An approach to the unwell kidney transplant patient

An approach to the unwell kidney transplant patient

Oct 10, 2017 0
emergency,General medicine,onthepods,renal

In this medical podcast, James talks to Dr Erin Vaughan about an approach to the unwell kidney transplant patient who requires a clinical review on the wards.

Summary Writer:  Cynthia Yang

Script Writer:  Erin Vaughan

Editor:  Erin Vaughan

Interviewee:  Erin Vaughan

About Dr Erin Vaughan

Erin Vaughan is a second-year Advanced Trainee in Nephrology at Royal Prince Alfred Hospital. She completed her Basic Physician Training at Royal Prince Alfred Hospital and internship and residency at Royal North Shore Hospital. Erin’s interests include general nephrology, dialysis and transplantation, junior doctor education and wellbeing.

An approach to the unwell kidney transplant patient 

With Dr Erin Vaughan, Renal Advanced Trainee, Royal Prince Alfred Hospital, Sydney, Australia.

Case

You have been called on the phone by a nurse to review a 50-year-old renal transplant patient with a fever of 38.6oC and a blood pressure of 95/60mmHg. The patient feels generally unwell.

  • Full panel of vital signs as a triage tool.
  • Brief patient history to form a list of differentials, such as presenting symptoms, background, medications.
  • This should be a clinical review call, to be seen within 30 minutes – but practically as soon as possible.
  • History
    • Focused history to determine the source of infection, followed by a systems review.
    • Consider common infections (respiratory, urinary, gastrointestinal symptoms), as well as rare and atypical infections.
      • Urinary symptoms: haematuria, dysuria, frequency, abdominal tenderness
      • Respiratory symptoms: viral or bacterial
      • Gastrointestinal: diarrhoea, abdominal pain
      • Systemic symptoms: fever, chills, rigors, muscle aches
    • Duration of symptoms.
    • Are they still making urine? – Acute kidney injury in a transplant patient is an emergency.
    • Previous infections and the microbiology results.
    • Transplant history: timing of transplant, immunosuppressant and medication compliance (orange card with up-to-date immunosuppressants), history of rejection.
    • Other background history: other causes of immunosuppression such as diabetes, other medications with potential side effects, travel history and sick contacts, vaccination history.
  • Examination
    • Renal transplant patients with a temperature of >37.2oC warrant a clinical review –these patients can present with subtle and atypical infections and deteriorate quickly
    • Regular observations – monitor the trend
    • Infection source; foreign bodies (urinary catheters, drains, dialysis catheters)and skin infections
    • Fluid assessment
    • Blood pressure
    • Trending weight and urine output
    • Systems review, especially palpate over the graft and auscultate for renal bruit
  • Infection until proven otherwise.
  • Other differentials of fever in a transplant patient include thromboembolism, rejection and malignancy.
  • Full septic screen: blood cultures at two different sites and exit sites, urine cultures, viral swabs, sputum cultures, stool cultures, chest X-ray.
  • Further investigations are guided by the history and examination.
  • Medication levels and think about drug interactions.
  • Involve senior colleagues early – transplant patients are unwell and can deteriorate quickly.
  • Ensure the patient is stable.
  • Start fluid resuscitation, monitor urine output, start broad-spectrum antibiotics early, e.g. Tazocin.
    • If there is a focal source of infection, target that.
  • Remember to adjust the dosage for renal impairment.
  • Consider risk of opportunistic infections, such as prophylactic for Pneumocystis Jiroveci pneumonia.
  • Cover for atypical infections, after consulting the renal and/or infectious disease teams.
  • Source control.
  • If the patient is still deteriorating after fluid resuscitation and antibiotics, they need escalation for ICU/HDU review – overwhelming sepsis can require inotrope support.
  • Watch for low BP and increasing HR despite IVF, as well as for decreased level of consciousness.
  • Serial VBGs are useful for monitoring lactate, a marker for perfusion, as well as for electrolyte derangements in the context of renal impairments.
  • Fever in a transplant patient is an infection until proven otherwise.
  • Dose-adjust medications.
  • Review medication list and withhold nephrotoxic medications.
  • Transplant patients can deteriorate very quickly – ask for help early.

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Tags: #abdominal tenderness,#acute kidney injury,#diabetes,#dysuria,#fever in the transplant patient,#frequency,#haematuria,#kidney transplant,#nephrology,#renal

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