On the monthly ward round of your satellite dialysis unit you come across a new patient: a man in his mid-50s, originally from Cyprus, who has recently been discharged from the renal ward and transferred to your unit in the last week.
From his discharge paper work and chatting to the patient you learn the following:
Having being labelled as having 'small kidneys' this gentleman spent 3 years on haemodalysis before receiving a deceased donor transplant 6 years ago. This transplant was complicated by 2 early episodes of rejection and his creatinine never got much below 180umol/l.
Concordance with clinic appointments and medicines was always deemed an issue by the medical team and 9 months ago the patient ceased to attend appointments.
It transpires that this was because a doctor in the transplant clinic had suggested that the current graft would reach the end of its useful life soon and, as a result, the patient had returned to Cyprus to try and find family members who could be potential live donors.
On return to the UK, he was admitted via A&E short of breath, oedematous and of a weight approx 13kg in excess of that recorded at his last clinic visit. Serum creatinine on admission was approx 600umol/l. He was aggressively medically diuresed and re-established on dialysis given his fluid overload and symptomatic uraemia. A transplant biopsy was performed which showed widespread fibrosis and some nodular hyalinosis within arterial walls.
During his absence from the UK the patient had continued to see a renal doctor in Cyprus and remained on his Tacrolimus and MMF immunosuppression. He has a few letters from this Cypriot doctor which document 'therapeutic' FK levels throughout this time. They also refer to him having had a number of UTIs, none of which warranted hospital admission. The treatment of these infections is listed but there are no visible positive microbiology results.
In the unit today, he is well and denies any concurrent medical problems. In particular he never experiences exertional chest pain and can climb several flights of stairs.
He is still slightly oedematous with a pre-dialysis BP of 180/90. Given his recent move to your satellite unit there is no useful information about inter-dialytic weight gains and he tells you he is still passing 'about 1 litre' of urine/day.
His current medicines are: Tacrolimus 2mg BD, MMF 500mg BD, Frusemide 250mg OD, Irbesartan 150mg BD, Atorvastatin 40mg OD, one Calcichew with meals and the unit's favourite epo.
Since returning to the UK the patient has resurrected his painting and decorating business, which he claims was always the cause of his poor concordance and he tells you he has a potential live donor travelling to the UK in the next few weeks.
1 - What issues need addressing prior to listing this gentleman for transplantation?
2 - What would you do with his existing immunosuppressive regime?
- Would this strategy be influenced if he were to be listed for live donor transplantation in the near future?
3 - Would you continue his high dose loop diuretic? Why?