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Abdominal Transplant Immunosuppression Management – Adult – Inpatient/Ambulatory

Abdominal Transplant Immunosuppression Management – Adult – Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Medications


1
Abdominal Transplant Immunosuppression
Management – Adult– Inpatient/Ambulatory
Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 2
SCOPE ...................................................................................................................................... 3
METHODOLOGY ...................................................................................................................... 3
INTRODUCTION ....................................................................................................................... 5
RECOMMENDATIONS .............................................................................................................. 5
UW HEALTH IMPLEMENTATION ............................................................................................30
REFERENCES .........................................................................................................................30
CPG Contact:
Name: Philip Trapskin, PharmD, BCPS, Drug Policy Manager
Phone Number: 608-265-0341
Email address: PTrapskin@uwhealth.org
Guideline Author(s):
Katie Cunningham, PharmD, BCPS; Jillian Descourouez, PharmD, BCPS; David Hager,
PharmD, BCPS; Kimberly Holdener, PharmD; Katelyn Richards, PharmD, BCPS
Coordinating Team Members:
Michael Armbrust, RN; Erica Bouska, RN; Christa Finch, RN; Susan Little, RN; Jaime
Myers, RN; Nancy Radke, RN
Review Individuals/Bodies:
D. Kaufman, MD; A D’Alessandro, MD; A. Djamali, MD; J. Odorico, MD; M. Lucey, MD
Committee Approvals/Dates:
Pharmacy and Therapeutics Committee: June, 2014
Lab Practice Committee: July, 2014
Release Date: October 2014
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2
Executive Summary
Guideline Overview
This document is intended to guide the use of immunosuppressive agents in both
the inpatient and outpatient setting for abdominal transplant patients. Medications
used for stress ulcer prophylaxis and supplementation are also addressed.

Immunosuppressive agents in this guideline include:

1. Azathioprine (Imuran®)
2. Belatacept (Nulojix®)
3. Cyclosporine (Neoral®, Gengraf®)
4. Dexamethasone
5. Everolimus (Zortress®)
6. Mycophenolic acid (Myfortic®, Cellcept®)
7. Prednisone
8. Sirolimus (Rapamune®)
9. Tacrolimus (Prograf®, Hecoria®)


Target Population
Adult inpatient and outpatient kidney, pancreas and liver transplant recipients.
Patients enrolled in investigational studies and patients with delayed graft
function are not included.

Practice Recommendations
Immunosuppression should be patient and organ specific, incorporating multiple
factors to determine the optimal regimen.

Companion Documents
1. Desensitization, induction and rejection for kidney recipients based on DSA

Pertinent UW Health Policies & Procedures
1. Multidisciplinary Patient Care- Abdominal

Patient Resources:
1. Transplant medication class handout
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3
Scope
Disease/Condition(s):
Adult kidney, pancreas, and liver transplant recipients

Clinical Specialty:
Transplant, Nephrology, Hepatology

Intended Users:
Physicians, Physician Assistants, Nurse Practitioners, Nurses, Pharmacists

CPG objective(s):
To provide recommendations for managing maintenance immunosuppression in
an inpatient and outpatient setting.

Target Population:
Adult kidney, pancreas, and liver transplant recipients

Interventions and Practices Considered:
This guideline recommends immunosuppression management for abdominal
transplant patients in order to help standardize care in both the inpatient and
outpatient settings. It also incorporates stress ulcer prophylaxis, and
recommendations for the use of supplements post-transplant.

Major Outcomes Considered:
Rejection, toxicity, graft survival, patient survival, and graft function

Guideline Metrics:
Rates of rejection, graft survival, patient survival, and graft function
Methodology
Description of Methods Used to Collect/Select the Evidence:
1. Searches of electronic databases (e.g., national and international guidelines
for immunosuppression management)
2. Hand-searches of Published Literature (Primary Sources)
3. Hand-searches of Published Literature (Secondary Sources)

Methods Used to Assess the Quality and Strength of the
Evidence:
Weighing according to rating scheme (scheme given below).

Rating Scheme for the Strength of the Evidence:
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4
A modified Grading of Recommendations Assessment, Development and
Evaluation (GRADE) developed by the American Heart Association and
American College of Cardiology (Figure 1) have been used to assess the Quality
and Strength of the Evidence in this Clinical Practice Guideline.

Figure 1: Quality of Evidence and Strength of Recommendation Grading Matrix*



Description of the Methods Used to Analyze the Evidence:
Systemic Reviews
Expert Opinion

Description of Methods Used to Formulate the
Recommendations:
A review of current literature, survey of provider preferences, and trends from
current practice were all incorporated into the formulation of recommendations.
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5
Rating Scheme for the Strength of the Recommendations:
See the “Rating Scheme for the Strength of Evidence”

Cost Analysis:
Not Applicable
Introduction
Maintenance immunosuppression regimens vary based on patient specific factors,
provider preference, and institutional policies and guidelines. This document is intended
to guide the use of maintenance immunosuppressive agents in both the inpatient and
outpatient setting for abdominal transplant patients. Induction immunosuppression
regimens, medications used for gulcer prophylaxis, medications to prevent thrombosis,
and vitamins and supplements are also addressed.

Agents for maintenance immunosuppression:
1. Calcineurin Inhibitors (CNI)
a. Tacrolimus (Prograf®, Hecoria®)
b. Cyclosporine (Neoral®, Gengraf®)
2. Anti-Proliferatives
a. Mycophenolic acid (Myfortic®, Cellcept®)
b. Azathioprine (Imuran®)
3. Corticosteroids
a. Prednisone
4. Mammalian Target of Rapamycin (mTOR) Inhibitors
a. Sirolimus (Rapamune®)
b. Everolimus (Zortress®)
5. Costimulation Blocker
a. Belatacept (Nulojix®)
Recommendations
Renal transplant immunosuppression:
1. Induction therapy, utilizing a combination of immunosuppressive medications,
is recommended to start before, or at the time of kidney transplantation.
(Desensitization, induction and rejection for kidney recipients based on DSA)
(Class I, Level of Evidence A)
2. Maintenance immunosuppression consists of a combination of
immunosuppressive medications which may include a CNI or costimulation
blocker (belatacept) and anti-proliferative agent with or without corticosteroids
(Class I, Level of Evidence A)
3. The preferred maintenance regimen consists of tacrolimus or belatacept and
mycophenolic acid, with or without prednisone (Class I, Level of Evidence A)
4. Recipients from living HLA-matched (HLA-identical) donors are not continued
on steroid maintenance immunosuppression (Class I, Level of Evidence A)
5. Recipients that receive alemtuzumab induction therapy are not continued on
steroid maintenance immunosuppression (Class I, Level of Evidence A)
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6
6. Maintenance medications used for immunosuppression include the following:

a. Tacrolimus (Class IIa, Level of Evidence C)
i. Tacrolimus is the preferred CNI for use in renal transplant
patients
ii. Initiate tacrolimus on POD 1 for all patients with a target
discharge tacrolimus level of 8 ng/mL by POD 5
iii. If a patient received thymoglobulin, initiation may be delayed if
renal function has not shown significant improvement (<30%
decline in serum creatinine from POD 1 to POD2)1
iv. There is no evidence that delaying the initiation of tacrolimus
results in decreased duration of delayed graft function
v. Intravenous tacrolimus is not indicated for use
vi. Tacrolimus should be administered with food
vii. Initial tacrolimus dosing:
1. If patient receives basiliximab induction:
a. Tacrolimus: 0.05 mg/kg/day (in two divided doses)
for max MFI <500
b. Tacrolimus 0.1 mg/kg/day (in two divided doses)
for max MFI >500 in two divided doses
2. If patient receives anti-thymocyte globulin induction:
a. Tacrolimus dosing should be tailored based on
potential sensitivity to tacrolimus and goal
tacrolimus level
b. If a patient meets any of the criteria for decreased
sensitivity to tacrolimus (Table 1), the initial dose
will be 2 mg twice daily
c. All other patients will be initiated on 1 mg twice
daily
Table 1. Factors for Identifying Tacrolimus Sensitive Patients2
Increased Tacrolimus Sensitivity Decreased Tacrolimus Sensitivity
NPO General Diet
Weight <80 kg Weight >80 kg
Significant drug interactions African-American

3. Target trough levels should be utilized for all subsequent
dose adjustments using the goals found below
a. These goals are based on concurrent use of
tacrolimus with mycophenolate
Table 2. Goal Tacrolimus (FK) Levels
Goal FK Level
0-3 months: 8-11 ng/mL
3-6 months: 7-9 ng/mL
6-12 months: 6-8 ng/mL
>12 months: 5-7 ng/mL
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4. Dose adjustments:
a. Dose adjustments will occur after a patient has
received 4 doses of the current regimen.
b. Below goal:
i. If a patient is >50% below their target goal,
the daily dose will be increased by 25-50%
ii. If a patient is <50% below their target goal,
the daily dose will be increased by 25%.
c. Above goal:
i. If a patient is >50% above their target goal,
the daily dose will be decreased by 25-50%
ii. If a patient is <50% above their target goal,
the daily dose will be decreased by 25%.
iii. May consider holding tacrolimus to facilitate
decrease in trough concentration.

viii. Laboratory Monitoring:
1. Tacrolimus levels will be ordered daily while inpatient and
patient is receiving daily tacrolimus doses (either post-
operatively or during readmission)
2. Once discharged, tacrolimus levels will be monitored at
the following frequency:
a. Day 0-90: not less than once weekly
b. Day 91-180: not less than twice monthly
c. Day 181-240: not less than one time monthly
3. Additional monitoring of tacrolimus trough levels is
warranted if there is a change in medication formulation
or patient status that may affect levels or if the creatinine
has increased 0.3 mg/dL above baseline
4. Check level in 3-7 days following dose adjustment
5. Check potassium and creatinine with each tacrolimus
level
6. A minimum of 2 levels should be within the goal range
before resuming the previous monitoring frequency

ix. Adverse effects due to tacrolimus:
1. Acute kidney injury:
a. Inpatient Management:
i. Assess tacrolimus trough level for
correlation with elevated creatinine
ii. If trough level is above goal and creatinine
has increased 0.3 mg/dL above baseline,
hold tacrolimus
iii. While tacrolimus is held, double current
prednisone dose
b. Outpatient Management:
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i. Assess tacrolimus trough level for
correlation with elevated creatinine
ii. If trough level is above goal and creatinine
has increased 0.3 mg/dL above baseline,
adjust tacrolimus dose as follows:
1. If a patient is >50% above their
target goal, the daily dose will be
decreased by 25-50%
2. If a patient is <50% above their
target goal, the daily dose will be
decreased by 25%.
3. May consider holding tacrolimus to
facilitate decrease in trough
concentration.

2. Neurological symptoms (tremor, headache)
a. Assess tacrolimus trough level for correlation with
tremors or headache
b. If trough level is above goal, adjust tacrolimus
dose and follow up with patient after the
subsequent tacrolimus lab draw
c. No dose adjustment is recommended if trough
level within target range
i. Follow up with patient in 1 week if no dose
adjustment is made
d. If adverse effects are intolerable or interacting with
daily activities and there is no other known cause
of symptoms, consult the transplant physician and
consider converting the patient to cyclosporine or
refer to primary care provider for supportive
therapy

3. Hyperglycemia
a. No dose adjustment is recommended
b. Consider diabetes management & nutrition
services for patient
c. Diagnosis of new onset diabetes after transplant
(NODAT) is defined by the World Health
Organization (WHO) and American Diabetes
Association (ADA) that develops for the first time
after kidney transplantation2
d. If there is no improvement in glucose control 6
months after transplant (NODAT requiring insulin
OR A1c >7% with glucose lowering agent) and
there have been 3 months of minimal
glucocorticoid doses:
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9
i. Consult transplant physician and consider
converting the patient to cyclosporine2,3

b. Cyclosporine (Neoral): (Class IIa, Level of Evidence C)
i. Cyclosporine will be initiated post-transplant in patients who
were previously intolerant of tacrolimus or were on cyclosporine
prior to transplant
ii. Initiate cyclosporine on POD 1
iii. If a patient received thymoglobulin, initiation may be delayed if
renal function has not shown significant improvement (<30%
decline in serum creatinine from POD 1 to POD2)1
iv. Initial dosing recommendation of 100-150 mg twice daily
1. Cyclosporine dosing should be tailored based on
potential sensitivity to cyclosporine and goal cyclosporine
level
2. If a patient meets any of the criteria for decreased
sensitivity to cyclosporine (Table 1), the initial dose will
be 150 mg twice daily
3. All other patients will be initiated on 100 mg twice daily
Table 3. Factors for Identifying Cyclosporine Sensitive Patients2

Increased Cyclosporine Sensitivity Decreased Cyclosporine Sensitivity
NPO General Diet
Weight <80 kg Weight >80 kg
Significant drug interactions African-American

4. Target trough levels should be utilized for all subsequent
dose adjustments using the goals below:

Table 4. Goal Cyclosporine (CSA) Levels







5. Dose adjustments:
a. Dose adjustments will occur after a patient has
received 4 doses of the current regimen
b. Below goal:
i. If a patient is >50% below their target goal,
the daily dose will be increased by 25-50%
ii. If a patient is <50% below their target goal,
the daily dose will be increased by 25%.
c. Above goal:
Goal CSA Level
0-3 months: 200-300 ng/mL
3-6 months: 150-250 ng/mL
6-12 months: 100-200 ng/mL
>12 months: 50-100 ng/mL
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10
i. If a patient is >50% above their target goal,
the daily dose will be decreased by 25-50%
ii. If a patient is <50% above their target goal,
the daily dose will be decreased by 25%.
iii. May consider holding tacrolimus to facilitate
decrease in trough concentration.

v. Laboratory monitoring:
1. Cyclosporine levels will be ordered daily while inpatient
and receiving daily cyclosporine doses (either post-
operatively or during readmission)
2. Once discharged, cyclosporine levels will be monitored at
the following frequency:
a. Day 0-90: not less than once weekly
b. Day 91-180: not less than twice monthly
c. Day 181-240: not less than one time monthly
3. Check level in 5-7 days following dose adjustment
4. Check potassium and creatinine with each cyclosporine
level
5. A minimum of 2 levels should be within the goal range
before resuming the previous monitoring frequency

vi. Adverse effects:
1. Management of adverse effects for cyclosporine is the
same as the management of adverse effects for
tacrolimus

c. Mycophenolic Acid (MPA): (Class IIa, Level of Evidence C)
i. Mycophenolic acid is the preferred anti-proliferative medication
used for renal transplant patients
ii. Initiate mycophenolate sodium 720 mg PO twice daily on POD 1
1. Equivalent mycophenolate mofetil dosing: 1000 mg PO
twice daily
2. African-American patients may be initiated on 720 mg PO
three times daily
iii. IV mycophenolate mofetil is indicated if the patient has an acute
condition that affects gastrointestinal absorption (i.e.,
gastrointestinal bleed or obstruction, malabsorption syndromes,
severe diarrhea or severe vomiting)
iv. Mycophenolate mofetil suspension is utilized for patients
receiving medications via nasogastric or orogastric tube
v. Laboratory monitoring of mycophenolic acid levels is not
recommended to assess for toxicity or efficacy
vi. Adverse effects:
1. Diarrhea:
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11
a. If a patient has ≥50% increase in their frequency
of daily bowel movements for ≥ 5-7 days
i. 0-3 months post-transplant:
1. Check Clostridium difficile,
Clostridium difficile toxin B PCR
ii. CMV PCR
iii. ≥3 months post-transplant, obtain the
following studies:
1. CMV PCR
2. Complete blood count
3. Clostridium difficile Clostridium
difficile toxin B PCR
4. Cryptosporidium
5. Giardia PCR
6. Norovirus PCR
7. Rotavirus AG
8. Stool culture, with E. Coli (Shiga)
toxin
9. Stool O&P (ova & parasite studies
including: parasitology, isospora,
cyclospora, pinworm) – do not order
for inpatients who have been in
house for >48-72 hours
iv. If the above studies are negative for an
infectious cause of diarrhea and it is
affecting activities of daily living or the
patient is having limited and/or decreased
oral intake:
1. Decrease mycophenolate by 50% to
a minimum dose of 180 mg twice
daily or 250 mg twice daily
2. Follow up with patient in 1 week
3. If dose is decreased to 180 mg twice
daily (MYF) or 250 mg twice daily
(MMF) consult provider to determine
if other immunosuppression needs to
be adjusted
4. Add loperamide 2 mg as needed
after each loose stool (max dose: 16
mg daily) or diphenoxylate/atropine
(Lomotil®) 5 mg four times daily as
needed (max dose: 20 mg/day)

2. Heartburn/nausea:
a. Counsel patient on taking MYF or MMF with food if
not already doing so
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12
b. Convert from MMF to MYF if only upper GI
complaints (heartburn, nausea)
c. Add calcium carbonate as needed, or the addition
of an H2RA or PPI if not already on
d. If symptoms continue following 1 week of daily
therapy increase H2RA or PPI dose to twice daily,
reassess in 1 week
e. If symptoms persist for ≥1 week, consider EGD to
rule out infection vs. ulceration

d. Prednisone: (Class IIa, Level of Evidence C)
i. Predisone 30 mg daily will be started on POD 4 following
dexamethasone and prednisone taper and will continue on
discharge for patients that receive thymoglobulin or basiliximab
for induction
ii. Patients that receive alemtuzumab for induction should finish a
steroid taper on POD 4 and not continue on prednisone for
maintenance immunosuppression
iii. Prednisone doses should be split to twice daily dosing for
patients requiring insulin for glucose control
iv. Assessment for prednisone taper should occur at 2 week post-
operative clinic visit
1. Factors that may influence the ability to taper prednisone
at that time include:
a. Current and historical tacrolimus/cyclosporine
levels
b. Current MPA dose
c. Current renal function
d. Episodes of rejection
v. If deemed appropriate for a prednisone taper at that time,
patients should decrease prednisone doses from 30 mg daily by
5 mg per week to a maintenance dose of 5 mg daily (if
tacrolimus levels are within goal and the patient is on full dose
mycophenolate)

e. Azathioprine: (Class I, Level of Evidence A)
i. Indicated for use in patients unable to tolerate adverse effects of
MPA
ii. Dosing:
1. 1-3 mg/kg/day as a single daily dose
iii. There is no recommended azathioprine level for monitoring
purposes.
iv. Recommend either discontinuation of allopurinol if azathioprine
is initiated or decreasing the allopurinol dose by 1/3 (33%) or
1/4 (25%).
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13
v. Recommend discontinuation of febuxostat if azathioprine is
initiated.
vi. If allopurinol or febuxostat is continued, close hematological
monitoring is warranted.

f. Sirolimus/Everolimus: (Class IIa, Level of Evidence C)
i. Indicated for use in patients as a replacement for azathioprine,
MPA or CNIs
ii. Dosing:
1. Sirolimus: 2 mg PO one time daily
2. Everolimus: 0.75 mg twice daily
iii. Subsequent doses should be adjusted based on trough levels
iv. Consult managing provider to determine dosing plan

Table 5: Goal Sirolimus and Everolimus levels
Goal Trough Levels
(SIRO/EVR+FK)
Goal Sirolimus Level
(SIRO/EVR+MPA)
0-3 months: FK: 5-7 ng/mL
SIRO/EVR: 4-7 ng/mL
SIRO/EVR: 8-10 ng/mL
3-6 months: FK: 5-7 ng/mL
SIRO/EVR: 4-7 ng/mL
SIRO/EVR: 8-10 ng/mL
6-12 months: FK: 3-5 ng/mL
SIRO/EVR: 3-5 ng/mL
SIRO/EVR: 5-8 ng/mL
>12 months: FK: 3-5 ng/mL
SIRO/EVR: 3-5 ng/mL
SIRO/EVR: 5-8 ng/mL

v. Laboratory monitoring:
1. Recommended one time weekly upon initiation and
with any dose changes
2. When the target trough level has been attained, it is
recommended to monitor levels one time monthly

g. Belatacept (Class I, Level of Evidence A)
i. Indicated for use in patients who are EBV seropositive as a
replacement for CNIs in combination with basiliximab induction,
mycophenolate and corticosteroids
ii. Dosing:
1. Initial phase:
a. Day 1/POD 0: 10 mg/kg/dose
b. Day 5: 10 mg/kg/dose
c. End of week 2, 4, 8, 12: 10 mg/kg/dose
2. Maintenance phase:
a. 5 mg/kg/dose every 4 weeks (±3 days)



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14
Pancreas transplant maintenance immunosuppression:
1. Induction therapy, utilizing a combination of immunosuppressive
medications, is recommended to start before, or at the time of pancreas
transplant alone (PTA), pancreas after kidney transplant (PAK) or
simulataneous kidney pancreas (SPK) transplant. (Desensitization,
induction and rejection for kidney recipients based on DSA) (Class IIa,
Level of Evidence C)
2. Maintenance immunosuppression consists of a combination of
immunosuppressive medications which may include a CNI and anti-
proliferative agent with or without corticosteroids. (Class IIa, Level of
Evidence C)
3. The preferred maintenance regimen consists of tacrolimus and
mycophenolic acid, with or without prednisone (Class IIa, Level of
Evidence C)
4. Recipients that receive alemtuzumab induction therapy are not continued
on steroid maintenance immunosuppression. (Class IIa, Level of Evidence
C)
5. Maintenance medications used for immunosuppression include the
following:

a. Tacrolimus: (Class IIa, Level of Evidence C)
i. Tacrolimus is the preferred CNI for use in pancreas transplant
alone, pancreas after kidney and simulataneous kidney
pancreas transplants.
ii. Initiate tacrolimus on POD 1 for all patients.
iii. If a patient received thymoglobulin induction, tacrolimus
initiation may be delayed if renal function has not shown
significant improvement in SPK transplants (<30% decline in
creatinine from POD 1 to POD2).1
iv. There is no evidence that delaying the initiation of tacrolimus
results in decreased duration of delayed graft function.
v. Intravenous tacrolimus is not indicated for use.
vi. Tacrolimus should be administered with food.
vii. Initial tacrolimus dosing:
1. If patient receives basiliximab induction:
a. Tacrolimus: 0.05 mg/kg/day (in two divided doses)
for max MFI <500
b. Tacrolimus 0.1 mg/kg/day (in two divided doses)
for max MFI >500 in two divided doses.
2. If patient receives anti-thymocyte globulin induction:
a. Tacrolimus dosing should be tailored based on
potential sensitivity to tacrolimus and goal
tacrolimus level
b. If a patient meets any of the criteria for decreased
sensitivity to tacrolimus (Table 1), the initial dose
will be 2 mg twice daily
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15
c. All other patients will be initiated on 1 mg twice
daily
Table 6. Factors for Identifying Tacrolimus Sensitive Patients2

Increased Tacrolimus Sensitivity Decreased Tacrolimus Sensitivity
NPO General Diet
Weight <80 kg Weight >80 kg
Significant drug interactions African-American

2. Target trough levels should be utilized for all subsequent
dose adjustments using the goals found below
a. These goals are based on concurrent use of
tacrolimus with mycophenolate

Table 7. Goal Tacrolimus (FK) Levels (SPK, PTA, PAK)
Goal FK Level
SPK
Goal FK Level
PTA/PAK
0-3 months: 10-12 ng/mL 9-12 ng/mL
3-6 months: 8-10 ng/mL 9-12 ng/mL
6-12 months: 8-10 ng/mL 9-12 ng/mL
>12 months: 6-8 ng/mL 9-12 ng/mL

3. Dose adjustments:
a. Dose adjustments will occur after a patient has
received 4 doses of the current regimen
b. Below goal:
i. If a patient is >50% below their target goal,
the daily dose will be increased by 25-50%
ii. If a patient is <50% below their target goal,
the daily dose will be increased by 25%.
c. Above goal:
i. If a patient is >50% above their target goal,
the daily dose will be decreased by 25-50%
ii. If a patient is <50% above their target goal,
the daily dose will be decreased by 25%.
iii. May consider holding tacrolimus to facilitate
decrease in trough concentration.

i. Laboratory Monitoring:
1. Tacrolimus levels will be ordered daily while inpatient and
patient is receiving daily tacrolimus doses (either post-
operatively or during readmission)
2. Once discharged, tacrolimus levels will be monitored at
the following frequency:
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16
a. Day 0-90: not less than once weekly
b. Day 91-180: not less than twice monthly
c. Day 181-240: not less than one time monthly
3. Additional monitoring of tacrolimus trough levels is
warranted if there is a change in medication formulation
or patient status that may affect levels or if the creatinine
has increased 0.3 mg/dL above baseline
4. Check level in 3-7 days following dose adjustment
5. Check potassium and creatinine with each tacrolimus
level
6. A minimum of 2 levels should be within the goal range
before resuming the previous monitoring frequency

ii. Adverse effects due to tacrolimus:
1. Acute kidney injury:
a. Inpatient Management:
i. Assess tacrolimus trough level for
correlation with elevated creatinine
ii. If trough level is above goal and creatinine
has increased 0.3 mg/dL above baseline,
hold tacrolimus
iii. While tacrolimus is held, double current
prednisone dose
b. Outpatient Management:
i. Assess tacrolimus trough level for
correlation with elevated creatinine
ii. If trough level is above goal and creatinine
has increased 0.3 mg/dL above baseline,
adjust tacrolimus dose as follows:
1. If a patient is >50% above their
target goal, the daily dose will be
decreased by 25-50%
2. If a patient is <50% above their
target goal, the daily dose will be
decreased by 25%.
3. May consider holding tacrolimus to
facilitate decrease in trough
concentration.

2. Neurological symptoms (tremor, headache)
a. Assess tacrolimus trough level for correlation with
tremors or headache
b. If trough level is above goal, adjust tacrolimus
dose and follow up with patient after the
subsequent tacrolimus lab draw
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c. No dose adjustment is recommended if trough
level within target range
i. Follow up with patient in 1 week if no dose
adjustment is made
d. If adverse effects are intolerable or interacting with
daily activities and there is no other known cause
of symptoms, consult the transplant physician and
consider converting the patient to cyclosporine or
refer to primary care provider for supportive
therapy

3. Hyperglycemia
a. No dose adjustment is recommended
b. Consider diabetes management & nutrition
services for patient
c. Diagnosis of new onset diabetes after transplant
(NODAT) is defined by the World Health
Organization (WHO) and American Diabetes
Association (ADA) that develops for the first time
after kidney transplantation2
d. If there is no improvement in glucose control 6
months after transplant (NODAT requiring insulin
OR A1c >7% with glucose lowering agent) and
there have been 3 months of minimal
glucocorticoid doses:
i. Consult transplant physician and consider
converting the patient to cyclosporine2,3

d. Cyclosporine (Neoral): (Class IIa, Level of Evidence C)
i. Cyclosporine will be initiated post-transplant in patients who
were previously intolerant of tacrolimus or were on cyclosporine
prior to transplant
ii. Initiate cyclosporine on POD 1
iii. If a patient received thymoglobulin, initiation may be delayed if
renal function has not shown significant improvement (<30%
decline in serum creatinine from POD 1 to POD2)1
iv. Initial dosing recommendation of 100-150 mg twice daily
1. Cyclosporine dosing should be tailored based on
potential sensitivity to cyclosporine and goal cyclosporine
level
2. If a patient meets any of the criteria for decreased
sensitivity to cyclosporine (Table 8), the initial dose will
be 150 mg twice daily
3. All other patients will be initiated on 100 mg twice daily

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Table 8. Factors for Identifying Cyclosporine Sensitive Patients2
Increased CyclosporineSensitivity Decreased CyclosporineSensitivity
NPO General Diet
Weight <80 kg Weight >80 kg
Significant drug interactions African-American

Table 9. Goal Cyclosporine (CSA) Levels (SPK, PAK, PTA)



4. Dose adjustments:
a. Dose adjustments will occur after a patient has
received 4 doses of the current regimen
b. Below goal:
i. If a patient is >50% below their target goal,
the daily dose will be increased by 25-50%
ii. If a patient is <50% below their target goal,
the daily dose will be increased by 25%.
c. Above goal:
i. If a patient is >50% above their target goal,
the daily dose will be decreased by 25-50%
ii. If a patient is <50% above their target goal,
the daily dose will be decreased by 25%.
iii. May consider holding tacrolimus to facilitate
decrease in trough concentration.

v. Laboratory Monitoring:
1. Cyclosporine levels will be ordered daily while inpatient
and patient is receiving daily cyclosporine doses (either
post-operatively or during readmission)
2. Once discharged, cyclosporine levels will be monitored at
the following frequency:
a. Day 0-90: not less than once weekly
b. Day 91-180: not less than twice monthly
c. Day 181-240: not less than one time monthly
3. Additional monitoring of cyclosporine trough levels is
warranted if there is a change in medication formulation
or patient status that may affect levels or if the creatinine
has increased 0.3 mg/dL above baseline
4. Check level in 3-7 days following dose adjustment
5. Check potassium and creatinine with each cyclosporine
level
Goal CSA Level
0-3 months: 200-300 ng/mL
3-6 months: 150-250 ng/mL
6-12 months: 100-200 ng/mL
>12 months: 100-200 ng/mL
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6. A minimum of 2 levels should be within the goal range
before resuming the previous monitoring frequency

vi. Adverse effects due to cyclosporine:
1. Management of adverse effects for cyclosporine is the
same as the management of adverse effects for
tacrolimus.

b. Mycophenolate dosing: (Class IIa, Level of Evidence C)
i. Mycophenolic acid is the preferred anti-proliferative medication
used for PTA, PAK and SPK transplant patients.
ii. Initiate mycophenolate sodium 720 mg PO three times daily on
POD 1.
1. Equivalent mycophenolate mofetil dosing: 1000 mg PO
three times daily
2. Mycophenolate will be decreased to BID dosing at 1
month post-transplant
iii. IV mycophenolate mofetil is administered for the first 4 doses
after transplant and may also be indicated if the patient has an
acute condition that affects gastrointestinal absorption (i.e.,
gastrointestinal bleed or obstruction, malabsorption syndromes,
severe diarrhea or severe vomiting).
iv. Mycophenolate mofetil suspension is utilized for patients
receiving medications via nasogastric or orogastric tube.
v. Laboratory monitoring of mycophenolic acid levels is not
recommended to assess for toxicity or efficacy.
vi. Adverse effects:
1. Diarrhea:
a. If a patient has ≥50% increase in their frequency
of daily bowel movements for ≥ 5-7 days
i. 0-3 months post-transplant:
1. Check Clostridium difficile, CMV
PCR
ii. ≥3 months post-transplant, obtain the
following studies::
1. CMV PCR
2. Complete blood count
3. Clostridium difficile Clostridium
difficile toxin B PCR
4. Cryptosporidium
5. Giardia PCR
6. Norovirus PCR
7. Rotavirus AG
8. Stool culture, with E. Coli (Shiga)
toxin
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9. Stool O&P (ova & parasite studies
including: parasitology, isospora,
cyclospora, pinworm) – do not order
for inpatients who have been in
house for >48-72 hours

iii. If the above studies are negative for an
infectious cause of diarrhea and it is
affecting activities of daily living or the
patient is having limited and/or decreased
oral intake:
1. Decrease mycophenolate by 50% to
a minimum dose of 180 mg twice
daily or 250 mg twice daily
2. Follow up with patient in 1 week
3. If dose is decreased to 180 mg twice
daily (MYF) or 250 mg twice daily
(MMF) consult provider to determine
if other immunosuppression needs to
be adjusted
4. Add loperamide 2 mg as needed
after each loose stool (max dose: 16
mg daily) or diphenoxylate/atropine
(Lomotil®) 5 mg four times daily as
needed (max dose: 20 mg/day)

2. Heartburn/nausea:
a. Counsel patient on taking MYF or MMF with food if
not already doing so.
b. Convert from MMF to MYF if only upper GI
complaints (heartburn, nausea).
c. Add calcium carbonate as needed, or the addition
of an H2RA or PPI if not already on.
d. If symptoms continue following 1 week of daily
therapy increase H2RA or PPI dose to twice daily,
reassess in 1 week.
e. If symptoms persist for ≥1 week, consider EGD to
rule out infection vs. ulceration.

c. Predisone (Class IIa, Level of Evidence C)
i. Prednisone 15 mg twice daily will be started on POD 4 following
dexamethasone and prednisone taper and will continue on
discharge for patients that receive thymoglobulin or basiliximab
for induction.
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ii. Patients that receive alemtuzumab for induction should finish a
steroid taper on POD 4 and not continue on prednisone for
maintenance immunosuppression.
iii. Assessment for prednisone taper should occur at 2 week post-
operative clinic visit.
1. Factors that may influence the ability to taper prednisone
at that time include:
a. Current and historical tacrolimus/cyclosporine
levels
b. Sensitization status
c. Primary vs. non-primary transplant
d. Current MPA dose
e. Current renal function
f. Episodes of rejection
iv. If deemed appropriate for a prednisone taper at that time,
patients should decrease prednisone doses from 30 mg daily by
5 mg every 2 weeks to a maintenance dose of 10 mg daily.
Further tapering to be determined by managing provider.

Liver transplant immunosuppression:
1. Induction therapy with antithymocyte globulin is recommended for patients
receiving a deceased after circulatory death (DCD) liver transplant. (Class
IIb, Level of Evidence C)
a. Antithymocyte globulin should be administered daily for 3 days at a
dose of 1.5 mg/kg/day or for a total cumulative dose of 4.5 mg/kg
2. Maintenance immunosuppression consists of a combination of
immunosuppressive medications that includes a CNI with or without an anti-
proliferative agent and corticosteroids. (Class IIa, Level of Evidence B)
3. The goal of treatment is to maintain hepatic integrity and minimize overall
immunosuppression. (Class IIa, Level of Evidence A)
4. The preferred CNI is tacrolimus and the preferred anti-proliferative agent is
mycophenolic acid. (Class IIa, Level of Evidence C)
5. Patients with an autoimmune (primary sclerosing cholangitis, primary biliary
cirrhosis, autoimmune hepatitis) cause of liver failure will be maintained on
prednisone and mycophenolic acid in combination with a CNI for maintenance
immunosuppression therapy. (Class IIa, Level of Evidence C)
6. Patients without an autoimmune mediated disease will be tapered off of
prednisone 2 months post-transplant and mycophenolic acid will be reduced
to half dose 3-6 months post-transplant. Exceptions to this include patients
with normal renal function and patients who have experienced rejection.
(Class IIa, Level of Evidence C)
a. Patients with normal renal function may be tapered off prednisone and
mycophenolate and continued on tacrolimus monotherapy. (Class IIa,
Level of Evidence C)
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7. Patients who have received a DCD liver transplant and have hepatitis C will
not be initiated on mycophenolate as part of the immunosuppression regimen.
(Class IIb, Level of Evidence C)
8. Maintenance immunosuppression medications include the following:

a. Tacrolimus (Class IIa, Level of Evidence C)
i. Tacrolimus is the preferred CNI for use in liver transplant
patients
ii. Initiate tacrolimus on POD 1 for all patients
iii. If a patient received induction therapy, initiation may be delayed
if renal function has not shown significant improvement on POD
1
iv. Initial dosing:
1. Tacrolimus dosing should be tailored based on potential
sensitivity to tacrolimus and goal tacrolimus level
2. If a patient meets any of the criteria for decreased
sensitivity to tacrolimus (Table 1), the initial dose will be 2
mg twice daily
3. All other patients will be initiated on tacrolimus 1 mg
twice daily
Table 10. Factors for Identifying Tacrolimus Sensitive Patients1

Increased Tacrolimus Sensitivity Decreased Tacrolimus Sensitivity
NPO General Diet
Weight <80 kg Weight >80 kg
Significant drug interactions African-American

4. Target trough levels should be utilized for all subsequent
dose adjustments using the goals found below:
a. Autoimmune disease patients include those with a
diagnosis of primary sclerosing cholangitis (PSC),
autoimmune hepatitis (AIH) and/or primary biliary
cirrhosis (PBC)

Table 11. Goal Tacrolimus Levels (Liver)











Autoimmune disease
and not on
mycophenolate
NOT autoimmune disease
OR on mycophenolate
Time
from Tx
Goal FK Level Goal FK Level
0-3 months: 8-10 ng/mL 5-7 ng/mL
3-6 months: 8-10 ng/mL 3-5 ng/mL
6-12 months: 6-8 ng/mL 3-5 ng/mL
>12 months: 4-6 ng/mL 2-5 ng/mL
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5. Dose adjustments (0-90 days post-transplant):
a. Dose adjustments will occur after a patient has
received 4 doses of the current regimen
b. Below goal:
i. If a patient is >50% below their target goal,
the daily dose will be increased by 25-50%
ii. If a patient is <50% below their target goal,
the daily dose will be increased by 25%.
c. Above goal:
i. If a patient is >50% above their target goal,
the daily dose will be decreased by 25-50%
ii. If a patient is <50% above their target goal,
the daily dose will be decreased by 25%.
iii. May consider holding tacrolimus to facilitate
decrease in trough concentration.
ii. Laboratory Monitoring:
1. Tacrolimus levels will be ordered daily while inpatient and
patient is receiving daily tacrolimus doses (either post-
operatively or during readmission).
2. Once discharged, tacrolimus levels will be monitored at
the following frequency:
a. Day 0-90: not less than once weekly
b. Day 91-180: not less than twice monthly
c. Day 181-240: not less one time monthly
3. Additional monitoring of tacrolimus trough levels is
warranted if there is a change in medications or patient
status that may affect levels or if there is a decline in
kidney function.
4. Check level in 3-7 days following dose adjustment.
5. Check potassium and creatinine with each tacrolimus
level.
6. A minimum of 2 levels should be within the goal range
before resuming the previous monitoring frequency.

iii. Adverse effects of tacrolimus:
1. Acute kidney injury:
a. Inpatient Management:
i. Assess tacrolimus trough level for
correlation with elevated creatinine
ii. If trough level is above goal and creatinine
has increased 0.3 mg/dL above baseline,
hold tacrolimus
iii. While tacrolimus is held, double current
prednisone dose
b. Outpatient Management:
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i. Assess tacrolimus trough level for
correlation with elevated creatinine
ii. If trough level is above goal and creatinine
has increased 0.3 mg/dL above baseline,
adjust tacrolimus dose as follows:
1. If a patient is >50% above their
target goal, the daily dose will be
decreased by 25-50%
2. If a patient is <50% above their
target goal, the daily dose will be
decreased by 25%.
3. May consider holding tacrolimus to
facilitate decrease in trough
concentration.

2. Neurological symptoms (tremor, headache)
a. Assess tacrolimus trough level for correlation with
tremors or headache
b. If trough level is above goal, adjust tacrolimus
dose and follow up with patient after the
subsequent tacrolimus lab draw
c. No dose adjustment is recommended if trough
level within target range
i. Follow up with patient in 5-7 days if no dose
adjustment is made
d. If adverse effects are intolerable or interacting with
daily activities and there is no other known cause
of symptoms, consult transplant physician to
consider converting the patient to cyclosporine.

3. Hyperglycemia
a. No dose adjustment is recommended
b. Consider diabetes management & nutrition
services for patient
c. Diagnosis of new onset diabetes after transplant
(NODAT) is defined by the World Health
Organization (WHO) and American Diabetes
Association (ADA) that develops for the first time
after kidney transplantation4
d. If there is no improvement in glucose control 6
months after transplant (NODAT requiring insulin
OR A1c >7% with glucose lowering agent) and
there have been 3 months of minimal
glucocorticoid doses:
i. Consult transplant physician to consider
converting patient to cyclosporine.4
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b. Cyclosporine: (Class IIa, Level of Evidence C)
i. Cyclosporine will be initiated post-transplant in patients who
were previously intolerant of tacrolimus.
ii. Initiate cyclosporine on POD 1.
iii. If a patient received induction therapy, initiation may be delayed
until if renal function has not shown significant improvement on
POD 1.
iv. Initial dosing recommendation of 100-150 mg twice daily.
a. Cyclosporine dosing should be tailored based on
potential sensitivity to cyclosporine and goal
cyclosporine level.
b. If a patient meets any of the criteria for decreased
sensitivity to cyclosporine (Table 1), the initial
dose will be 150 mg twice daily.
c. All other patients will be initiated on 100 mg twice
daily.
Table 12. Goal Cyclosporine Levels





v. Dose adjustments (0-90 days post-transplant):
a. Dose adjustments will occur after a patient has
received 4 doses of the current regimen
b. If a patient is >50% below their target goal, the
dose will be increased by 25-50% per dose.
c. May consider holding tacrolimus to facilitate
decrease in trough concentration.
d. If a patient is <50% below their target goal, the
total daily dose will be increased by 25%.

vi. Laboratory monitoring:
1. Cyclosporine levels will be ordered daily while inpatient
and receiving daily cyclosporine doses (either post-
operatively or during readmission)
2. Once discharged, cyclosporine levels will be monitored at
the following frequency:
a. Day 0-90: not less than once weekly
Autoimmune disease
and not on
mycophenolate
NOT autoimmune disease
OR on mycophenolate
Time
from Tx
Goal CSA Level Goal CSA Level
0-3 months: 150-200 ng/mL 125-175 ng/mL
3-6 months: 125-150 ng/mL 100-125 ng/mL
6-12 months: 100-125 ng/mL 75-100 ng/mL
>12 months: 100 ng/mL 50-75 ng/mL
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b. Day 91-180: not less than twice monthly
c. Day 181-240: not less than one time monthly
3. Check level in 5-7 days following dose adjustment
4. Check potassium and creatinine with each cyclosporine
level
5. A minimum of 2 levels should be within the goal range
before resuming the previous monitoring frequency

vii. Adverse effects:
1. Management of adverse effects for cyclosporine is the
same as the management of adverse effects for
tacrolimus

c. Mycophenolic acid (Class IIa, Level of Evidence C)
i. Mycophenolic acid is the preferred anti-proliferative medication
used for liver transplant patients
ii. Initiate mycophenolate sodium 720 mg PO twice daily on POD 1
1. Equivalent mycophenolate mofetil dosing: 1000 mg PO
twice daily
iii. IV mycophenolate mofetil is indicated in the immediate post-
transplant setting if the patient has an acute condition that
affects gastrointestinal absorption (i.e., gastrointestinal bleed or
obstruction, malabsorption syndromes, severe diarrhea or
severe vomiting).
iv. Mycophenolate mofetil suspension is utilized for patients
receiving medications via nasogastric or orogastric tube.
v. Mycophenolate will be reduced to half dose between 3-6
months post-transplant with the exception of patients with
normal renal function and patients who have not experienced
rejection.
vi. Mycophenolate will be discontinued between 3-6 months post-
transplant in patients with normal renal function and in patients
who have not experienced rejection.
vii. Laboratory monitoring of mycophenolic acid levels is not
recommended to assess for toxicity or efficacy.
viii. Adverse effects:
1. Diarrhea:
a. If a patient has ≥50% increase in their frequency
of daily bowel movements for ≥ 5-7 days
i. 0-3 months post-transplant:
1. Check Clostridium difficile, CMV
PCR
ii. ≥3 months post-transplant, obtain the
following studies:
1. CMV PCR
2. Complete blood count
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3. Clostridium difficile Clostridium
difficile toxin B PCR
4. Cryptosporidium
5. Giardia PCR
6. Norovirus PCR
7. Rotavirus AG
8. Stool culture, with E. Coli (Shiga)
toxin
9. Stool O&P (ova & parasite studies
including: parasitology, isospora,
cyclospora, pinworm) – do not order
for inpatients who have been in
house for >48-72 hours

iii. If the above studies are negative for an
infectious cause of diarrhea and it is
affecting activities of daily living or the
patient is having limited and/or decreased
oral intake:
1. Decrease mycophenolate by 50% to
a minimum dose of 180 mg twice
daily or 250 mg twice daily
2. Follow up with patient in 1 week
3. If dose is decreased to 180 mg twice
daily (MYF) or 250 mg twice daily
(MMF) consult provider to determine
if other immunosuppression needs to
be adjusted
4. Add loperamide 2 mg as needed
after each loose stool (max dose: 16
mg daily) or diphenoxylate/atropine
(Lomotil®) 5 mg four times daily as
needed (max dose: 20 mg/day)

2. Heartburn/nausea:
a. Counsel patient on taking MYF or MMF with food if
not already doing so
b. Convert from MMF to MYF if only upper GI
complaints (heartburn, nausea)
c. Add calcium carbonate as needed, or the addition
of an H2RA or PPI if not already on
d. If symptoms continue following 1 week of daily
therapy increase H2RA or PPI dose to twice daily,
reassess in 1 week
e. If symptoms persist for ≥1 week, consider EGD to
rule out infection vs. ulceration
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d. Prednisone (Class IIa, Level of Evidence C)
i. Predisone 10 mg twice daily will be started on POD 5 following
dexamethasone taper and will continue on discharge
ii. Prednisone doses should be split to twice daily dosing for
patients who require insulin for glucose control
iii. Assessment for prednisone taper should occur at 3-4 weeks
post-operatively for patients without autoimmune disease
1. Factors that may influence the ability to taper prednisone
at that time include:
a. Current and historical tacrolimus/cyclosporine
levels
b. Current liver function
c. Episodes of rejection
iv. If deemed appropriate for a prednisone taper at that time,
patients should decrease prednisone doses from 10 mg twice
daily using the following schedule:
1. Prednisone 10 mg every morning and 5 mg every
evening for 2 weeks
2. Prednisone 5 mg twice daily for 2 weeks
3. Prednisone 5 mg daily for 2 weeks and then STOP
a. Patients with a history of autoimmune disease
should be tapered down to 5 mg daily and
continued on that dose

e. Azathioprine: (Class IIa, Level of Evidence C)
i. Indicated for use in patients unable to tolerate adverse effects of
MPA
ii. Thiopurine methyltransferase (TPMT) genotyping is
recommended prior to azathioprine initiation to determine dose.
iii. Dosing:
1. 1-3 mg/kg/day as a single daily dose
iv. There is no recommended azathioprine level for monitoring
purposes.
v. Recommend either discontinuation of allopurinol if azathioprine
is initiated or decreasing the allopurinol dose by 1/3 (33%) or
1/4 (25%).
vi. Recommend discontinuation of febuxostat if azathioprine is
initiated.
vii. If allopurinol or febuxostat is continued, close hematological
monitoring is warranted.

f. Sirolimus/Everolimus: (Class IIa, Level of Evidence C)
i. Indicated for use in patients as a replacement for azathioprine,
MPA or CNIs and for patients with recurrent hepatocellular
carcinoma
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ii. Sirolimus should not be used within 30 days of liver transplant
iii. Dosing:
1. Sirolimus: 2 mg PO one time daily
2. Everolimus: 0.75 mg twice daily
iv. Subsequent doses should be adjusted based on the following
goal trough levels:

Table 13. Goal Sirolimus Levels (Liver)
Goal Sirolimus Level
(Monotherapy)
Goal Sirolimus Level
(+FK or MPA)
0-3 months: 8-10 ng/mL 5-8 ng/mL
3-6 months: 5-8 ng/mL 5-8 ng/mL
6-12 months: 5-8 ng/mL 3-5 ng/mL
>12 months: 3-5 ng/mL 3-5 ng/mL


v. Laboratory monitoring:
1. Recommended one time weekly upon initiation and with
any dose changes.
2. When the target trough level has been attained, it is
recommended to monitor levels one time monthly.

General Transplant Recommendations:

a. Gastric ulcer prophylaxis: (Class IIa, Level of Evidence C)
i. It is recommended that patients with no prior history of
gastroesophageal reflux disease (GERD) who were not taking a
proton pump inhibitor prior to transplant should be started on an
H2 receptor antagonist (H2RA) post-transplant
ii. Ranitidine is the preferred H2RA for use:
1. Dosing: Ranitidine 150 mg PO twice daily (requires renal
dose adjustment).
iii. Patients that were on a PPI prior to transplant or have a history
of GERD should be started on a PPI post-transplant
iv. Pantoprazole is the preferred PPI for use.
1. Dosing: Pantoprazole 40 mg PO daily
v. If a patient complains of heartburn on daily dosing of the H2RA
or PPI, frequency may be increased to twice daily (pending
renal function).
vi. If a patient continues to experience heartburn or reflux
symptoms on twice daily H2RA, it is recommended to change to
a PPI.
vii. It is recommended to discontinue prophylaxis in patients with no
history of hearburn/GERD prior to transplant when the dose of
prednisone is ≤10 mg daily.

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b. Thrombosis prophylaxis: (Class I, Level of Evidence A)
i. All transplant recipients should receive aspirin 81 mg PO daily
for thrombosis prophylaxis.
ii. Liver transplant recipients should not be started on aspirin until
platelets are >50,000.

c. Vitamins and supplements: (Class IIa, Level of Evidence B)
i. All transplant recipients are recommended to take a daily
multivitamin appropriate for their age & gender.
ii. All transplant recipients are recommended to take calcium 1000
mg daily (based on elemental calcium dosing).
iii. All transplant recipients are recommended to take vitamin D
1000 units daily.
UW Health Implementation
Potential Benefits:
This guideline is intended to help standardize care for medication management in
adult kidney, pancreas and liver transplant recipients.

Potential Harms:
Side effects and adverse events associated with various medications and drug
treatments.

Implementation Plan and Tools
1. Guideline will be housed on UConnect in a dedicated folder for Clinical
Practice Guidelines.
2. Links to this guideline will be created in appropriate Health Link or equivalent
tools.
References
1. Mallon DH, Summers DM, Bradley JA, Pettigrew GJ. Defining delayed graft function
after renal transplantation: simplest is best. Transplantation. 2013 Nov
27;96(10):885-9.
2. Staatz CE, Tett SE. Clinical pharmacokinetics and pharmacodynamics of tacrolimus
in solid organ transplantation. Clin Pharmacokinet. 2004;43(10):623-53.
3. Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group.
KDIGO clinical practice guideline for the care of kidney transplant recipients.
American Journal of Transplantation 2009; 9 (Suppl 3): S1–S157.
4. Ghisdal L, Van Laecke S, Abramowicz MJ, Vanholder R, Abramowicz D. New-onset
diabetes after renal transplantation: risk assessment and management. Diabetes
Care. 2012 Jan;35(1):181-8.
5. Lucey MR, Terrault N, Ojo L, Hay JE, Neuberger J, Blumberg E, and Teperman LW
(2013), Long-term management of the successful adult liver transplant: 2012 practice
guideline by the American Association for the Study of Liver Diseases and the
American Society of Transplantation. Liver Transpl, 19: 3-26. doi:10.1002/lt.23566

Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org



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Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
08/2017CCKM@uwhealth.org