J Am Soc Nephrol 11: S1–S86, 2000 Recommendations for the Outpatient Surveillance of Renal Transplant Recipients BERTRAM L. KASISKE,* MIGUEL A. VAZQUEZ,† WILLIAM E. HARMON,‡ ROBERT S. BROWN,§ GABRIEL M. DANOVITCH,ʈ ROBERT S. GASTON,¶ DAVID ROTH,§§ JOHN D. SCANDLING, JR.,ʈʈ and GARY G. SINGER¶¶ FOR THE AMERICAN SOCIETY OF TRANSPLANTATION *Division of Nephrology, Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota; †Division of Nephrology, Southwestern Medical Center, University of Texas, Dallas, Texas; ‡Children’s Hospital, Harvard University, Boston, Massachusetts; §Renal Unit, Beth Israel Hospital, Harvard University, Boston, Massachusetts; ʈDivision of Nephrology, Department of Medicine, UCLA Medical Center, University of California, Los Angeles, California; ¶Division of Nephrology, UAB Medical Center, University of Alabama at Birmingham, Birmingham, Alabama; §§Division of Nephrology, University of Florida, Miami, Florida; ʈʈTransplantation, Division of Nephrology, Department of Medicine, Stanford University Medical Center, Stanford University, Palo Alto, California; and ¶¶Washington University School of Medicine, St. Louis, Missouri. Abstract. Many complications after renal transplantation can pediatric renal transplant recipients, and they cover the outpa- be prevented if they are detected early. Guidelines have been tient screening for and prevention of diseases and complica- developed for the prevention of diseases in the general popu- tions that commonly occur after renal transplantation. They do lation, but there are no comprehensive guidelines for the pre- not cover the diagnosis and treatment of diseases and compli- vention of diseases and complications after renal transplanta- cations after they become manifest, and they do not cover the tion. Therefore, the Clinical Practice Guidelines Committee of pretransplant evaluation of renal transplant candidates. The the American Society of Transplantation developed these guidelines are comprehensive, but they do not pretend to cover guidelines to help physicians and other health care workers every aspect of care. As much as possible, the guidelines are provide optimal care for renal transplant recipients. The guide- evidence-based, and each recommendation has been given a lines are also intended to indirectly help patients receive the subjective grade to indicate the strength of evidence that sup- access to care that they need to ensure long-term allograft ports the recommendation. It is hoped that these guidelines will survival, by attempting to systematically define what that care provide a framework for additional discussion and research encompasses. The guidelines are applicable to all adult and that will improve the care of renal transplant recipients. The morbidity and mortality rates associated with renal trans- The recent emphasis on cost-cutting in medicine has created plantation and the use of immunosuppressive medications are an impetus for health plans to develop guidelines designed to high. However, many posttransplant complications can be pre- reduce expenditures. Unfortunately, guidelines developed by vented, or at least more effectively treated, if they are detected payers are rarely evidence-based and may not be primarily earlier, rather than later. Guidelines have been developed for focused on optimizing patient outcomes. The American Soci- the prevention of diseases in the general population, but there ety of Transplantation (AST) conducted a survey of medical are no comprehensive guidelines for the prevention of diseases and surgical directors of United Network for Organ Sharing and complications after renal transplantation. In addition, (UNOS) renal transplant centers. Of the 117 respondents, 97% whether general disease prevention strategies and guidelines agreed that there was a need for recommendations guiding the developed for the general population are applicable to trans- surveillance of renal transplant recipients (R.S. Gaston, B.L. plant recipients has not been addressed in a systematic manner. Kasiske, R.J. Tesi, G.M. Danovitch, and M.J. Bia, unpublished observations). The AST Board of Directors also concluded that there is a need for evidence-based recommendations designed Correspondence to Dr. Bertram L. Kasiske, Division of Nephrology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415. Phone: to reduce the burden of disease after renal transplantation, in a 612-347-5871; Fax: 612-347-2003; E-mail: [email protected] cost-effective manner. It was also recognized that guidelines Address reprint requests to the American Society of Transplantation, 236 could indirectly help patients receive the access to care that Route 38 West, Suite 100, Moorestown, NJ 08057. Phone: 856-608-1104; Fax: they need to ensure long-term allograft survival. Therefore, the 856-608-1103; E-mail: [email protected]; http: www.a-s-t.org Board asked the AST Clinical Practice Guidelines Committee 1046-6673/1110-0001 Journal of the American Society of Nephrology to develop recommendations for the outpatient surveillance of Copyright © 2000 by the American Society of Nephrology renal transplant recipients. S2 Journal of the American Society of Nephrology J Am Soc Nephrol 11: S1–S86, 2000 Scope support the recommendation that the condition be specifically con- These guidelines are applicable to all (adult and pediatric) sidered in a periodic health examination; C, there is poor evidence renal transplant recipients. They cover outpatient screening for regarding the inclusion of the condition in a periodic health exami- and prevention of diseases and complications that commonly nation, but recommendations may be made on other grounds; D, there is fair evidence to support the recommendation that the condition be occur after renal transplantation. They do not cover the diag- excluded from consideration in a periodic health examination; E, there nosis and treatment of diseases and complications after they is good evidence to support the recommendation that the condition be become manifest. They do not cover the pretransplant period, excluded from consideration in a periodic health examination. and guidelines for the evaluation of renal transplant candidates have been published (1). They do not address the choice of Organizational Scheme immunosuppressive medications and cover only outpatient The guidelines are organized in sections and tables. Most monitoring for and prevention of complications. They do not tables indicate the incidence of the disease or complication cover the treatment or prevention of renal allograft rejection. In being screened, the consequences of the disease or complica- addition, the guidelines do not cover every aspect of screening tion, the rationale for screening and/or prophylaxis, and spe- and prevention, and omissions should not be construed as cific recommendations. Each table is followed by a detailed recommendations for avoiding particular screening measures discussion, which may include a definition of the disease or or preventive strategies. complication and discussions of the incidence, the conse- Intended Users quences, and the rationale for screening or prophylaxis. Table 1 is a table of contents. These guidelines were designed to be used by physicians and health care workers who care for renal transplant recipients in the outpatient clinics of kidney transplant centers. They were I. Frequency and Timing of Outpatient Visits not specifically developed for primary care physicians; how- (Table 2) ever, local referring physicians may find them useful. In addi- There are virtually no scientific data on which to base tion, these guidelines may be helpful for trainees at all levels decisions regarding the optimal frequency or type of contact who wish to learn about renal transplantation. To the extent between renal transplant recipients and transplant centers. that these guidelines are evidence-based, they may also be Most outpatient encounters occur on the basis of circumstances useful for those seeking to identify future research needs. and experiences that may be unique to each patient population Finally, we recognize that some health care planners and and individual transplant center. To better understand current providers may find that the guidelines help them to understand practices, we conducted a survey of medical and surgical what is involved in the optimal treatment of renal transplant directors of UNOS renal transplant centers. recipients. Respondents to the survey reported that three-quarters of adult renal allograft recipients leave the hospital within 8 d Materials and Methods after transplantation. Although the issue was not addressed in The committee searched the medical literature and reviewed per- the survey, pediatric patients generally require longer hospital- tinent publications. Searches were conducted using Medline and re- izations (4). Virtually all patients return home, although some cent pertinent bibliographies. An electronic database was used to centers maintain nearby facilities for patients living a long collate references, but no systematic data extraction or synthesis was distance away. In the AST survey, 80% of centers reported performed. A draft of recommendations was developed using the monitoring patients two or three times each week during the expertise of committee members and the results of the literature first 1 mo after transplantation. Between 1 and 3 mo after review. This draft was sent to societies and individuals for review and transplantation, 86% of