Synopsis
Understand kidney transplant assessment and aftercare, protect graft function, and recognise rejection, infection, surgical complications and immunosuppressant toxicity without unsafe medicine interruption.
- Kidney transplantation is kidney replacement therapy, not a cure: recipients retain cardiovascular risk, need lifelong surveillance and usually require continuing immunosuppression while the graft functions.
- Suitable people should be assessed before dialysis where possible; living-donor and deceased-donor routes require consent, infection and cancer screening, cardiovascular assessment, ABO and HLA work-up and a current crossmatch strategy.
- A rising creatinine is graft dysfunction, not synonymous with rejection: dehydration, obstruction, vascular compromise, infection, calcineurin-inhibitor toxicity, recurrent disease and non-adherence must also be assessed urgently.
- Rejection can be clinically silent and is often detected by surveillance blood tests; never wait for graft pain or fever before contacting the transplant centre about deteriorating function.
- Tacrolimus has a narrow therapeutic window and major CYP3A interactions; take trough samples immediately before the scheduled dose and never switch formulation or brand casually.
- Do not stop, double or empirically change anti-rejection medicines during vomiting, diarrhoea, infection or inability to swallow—obtain same-day transplant advice because both underexposure and toxicity threaten the graft.
- Fever, shivering, severe headache, persistent diarrhoea or vomiting, breathlessness, chest pain, feeling markedly unwell, or little or no urine are NHSBT warning signs requiring transplant-team contact.
- Immunosuppression increases opportunistic infection and malignancy risk; prophylaxis, non-live vaccination, sun protection and national cancer screening are part of graft care.
- Mycophenolate is a major human teratogen; pregnancy must be planned with the transplant team so a safer regimen can be established without precipitating rejection.
Key red flags
Anuria or a rapid creatinine increase after transplantation requires same-day transplant-centre assessment for vascular occlusion, obstruction, rejection, sepsis and severe volume depletion.
Fever or rigors in an immunosuppressed recipient may progress with muted inflammatory signs; use urgent sepsis assessment and seek transplant or infection advice early.
Sudden graft-region pain, hypotension, falling haemoglobin or abrupt oliguria soon after surgery raises bleeding, vascular thrombosis or urine leak and needs surgical review.
Severe diarrhoea or vomiting risks dehydration, missed immunosuppression and unpredictable tacrolimus exposure; it is a same-day medicine and graft-safety problem.
New neurological symptoms with severe hypertension, headache, seizure or visual change may indicate calcineurin toxicity or posterior reversible encephalopathy and requires emergency assessment.
Pregnancy, suspected pregnancy or pregnancy planning during mycophenolate therapy needs urgent specialist review, but the patient must not stop treatment without a safe replacement plan.
Night sweats, unexplained weight loss, lymphadenopathy, persistent fever or a new skin lesion warrants prompt malignancy and infection investigation in a transplant recipient.
Investigation priorities
Detect graft dysfunction early and define tempo against the recipient's post-transplant baseline.
Management branches
Advanced CKD is likely to progress to kidney failure and transplantation could be suitable.
- Refer early for multidisciplinary assessment, explaining living and deceased donation, waiting, surgery, lifelong medicines and realistic graft outcomes in accessible language.
- Define recurrence risk and evaluate cardiovascular health, infection, malignancy, urinary tract, iliac vessels, frailty, psychosocial needs and ability to manage the regimen.
- Perform ABO, HLA antibody and compatibility work-up under NHS Blood and Transplant and centre protocols, treating living donors as independent volunteers with separate advocacy.
- Optimise vaccination, dental and infection status, maintain regular wait-list reviews and provide clear instructions for illness or a potential organ offer.