Transplant recovery and rehabilitation

You will be very carefully monitored in the post-operative period. Keeping your blood pressure stable is very important to help the new kidney to work. You will be given intravenous fluids for 2-4 days and frequent blood tests are done to check your progress. The urinary catheter is usually left in the bladder for four days. Occasionally longer periods are needed if the kidney continues to produce very large volumes of urine or in males with prostate enlargement. The drains are also left in for about the same period of time.

Pain relief is given intravenously for the first couple of days using a patient controlled analgesia (PCA) pump. After that oral medication is usually enough to keep you comfortable.

You are usually up and about by the second day and starting to eat and drink.

The staff will continually ask you about whether your bowels are working! It is important that this is sorted out before you leave hospital. Constipation is common after any operation, but is particularly important after a transplant because if your bowel is not working well, the transplant medications may not be as well absorbed.

About 80% of kidneys from deceased donors and 98% from live donors work immediately. In patients with delayed transplant function, dialysis (either haemodialysis or peritoneal dialysis) may be needed. The transplanted kidney has a great capacity for healing itself and almost always recovers well. This can range from a few days to a couple of weeks. You will be closely monitored during this time and will probably need to have a transplant biopsy if the kidney does not work straight away.

Patients are generally ready for discharge on average between 5–7 days after the transplant, though complications and infections may extend the time needed in hospital.

As soon as possible patients will be supported by transplant ward staff to independently manage their medications (including pain relief), exercise and daily living activities. The sooner you recover and learn the medications the sooner you will be able to return home.

After discharge you will attend outpatients clinics at the hospital for 3-8 weeks.

The transplant ward and the outpatients clinic are your main contact if you have concerns. It is staffed 24 hours a day, so you can contact us at any time.

Medical concerns for transplant patients

Transplant patients can get more infections as their immunity is lowered to reduce the risk of their body rejecting their newly transplanted organ. Patients can also be affected by the new medications they are on, especially the steroid based medication.

Getting up and moving as soon as possible after an operation, reduces your risk of the life-threatening complications of pneumonia and/or clots in legs and lungs.

Time spent in hospital increases your risk of exposure to antibiotic-resistant infections or “super bugs” so we aim to get you ready for discharge as soon as we can.

Potential complications

Salt and water balance

The new kidney takes a few days to weeks to settle in and maintain the correct salt and fluid balance. It is common to have oedema (swelling) after the transplant and it gets better over a couple of weeks. Some kidneys cannot concentrate urine early on and patients pass many litres of urine—if so it is important that you drink lots to keep up with the kidney. Dehydration can cause the creatinine to go up.

You will be weighed every day and for the first couple of weeks, the urine you pass will be measured. The doctors will give you a target amount of fluid to drink, usually about 3 litres but sometimes more. It is a big change from dialysis where you are constantly trying to limit the intake of fluids and run 'dry'.

If you were not passing urine before the transplant, the bladder can contract and only have a volume of 100ml. That means a lot of trips to the toilet if you are making 4 litres of urine a day! Also, you will pass urine day and night, therefore, you may expect many trips to the toilet overnight. Do not be alarmed. The good news is that this gets better fairly quickly and after a couple of weeks things are back to normal.

Rejection

This is the term used to describe the reaction of the immune system against the transplant. This causes deterioration in the kidney function.

Acute rejection is a type of rejection that occurs in the early period following transplantation, although it can occur at any time if you stop/miss your medications. It refers to a very rapid reaction of the immune system against the transplanted kidney. Usually it is discovered because the blood test shows a rise in the level of creatinine (measure of kidney function). This is why you come to clinic so regularly. Most patients with rejection do not notice any physical changes or symptoms. If rejection is suspected, several tests are usually performed to confirm this and exclude other reasons that cause decreased kidney function. Scans of the kidney, as well as a biopsy, may be needed.

The biopsy is done using a needle with a local anaesthetic. The correct position in the kidney is identified by ultrasound. A small piece of the kidney is removed and is examined under a microscope. Approximately 10 - 20% of patients will experience an acute rejection episode following their transplant. However, with treatment over 90% of these can be overcome to allow continued function of the kidney. The treatment for acute rejection involves extra medications or plasma exchange for short periods of time.

High dose steroids are usually used for a first rejection episode, particularly if it is only mild.

Other medications and treatments for rejection are:

• Plasma Exchange is used when the rejection is caused by antibodies to HLA, it is possible to remove them with plasma exchange. This process is similar in some ways to haemodialysis. Blood is passed through a filter and the liquid portion which contains the damaging antibodies, the plasma, is removed and replaced with fresh plasma from the blood bank, protein and salt solutions that do not contain the harmful antibodies. Plasma exchange is usually given for a course over several weeks.
• Anti-lymphocytic medications are prepared from animals and specifically destroy the lymphocytes that cause rejection. They are usually reserved for severe or recurrent rejection. ATG, Thymoglobulin and ATGAM can be used and are given intravenously for 7–14 days. The patient is usually admitted to hospital for the first few doses, although later on it can be given as an outpatient. If you need this therapy, the doctors will go through the risks and benefits of these medications in more detail.
• Chronic immunological damage (chronic rejection) occurs later and usually does not become apparent for several years following the transplant. It is a more gradual process and the reason why it occurs in some patients is not well understood, but may relate to having too little immunosuppression. You may need a biopsy to diagnose this and/or a change in your medications to treat it. Unfortunately, chronic rejection can be difficult to treat and it can lead eventually to loss of the kidney.

Infection

Because the immune system is depressed to prevent rejection, transplant patients are more likely to get infections. You will be given medications in the early post-transplant period to try and decrease the infection risk. These medications include:

• Cotrimoxazole (Resprim) is taken long-term and prevents pneumocystis infection
• Valganciclovir (Valcyte) is given for 3 -6 months and it helps to prevent cytomegalovirus infection (CMV)
• Amphotericin lozenges are given for 1 month to prevent candida infection in the mouth (thrush)

The increase in risk includes common viral infections that can just take longer to get better, but also unusual infections that are only seen in immuno-suppressed patients.

In the early post-operative period you will be checked for wound infections, urine infections, chest infections, etc.

It is important to use common sense and act promptly – if you have a temperature or a symptom of infection it is important to seek advice early.

Viral infections

We check before the transplant to see if you (and the donor) have had common viruses that include:

• Cytomegalovirus or CMV
• Epstein-Barr virus EBV (glandular fever virus)
• Varicella virus or VZV (chicken pox or shingles)
• BK virus

Once you have had these viruses they will stay in the system and can become 're-activated' once you start on the immunosuppressive medications. The risk is highest in the early post transplant period when the medication doses are highest. You will be routinely screened for these viral infections.

Other rare and unusual infections are increased in transplant recipients. The key is to be aware of the increase in risk and be on the look out for anything unusual. If you have a fever or symptoms of infection, seek medical advice early.

Dental prophylaxis is recommended and it is advised that you are given a dose of antibiotics before any invasive dental work.

You should have the flu vaccine every year.

Diabetes

Diabetes is one of the most common post-transplant complications and it occurs in up to 25% of patients. You will be more at risk of becoming diabetic if you are overweight and/or have a family history of diabetes. Some of the immunosuppressive medications will promote high blood glucose levels (blood sugar), therefore the risk is highest in the first few weeks following the transplant when the doses of the medications are highest.

If your glucose level is high, you will be taught how to monitor the levels by using a finger prick blood test. If you develop diabetes, you will probably need medication and Insulin is often used in this period. Many patients will remain diabetic, even when the immunosuppressant medications are decreased.

Cancer

There is an increased risk of cancer developing after a transplant. In Queensland, skin cancer is a particular problem and transplant patients must take extra precautions in protecting their skin from the sun.

It is important to keep recommended bowel, breast and cervical screening tests up to date (as applicable).

Hypertension

High blood pressure can continue to be a problem despite a successful transplant, so continued treatment with medications may be necessary. There is evidence that transplants last longer in patients with good blood pressure control.

Heart Disease

Like all patients with kidney failure, the risk of heart disease is increased and it will be important to reduce the risk factors for heart disease. These risk factors include smoking, sedentary lifestyle, high blood pressure, high cholesterol and diabetes.

Osteoporosis and arthritis

In some patients weakening of the bones (osteoporosis) can occur. With the use of newer immunosuppressants, this is less common than in the past. Occasionally, severe arthritis (avascular necrosis) that mainly affects the hips can be a problem and surgery may be necessary. It is recommended that you have a bone density scan before or soon after your transplant and then every two years after transplantation. If there is evidence of osteoporosis, then you may be given more therapy to control or reverse this.

Weight Gain

Once you have a transplant, there is greater freedom to enjoy the foods that have been restricted before your transplant. You will feel better and your appetite will improve. It is important that you enjoy a nutritious diet and regular physical activity as weight gain following a kidney transplant is common. The average weight gain in the first year after a transplant is about 6-10kg. It is worth remembering that being overweight increases your risk of diabetes and that it is always easier to put it on than take it off.

Rehabilitation

In the initial recovery and rehabilitation phase, a physiotherapist will visit regularly, to ensure no complications with lungs, and that walking distance, arm and leg exercises continue to improve. Nursing staff undertake regular ward rounds to ensure that you are regularly reviewed. Please raise any concerns you have with the nursing staff.

You will initially feel fatigued and may be feeling pain or discomfort. The transplant unit staff will encourage you to begin doing things for yourself like reaching for water and tissues, eating, moving in the bed and walking ever increasing distances. It is not unusual to feel even more tired and sore after resuming activity, but it is important to continue, and eventually this discomfort decreases.

Whilst quality rest is encouraged, the post-transplant time is not for passive convalescence. Participating in their care and recovery every step along the way, enables patients to make the strongest contribution to the best outcome. Other strategies for success include:

• Schedule rest periods after activities
• Restrict numbers of visitors, to reduce tiring
• Involve visitors in the post-transplant education process
• Going for walks around the hospital, including to the atrium or herb garden for instance.

Nutrition in the recovery period

After a transplant you will gradually return to a normal diet to supply all the nutrients and energy you need to heal. If your appetite has not returned try:

• Eating small frequent amounts until stomach can tolerate larger volumes.
• Eating high value, healthy foods, rather than foods with empty calories.
• Discussing food and nutrition matters with the Dietitian.

It is important to eat well and drink the recommended amount of water for the rest of your life to ensure the best outcome for your transplant.

Outpatient clinics

Patients will attend daily outpatient clinics at the PA Hospital for the first 3-4 weeks after being discharged, then 3 days a week for the next 3-4 weeks. You will need to be at the hospital by 8am for these clinics and will usually be finished by mid-morning.

Transport to and from the outpatients clinic is your responsibility. Most patients will not be able to drive for at least 6 weeks after transplantation.