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Kidney Transplant

Followup

Transplant Center Evaluation and Therapy

Sam was admitted to the transplant team on February 2. That same day a needle biopsy was done under local anesthetic in which a small needle was put into the transplanted kidney. The needle captured enough nephrons for a pathologist to evaluate under the microscope. At that point no one knew whether this was a rejection or if it might be an early recurrence of Sam's underlying kidney disease. The preliminary report of the biopsy indicated an early chronic rejection, not an acute rejection which might have responded better to the medications tried over the past week.

The next day, after extensive discussion with Sam and members of the transplant team, the team decided to put him on Orthoclone OKT3®. OKT3® is a potent anti-rejection therapy available in IV form, which must be administered with close clinical supervision. Sam was admitted to intensive care for the initiation of OKT3®, the standard procedure because of possible severe reactions to the drug. His creatinine was 4.2 and BUN was 82. He tolerated the therapy without reactions. By February 5th he was out of intensive care and by the following day he was discharged and able to return to a short-stay unit for administration and monitoring of the OKT3®. For the next ten days Sam returned daily as an outpatient to receive OKT3® and monitoring in the short-stay center.

During this time Sam had not had the obvious signs of rejection such as decreased urination, fever or tenderness over the transplant site. This underscores the great challenge in transplant follow-up care for both patients and their caregivers during the first year after surgery. On the one hand, the goal is of course to allow transplantation to enable the individual to resume work and activities of normal life. On the other hand, close monitoring is necessary to assess for possible problems such as rejection, toxicity levels of certain drugs and medication side effects. After six or more months of a well-functioning transplant, transplant care providers often struggle with the fine line between constant appointments for assessment versus less frequent visits which can allow the patient to return to a more normal lifestyle. Most follow standard protocols for follow-up visits and medication dosages as long as things are stable, increasing visits only if there are problems.

No one knows why rejection began right after Christmas. Sam had no signs of rejection and was feeling well. He was on a typical regimen of post-transplant care and was well educated on side effects of drugs and symptoms of rejection and problems to report. Lab values had been stable over the past few months. Rejection can occur after any transplant procedure at any time. Sometimes the reason is understood. Sometimes it is never understood, a fact that gives much uncertainty and frustration to all individuals involved.

Since the OKT3® was helping at the end of one week of therapy with creatinine level down to 2.7, the decision was made to continue this expensive and inconvenient therapy one more week. OKT3® and its administration costs about $1,000 per treatment. Unfortunately, the creatinine steadily crept up each day during the second week of therapy, reaching 3.3 at the end of therapy.

Describe the feelings and viewpoints of people involved with this transplant