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Transplant Laboratory and Diagnostic Test Ordering - Adult/Pediatric - Ambulatory [34]

Transplant Laboratory and Diagnostic Test Ordering - Adult/Pediatric - Ambulatory [34] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols


Delegation Protocol Number: 34

Delegation Protocol Title:
Transplant Laboratory and Diagnostic Test Orders – Adult/Pediatric – Ambulatory

Delegation Protocol Applies To:
UW Health Transplant Clinics

Target Patient Population:
Adult and pediatric transplant patients and living donors

Delegation Protocol Champion:
Didier Mandelbrot, MD – Department of Medicine – Nephrology

Delegation Protocol Reviewers:
Division Chairs:
Dixon Kaufman, MD, PhD – Department of Surgery - Transplantation
Arjang Djamali, MD – Department of Medicine - Nephrology
Shahab Akhter, MD – Department of Surgery - Cardiothoracic Surgery
Michael Lucey, MD – Department of Medicine – Gastroenterology

Program Directors:
Richard Cornwell, MD – Department of Medicine – Pulmonary
Anthony D’Alessandro, MD – Department of Surgery – Transplant
Nilto De Oliveira, MD – Department of Surgery – Cardiothoracic Surgery
Luis Fernandez, MD – Department of Surgery – Transplant
David Foley, MD – Department of Surgery – Transplant
Maryl Johnson, MD – Department of Medicine – Cardiology
Lucian Lozonschi, MD – Department of Surgery – Cardiothoracic Surgery
Didier Mandelbrot, MD – Department of Medicine – Nephrology
Josh Mezrich, MD – Department of Surgery – Transplant
Jon Odorico, MD – Department of Surgery – Transplant
John Rice, MD – Department of Medicine – Gastroenterology

Administration:
Jill Ellefson, MBA – Organ Donation and Transplant Service Line Director
Elizabeth Strutz, MSIE – Director Transplant Operations
Nancy Jones, RN – Transplant Clinic Manager
Jaime Myers, RN, MSN – Liver and Pancreas Transplant Manager
Catherine Werwinski, RN, MSN – Kidney and Living Donor Transplant Manager
Heather Jaeger, RN – Heart Transplant Coordinator
Don Hawes, RN – Lung Transplant Coordinator

Responsible Departments:
Department of Surgery – Transplantation, Cardiothoracic Surgery
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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2

Department of Medicine – Nephrology, Cardiovascular Medicine, Gastroenterology and Hepatology,
Pulmonary and Critical Care

Purpose Statement:
To delegate authority from the patient’s transplant physician to Transplant Coordinators, Registered
Nurses (RNs), Licensed Practical Nurses (LPNs), Medical Assistants (MAs) or Scheduling Assistants who
have Health Link orders security in the Transplant Clinic and are trained in the use of this delegation
protocol to place orders for laboratory or diagnostic tests for Transplant Clinic visits.

Who May Carry Out This Delegation Protocol:
Transplant Coordinators, Registered Nurses (RNs), Medical Assistants (MAs) or Department Assistants
who have successfully completed training in the use of this delegation protocol.

• Transplant Coordinators with Health Link orders security may order any of the tests listed in this
protocol.
• Transplant Clinic RNs, LPNs and MAs with orders security may place orders for all tests listed in this
protocol that are not designated as "Transplant Coordinator Only."
• Department Assistants who do not have a written provider order, will pend orders and route them to
physicians, Nurse Practitioners, Transplant Coordinators or RNs for review and sign before they are
activated. If the Department Assistant has a written order, they may sign the order which will
generate a cosign message to the ordering provider. These orders may be cosigned after the test is
completed.

Guidelines for Implementation:
1. Clinic staff will use the tables in this protocol to determine the laboratory and diagnostic test orders
to place. The required orders will be determined by using the following criteria:
1.1. Wait list organ type
1.2. Organ type
1.3. Time since transplant
1.4. Status of transplant
1.5. Existing medical conditions or other medications the patient is currently taking requiring
continued monitoring
1.6. Type of appointment
2. Prior to entering any orders, clinic staff will review the patient’s chart to identify previously entered
orders to minimize duplication.

Order Mode: Laboratory Orders: Cosign Required Protocol/Policy

References
1. The Evaluation of Renal Transplant Candidates: Clinical Practice Guidelines. American Journal of
Transplantation; 1(s2):1.
2. Sharma P, Rakela J. Management of the pre-liver transplantation patients-part 1. Liver Transpl.
2005; 11(2):124-133.
3. Sharma P, Rakela J. Management of the pre-liver transplantation patients-part 2. Liver
Transpl.2005;11(3):249-260.
4. Liver and Biliary Diseases. Second Edition. (Text Book)
5. A Clinician’s guide to Donation and Transplantation. NATCO; Dianne LaPointe Rudow, Dr. NP, CCTC;
Linda Ohler, RN, MSN, CCTC, FAAN; Teresa Shafer, RN, MSN, CPTC
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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3

6. Murray KF, Carithers RL. (2005) AASLD practice guidelines: Evaluation of the patient for liver
transplantation. Hepatology.1407-1431.
7. Core Curriculum for Transplant Nurses. Linda Ohler and Sandra Cupples (Text Book)
8. Rueben A. Long-term management of the liver transplant patient: diabetes, hyperlipidemia, and
obesity. Liver Transpl. 2001;7(11 Suppl 1):S13-21.
9. Seem DL, Lee I, Umscheid CA, Kuehnert MJ. PHS Guideline for reducing human immunodeficiency
virus, hepatitis B virus and hepatitis C virus transmission through organ transplantation. Public
Health Rep. 2013;128(4);247-343. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3675207/.
Accessed May 13, 2016.

Collateral Documents
1. Abdominal Transplant Immunosuppression Management Clinical Practice
Guideline https://uconnect.wisc.edu/clinical/cckm-
tools/cpg/guidelines/medications/resources/name-71413-en.file

Approval
UW Health Ambulatory Protocol Committee: January 2013, June 2016 (expedited review)
UW Health Lab Practices Committee: February 2013, June 2016 (expedited review)
UW Health Center for Clinical Knowledge Management Council: March 2013, June 2016 (expedited
review)
UWHC Medical Board: March 2013, July 2016 (expedited review)
UW Health Chief Medical Officer: March 2013, July 2016 (expedited review)

Effective Date: July 2016

Scheduled for Review: July 2019

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

4

Adult Kidney Transplant

Kidney Pre-Transplant Evaluation
Indication Orders
All
ABO and Rh Typing
Activated Partial Thromboplastin Time (aPTT)
Alkaline Phosphatase
ALT/SGPT
AST/SGOT
Antithrombin III, Activity
Bilirubin, Total
BK Virus Quantitative by PCR (if known history of
BK virus)
Cardiolipin Ab, IgA
Cardiolipin, AB, IgG/IgM
Creatinine Clearance (if not on dialysis)
EBV Ab to Viral Capsid, Ag, IgG (pediatrics only)
Factor V Leiden Gene Mutation Analysis
Factor V Leiden/Prothrombin Gene Mutation
Analysis
GGT/Gamma Glutamyl Transferase
Hepatitis B Core Ab, Total
Hepatitis B Surface Ab
Hepatitis B Surface Ag
Hepatitis C Ab
HIV-1, 2 Ab
HLA Class I typing (A, B, C) Pre- Transplant
HLA Class I Donor Specific HLA Ab by Luminex, Pre-
Transplant
HLA Class II Donor Specific Ab by Luminex, Pre-
Transplant
HLA-DR/DQ Typing by PCR-SSP, Pre- Transplant
Lupus Anticoagulant
Protein C Ag
Protein S Ag
Protein S Ag, Free
Protein, Urine 24 hour (if patient not on dialysis)
Prothrombin Time/INR
Quantiferon TB Gold (if high risk for TB: history of
exposure to someone with TB, born in a country
with high rates of TB, travel to a country with high
rates of TB, residence in an area with high rates of
TB, or per Infectious Disease recommendation)
PSA Total, Screen (males only)
Varicella-Zoster Virus Antibody, IgG

X-Ray Chest PA & Lat views
Hepatitis C Positive Patients – Additional Orders
Albumin
Alpha Fetoprotein (AFP) Maternal
Cryoglobulin, Quantitative
Hepatitis C Genotyping
Hepatitis C RNA, Qualitative, PCR
Hepatitis C RNA, Quantitative, PCR
Platelet Count
Hepatitis B Positive Patients – Additional Orders
Albumin
Alpha Fetoprotein (AFP) Maternal
CBC with Differential
Cryoglobulin, Qualitative
Cryoglobulin, Quantitative
Hepatitis B DNA, Quantitative, PCR
Hepatitis Be Virus Antigen
Hepatitis Be Virus Antibody
Hepatitis Delta Virus Antibody
Platelet Count
Rheumatoid Factor


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

5

Kidney Post Transplant
Time Frame Post-Transplant Orders
All
Week 2 Kidney – Full except NO fasting lipid panel, PTH, or
vitamin D
Weeks 6, 9; then Months 3, 9 Kidney - Abbreviated
Month 6; then yearly Kidney - Full
Weeks 3, 6, 9, 12; then Monthly through 4-5
months; ALSO every month through 6-9 months
unless otherwise directed by provider, then every
1-2 months through 2 years. For any patient with
a history of positive BK, order annually.
BK Quantitative by PCR
Low Risk: Months 6, 12, then yearly
(Low Risk: Non-Allosensitized Recipients, i.e.,
nonsensitized first transplantation, no detectable HLA
antibodies by SA bead testing)

Moderate Risk: Week 3, then Months 6, 12 then
yearly
(Moderate Risk: Allosensitized, i.e., any anti-HLA
antibodies or history of DSA but currently negative by
SA bead Testing)

High Risk: Post Op: Week 3,6; then Months 3, 6,
12; then yearly
(High Risk: Donor-Specific Antibody (DSA) positive by
SA bead testing (FCXM positive or negative, significant
change in immunosuppression, suspected
nonadherence, graft dysfunction, monitoring
effectiveness of rejection therapy, etc.)
Donor Specific Antibody (DSA) I & II Post-Tx
For CDC Increased Risk Donor Recipients
Months 1, 3 HCV RNA Quantitative by PCR, Hepatitis B Core Ab
Total, Hepatitis B DNA Quantitative by PCR,
Hepatitis B Surface AG, HIV RNA

Kidney Transplant Biopsy
Time Frame Post-Transplant Orders
All
If full set has been drawn in the past 6 months Kidney - Abbreviated
If full set NOT drawn in the past 6 months Kidney - Full
All PT/INR, Donor Specific Antibody (DSA) I & II, BK
Quantitative by PCR
IV start


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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6

Kidney Full (KFULL) Orders
Albumin
Alkaline Phosphatase
ALT/SGPT
AST/SGOT
Bilirubin, Total
BUN
Calcium
CBC w/Differential
Creatinine
Electrolytes
GGT/Gamma Glutamyl Transferase
Glucose
Immunosuppressant drug level
Lipid Panel
Magnesium
Phosphate
PTH
Protein/Creatinine Ratio
Uric Acid
UA (Transplant)
Vitamin D, 25-Hydroxy by HPLC


Kidney Abbreviated (KABB) Orders
BUN
Calcium
CBC w/Differential
Creatinine
Electrolytes
Glucose
Immunosuppressant drug level
Magnesium
Phosphate
Protein/Creatinine Ratio
UA (Transplant)


Kidney Recipient Post Transplant Monitoring– Transplant Coordinators Only
Time Frame Post-Transplant Labs Frequency Immunosuppressant Levels Frequency
Weeks 1-6 2 times/week 1 time/week
Weeks 7-12 1 time/week 1 time/week
Months 3-6 Every other week Every other week
Months 7-9 1 time/ month 1 time/month
Months 10-12 1 time/month 1 time every 3 months


Kidney Monitoring Orders
Creatinine
Glucose
Hematocrit
Immunosuppressant drug level
Potassium
WBC



Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

7

Pediatric Kidney Transplant

Pediatric Kidney Post Transplant
Time Frame Post-Transplant Orders
All
1
st
Year Kidney - Pediatric
1
st
Year – Every clinic visit or every month EBV Quantitative by PCR, CMV Quantitative by
PCR, BK PCR blood, BK PCR urine
Clinic visits other than 6 month and yearly Kidney - Pediatric - Abbreviated
Month 6, then yearly Kidney – Pediatric - Full
For Donor Recipients at Increased Risk for HIV, Hepatitis B or C per Public Health Service Standards*
Months 1, 3 HCV RNA Quantitative by PCR, Hepatitis B Core Ab
Total, Hepatitis B DNA Quantitative by PCR,
Hepatitis B Surface AG, HIV RNA


Pediatric Kidney – First Year Post-Transplant Orders
BK Virus, Quantitative by PCR
BK Virus Quantitative by PCR, Urine
BUN
CBC w/Differential
CMV, Quantitative by PCR
Creatinine
Culture, Urine
EBV Quantitative by PCR, Blood
Electrolytes
Glucose
Immunosuppressant drug level
Protein/Creatinine Ratio
Urinalysis with Microscopy – midstream


Pediatric Kidney Full Orders
Albumin
Alkaline Phosphatase
ALT/SGPT
AST/SGOT
Bilirubin, Total
BUN
Calcium
CBC w/Differential
Creatinine
Culture, Urine
Electrolytes
GGT/Gamma Glutamyl Transferase
Glucose
Immunosuppressant drug level
Lipid Panel
Magnesium
Phosphate
PTH
Protein/Creatinine Ratio
Urinalysis with Microscopy – midstream


Pediatric Kidney Abbreviated Orders
BUN
Creatinine
Culture, Urine
Electrolytes
Glucose
Hematocrit
Immunosuppressant drug level
Protein/Creatinine Ratio
Urinalysis with Microscopy – midstream
WBC


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

8

Living Kidney Transplant Donors

Living Kidney Donor Evaluation Orders – Transplant Coordinator Only
ABO and Rh Typing
Activated Partial Thromboplastin Time (PTT)
Albumin
Alkaline Phosphatase
ALT/SGPT
AST/SGOT
Bilirubin, Total
BUN
Calcium
CBC w/Differential
Creatinine
Creatinine, Urine, Random
Donor Lymphocyte Extraction (60 mL heparinized
syringe for HLA)
Electrolytes
GGT/Gamma Glutamyl Transferase
Glucose Tolerance, 2 hour – Fasting
Glucose Tolerance, 2 hour – Serum only
Hemoglobin A1C)
HLA Flow Cytometry Crossmatch
HLA for auto crossmatch
Lipid Panel
Living Related Donor Viral Screen
Magnesium
Microalbumin, Urine
Phosphate
Pregnancy, Urine
Protein/Creatinine Ratio
Protein, Urine Random
Prothrombin Time/INR
PSA Total, Screen (males > 50 yrs)
Uric Acid
UA (Transplant)

X-Ray Chest PA & Lat views
CT Scan (Renal Donor, with and without contrast)
CT Angio w/KUB
ECG – 12 Lead with Rhythm Strip

Living Kidney Donor Post-Procedure Orders
Time Frame Post-Donation Orders
All
Once 2-4 weeks post donation; then 4-8 months
post donation
BUN
CBC
Creatinine
Electrolytes
Glucose
Microalbumin, Urine
UA (Transplant)
Yearly times 2 Creatinine
UA (Transplant)
Microalbumin
Urine



Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

9

Pancreas/Simultaneous Pancreatic-Kidney (SPK)/Islet Transplants

Pancreas Pre-Transplant Evaluation – Transplant Coordinators Only
Indication Orders
All
Activated Partial Thromboplastin Time (PTT)
Alkaline Phosphatase
ALT/SGPT
AST/SGOT
Antithrombin III, Activity
Bilirubin, Total
BK Virus Quantitative by PCR (if known history of
BK virus)
Cardiolipin Ab, IgA
Cariolipin, AB, IgG/IgM
C-Peptide
Creatinine (if not on dialysis)
Creatinine Clearance (if not on dialysis)
Factor V Leiden Gene Mutation Analysis
Factor V Leiden/Prothrombin Gene Mutation
Analysis
GAD Ab
GGT/Gamma Glutamyl Transferase
Hepatitis B Core Ab, Total
Hepatitis B Surface Ab
Hepatitis B Surface Ag
Hepatitis C Ab
HgA1c
HIV-1, 2 Ab
HLA Class I typing (A, B, C) Pre-Transplant
HLA Class I Donor Specific
HLA Ab by Luminex, Pre- Transplant
HLA Class II Donor Specific Ab by Luminex, Pre-
Transplant
HLA-DR/DQ Typing by PCR-SSP, Pre-Transplant
Insulin Ab
Islet Cell Antibody, IgG
Lupus Anticoagulant
Protein C Ag
Protein S Ag
Protein S Ag, Free
Protein, Urine 24 hr (if pt not on dialysis)
Prothrombin Time/INR
Quantiferon TB Gold (if high risk for TB: history of
exposure to someone with TB, born in a country
with high rates of TB, travel to a country with high
rates of TB, residence in an area with high rates of
TB, or per Infectious Disease recommendation)
PSA Total, Screen (males only)
Varicella-Zoster Virus Antibody, IgG

X-Ray Chest PA & Lat views
Hepatitis C Positive Patients – Additional Orders
Albumin
Alpha Fetoprotein (AFP) Maternal
Cryoglobulin, Quantitative
Hepatitis C Genotyping
Hepatitis C RNA, Qualitative, PCR
Hepatitis C RNA, Quantitative, PCR
Platelet Count
Hepatitis B Positive Patients – Additional Orders
Albumin
Alpha Fetoprotein (AFP) Maternal
CBC with Differential
Cryoglobulin, Qualitative
Cryoglobulin, Quantitative
Hepatitis B DNA, Quantitative, PCR
Hepatitis Be Virus Antigen
Hepatitis Be Virus Antibody
Hepatitis Delta Virus Antibody
Platelet Count
Rheumatoid Factor



Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

10

Simultaneous Pancreas-Kidney (SPK) Post Transplant
Time Frame Post-Transplant Orders
All
Kidney/Pancreas (or PAK/KAP) only:
Weeks 3, 6, 9, 12; then monthly through 6-12
months; then every 1-2 months through 2 years.

At annual clinic visit for any patient who has had a
history of positive BK.
BK Quantitative by PCR
Low Risk: Months 6, 12, then yearly
(Low Risk: Non-Allosensitized Recipients, i.e.,
nonsensitized first transplantation, no detectable HLA
antibodies by SA bead testing)

Moderate Risk: Week 3, then Months 6, 12 then
yearly
(Moderate Risk: Allosensitized, i.e., any anti-HLA
antibodies or history of DSA but currently negative by
SA bead Testing)

High Risk: Post Op: Week 3,6; then Months 3, 6,
12; then yearly
(High Risk: Donor-Specific Antibody (DSA) positive by
SA bead testing (FCXM positive or negative, significant
change in immunosuppression, suspected
nonadherence, graft dysfunction, monitoring
effectiveness of rejection therapy, etc.)
Donor Specific Antibody (DSA) I & II Post-
Transplant
For CDC Increased Risk Donor Recipients
Months 1, 3 HCV RNA Quantitative by PCR, Hepatitis B Core Ab
Total, Hepatitis B DNA Quantitative by PCR,
Hepatitis B Surface AG, HIV RNA

Simultaneous Pancreas-Kidney and Isolated Pancreas Post Transplant
Time Frame Post-Transplant Orders
All
First Post-Op visit with surgeon Kidney/Pancreas Full – except NO fasting lipid
panel, PTH, or Vitamin D
All other clinic visits with Surgery or Nephrology Kidney/Pancreas – Abbreviated
First visit with Nephrologist & Annual Visits Kidney/Pancreas – Full
1
st
Year at each clinic visit C-peptide (all) and BK Virus (patients with history
of kidney transplant only)
After 1
st
year (every 6 months) C-peptide
For CDC Increased Risk Donor Recipients
Months 1, 3 HCV RNA Quantitative by PCR, Hepatitis B Core Ab
Total, Hepatitis B DNA Quantitative by PCR,
Hepatitis B Surface AG, HIV RNA


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
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11

Islet Cell Post Transplant
Time Frame Post-Transplant Orders
All clinic visits Islet Cell Labs


Pancreas Biopsy Orders
Time Frame Post-Transplant Orders
All
All biopsies Kidney/Pancreas Abbreviated AND Platelets, PTT,
Prothrombin Time/INR, Donor Specific Antibody
(DSA) I & II, Type and Screen
Patients with a history or kidney transplant
All Biopsies BK Virus


Kidney-Pancreas Full (KPFULL) Post-Transplant Orders
Albumin
Alkaline Phosphatase
ALT/SGPT
Amylase
AST/SGOT
Bilirubin, Total
BUN
Creatinine
Calcium
CBC w/Differential
C-Peptide
Donor Specific Antibody (DSA) I & II
Electrolytes
Glucose
A1c
Immunosuppressant drug level
Lipase
Lipid Panel
Magnesium
Phosphate
PTH
Protein/Creatinine Ratio
UA (Transplant)
Vitamin D, 25-Hydroxy by HPLC


Kidney-Pancreas Abbreviated (KPABB) Post-Transplant Orders
Amylase
BUN
CBC without Differential
Creatinine
Electrolytes
Glucose
A1c
Immunosuppressant drug level
Lipase
Protein/Creatinine Ratio
UA (Transplant)

Islet Cell Post-Transplant Orders
Alkaline Phosphatase
ALT/SGPT
AST/SGOT
Bilirubin, Total
BUN
CBC w/Differential
C-Peptide
Creatinine
Electrolytes
GGT/Gamma Glutamyl Transferase
Glucose
A1C
Immunosuppressant drug level
Lipid Panel
Protein/Creatinine Ratio
UA (Transplant)
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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12

Management of Post-Pancreas Transplant (Simultaneous Pancreas-Kidney and Isolated Pancreas) –
Transplant Coordinators Only
Time Frame Post-Transplant Labs Frequency Immunosuppressant Levels
Frequency
Weeks 1-6 2 times/week 1 time/week
Weeks 7-12 1 time/week 1 time/week
Months 3-6 Every other week Every other week
Months 7-9 1 time/ month 1 time/month
Months 10-12 1 time/month 1 time every 3 months
Years 2-4 Every 1-2 months 1 time every 3 months
Year 5 and greater Every 1-3 months 1 time every 3 months

Kidney-Pancreas Monitoring (PMON) (Simultaneous Pancreas-Kidney and Isolated Pancreas)
BUN
Creatinine
Glucose
Amylase
Hematocrit
A1c every 90 days
Immunosuppressant drug level
Lipase
Potassium
WBC without differential



Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

13

Liver Transplant

Liver Pre-Transplant Evaluation Orders – Transplant Coordinators Only
Type Order
Labs ABO and Rh Typing X 2
Activated Partial Thromboplastin Time (PTT)
AFP (Alpha Fetoprotein)
Albumin
Alkaline Phosphatase
ALT/SGPT
Alpha 1 Antitrypsin Phenotype
Ammonia
ANA Screen with Titer if Positive
AST/SGOT
Bilirubin, Total
BUN
Calcium
CBC with Differential
Ceruloplasmin
Creatinine
Electrolytes
Ferritin
GGT/Gamma Glutamyl Transferase
Glucose
HCG, Qualitative, Urine (females, post-menarche to r/o
pregnancy)
Iron
Iron/ TIBC with Saturation
LD (Lactate Dehydrogenase)
Magnesium
Mitochondrial Ab
Phosphate
Protein, Total
Prothrombin Time/INR
PSA Total, Screen (males only)
Smooth Muscle Ab
Urinalysis with microscopy (clean catch, midstream)
Infectious Disease Serology Labs Hepatitis A Ab, IgM
Hepatitis A Ab, Total
Hepatitis B Core Ab, IgM
Hepatitis B Core Ab, Total
Hepatitis B Surface Ab
Hepatitis B Surface Ag
Hepatitis C Ab (Anti-HIV)
Hepatitis C RNA, Qualitative
HIV-1, 2 Ab
Varicella-Zoster Virus Antibody, IgG
Diagnostic Testing/ Imaging ECG – 12 Lead w/ Rhythm Strip
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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14

Esophagogastroduodenoscopy (EGD) as directed by
provider
Exercise Stress. Dobutamine Stress Echocardiogram if
patient is unable to exercise
Transthoracic Resting Echocardiogram with agitated
bubble study
Carotid Dopplers as directed by provider
X-Ray Chest PA & Lat views
Chest CT for diagnosis of hepatocellular carcinoma (HCC)
or cholangiocarcinoma
CT Angio Abdomen (may substitute MRI/MRA/MRCP or
Ultrasound* if provider directed and surgeon must
approve)
Pulmonary Function Tests (Pre-Op Non-Thoracic) (if COPD
or history of pulmonary disease or as directed by provider
Preventive Screening Colonoscopy: for patients > 50 years old
Cytology, Conventional Pap Smear (females)
Mammogram (for females > 40 years old
*Note: Cancer screening guidelines should be performed
according to American Cancer Society Guidelines and in
general should be arranged through patient’s primary
care provider
Bone density as clinically indicated (h/o PBC/autoimmune
disease; women > 65 yrs, presence of risk factors)
Vaccinations as directed by provider
Dental examination or Panorex
Patients with transferring SAT >45 and/or
increased ferritin – additional labs
Hemochromatosis Mutation Detection
Hep B positive patients – additional labs Cryoglobulin, Qualitative
Hepatitis B DNA, Qualitative
Hepatitis Be Virus Antigen
Hepatitis Be Virus Antibody
Hep C positive patients – additional labs Hepatitis C Genotyping
Cryoglobulin, Qualitative
Patients with risk of TB – additional labs
(history of exposure to someone with TB,
born in a country with high rates of TB,
travel to a country with high rates of TB,
residence in an area with high rates of TB,
or per Infectious Disease recommendation)
Quantiferon TB Gold
Histocompatibility for combined
kidney/liver – additional labs
HLA Class I typing (A, B, C) Pre-Transplant
HLA Class I Donor Specific HLA Ab by Luminex, Pre-
Transplant
HLA Class II Donor Specific Ab by Luminex, Pre-Transplant
HLA-DR/DQ Typing by PCR-SSP, Pre-Transplant
Primary Sclerosing Cholangitis Diagnosis
and/or Suspected Cholangiocarcinoma –
Cancer Antigen-GI (CA 19-9)
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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15

additional labs
Consults (as needed) AODA (patient with AODA history flagged by provider,
transplant coordinator or social worker)
Nutrition
Social Work
Other consults as directed by provider


Liver Pre-Transplant
Time Frame Orders
All clinic visits Pre-Liver Original

Liver Pre-Transplant [Pre-Liver Original (PRELO)] Orders
Albumin
Alkaline Phosphatase
Alpha-Fetoprotein
ALT/SGPT
AST/SGOT
Ammonia
Bilirubin, Total
BUN
Calcium
CBC without Differential
Cholesterol
Creatinine
Electrolytes
GGT
Glucose
Magnesium
Prothrombin Time/INR


Liver Post Transplant
Time Frame Orders
All
First postoperative visit with surgeon Liver – Full except NO fasting lipid panel and no
Vitamin D
First visit with Hepatologist after transplant and
Annual visits
Liver - Full
All other clinic visits with Surgery or Hepatology Liver - Abbreviated
For CDC Increased Risk Donor Recipients
Months 1, 3 HCV RNA Quantitative by PCR, Hepatitis B Core Ab
Total, Hepatitis B DNA Quantitative by PCR,
Hepatitis B Surface AG, HIV RNA


Liver Biopsy Orders
Time Frame Post-Transplant Orders
All Liver Abbreviated, PT/INR, Donor Specific Antibody
(DSA) I & II



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Liver Full Orders
Albumin
Alkaline Phosphatase
ALT/SGPT
AST/SGOT
Bilirubin, Total
BUN
Calcium
CBC w/Differential
Creatinine
Donor Specific Antibody (DSA) hold tube
Electrolytes
GGT/Gamma Glutamyl Transferase
Glucose
Immunosuppressant drug level
Lipid Panel
Magnesium
Protein/Creatinine Ratio
Urinalysis (Transplant)
Vitamin D, 25 Hydroxy, HPLC
Liver Abbreviated (LABB) Orders
Alkaline Phosphatase
ALT/SGPT
AST/SGOT
Bilirubin, Total
BUN
CBC without Differential
Creatinine
Electrolytes
GGT
Glucose
Immunosuppressant drug level


Liver Post Transplant Monitoring – Transplant Coordinators Only
Time Frame Post-Transplant Labs Frequency Immunosuppressant Levels
Frequency
Weeks 1-6 2 times/week 1 time/week
Weeks 7-12 1 time/week 1 time/week
Months 3-6 Every other week Every other week
Months 7-9 1 time/ month 1 time/month
Months 10-12 1 time/month 1 time every 3 months
Years 2-4 Every 1-2 months 1 time every 3 months
Year 5 and greater Every 1-3 months 1 time every 3 months


Liver Monitoring (LMON) Orders
Alkaline Phosphatase
ALT/SGPT
AST/SGOT
Bilirubin, Total
Creatinine
GGT
Glucose, if patient has Impaired Fasting Glucose or
Diabetes
Hematocrit
Immunosuppressant drug level
Potassium
WBC (add differential if WBC <2)



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17

Pediatric Liver Transplant

Pediatric Liver Pre-Transplant Orders
Albumin
Alkaline Phosphatase
Alpha-Fetoprotein
ALT/SGPT
AST/SGOT
Ammonia
Bilirubin, Total
BUN
Calcium
CBC without Differential
Cholesterol
Culture, Urine
Creatinine
Electrolytes
GGT
Glucose
Magnesium
Prothrombin Time/INR
Protein/Creatinine Ratio
Urinalysis with Microscopy – midstream


Pediatric Liver Post-Transplant
Time Frame Post-Transplant Orders
All
Months 1, 6; then yearly Liver - Full
Months 3, 9 Liver - Abbreviated
Months 3, 6, 12 Donor Specific Antibody (DSA) I & II
1
st
Year – Every clinic visit EBV Quantitative by PCR,
CMV Quantitative by PCR
For CDC Increased Risk Donor Recipients
Months 1, 3 HCV RNA Quantitative by PCR, Hepatitis B Core Ab
Total, Hepatitis B DNA Quantitative by PCR,
Hepatitis B Surface AG, HIV RNA


Liver Living Donor Evaluation

Liver Living Donor Evaluation Orders – Transplant Coordinators Only
Type Order
Labs ABO and Rh Typing
Activated Partial Thromboplastin Time (PTT)
Alpha 1 Antitrypsin
Ammonia
ANA Screen with Titer if Positive
Antithrombin III Activity
CBC with Differential
Ceruloplasmin (If low, order Wilson disease
screening panel, serum)
Comprehensive Metabolic Panel
Factor V (leiden) Mutation by PCR
Ferritin
Fibrinogen
GGT/Gamma Glutamyl Transferase
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HCG, Qualitative, Urine (females, post menarche
to r/o pregnancy – unless surgically sterile)
Hepatitis A Ab IgG
Hepatitis B Surface AB
Homocysteine
Iron/TIBC with saturation
LD (Lactate Dehydorgenase), Total
Lipid Panel
Lupus Anticoagulant Workup
Magnesium
Mitochondrial Antibody
NAT Testing-Living Donor Screen Phosphate
Protein S Activity
Protein S AG Free
Prothrombin Gene Mutation by PCR
PSA, Total (males > 50 yrs)
Prothrombin Time/INR
Smooth Muscle Antibody
Urinalysis without microscopy (clean catch,
midstream – unless POS leukocyte)
Uric Acid
Diagnostic Testing/Imaging CTA (triphasic CT) Abdomen with and without
contrast for vessel anatomy and liver volume
ECG – 12 Lead w/ Rhythm Strip
Exercise Stress. Dobutamine Stress if unable to
exercise.
Echocardiogram if clinically indicated
Transthoracic Resting Echocardiogram
MRI/MRCP for bile duct mapping and fat content
X-Ray Chest PA & Lat views

Consults Health Psychiatry
Internal Medicine
Live Donor Advocate
Nutrition
Social Work
Transplant Hepatology
Transplant Surgery



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19

Heart Transplant

Heart Pre-Transplant Evaluation – Transplant Coordinators Only
Type Order
Labs ABO and Rh Typing (two times at least 24 hours
apart)
Albumin
Alkaline Phosphatase
Alkaline Phosphatase, Bone Specific
ALT/SGOT
ALT/SGPT
B-Type Natriuretic Peptide
Bilirubin, Total
BUN
Calcium
Carbon Dioxide
Creatinine
ESR
Ferritin
Glucose
Hemoglobin A1C
Iron and Transferrin with TIBC, Saturation
Iron
Lipid Panel
LD, Total
Magnesium
Phosphate
Potassium
Prealbumin
Protein, Total
PTH
PTT
Quantiferon-TB Gold
Reticulocyte Count
Sodium
T3, Free
T4, Total
TSH
Uric Acid
Vitamin D 25-Hydroxy by HPLC
HLA Antibody Screen, Routine, Pre-Transplant
HLA Class I typing (A, B, C) Pre-Transplant
HLA-DR/DQ Typing by PCR-SSP, Pre-Transplant
HLA - Luminex
Labs – Infectious Disease Serology CMV, ABS, IGG/IGM
Varicella Zoster AB, IGG
HIV Ab/Ag Combo
Herpes Simplex Type 1 and 2 AB, IGG
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Hepatitis A Ab, IgG
Hepatitis B Core AB, Total
Hepatitis B Surface AB (immune status)
Hepatitis B Surface AG
Hepatitis C AB
EBV Ab to Viral Capsid Ag, IgG
EBV Ab to Viral Capsid Ag, IgM
RPR, confirm if positive
Labs – Fungal Serology Blastomyces AB by CF
Coccidioides AB by CF
Histoplasma AB by CF
Toxoplasma AB, IGG/IGM
Labs – Other – If indicated by provider Cold Agglutinins, Qualitative
Creatinine Clearance
Nicotine (includes Cotinine) Urine
Occult Blood (Immunoassay), Screen, Stool
PSA Total, Diagnostic
Protein, Total, Urine, 24 Hour
Urinalysis with Microscopy
Diagnostic Testing/Imaging Ankle/Brachial Index
Bilateral Carotid Doppler
Bilateral lower extremity ankle brachial index
Bone Mineral Density Scan (DEXA) lumbar spine
and hip bone
Cardiopulmonary Exercise Test (EVO2)
Colonoscopy (patient > 50 years of age)
CT Angio Head, Neck with Perfusion
CT Chest with and without IV Contrast
ECG – 12 Lead
Esophagogastroduodenoscopy (EGD)
Gallbladder ultrasound
Left Heart Catheterization
Mammogram (women > 40 years of age)
NM Lung Perfusion Scan
Pap & Pelvic Exams
Pulmonary Function Tests and ABG
Right/Left Heart Catheterization (every 3 – 6
months for patients without an implanted VAD
Transthoracic Resting Echocardiogram
Ultrasound Carotid Duplex
US Abdomen Complete - Gallbladder
X-Ray Chest PA & Lat Views
X-Ray Panorex (Orthopantogram)
Consults Cardiothoracic Surgery
Dental
Financial
Health Psychology
Infectious Disease
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Nutrition
Ophthalmology
Social Work
Transplant Coordinator
Women’s Health Evaluation


Heart Post-Transplant Management – Transplant Coordinators Only

Biopsy Schedule
Time Frame Post-Transplant Frequency Orders
All
Months 0 -1 Weekly x 4 Weeks
Right Heart Catheterization
(RHC) & Biopsy*
Months 1 - 3 Every 2 Weeks x 8 RHC & Biopsy*
Months 4 - 6 Every 4 Weeks x 12 RHC & Biopsy*
If no treated rejection during first year

Yearly until 2 years post
transplant, then at provider
discretion
RHC & Biopsy*
If treated rejection during first year:
Months 13 - 24 Every 3 Months x 3 RHC & Biopsy*
Months 25+ Every 6 months until 3 years
post-transplant, then 1 Time
Every Year x 5 (PRN discretion of
MD)
RHC & Biopsy*
*C3D, C4D staining as directed by provider

Clinic Visits: With each biopsy after hospital discharge through year 1, then at least every 3-6 months as
clinically indicated (rejection history, recent infection history, and co-morbidities).

Echocardiogram Schedule
Time Frame Post-Transplant Frequency Orders
Week 1 Once (Biopsy #1) Transthoracic Echocardiogram
Week 4-12 Monthly x 3 (Biopsy #4, 6, 8) Transthoracic Echocardiogram
Weeks 24 Once (Biopsy #11) Transthoracic Echocardiogram
Week 36 Once (Biopsy #13) Transthoracic Echocardiogram
Week 52 Once Transthoracic Echocardiogram
Month 15 Once Transthoracic Echocardiogram
Month 18 Once Dobutamine Echocardiogram
Months 21. 30, 36, 48, 60 Once Transthoracic Echocardiogram
Year 6 + Every other year (even years) Transthoracic Echocardiogram
Year 7 + Every other year (odd years) Dobutamine Echocardiogram


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Heart Post-Transplant Laboratory and Diagnostic Testing Schedule
Time Frame Post-Transplant Orders
AT each biopsy visit or every three months Albumin, , ALT/SGPT, AST/SGOT, Bilirubin-Total,
BUN, Calcium, CK-Total, , Electrolytes, Creatinine,
Glucose, Heme Survey with Differential, ,
Magnesium, Phosphate, Platelets, Protein,
immunosuppressive level,
At each biopsy visit X-Ray chest PA & Lat Views
Every 6 months or 3 months after change in lipid
management
Fasting Lipid Panel
First Annual Visit HIV-1, RNA, Quantitative, Hepatitis B, Ultra
Quantitative by PCR, Hepatitis C RNA, Quantitative
by PCR

Yearly Albumin, , ALT/SGPT, AST/SGOT, Bilirubin-Total,
BUN, Calcium, CK-Total, Creatinine, Electrolytes, ,
Glucose, Heme Survey with Differential,
Magnesium, Phosphate, Platelets, Vitamin D 25,
hydroxy by HPLC, Protein, Immunosuppressant
level, X-Ray Chest PA & Lat Views, Axial Bone
Density Study (scan at year one (and as clinically
indicated if osteopenia or osteoporosis)
Mammogram/PAP/Pelvic tests done locally (for
female patients only), PSA (for all male patients)
Yearly 1-5 and 10 years post transplant Right heart catheterization coronary angiography*,
+/- IVUS
For CDC Increased Risk Donor Recipients
Months 1, 3 HCV RNA Quantitative by PCR, Hepatitis B Core Ab
Total, Hepatitis B DNA Quantitative by PCR,
Hepatitis B Surface AG, HIV RNA
*Dobutamine echocardiogram substituted for angiography if patient has significant renal insufficiency;
both may be deferred at provider discretion. Annual evaluation more than 10 years following transplant
will be individualized depending on patient’s overall status, renal function, history of allograft CAD, etc.


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23

Lung Transplant

Lung Transplant Pre-Transplant Evaluation – Transplant Coordinators Only
Type Order
Labs ABO and Rh Typing (2 times)
Activated Partial Thromboplastin Time (PTT)
CBC with Differential
CMV Ab, IgG
Cold Agglutinins (CAGG)
Comprehensive Metabolic Panel
Creatinine
Epstein-Barr Virus Ab to Nuclear Ag, IgG
Ferritin
Hemoglobin A1C
Hepatitis B Surface Ab
Hepatitis B Surface Ag
Hepatitis C Ab
HIV-1, 2 Ab
HLA Class I and Class II AB by Luminex, Pre-Tx
HLA DR/DQ/DP Locus, Pre-Tx
HLA Class I Typing, A, B, & C Locus, Pre-Tx
LD (Lactate Dehydrogenase)
Lipid Panel
Magnesium
Microalbumin, Urine
Nicotine (includes Cotinine), Urine
Prealbumin
Prothrombin Time/INR
PTH
Quantiferon – TB Gold
TSH
Toxoplasma gondii Antibodies, IgG & IgM
Uric Acid
Urinalysis with Microscopy
Urine Creatinine
Varicella-Zoster Virus Antibody, IgG
Vitamin D, 1, 25-Dihydroxy
Diagnostic Testing/Imaging Bone Mineral Density Scan
Chest and Sinus CT
Echocardiogram
Electrocardiogram
Impedance PH (exclude COPD patients)
Right/Left Heart Catheterization
Manometry (exclude COPD patients)
Nuclear Medicine Lung Perfusion Scan
Pulmonary Function Tests
X-Ray Chest PA & Lat Views
X-Ray Panorex (can be done locally with dentist
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24

consult)
TB Skin Testing
Six-minute Walk Test
PH Impedance, Manometry and Esophagram (all
three for patients with connective tissue disease)
Consults ENT Consults - Cystic Fibrosis (CF) patients only
Dental – can be done locally with Panorex
Financial
Health Psychology
Infectious Disease
Nutrition
Social Work
Surgery Consult/Consent


Lung Post-Transplant Orders
Time Frame Post-Transplant Orders
Bronchoscopy - prior to discharge. All other
testing within two weeks post discharge
Bronchoscopy, Pulmonary Function Tests –
Spirometry, Six-Minute Walk Test, Clinic Visit
Attendance
Week 6 Comprehensive Metabolic Panel, CBC with
Differential, Immunosuppressive Trough Levels,
Magnesium,.
Bronchoscopy with biopsy, Clinic Visit with Six-
Minute Walk Test, Pulmonary Function Tests –
Spirometry, X-Ray Chest PA & Lat Views
Month 1, 2 Increased Risk Patients – CDC increased risk labs,
Donor specific antibody testing
Month 3

Comprehensive Metabolic Panel, CMV Quant by
PCR, CBC with Differential, Immunosuppressive
Trough Levels, Magnesium.
Bronchoscopy with biopsy, Clinic Visit with Six-
Minute Walk Test, Pulmonary Function Tests –
Spirometry, X-Ray Chest PA & Lat Views
Increased Risk Patients – CDC increased risk labs,
Donor specific antibody testing
Month 6

Comprehensive Metabolic Panel, CMV Quant by
PCR, CBC with Differential, Immunosuppressive
Trough Levels, Magnesium, Lipid Panel, Vitamin
D25 OH.
Bronchoscopy with biopsy, Clinic Visit with Six-
Minute Walk Test,
Pulmonary Function Tests – Spirometry, X-Ray
Chest PA & Lat Views
All Recipients: Donor specific antibody testing
Month 9 Comprehensive Metabolic Panel, CMV Quant by
PCR, CBC with Differential, Immunosuppressive
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Trough Levels, Magnesium,.
Bronchoscopy with biopsy, Clinic Visit with Six-
Minute Walk Test, Pulmonary Function Tests –
Spirometry, X-Ray Chest PA & Lat Views
First Annual Post-Transplant Visit Comprehensive Metabolic Panel, CBC with
Differential, Platelets, Prothrombin Time/INR, PTT,
Lipid Panel, Magnesium, Phosphorous, Uric Acid,
Hepatitis B Panel, Hepatitis C, CMV Quantitative by
PCR, PSA (for male patients only), Urinalysis with
Microscopy, Urine Protein, Urine
Protein/Creatinine Ratio, Vitamin D25 OH.
Axial Bone Density Study,
Bronchoscopy with biopsy,
Mammogram/PAP/Pelvic tests done locally (for
female patients only), Pulmonary Function Tests –
Spirometry, X-Ray Chest PA & Lat Views
Donor specific antibody testing
Months 15, 18, 21 Comprehensive Metabolic Panel, CBC with
Differential, Immunosuppressive Trough Levels,
Magnesium.
Clinic visit with Six-Minute Walk Test, Pulmonary
Function Tests – Spirometry, X-Ray Chest PA & Lat
Views
Second Annual Visit (and subsequent) Comprehensive Metabolic Panel, CBC with
Differential, Lipid Panel, Immunosuppressive
Trough Levels, Magnesium, PSA (for all male
patients), Urinalysis with Microscopy, Urine
Protein, Urine Protein/creatinine ratio, Vitamin D
25 (OH).
Clinic Visit with Six Minute Walk Test, Axial Bone
Density Study,
Mammogram/PAP/Pelvic tests done locally (for
female patients only), Pulmonary Function Tests –
Spirometry, X-Ray Chest PA & Lat Views
For CDC Increased Risk Donor Recipients
Months 1, 3 HCV RNA Quantitative by PCR, Hepatitis B Core Ab
Total, Hepatitis B DNA Quantitative by PCR,
Hepatitis B Surface AG, HIV RNA
For patients with Cystic Fibrosis
Month 9 to 1 year Colonoscopy. Okay to be done locally.
First annual visit Amylase, Bilirubin Direct, GGT, Vitamin A, Vitamin
E, Immunoglobulin E, Hemoglobin A1C (if
diabetic),Nutrition Consult
2
nd
annual visit (and subsequent) Amylase, Bilirubin Direct, GGT, Vitamin A, Vitamin
E, Immunoglobulin E, Hemoglobin A1C (if
diabetic),Nutrition Consult

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Desensitization
Patients undergoing desensitization should have CMV VL checked at 6, 9, and 12 months. Refer to the
Desensitization and Induction for Kidney Recipients Based on DSA and Rejection Treatment Clinical
Practice Guideline.
https://uconnect.wisc.edu/clinical/references/transplant-guidelines---solid-
organs/clinical/resources/name-71501-en.file

Immunosuppressant Drug Level Monitoring

Tacrolimus Monitoring
Time Since Initiation of Tacrolimus Frequency* Labs
Day 0-90 Once weekly Tacrolimus trough, potassium,
creatinine Day 91-180 Twice monthly
Day 181-240 Monthly

*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. Check level in 3-7 days following dose adjustment. A minimum of 2 levels should be within
the goal range before resuming the previous monitoring frequency

Cyclosporine Monitoring
Time Since Initiation of Cyclosporine Frequency* Labs
Day 0-90 Once weekly Cyclosporine trough, potassium,
creatinine Day 91-180 Twice monthly
Day 181-240 Monthly

*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. Check level in 3-7 days following dose adjustment. A minimum of 2 levels should be within
the goal range before resuming the previous monitoring frequency

Sirolimus/Everolimus
Time Since Initiation of
Sirolimus/Everolimus
Frequency* Labs
Day 0+ Once weekly Sirolimus/Everolimus trough
Once target trough attained Monthly Sirolimus/Everolimus trough

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