This page covers immunosuppression from about 6 months [rationalise order and headings]
Six month review
The immunosuppressive regimen should be reviewed at 6 months post-transplant by the nephrologist responsible for the care of the patient. Patients will be informed prior to transplantation that their immunosuppressive regimen will be reassessed at this stage. The decision must be clearly documented.
STRONGLY RECOMMEND CONSIDERATION OF RENAL BIOPSY REGARDLESS OF CREATININE IF CONSIDERING STEROID WITHDRAWAL, ALTERATION/SWITCH IN IMMUNOSUPPRESSION AND CREEPING CREATININE (remove caps; consider content, shorten)
Considerations for long-term Immunosuppression
Low risk recipient, consider:
- Steroid withdrawal
- Using a lower initial dose of MMF or replacing it with Azathioprine
- Is pregnancy possible?
Aged >60 years, consider
- For patients aged >60 years with standard immunological risk (no DSA), the initial dose of MMF is suggested to be 500mg twice daily. This is due to a lower risk of rejection, and a high rate of intolerance to full dose MMF.
New Diabetes after Transplant (NODAT), consider
- Steroid withdrawal
- Low CNI level
Steroid reduction: suggested tapering
- Week 4 Prednisolone 15mg
- Week 8 Prednisolone 10mg
- Week 12 Prednisolone 5mg
Maintaining the dosage of MMF is preferable to allow minimisation of CNI dosage. However, side-effects may occur and many patients will require dose reduction. (is this the right place or is it on the MMF page or early page?) x-refer if so
Gastrointestinal side-effects are common. Consider an an alternative cause of diarrhoea and exclude infection. If felt to be due to MMF, consider:
- Splitting dose to 500mg qds is the first line approach
- Switching to Myfortic (720mg bd = 1g MMF bd)
- Reducing dose
- Switch to azathioprine
Leucopenia may occur. Exclude CMV infection. Consider:
- A small dose reduction and monitor white cell count.
Due to the teratogenicity of mycophenolate, women of childbearing age must be advised on appropriate contraception following transplant (see Appendix VIII (insert page link). It is recommended that women avoid becoming pregnant in the first year following transplant. Thereafter pre-pregnancy counseling is advised and the following measure should be undertaken.
- Replace MMF with Azathioprine prior to conception or as soon as possible after conception in the event that pregnancy was unplanned.
- Commence folic acid.
- If deemed high risk of pre-eclampsia (allograft dysfunction, overt proteinuria, previous pre-eclampsia), aspirin may be warranted. Patient should be referred to high risk pregnancy obstetrician.
Advice for men taking MMF/Myfortic:
Recent updates to the Summary of Product Characteristics (SmPC) for proprietary brands of mycophenolate derivatives (CellCept® and Myfortic®) include new advice that sexually active men exposed to these agents should use condoms during treatment and for 90 days or 13 weeks (respectively) after discontinuation. This does not appear to be based on any new evidence and registry studies of paternal exposure have not identified an increased incidence of fetal malformations.
The following advice is from the Renal Association/Renal Pharmacy Group:
We recommend that potential fathers taking mycophenolate derivatives are informed of the theoretical risks of mycophenolate exposure to a fetus and be made aware of the contraceptive advice given by the MHRA and contained in the SmPC. We advise that these theoretical risks should be balanced against the risks of conversion to alternative immunosuppressive regimes on their kidney transplant status in an individualised discussion.