PediatricKidneyPost-Transplant Protocol

Intra-op meds:

  1. Mannitol (0.25 gm/kg)
  2. Lasix (1 mg/kg)
  3. Methylprednisolone, Thymoglobulin (in most cases, see below)
  4. Cefazolin

Fluid Management:

  1. Insensible Losses: D5W @ 20 ml/hr
  2. Urine replacement: 0.45% NS + 20 meq NaHCO3/L @ ml/ml of urine losses
  • After initial post-operative period (24-48hr), change to fixed intake (PO + IV) of 1.5x maintenance.
  • Long-term: Target enteral intake of 1.5x maintenance.

Immunosuppression:

  1. For typical immune risk:

Thymoglobulin (rabbit polyclonal antithymocyte preparation)

  • Initiated intra-op, give 1 mg/kg IV over 6 hours, then daily (over 4 hours), for a total of 5-6 doses
  • Premedicate with methylprednisolone, acetaminophen and diphenhydramine

OR if previous thymoglobulin anda high titer of anti-rabbit antibodies: Alemtuzumab (Campath) is used

  1. Mycophenolate mofetil
  • 300 mg/m2 PO BID while on Thymoglobulin, then 600 mg/m2 BID
  • Dose adjusted as needed based on WBC.

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  1. Methylprednisolone/prednisone
  • Intra-op: 10 mg/kg
  • Post-op:

POD#1: 2 mg/kg IV - will serve as a premed for Thymoglobulin

POD#2-4: 1 mg/kg IV daily – will serve as a premed for Thymoglubulin

  • Subsequent early steroid taper (prednisone):

Post-op dayDose per day (mg/kg) 5-6 0.6 7-8 0.5 9-10 0.4 11+ 0.3

  • Eventual taper to low dose on an alternate day dosing schedule
  1. Tacrolimus (Prograf)
  • ~ 0.1 mg/kg/dose PO q 8hr if < 6yrs old, q 12hr if older
  • Target trough level of 10-12
  • First dose once renal function well established

Blood Pressure Management:

  • While in PCCU: Nifedipine 0.1 mg/kg/dose PO prn SBP > 99% for age & gender, if pain well controlled
  • Transition to Amlodipine PO, BP target is 50% for age & gender
  • Stepwise use addition of atenolol and other antihypertensives as needed.

Prophylaxis:

  1. Wound: Cefazolin IV intra-op
  2. Candida: Nystatin suspension, starting POD #1
  3. PCP & UTI: Bactrim PO nightly, starting POD #1

*If sulfa allergy: Dapsone & Macrodantin

  1. CMV: If patient and/or donoris CMV +, treat with valganciclovir (Valcyte) PO daily for 6 months. ( R- D+ / R+ D+ / R+ D- )
  2. GI: Famotidine (Pepcid) IV q day, then PO BID

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Monitoring:

  1. CBC/diff, BMP on arrival to PACU/PCCU

* thenHct, BMP q 6h x2

* CBC/diff/plts, BMP, Ca PO4, Mg q am

* daily FK trough levels once tacrolimus started

  1. If temp >38.5, obtain blood cultures from appropriate lines, urine culture and CXR, if indicated by clinical status.

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