(microsoft word - post-transplant continuing care form for kidney recipient_\205)

Post-Transplant Continuing Care Form for Kidney Recipients
Patient Name: ____________________________________________
Date of Birth: _________________ Medical Record # _______________
Date of Transplant: __________________

Date __________________
Dear Dr. __________________________________
This form contains information about your patient's recent transplant. We have included our
recommendations for laboratory monitoring and immunosuppressive drug levels. Additional details may
be found in the most recent Transplant Clinic notes which will also be forwarded to you.
Please could you keep us updated with any changes in the patient’s status or with any changes made to
the patient’s medications?
As always, thank you very much for allowing us to participate in your patient's care Please do not hesitate
to call us at (_____) ______ - ________ with any questions regarding the ongoing care of your patient.

Transplant Type:
Graft Function:
Delayed Graft Function: No ____ Yes ____
Donor: A _____ B_____ DR ______
Baseline Creatinine: ______________
Recipient: A _____ B_____ DR ______
CMV status: Donor_____ Recipient_____
Infection: No _____ Yes ____
EBV status: Donor_____ Recipient_____
___________________________________
Hepatitis C status: Donor__ Recipient____
Rejection Episode(s): No _____ Yes _____
Induction agent: __________________
New Onset Diabetes: No ____ Yes ____
___________________________________
Ureteral Stent? No ___ Yes ___
Maintenance Immunosuppression and Infection Prophylaxis:
Trough Target
Trough Target
Trough Target
Month 3-6
Month 6-12
Month >12
Infection Prophylaxis Stop Date
 Antiviral ______________________
 Antifungal _____________________
 Bactrim/Dapsone _______________

Comments:_________________________________________________________________________
__________________________________________________________________________________
This form is provided by the American Society of Transplantation and can be found at www.a-s-t.org Recommended Screening Laboratory Tests:
Recommended Interval and Method
 Complete blood count with differential  Metabolic profile with serum creatinine  Drug level (tacrolimus, cyclosporine, sirolimus)
General Recommendations for the Care of the Transplant Recipient:
Continue immunosuppression indefinitely, recommend consultation with transplant center before making changes Consider potential drug interactions when initiating/adjusting other agents Avoid empiric use of “pulse dose steroids” Please contact the transplant center with any concerns regarding:  Immunosuppressive agents (drug levels, side effects, drug interactions)  Worsening renal function (unexplained >10% increase from baseline creatinine), proteinuria, hematuria or other findings that may require biopsy or other diagnostic procedures  Infections or malignancy  Tapering of immunosuppression, need for transplant nephrectomy, consideration of retransplantation Routine screening procedures (colonoscopy, mammogram, Pap, PSA) based on general recommendations/prior testing results Immunizations - yearly influenza, Pneumovax booster every 5-years. Do not use live vaccines.
Skin cancer risk- annual dermatology screening, use of sunscreen and avoidance of overexposure to sun Evaluate anemia in patients with hemoglobin <12 g/dL at more than 3-months post-transplant (rbc indices, reticulocyte count, iron studies, folate and B12 levels, stool occult blood) Initiate treatment with erythropoiesis stimulating agents if clinically indicated. Avoid ESA therapy if hemoglobin levels > 13 g/dL Dyslipidemia screening and dietary and/or pharmacologic control (Goal LDL <100 mg/dL or <70 mg/dL in patient with CAD, TGL < 150 mg/dL). Advise patients to report muscle pain or weakness, monitor LFT’s and CK levels with use of lipid lowering agents) Aspirin administration unless contraindicated Cardiovascular screening (stress test) in symptomatic or high risk patients (DM, history of CAD) Calcium supplementation (1000 – 1500 mg/day) in non-hypercalcemic patients Consider hip DEXA scan – baseline within 6 months after transplant then at 12 and 24 months post-transplant (especially in patients receiving maintenance steroids) Consider use of bisphosphonates or alternative anti-resorptive agents in appropriate patients with osteoporosis or worsening osteopenia This form is provided by the American Society of Transplantation and can be found at www.a-s-t.org

Source: http://www.diablonephrology.com/forms/post-transplant.pdf