basiliximab 20mg to be given pre-operatively [4] Prescribe Ranitidine 150mg bd (unless previously on PPI in which case

continue same) [5] Prescribe compression stockings (TEDs) [6] Ensure that patient has FBC, renal profile blood tests sent off within 2 hours of

returning to the ward post-operation [7] Ensure blood forms for routine post transplant tests including daily FBC, Renal

profile, 3/week tacrolimus level are put out for at least the following 7-10 days Lead ABOi surgeon will: [1] If required intra-operatively will only use donor specific or AB negative FFP

for the recipient. [2] If required intra-operatively will use recipient blood group specific packed RBCs Lead ABOi nephrologist will: [1] Review the patient post-operatively and arrange for HD/CAPD if necessary for

standard biochemical / clinical indications. NO BLOOD TRANSFUSIONS SHOULD BE ADMINISTERED TO THE PATIENT UNLESS AUTHORISED BY THE LEAD ABOi NEPHROLOGIST OR SURGEON

13

Day +1 Ward SHO/ Registrar will: [1] Undertake routine assessment and care as per unit transplant protocol [2] Arrange for USS + Doppler of the transplant kidney [3] If immediate and good graft function, commence patient on Valganciclovir. The

dose needs to be adjusted according to creatinine clearance (not estimated GFR3): - CrCl less than 10ml/min: Valganciclovir is not recommended - CrCl 10-24ml/min: Valganciclovir 450mg twice a week - CrCl 25-39ml/min: Valganciclovir 450mg every two days - CrCl 40-59ml/min: Valganciclovir 450mg daily - CrCl greater than: 60ml/min Valganciclovir 900mg daily

[4] Ensure anti-A/B titre sent off to WTAIL by 9am [5] Once titre result available later in the day, discuss the same with lead ABOi

nephrologist/surgeon. Lead ABOi nephrologist/surgeon will: [1] Review the patient [2] Decide frequency / timing of further PEX sessions Day +2 Ward SHO/Registrar will: [1] Undertake routine assessment and care as per unit transplant protocol Lead ABOi nephrologist/surgeon will: [1] Review the patient [2] Decide on frequency / timing of further PEX sessions Day +3 Ward SHO/Registrar will: [1] Undertake routine assessment and care as per unit transplant protocol [2] Prescribe second / final dose of IV Basiliximab 20mg [3] Ensure anti-A/B titre sent off to WTAIL by 9am [4] Once titre result available later in the day, discuss the same with lead ABOi

nephrologist/surgeon. [5] Prescribe 75mg Aspirin PO od and Heparin 5000 units SC bd (if no further PEX

treatments planned) Lead ABOi nephrologist/surgeon will: [1] Review the patient [2] Decide on frequency / timing of further PEX sessions. NO BLOOD TRANSFUSIONS SHOULD BE ADMINISTERED TO THE PATIENT UNLESS AUTHORISED BY THE LEAD ABOi NEPHROLOGIST OR SURGEON

14

Days +4 to discharge: Ward SHO/Registrar will: [1] Ensure anti-A/B titre sent off to LAB by 9am on days +6, +8 and +10 [2] If good graft function, Valganciclovir dosage to be increased as per CMV

prophylaxis protocol Lead ABOi nephrologist/surgeon will: [1] Review the patient daily [2] Review medications and adjust according to clinical need [3] Decide on frequency / timing of further PEX sessions. If PEX session required,

lead ABOi nephrologist will liaise with Acute Dialysis team lead nurse / nurse to arrange for the same.

Post transplant follow up arrangements: Recipients of ABOi transplantation will be followed up as per unit protocol for the first 4 weeks after discharge and anti-A/B titres checked at least once/week [on days +14, +21 &+28]. Lead ABOi nephrologist will co-ordinate removal of central venous access if placed for the purpose of PEX once PEX no longer required. Further follow up as per transplant protocol with anti A/B titres measured fortnightly till day +90. Beyond day+90 patients will revert to conventional post transplant follow up practice. Dorset and Exeter ABOi recipients will require at least fortnightly review in Bristol until day +90, when patients with stable graft function will be transferred back for long term post transplant care. If the patient requires blood transfusions prior to day+90 please discuss with lead ABOi nephrologist before prescribing / administering the same.

15

Appendix 1 Blood test protocol for patients undergoing ABOi transplantation

Test required / day

Day -30

Day -14

Day -10

Day -8

Day -6

Day -4

Day -2

Day -1

Day 0

Day +1

Day +2

FBC X X X X X X X X X X X

Renal profile + Mg2+

X X X X X X X X X X X

Clotting screen

X X X X

Anti-A/B titre

X X X X X X X X X

Tacrolimus level

X X X X X

Test required / day

Day +3

Day +4

Day +5

Day +6

Day +7

Day +8

Day +10

Day +12

Day +14

Day +21

Day +28

FBC X X X X X X X X X X X

Renal profile

X X X X X X X X X X X

Anti-A/B titre

X X X X X X X

Tacrolimus level

X X X X X X X X

After Day 28, patient should be managed as any other transplant patient. If there is an episode of acute transplant dysfunction within 3 months of transplantation and the patient is due to be admitted please arrange for urgent Anti-A/B titres* estimation along with clotting screen, US transplant etc before admission. *6mls EDTA blood sample labelled “Blood group antibody titre estimation – FAO Jasna Parsons / Mary Younie”. If sample needs to be processed urgently please ring LAB staff.

16

Appendix 2 Immunosuppression protocol for ABOi transplantation:

Day Rituximab Basiliximab Tacrolimus MMF Prednisolone PEX Other

Agents

Day -30

As per protocol

Day -14

500mg

bd X

Day -12

X

Day -10

X

Day -8 X

Day -6 X

Day -4 X

Day -2 0.05mg/Kg

bd 1gm bd 15-30mg od X

Adalat Retard, Co-Trimoxazole,

Nystatin

Day -1 X

Day 0 20mg

Day +1 PRN Valganciclovir

as CrCl allows

Day +3 PRN

Day +4 20mg

Day +7 PRN

Day +14

Day +30

Taper as per unit protocol

Day +60

5mg or 7.5mg

Day +90

Day +180

>12 months

As clinically

indicated

As clinically indicated

Tacrolimus trough level targets: Day 0 to Day +30: 8-12ng/ml Day 30 to 12 months: 8-10ng/ml >12 months: As clinically indicated

17

RITUXIMAB (MabThera®) INTRAVENOUS INFUSION Prescription for patients undergoing ABO incompatible renal

transplantation

Pre Rituximab (30 minutes before starting infusion)

Drug Dose Route Prescriber’s Signature Given

by Date

and time

Paracetamol 1g Orally

Chlorpheniramine 10mg IV bolus

Hydrocortisone 100mg Slow IV bolus

Rituximab dosage

• Based on patient’s weight and height, see table below

• Check weight first, then match to height and select appropriate dose Patient Weight (kg): …………….……………….Height (cm): ………….…………………

Weight Height

50-70 kg 71-90 kg 91-110kg

150-159 cm 600 mg 700 mg NA

160-169 cm 700 mg 800 mg NA

170-179 cm 700 mg 800 mg 900 mg

180-189 cm 800 mg 800 mg 900 mg

190-199 cm NA 900 mg 1000 mg

200-210 cm NA 900 mg 1000 mg

Rituximab dose:…………………….Prescriber’s signature:………………………… Rituximab infusion preparation and administration

• Rituximab is available as 10mg/ml vials and should be infused in 250ml sodium chloride 0.9%.

• 250ml is the total volume to be infused so need to withdraw sodium chloride 0.9% from the bag before adding rituximab. This volume corresponds to the amount of rituximab that will be added to make up the infusion (for example, withdraw 80ml sodium chloride 0.9% if rituximab dose is 800mg).

• For mixing the solution, gently invert the bag in order to avoid foaming.

• Rituximab infusion rate starts slowly and patient must be closely monitored throughout infusion.

• For patients who experience an infusion reaction, the infusion should be stopped or the rate decreased. If the patient’s symptoms improve, infusion can be continued at 50% of the rate prior to the reaction and accelerated as tolerated.

Appendix 3 North Bristol NHS TRUST

Richard Bright Renal Unit

Page 1 of 2

18

DATE DRUG INFUSION

RATE

PUMP RATE SET

BY

DATE/ TIME

TIME T=0

RITUXIMAB I.V. INFUSION (Dose……….mg in 250ml

sodium chloride 0.9%)

12.5 ml/hr

T=30mins RITUXIMAB I.V. INFUSION 25

ml/hr

T=60mins RITUXIMAB I.V. INFUSION 37.5 ml/hr

T=90mins RITUXIMAB I.V. INFUSION 50

ml/hr

T=120mins RITUXIMAB I.V. INFUSION 62.5 ml/hr

T=150mins RITUXIMAB I.V. INFUSION 75

ml/hr

T=180mins RITUXIMAB I.V. INFUSION 87.5 ml/hr

T=210mins

RITUXIMAB I.V. INFUSION

100 ml/hr

(until infusion complete)

Protocol written and approved by:

…………………………………..(Consultant)

…………………………………..(Pharmacist)

Date:…………………………………...……..

Page 2 of 2

19

Appendix 4 Immunosuppression & Steroid Dosing Regime

Tacrolimus dose by weight

Weight (Kg) 50 60 70 80 90 100 110

Daily Tacrolimus Dose (mg)

2.5mg BD

3mg BD 3.5mg

BD 4mg BD

4.5mg BD

5mg BD

5.5mg BD

Steroid initiation and reduction regimen by weight band:

Daily Prednisolone Dose (mg)

Weight (Kg) Week

1 Week

2 Week

3 Week

4 Week

5 Week

6 Week

7 Week

8

<50 15 15 12.5 12.5 10 10 7.5 5

55 17.5 15 15 12.5 10 10 7.5 5

60 17.5 17.5 15 15 12.5 10 10 5

65 20 17.5 17.5 15 12.5 12.5 10 7.5

70 20 20 17.5 17.5 15 12.5 10 7.5

75 22.5 20 20 17.5 15 12.5 10 7.5

80 25 22.5 22.5 20 15 15 10 7.5

85 25 22.5 22.5 20 17.5 15 12.5 7.5

90 27.5 25 25 22.5 17.5 15 12.5 7.5

95 27.5 25 25 22.5 17.5 15 15 7.5

>100 30 27.5 27.5 25 20 17.5 15 7.5

Note: round to nearest 5kg weight, i.e. 52kg->50kg but 53kg->55kg

A card (like the one below) will be made out by the renal pharmacists following transplant and (1) given to the patient / (2) filed in the notes.

• Patients will be told to reduce their prednisolone on the date stated, even if this is not a clinic date.

• Doctors or nurses seeing the patients in transplant should keep the prednisolone dose up-to-date on Proton each time they see the patient.

• If a patient has an episode of rejection, and the reduction regimen is altered, please ask the pharmacists to prepare a new card with new dates.

20

Appendix 5 Fresh Frozen Plasma & Albumin for patients undergoing blood group in-

compatible renal transplant

Expected date of renal transplantation: …………………………………………………… Recipient FFP requirement: ………………………………………………………………… Planned treatment schedule

Date Day Event

-30 Admit to RDCU. Rituximab infusion

-14* Admit to T ward. Commence PEX sessions. Albumin replacement fluid# unless specified otherwise.

-1 Final pre-operative PEX session with FFP replacement fluid@

0 Renal transplant

+1 PRN PEX session. Albumin replacement fluid unless specified otherwise

+3 PRN PEX session. Albumin replacement fluid unless specified otherwise

*Most patients will require 7-8 pre-operative PEX sessions. PEX treatments will be carried out on alternate days, usually Monday/Wednesday/Friday. Depending on haemagglutinin titre level first PEX treatment may be +/-3 days from day -14. #Albumin replacement per session will typically consist of 1 x 500ml of 4.5% Human albumin solution and 1 x 100ml of 20% Human albumin solution. @FFP replacement will typically be 15mls/kg (maximum of 1500mls in total). The exact amount required will be prescribed by the lead ABOi nephrologist/surgeon. For any clarifications please contact Dr Rommel Ravanan, Consultant Nephrologist on extension 35235 or by pager via switch board.

Recipient Details Donor Details Name: …………………………… …………………………… Hospital Number: …………………………… …………………………… DOB (age): …………………………… …………………………… Sex: …………………………… …………………………… Address: …………………………… …………………………… …………………………… …………………………… …………………………… ………………………….... Weight: …………………………… ……………………………. Blood Group: ........................................ …………………………….

21

Appendix 6

DFPP prescription for ABOi and HLAi renal transplantation

Treatment 1: Date:

Treatment 2: Date:

Recipient weight/dry weight: ………….…Kg Recipient height: ……………...cm Recipient blood group: …………………………………….... Donor blood group: ………………………………………

Blood flow rate: …………ml/min Plasma volume: …………….Litres Plasma %: …………… Drain plasma %:………… Replacement plasma %:………… 0.9% Normal saline: ………….x 1000mls 0.9% Normal saline: ………… x 1000 mls with Heparin ……………..IU/1000mls Heparin: Infusion rate: ………….IU/hour Human albumin solution: ……… x 500ml of 4.5% HAS …………. x 100 ml of 20% HAS Fresh frozen plasma: …………..units of FFP Pre-treatment BP: …………mm/Hg Post treatment BP: …………mm/Hg Hypotensive episodes: Yes / No Doctor’s signature/name: …………………………Nurse’s signature/name:…...............................

Blood flow rate: …………ml/min Plasma volume: …………….Litres Plasma %: …………… Drain plasma %:………… Replacement plasma %:………… 0.9% Normal saline: ………….x 1000mls 0.9% Normal saline: ………… x 1000 mls with Heparin ……………..IU/1000mls Heparin: Infusion rate: ………….IU/hour Human albumin solution: ……… x 500ml of 4.5% HAS …………. x 100 ml of 20% HAS Fresh frozen plasma: …………..units of FFP Pre-treatment BP: …………mm/Hg Post treatment BP: …………mm/Hg Hypotensive episodes: Yes / No Doctor’s signature/name: …………………………Nurse’s

22

Appendix 7

DFPP treatment related information

Treatment 1: Date:

Treatment 2: Date:

Appendix 4 DFPP treatment related information

Time

Arterial pressure

Venous pressure

TMP1

TMP2

Acc Plasma volume

Acc drain volume

Nurse’s signature/name:…...............................

Time

Arterial pressure

Venous pressure

TMP1

TMP2

Acc plasma volume

Acc drain volume

Nurse’s signature/name:…...............................