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Long-Term Management

Eating Right: Your Nutrition and Diet
Good nutrition is an important part of the recovery process. A common problem after transplant is weight gain. This can be difficult for post transplant patients to follow. Prednisone will increase appetite, especially for sweet, sugary foods. Plus, you will able to enjoy foods you were restricted to eat on dialysis. Moderation is the key to your eating habits after a transplant. A dietitian will be available for consult to help you develop a specific individual nutritional plan.

A Few Warnings About Food After Your Transplant

• Prograf, Neoral, and Prednisone can increase your blood sugar. Some individuals will become Diabetics once they are on these medications. If you are already a diabetic on insulin, your insulin requirements will increase. If you are a diabetic on oral medications or diet control, there is a good possibility you will require insulin after transplant. If you have a strong family history or are overweight, you also have an increased risk of developing diabetes after transplant. Symptoms of diabetes include an increase in thirst, increase in frequency of urination, blurred vision, and confusion. Please notify the transplant team immediately if you develop these symptoms.

• Prograf and Neoral can increase your potassium. Some individuals will be required to monitor their potassium intakes. Some individuals will also require medication to keep their potassium normal.

• Prograf and Neoral can deplete your magnesium. Some individuals will be required to take magnesium supplements after transplant.

• Rapamune may increase your cholesterol. We will monitor this with your labs. You may need to take medication to reduce cholesterol.

Exercising
After transplant it is recommended you participate in a regular exercise plan. Exercise can help control weight gain, decrease blood pressure, lower cholesterol, increase energy, improve digestion, improve sleep, reduce stress, and improve self esteem. As you can see, there are many excellent benefits to exercise! Exercise takes only a little time, thought and commitment to a healthy lifestyle. Walking is one of the best forms of exercise. Anyone can participate in this activity at no cost. We will encourage you to start exercising in the first 2 to 4 weeks post-transplant. Discuss your exercise plan with your doctor before you start. NO LIFTING GREATER THAN 10 LBS. FOR THE FIRST FOUR TO SIX WEEKS POST-TRANSPLANT. NO SIT-UPS FOR THE FIRST SIX MONTHS POST-TRANSPLANT. Sit-ups can cause hernias in the incision if started too early.

Caring For Your Skin

1. Prednisone and other medications cause transplant recipients to have an increased risk for skin cancers. Avoid extended exposure and wear a sunscreen lotion of at least SPF 15 while outside. Remember sunscreens wear and wash off with swimming and sweat. You may have to reapply lotion often.
2. Prednisone can cause acne on your face, shoulders, chest, or back. If you develop acne it is recommended you wash the affected area three times per day with a mild cleanser.

3. Dry skin can also become a problem for some transplant recipients. Use mild soap with body lotion after bathing.

4. If you are taking Prednisone your skin will not heal as quickly as it once did. Minor cuts and scrapes should be washed with soap and water daily. An antibiotic ointment may be applied with a clean bandage. Report any redness, swelling, or drainage to your transplant team immediately.

5. Prednisone can affect the condition of your hair. Perms, permanent hair dye, tints, and bleach make hair brittle and break off. Use a good conditioner and advise your hairdresser you are on medication that can affect the condition of your hair.

6. You may experience excessive hair growth due to cyclosporine/neoral. Hair removal creams (depilatory), bleaching, waxing, and electrolysis are options you may want to use to remove or hide excess hair growth. Remember to follow directions carefully when using these products.

Caring For Your Teeth
You will need to have regular dental checkups and cleanings. If you experience any dental pain you need to contact your dentist immediately. You will need to take antibiotics before any dental work and cleanings. Please inform the transplant team or primary care physician of your dental appointment at least 5 to 7 days in advance.

Caring For Your Surgical Incision
Good hygiene is essential in the immunosuppressed transplant recipient. It is important to clean your incision with soap and water on a daily basis. You may even be asked to shower twice a day to improve the healing of your incision. If you notice any thick, foul -smelling drainage from your incision, or the area around your incision is red or warm to the touch, or there is any widening or opening of your incision contact your transplant team immediately.

Using Alcohol
Do not drink alcohol beverages. Alcohol and some of your medications are broken down by the liver. Mixing alcohol and your medications can lead to liver damage. The medications that are broken down by your liver are Cyclosporine, Neoral, Prograf and Imuran.

Smoking
It has been determined by the Surgeon General that smoking can be harmful to your health. It is recommended that you do not start smoking after transplant. If you already smoke, it is strongly recommended that you stop smoking.

Driving and Returning To Work
This will depend on your recovery, and length of recovery is individualized. The usual time for returning to work is 4 to 6 weeks. For driving the usual time is 4 weeks.

Traveling and Immunizations
If you plan to travel please let your transplant coordinator know ahead of time. Foreign travel may require immunization. Transplant patients can not receive live virus immunizations (small pox, measles, etc.). Ask your transplant team to send a letter to your local passport bureau stating that you cannot receive these vaccines. Because you are not immunized, some foreign travel may not be safe for you.

Sexual Activity
You may return to sexual activity as soon as you feel well enough. Like driving and working this is dependent on your recovery period. You may discuss any problems or concerns you have with your transplant team at your clinic appointments.

Becoming Pregnant
There have been a number of successful pregnancies among women who have had kidney transplants. Pregnancy may cause special risks for the baby and the transplant recipient. Women should avoid pregnancy for one year following transplant and any attempt to become pregnant should first be discussed with the transplant team. You should also discuss with your transplant team which method of birth control you would like to use.

Finding Support
Receiving a transplant can be a stressful, overwhelming experience. Keeping yourself and your new kidney healthy is a lifetime commitment. YOU ARE NOT ALONE. The transplant center has monthly support group meetings.Transplant social workers are available to help with support programs and coping.

Rejection
Your body's immune system protects you from foreign substances like bacteria, fungus, and viruses that can cause infection. Your immune system also recognizes your new transplanted organ as a foreign substance. You will take immunosuppressive medications to fool your body and prevent your immune system from attacking and destroying your new liver. When your body's immune system attempts an attack against your new liver it is called Rejection. Rejection most often occurs in the first 3 months after transplant. This is why you will have frequent visits to the clinic with blood tests during the first three months.

You must learn the signs and symptoms of rejection. If you experience any of the following signs and symptoms, report them to your transplant team immediately.

The signs and symptoms of rejection are:

• fever
• swelling of ankles/hands
• fatigue/weakness
• tenderness of kidney
• decreased urine output
• increase in weight gain

Recognizing and Preventing Infections
We will be lowering/suppressing your immune system with the immunosuppressive medications. This will make you more susceptible to infections. The following guidelines will help you prevent infections.

• Wash your hands frequently.
• Keep your hands away from your mouth and eyes.
• Stay away from people with colds and other infections.
• Avoid crowded enclosed areas for the first three months post transplant and after any treatment for rejection.
• Ask friends to visit only when they are well.
• Wash your hands after coughing and sneezing. Throw tissues into the trash imMediately.
• Do not eat or drink using the same glass or eating utensils after friends or family members.
• Family or friends who live with you should follow the same guidelines when they are sick.
• Avoid working in the soil or gardening for the first 6 months. When you are allowed to work in the soil you must wear gloves.
• Avoid handling animal waste and avoid contact with animals who roam outside. Do not clean bird cages, fish or turtle tanks, or cat litter. The cat litter box should be covered.
• Avoid vaccines that consist of live viruses, such as Sabin oral polio, measles, mumps, German measles, yellow fever, or smallpox. The live virus can cause infection. If you or any family member intends to receive any vaccinations, notify your transplant team.
• The mouth and teeth can be a source of infection. Daily mouth care (brushing and flossing) are essential to staying healthy. You must have regular dental checkups.

You must learn the warning signs of infection. They are the following:

• Fever over 100 degrees F.
• Flu symptoms: chills, aches, fatigue, headaches, dizziness, nausea, and vomiting.
• "Wet" productive cough and/or shortness of breath.
• Nasal congestion with thick greenish or yellow drainage.
• Sore throat.
• Diarrhea.
• Pain, burning during urination, or feeling constant urge to urinate.
• Any wound that is red, swollen with some drainage.
• Mouth sores or thrush.
• Rashes or skin lesions.

If you develop any of these symptoms report them to your transplant team imMediately.

As a transplant recipient you are more susceptible to certain types of infections that you should become familiar with them. They are the following:

1. Viral Infections:
   1. Cytomegalovirus (CMV): Approximately 30-80% of the population (depending on where you live) has had this virus at some time in their life. This virus is not dangerous in the general public, but can be serious in the transplant recipient due to their lowered immune system. Signs can include fatigue, high fever, aching joints, headaches, nausea, vomiting, visual disturbances, and pneumonia.

   2. Herpes-simplex virus type I and II: Type I herpes generally causes cold sores and blisters around the mouth. Type II herpes causes genital sores. Most herpes infections are mild, but occasionally they can be severe. There is no cure for herpes, but it can be treated. The treatment depends on the severity of the infection. The treatment may be oral or intravenous. Notify your transplant team immediately if you believe you have herpes.

   3. Herpes zoster (shingles): Shingles appear as a rash or small water blisters. They appear usually on the chest, back, or hip. The rash may or may not be painful. Notify your transplant team imMediately if you believe you have shingles. The severity of the infection determines whether treatment will be oral or intravenous.

2. Fungal Infections:
   1. Candida is a fungus that can cause a variety of ifections in transplant recipients. It most commonly infects the mouth and throat, but can also be found in surgical wounds, eyes, respiratory and urinary tracts, or the bloodstream. Candida that infects the mouth and throat is called Thrush. Thrush produces white, patchy lesions, pain or tenderness, a white coating on the tongue, and difficulty swallowing. You will take mycelex troches 10 mg three times per day to prevent thrush. Candida that infects the vagina is called a "yeast infection." Symptoms are abnormal white or yellow discharge from the vagina. Notify your transplant team if you suspect you have a candida infection.

3. Bacterial Infections:
   1. There are many different types of bacterial infections. Different types of bacteria can affect any area of the body. Most common are urinary tract infections, bronchitis, pneumonia, sinusitis, wound infections, and blood infections. It is important as a transplant recipient that you contact your transplant team if you believe you have an infection (Review the signs and symptoms of infections previously listed.).

4. Parasitic Infections:
   1. Pneumocystis carinii is a parasitic infection that is normally found in the lungs. It can cause a type of pneumonia called PCP. PCP can be prevented by taking Bactrim. If you are allergic to Bactrim another medication will be substituted. Symptoms of PCP are shortness of breath, dry cough, and fever. Notify the transplant team imMediately if you have these symptoms.

Medications
You are responsible for taking the medications prescribed for you. You will be required to be familiar with your medications before you go home. Not taking your medications at the right time and in the correct amount is one of the most common reasons for transplant failure.

1. To take your medications correctly, you must:
   1. Know the name and purpose of each medication.
   2. When to take each medication. Take each medication at the times prescribed on the medication sheet filled out by the transplant team. Take all medication exactly as directed. Try to take each medication at the same time every day.
   3. Never skip a dose or change the amount of medication prescribed for you, unless instructed by your transplant coordinator or physician.
   4. If you accidentally miss or skip a dose of your medication, call your transplant coordinator or physician immediately.
   5. Know the main side effects of the medications. If you experience side effects, call the transplant coordinator or physician. Do not stop taking medications without permission from your physician.
   6. Know how and when to reorder your medications. Investigate with your insurance company which pharmacy they prefer you use.
   7. Do not take any medication not prescribed by your transplant team without first checking with the team. This includes all over the counter medications. Do not take Advil, Ibuprofen, Aspirin, Aleve, and Motrin without discussing with the transplant team - you may take Tylenol. Please remember to follow dosing instructions.
   8. Notify the transplant team if you have prolonged nausea, vomiting, and/or diarrhea. These symptoms may affect the absorption of your medications.

2. The following are some general medication storage guidelines:
   1. Keep medications in the original container with the cap on tightly. If you use a special container to store medications, keep the container tightly sealed. Never take your cyclosporine/neoral out of the blister pack until you are ready to take it.
   2. Store you medication in a cool, dry place away from direct sunlight. Never store medications in the bathroom. Moisture can cause medications to lose their strength.
   3. Do not store medications in the refrigerator unless your physician or pharmacist advises you to do so. Never allow liquid medications to freeze.
   4. Keep all medications away from children!

Immunosuppresive Medications