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Benefit Definition: Renal Transplant

07 March 2012

Version 1.0

Contents 1. Background and purpose of this Benefit definition ........................................................................ 2

2. Indications for renal transplant ...................................................................................................... 2

3. Inclusion criteria for renal transplant ............................................................................................. 2

3.1 Recipient ................................................................................................................................. 2

3.2 Living donor............................................................................................................................. 3

4. Evaluation and pre-operative assessment ...................................................................................... 3

4.1 Work-up and evaluation of the recipient ............................................................................... 3

4.2 Work-up and evaluation of the donor .................................................................................... 6

5. Surgery and in-hospital care ........................................................................................................... 7

6. Post-operative care and follow-up ............................................................................................... 10

6.1 Follow-up schedule for recipients ......................................................................................... 10

6.2 Follow-up of the donor post operatively .............................................................................. 13

7. Pharmacotherapy.......................................................................................................................... 14

7.1 Immunosuppressive induction therapy for recipient per scheme formulary: ..................... 14

7.2 Immunosuppressant maintenance ....................................................................................... 14

7.3 Prophylactic treatment for the recipient .............................................................................. 14

7.4 Pharmacological management of immunotherapy side effects: .......................................... 14

8. Management of Kidney graft failure ............................................................................................. 15

8.1 Types of graft failure ............................................................................................................. 15

8.2 Investigations ........................................................................................................................ 15

8.3 Treatment of transplant rejection ........................................................................................ 15

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1. Background and purpose of this Benefit definition The main aim for developing this benefit definition (BD) is to define a package of care for renal

transplants. This should assist healthcare professionals in caring for patients requiring transplant

Through the defining of the entitlements, the BD should assist health care funders to estimate and

budget for renal transplant costs. The initial draft benefits were published and both funders and

providers had an opportunity to comment. Comments were reviewed by the CMS and incorporated

in this version.

Although the benefits are intended to define basket of services and incorporate possible ICD 10

codes, investigations and treatment, it need to be noted that it does not cover a non-normal patient

who may require investigation and treatment other than stated here.

There is no data regarding the occurrence of renal failure as renal failure is not a notifiable disease.

South African Dialysis and Transplant Registry (SADTR) aims to register number of patients on renal

replacement therapy however due to poor reporting are unable to report reliable numbers. It is well

known that transplantation is the most cost effective treatment for end stage organ failure1’2. Not

only does dialysis carry high morbidity and mortality rates (as high as 50% mortality rates at 5

years3), it reduces patient’s quality of life as compared to transplantation4. From a cost point of

view, breakeven time for kidney transplantation compared to dialysis is 12 months. Thereafter,

there is a substantial cost benefit to transplantation, without considering the survival or quality of

life issues.

2. Indications for renal transplant Renal transplant is indicated in all patients with end stage renal failure (ICD 10 N18.0) regardless of

cause.

3. Inclusion criteria for renal transplant

3.1 Recipient

i. End stage renal failure ii. Vaccinated against Hep B and all EPI (South African extended program in immunisation

schedule) immunisations. Proof of immunisation must be provided if available and patients should receive any outstanding immunisation as per EPI programme. (It should be considered that EPI programme has evolved overtime and scheduling may differ amongst age groups)

iii. No active Hepatitis B infection

1 Courtney AE, Maxwell AP. The challenge of doing what is right in renal transplantation: balancing equity and utility.

Nephron Clin Pract 2009; 111(1) 2 Singh P, Bhandari M. Renal replacement therapy options from an Indian perspective: dialysis versus transplantation.

Transplant Proc. 2004 Sep 36(7):2013-4 3 Chang TI, Paik J, Greene T et al. Updated comorbidity assessments and outcomes in prevalent hemodialysis patients.

Hemodial Int 2010 Oct 14(4) 478-85 4 Senol V, Sipahioglu MH, Ozturk A et al. Important determinants of quality of life in a peritoneal dialysis population in

Turkey. Ren Fail. 2010; 32 (10) 1196-201

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iv. No active infectious disease, including infections which do not respond to treatment v. Malignancies must be in remission. See Annexure 1 for minimum transplant recommendations

for malignancy. vi. No drug / alcohol addiction or abuse as per DSM criteria. (See general principles on organ

transplant) vii. No significant advanced, irreversible or progressive other organ dysfunction

viii. No unstable cardiac disease, progressive neurological / muscular disorders, pulmonary disease ix. Patient must be reviewed by multidisciplinary transplant team for approval before being active

on transplant list

3.2 Living donor

Living donor transplant should always be considered and patients listed for cadaver donor when

none is forthcoming.

i. Accept voluntary donations, with consent form signed as defined in the National Health Act ii. Living donors must be competent to give informed consent

iii. No concomitant diseases that may affect overall survival rate iv. No active Hepatitis infection v. Not HIV positive if recipient is HIV negative, however HIV positive donors may donate to HIV

positive recipients provided donor is in WHO stage 1 or 2 disease or stable on antiretroviral treatment

vi. No history of uncontrolled malignancy vii. Not obese (BMI < 35kg/m2)

viii. No History of non-rehabilitated alcohol or substance misuse ix. Unrelated kidney donation must be approved by the department of health

4. Evaluation and pre-operative assessment

4.1 Work-up and evaluation of the recipient

Work-up and evaluation of recipients has four main objectives: to determine causes of end stage

renal disease, to determine inclusion and exclusion criteria, to provide psychosocial assessment and

to assess fitness for surgery. Table 1 indicates possible procedure codes for transplant work-up and

evaluation.

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Table 1: Procedures and Codes for work-up and evaluation of recipient

5 South African National HIV counselling and testing Policy Guideline. National department of Health. 2010.

Procedure code Procedure Proposed utilisation

Medical and psychosocial assessment

190-192 Medical consultation (this will depend on the specialities of Transplant team members as accredited by DOH)

This will depend on the

constituent of

transplant team as

accredited by DOH and

individual patients

clinical circumstances.

8102 Dental check-up Appropriate basic dentistry treatment offered

200-205

Psychosocial assessment (can be done by the social worker or psychologist depending on the multidisciplinary team staffing and specific individual needs Normally a psychosocial assessment would need to address the following Readiness for transplant Family consultation for assessment of support structures Socio-economic evaluation and assessment of impact of socio-economic status on outcomes of transplant Coping behaviours Intervention plan

Minimum 2 sessions (including family session) Additional sessions should depend on the outcome of the initial assessment. The provider should motivate a need for this service.

Confirmation of End stage Kidney disease (This is funded from Chronic renal disease benefit)

0316 Fine needle aspiration for soft tissue (all areas) 1

1839 Renal biopsy: Per kidney: Open 1

1841 Renal biopsy: Needle 1

1843 Peritoneal dialysis: First day 1

1949 Cystoscopy: Hospital equipment 1

1964 And control of haemorrhage and blood clot evacuation 1

1993

Voiding Cysto Urethrogram contrast X -ray study 1

5094 Cutting needle biopsy with image guidance 1

Screening for infectious disease and malignancy

Infectious diseases

3932

5HIV: Rapid HIV finger prick test for screening and confirmatory test. ELISA only necessary if the screening and confirmatory finger prick tests are discordant. HIV viral load in a patient who is HIV negative and it is suspected that they are in a window period and transplant need to occur within 6 weeks. (When it is impossible to wait for 6 weeks window period). There is no need to do ELISA a and Western Blot as a screening and confirmatory tests as the tests are much more costly as compared to finger screening and confirmatory test. Also finger prick test is a bedside test with rapid turnaround of results. Breastfeeding infants and those under 6 weeks should be offered PCR. When finger test strips are unavailable providers may request ELISA.

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3974 or 4531 Hepatitis studies, which include HBV surface Antigen, HBV surface Antibody, HBV core antibody and HCV antibody

1

3946/3948 CMV 1

3951 WR/RPR 1

3970 EBV 1

3948 Varicella IgG 1

3948 HSV IgG 1

3948 Toxoplasmosis IgG 1

3743 ESR 1

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6 South African TB National TB control Programme. National guidelines. National Department of Health. Pretoria. 2004

3915 3881 3885 3916 or 4651 3915 0201 4431 or 3929 3920 or 3930 3919 1240

TB symptomatic screening6 in all recipients and Sputum AFB test only in patients with positive symptoms. Due to similarity of TB and chronic illness symptoms more tests may be required to exclude TB in patients with CRF. (TB Symptomatic screening may have a reduced predictive value). Chest x-ray should be offered routinely as part of the workup process in light of the pending immunosuppression. TB culture should only be ordered if there is a clinical suspicion of TB and AFB is negative. Tuberculin skin test is indicated for screening of latent TB with an intention of providing Isoniazid prophylactic treatment.

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Screening for Malignancy

4519 Prostate specific antigen in men > 50 years 1

4566 Pap-smear > 18 years who are sexually active 1

3605 Breast examination /Mammogram. In women >40 years 1

1653 1587

Gastrointestinal scopes (Colonoscopy or Gastroscopy) if GIT malignancy is suspected or there is a strong positive history. (This is a high risk screening strategy and patients at risk must be selected for screening. Patients without any risk or suggestive symptoms would not benefit from this)

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Fitness for surgery

3755 FBC 1

3805 3837

PI/INR and PTT 1

3797 Platelet count 1

1230-1233 1236

ECG / stress ECG / Dobutamine Stress ECG / Coronary angiogram- 1

4171 4032

Urea ,Electrolytes and Creatinine 1

4027 Total Cholesterol 1

1512 Duplex evaluation of Iliac vessels for technical suitability 1

4134 4130 4231

Liver function tests: Done once routinely in light of the pending immunosuppression and potential concomitant disease processes that might exclude the patient from transplant.

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0109 Flow cytometry and/or CDC crossmatch (Living donor) 3 (annually) for recipients with living donors .

0109 Virtual crossmatch (deceased ) At the time of all potential donors

Tcells 78046 B Cells 78046

CDC crossmatch (deceased donor) At the time of all potential donors

3764 4763 4426 * 3 4427 * 2

HLA tissue typing (deceased and living donor) Once at listing

4601 * 3 4602 * 2 4605 or

Single antibody testing or

Once at listing and every 3 months whilst waiting for deceased donor

class i 3816 4601*2 4604*3 or class ii 3816 4602*2 4605*2

Luminex single antibody testing

13100, 30110 or 30120 Chest x-ray 1

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4.2 Work-up and evaluation of the donor

Evaluation of donor includes 3 phases: psychological assessment, compatibility assessment and

medical and fitness assessment for surgery. Should the medical assessment screening test detect

any abnormalities the donor should seek further treatment which should be funded by their usual

funder (Government or medical aid).

Table 2: Donor work-up and evaluation

NHRPL codes Procedure Proposed utilisation and frequency

Medical and psychosocial assessment

190-192 Medical consultation

Minimum consultation is 2. It is difficult to determine number of consultations required as this depends on the clinical presentation of the donor. Schemes may approve initial 2 consultations. 1

st visit is for evaluation and

second visit for review of pathology and radiology investigations. Further consultations may be required depending on the outcome of 2 initial consults

200-205

Psychosocial assessment: can be done by a social worker or psychologist depending on the make-up of the transplant team however psychologist may be more appropriate to assess mental health status of a person donating the organ

3 visits First consultation will be used to assess capacity to give informed consent and assess if the patient is aware of what they are doing. 2

nd consultation is required as the donor requires

a cool-off period before deciding.

Screening for infectious disease and malignancy

Infectious diseases

No code for finger prick test

HIV finger prick tests and confirmatory. Repeat test after 6 weeks. If transplant needs to occur within 6 weeks therefore not allowing for window period to elapse, then viral load test.

1

3942/ 4531 Hepatitis studies, which include HBV surface Antigen, HBV surface Antibody, HBV core antibody and HCV antibody

1

4439 CMV 1

3951 WR/RPR 1

3970 EBV 1

3743 ESR 1

3881 3885 3916 OR 4651 3915 0201 4431 0R 3929 OR 3919 3920 OR 3930

Symptomatic screening is the first step followed by sputum in asymptomatic cases. If a patient has any clinical symptoms suggestive of TB and requires diagnostic work-up, the donor’s funder (either government or medical scheme) is responsible for further diagnostic work-up. Only TB symptomatic screening and sputum AFB is a PMB level of care amongst donors.

1

Screening for Malignancy

4519 Prostate specific antigen (> 50 years) 1

4566 Pap-smear > 18 years 1

3605 Breast examination in patients < 40 years and Mamography in patient 40 years and older.

1

Fitness for surgery and suitability of organs

3755 FBC 1

3805 3837

PI/INR and PTT 1

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5. Surgery and in-hospital care In hospital procedures will include surgery and care in ICU, high care and general ward for both

donor and recipient. The average length of stay is 11 ± 7days for recipients. Table 4 indicate possible

surgical procedures in donors and recipients.

Table 3: Surgical procedure and codes for donors and recipients

NHRPL codes Procedure

Cadaver donor codes

0173 Consultation in hospital

1889 Nephrectomy for Allograft: Living or dead

0008 Specialist assistant

0009 Assistant

0011 Afterhours fee

Living donor codes

0173 Consultation in hospital

1889 Nephrectomy for Allograft: Living or dead

0008 Specialist assistant

0009 Assistant

0011 Afterhours fee

1228/1229-1230-1233 1236

ECG 1

4171 Urea and electroloytes 1

4057 Fasting plasma glucose 1

4027 Total cholesterol 1

1241 Chest X-ray 1

4131(ALT) 4134 (GGT) 4130 (AST)

Liver function tests 1

1237, 1239, 88,302

24 hour BP monitoring Dr code, interpretation and Hiring equipment

1

Assessment of the suitability of the organ

00990 EDTA GFR (Nappi Code88025002) 1

6462 CT angiography of renal vascular supply (aorta and branches)

1

3627 Abdominal ultrasound 1

Compatibility assessment

3764 3765 3756

Blood grouping and cross matching

1 for every potential living donor ( Maximum 3 test per beneficiary for living donor) and every time the deceased potential donor become available

4607-4609 HLA typing

1 for every potential living donor ( Maximum 3 test per beneficiary for living donor) and every time the deceased potential donor become available

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Kidney transplant codes

0173 Consultation in hospital

1895 Allo transplantation of kidney

1927 Uretero-neo-cystostomy

0008 Specialist assistant

0009 Assistant

0011 Afterhours fee

Other codes applicable

1853 Nephrectomy: Primary nephrectomy

1855 Nephrectomy: Secondary nephrectomy

1859 Nephrectomy: Partial

1863 Nephro-ureterectomy

1865 Nephrotomy with drainage nephrostomy

1807 Laparoscopic assisted nephrectomy in Living donor

1915 Uretero-ureterostomy

1925 Uretero-Pyelostomy

1952 JJ Stent Catheter

1379 Iliac graft / thromboendarterectomy

1389 Endarterectomy

Peri-Operative Histology

4567 Block x1

4571 Additional Block

4589 Haematoxylin and eosin

4589 Pas stain

4591 C4D stain

4589 Gomori's trichrome

4589 Silver meths x 2 slides

4592 Immunoperoxidase

4591 Immunofluorescence

Table 4: In-Hospital care of donors and recipients

NHRPL code Procedure Average length of stay for donor

Average length of stay for recipient

1204 High Care 2 5

1205-1210 ICU 2 5

0109 0111 General ward

3 4

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Table 5: Category of health care providers in-hospital care

NHRPL code Category of staff Comments

190-192 Specialist as per transplant team members

84200-84203 Dietician Necessary to advice with dietary intake post-op

701 or 702 Physiotherapist Necessary for post-operative rehabilitation

862000-86211 + 86290 89200-89211

Social worker/Psychologist In patient support not necessary immediately post-op however patients must be seen prior to or immediately after discharge to assess motivation for adherence to treatment and social support.

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6. Post-operative care and follow-up

6.1 Follow-up schedule for recipients

The first year post transplant requires intensive review. On average the patients will consult with the

transplant team 14 times in the first year for routine review. The main objective of the follow-up in a

renal donor recipient is to assess functionality of the kidney, assess effect of immunotherapy and

evaluate post-operative. Review should be multidisciplinary (medical, psychological, rehabilitation

services and dietician) and should include pathology test and diagnostic imaging. An uncomplicated

transplant requires reviews quarterly after first year of care.

Table 6: Procedures and codes for follow-up post renal transplant for both recipient and living donor:

Code Procedure

3627 Ultrasound Study Of The Abdomen

3743 Erythrocyte Sedimentation Rate

3755 Full Blood Count

3797 Platelet Count

3887 Antibiotic Susceptibility Test

3893 Bacteriological Culture

3922 Viable Cell Count

3932 Antibodies To Human T Cell Lymphotoropic Virus Iii

3947 C-Reactive Proteins

4001 Alkaline Phosphatase

4032 Creatinine

4109 Phosphate

4113 Potassium

4117 Protein (Total)

4151 Urea

4171 Urea and Electrolytes

4188 Urine Dipstick

4370 Drug Level And Concentration

4528 Ferritin

4531 Hepatitis - Australia Antigen

Single antibody testing where indicated for poor function

1839, 1841 Kidney biopsy if indicated in first year

4082 Immunosuppressant drug levels

MAG-3 radioneucleotide scans

Kidney transplant biopsy

Kidney transplant Duplex / sonar evaluation

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Table 7: Post-operative blood test within 72 hours post-operatively

Codes Procedure Total maximum required

3755 FBC,diff 3

3797 Platelets 3

3805 INR/PI 3

3837 PTT 3

4171 U&E 3

4032 Creatinine 18

4017 Calcium 3

3999 Albumin 3

4094 Magnesium 3

4109 Phosphate 3

3762 Hb 15

3791 Hct 15

4112 Potassium 15

4076

Arterial Blood Gas/ Acid-base status

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4031 CO2 18

The blood tests above are repeated at least twice immediately post op and repeated again a day after the

operation

Table 8: Blood test from day 2 to day 14 post-operatively (Daily)

Codes Procedure Frequency Total required in the first 2 weeks post transplant

3755 FBC,diff Daily 12

3797 Platelets Daily 12

4171 U&E Daily 12

4032 Creatinine Daily 12

4017 Calcium Daily 12

3999 Albumin Daily 12

4094 Magnesium Daily 12

4109 Phosphate Daily 12

4082 Tacrolimus Daily 12

4076 Automated ABG &PH Daily 12

Once the patient is stable and discharged from hospital the following annual follow-up schedule is

recommended:

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Table 9: Multidisciplinary Care Health workers

Codes Procedure Purpose Frequency

084200-84203 Dietician

Frequent evaluation of dietary support

4 times per year

86200-86211

89200-89211 Psychologist/social worker

Initial assessment of

Maximum 4 times post transplant. If a patient is defaulting treatment or presenting with rejection the providers needs to provide clinical information to the scheme including blood tests results. Maximum of 4 psychotherapy sessions are recommended annually when patient is defaulting treatment.

Teenagers may require more regular psychosocial support maximum of 6 sessions annually is recommended for teenagers as they are at high risk for defaulting treatment. Since psychosocial support has no tangible end points schemes may manage this by requesting additional clinical information as per scheme rules.

190-192 Physician/Surgeon/ Nephrologist/ paediatricians

Monthly for first year (to assess the kidney function, adherence to medicine and manage adverse events associated with and thereafter quarterly. Patients who stabilise (Adhering to treatment, normal U&E, normal therapeutic drug levels) early do not necessarily need monthly consultation in the later months of first year. Stable patients may attend transplant clinic once every quarter. Unstable patients would require individualised follow-up plan.

4171, 4032: Urea, electrolyte and creatinine are required at each visit. Tacrolimus levels and blood culture will be requested when required.

Please note psychosocial support post transplant is essential to ensure that patients adhere to

therapy. The number of visits is slightly higher in the first year of therapy as patient experiences

huge psychosocial barriers in the first year of life. This model is also advocated by DOH for

adherence to ARV although low cadres of staff such as auxiliary social workers and adherence

counsellors are used. This is considered much more costs-effective as compared to developing

rejection due to non-compliance to treatment. Please note that teenagers (11 to 19 years) may

require more sessions as risk of non-compliance is high in this group.

The following blood tests are requested only if a patients develop pyrexia and requires investigation

to determine the source.

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Table 10: Blood tests to be requested on per required basis in recipients with pyrexia or signs of infection at

any stage of post-transplant

NHRPL code Test

Frequency (per incidence)

3958 BD Glucan/Anti Gad/Ia2 antibodies PRN

3958 C-Diff Toxin

PRN

3902 Culture Aerobic

PRN

3895 Culture Campylobacter Fetus

PRN

3895 Microscopy only wet prep

PRN

3867 Bld Parasites Concentration

PRN

3883 Blood Cult Aerobic Growth

PRN

4651 Biochem ID Bacterium Abridged

PRN

3923 Microscopy Only Stained Prep

PRN

3867 Disc Sensitivity - per organism(This can be up to 4 times, depending on the organisms.

PRN

3887 CSF cell count

PRN

4401 Bactec MGIT Bottle

PRN

O201 Aerobic Blood Culture

PRN

4651 Anaerobic Blood Culture

PRN

4651 PCR for bacterial identification

PRN

3974 Aspergillus Precip Test

PRN

3938 Identification of Mycobacteria

PRN

3919 Radiometric Mycobact

PRN

3930 Beta Lactamase Assay

PRN

3911 Synergism/Antagonism

PRN

3921 Fungal cultures

PRN

3901 Exfoliate Cytology

PRN

4561 EXF Cytology Additional unit

PRN

4563 EXF Cytology Additional unit

PRN

6.2 Follow-up of the donor post operatively

The recipient scheme is responsible for screening for potential however not for management of subsequent complications. Once the donor has recovered from surgery and received a 6 weeks post-

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surgery review the following are recommended for chronic follow-up by a clinical nurse practitioner, registered nurse or general practitioner: NHRPL CODE Test Frequency

0190 Annual check-up including BP screening Urine dipstix

Once a year

4171, 4032 Urea, electrolyte and creatinine

Once a year

7. Pharmacotherapy The MSA allows schemes to develop evidence based formulary and make allowances for patients

in whom formulary was shown to be harmful. Immunosuppressant therapy should therefore be

based on scheme formulary and allowances made for exceptions as per 15H regulation.

7.1 Immunosuppressive induction therapy for recipient per scheme formulary:

i. Steroids

ii. Immunosuppressant induction therapy (Monoclonal antibody , Anti-thymocyte globulin

(ATG), or Thymoglobulin or Retuximab)

7.2 Immunosuppressant maintenance

i. Steroids

ii. Antimetabolites

iii. Calcineurin inhibitors

iv. Others = TOR Inhibitors: (Rapamycin, Certican)

7.3 Prophylactic treatment for the recipient

i. Pneumococcal vaccine

ii. Flu vaccine

iii. Bactrim for PCP

iv. CMV prophylaxis (Valgancyclovir; 3 Months if donor/recipient +/+ or -,+, 6 months if

donor/recipient +/-, and not required if donor/recipient -/-)

v. Isoniazid prophylaxis therapy in patients with latent TB infection as per

Analgesia for both recipient and donor in ICU, general ward and to continue on outpatient

basis

7.4 Pharmacological management of immunotherapy side effects:

i. Infections: Antibiotics, antifungal and antiviral as per scheme formulary/ national protocol or

as per microscopy and sensitivity results

ii. Upper GIT protection: Proton Pump inhibitors as per scheme’s formulary

iii. Anaemia: Iron and folic acid

iv. Osteoporosis: Biophosphonates

v. Diabetes mellitus: screening with fasting blood glucose, or Hb A1c (annually) and

management a per MSA algorithm

vi. Hypercholesterolemia: Annual cholesterol level and treatment as per published algorithm

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8. Management of Kidney graft failure Graft failure is expected to occur in 10%-30% of all transplants.

8.1 Types of graft failure

i. Hyper-acute rejection This type of rejection is very rare and is caused by antibody-mediated damage to the graft. The

clinical manifestation of hyper-acute rejection is a failure of the kidney to perfuse properly on

release of the vascular clamps just after vascular anastomosis is completed. The kidney initially

becomes firm and then rapidly turns blue, spotted, and flabby. The presence of neutrophils in the

glomeruli and peritubular capillaries in the kidney biopsy confirms the diagnosis. Hyper- acute

rejection is prevented by antibody screening, HLA tissue typing and cross-matching protocols at the

time of a donor organ being available.

ii. Acute rejection

This single episode of acute rejection may be a cause for concern if not recognized and treated

promptly. Intensive early monitoring with biopsies is essential to differentiate between surgical,

immunosuppressant toxicity, acute tubular necrosis and acute rejection.

iii. Chronic rejection

Chronic rejection is a result of subclinical and clinical acute rejections over time. Chronic rejection

results in graft failure which may result in end stage kidney disease.

It normally occurs 2 years after the allograft.

8.2 Investigations

Table 11: Investigation to confirm acute rejection

Investigation NHRPL code Frequency

Voiding Cystourethrography 1993 Once during an episode

Duplex doplar Ultrasound Once during an episode

Sonar 3627 Once during an episode

Sonar guided biopsy 1841 Once during an episode

Urea and electrolytes and creatinine 4171 4032

Daily until adequate suppression is achieved

8.3 Treatment of transplant rejection

i. Hyper-acute rejection

Hyper-acute rejection is managed intra-operatively by immediate removal of the graft. Treatment is

its avoidance by having allocation and cross matching protocols in place for the transplant unit.

ii. Acute rejection

Poor adherence to treatment is the common cause of graft failure. Improving adherence in

patients with acute rejection will ensure that patients avoid multiple acute rejections which

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will eventually result in chronic rejection. Patient with acute reaction will need psychosocial

support which will assess and address barriers to adherence as well as be re-educated on

drug treatment. Two sessions annually after the first year are recommended, schemes may

request motivation for this two sessions and reports to assess progress.

Medical treatment includes high IV steroids as first line, if no response patients must be

given monoclonal antibody, anti-thymocyte globulin (ATG) thymoglobulin or retuximab.

These agents should not be used as first line due to increased risk of side effects and high

costs.

Plasmaphoresis (for episodes of proven antibody rejection)

Repeat biopsy may be required to assess outcomes of treatment

iii. chronic rejection

Patients with Chronic graft rejection must be managed similar to chronic renal failure patients. End-

stage renal disease management include dialysis and re-transplant. Patients with chronic rejection

require individualised follow-up plan that is generally more frequent than patients with no

rejections.

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Annexure 1: Minimum transplant recommendations for malignancies.

Type of Cancer

Recommendation (years)

Breast cancer > 5 (> 2 for early disease)

Colorectal cancer > 5 (> 2 for Dukes Stage A or B1)

Melanoma > 5 (> 2 melanoma in situ)

Uterine cervical cancer

cancer)

> 2 (> 5 for more advanced cervical

Renal cell carcinoma/Wilm's tumor

for incidental tumor < 5 cm)

> 2 (> 5 for large cancers; no wait for incidental tumor < 5cm)

Bladder cancer > 2

Kaposi sarcoma > 2

Leukemia

recommendation)

> 2 (limited data to make recommendations)

Lung cancer > 2

Lymphoma > 2 (possibly > 5)

Prostate cancer

disease)

> 2 ( possibly less for localized

Testicular cancer > 2

Thyroid cancer > 2

Skin (nonmelanoma) cancer

carcinoma)

0-2 (no wait for basal cell

Liver cancer

Unable to give recommendation

Myeloma Unable to give recommendation