Transplant Surgery

GENERIC NAME

TRADE NAME

DESCRIPTION

• FK506 suppresses the immune system.
• This is necessary in kidney transplant patients to prevent organ rejection by the normal immune function of the body.
• 

DURATION

How long will I need to take Prograf?

•  You will need to take FK506 for as long as the transplanted kidney remains working.

DOSAGE

• Doses are different for each patient.
• We generally start this medication at a low dose in the hospital after the transplant procedure and then titrate the dose of the medication up so that we can achieve an adequate level of drug in your blood.
• You will be required to take blood tests so that we can adjust the dose according to how much of the drug is in your blood.
• Doses of this medication change often, especially right after the transplant.  It is important that you know how much of this medication you are taking at all times.

DIRECTIONS

• Follow your transplant team’s instructions carefully.
• This medication is generally given twice a day (the best way to take it is every 12 hours).
• You will be asked to take this medication with food to help prevent stomach upset.

TESTS

• In order to make sure that you get the appropriate dose of FK506, it is necessary for the transplant team to check how much of this drug is in your blood.
• We will check your FK506 blood level every time you come to the outpatient transplant clinic for labs.

To successfully check the FK506 level in your blood you must follow several steps:

1.      Take all morning medications, except for the FK506, prior to coming to the clinic.

2.      Once you arrive in the clinic go to give a blood sample.

3.      After you have given the blood sample, take your morning dose of FK506.

4.      It takes 4 – 6 hours for us to get results back, so, if we need to change your FK506 dose, we will call you at home to change your evening dose.

DRUG INTERACTIONS

• An interaction generally means that one drug may increase or decrease the effect of FK506.
• Also, the more medications a person takes, the more likely there will be a drug interaction.
• FK506 interacts with many prescription and non-prescription medications, as well as some dietary supplements.  
• Please consult with your transplant nephrologists or transplant pharmacist before starting any new medications because of the potential for drug interactions.

FOOD/BEVERAGE INTERACTIONS

• It has been shown that grapefruit, grapefruit juice and other foods and beverages that contain grapefruit (for example, the soda Fresca has natural grapefruit juice in it) can increase the blood level of FK506.
• It is recommended that you avoid grapefruit, grapefruit juice and other foods and beverages that contain grapefruit while taking FK

SIDE EFFECTS

• Increased creatinine:  FK506, especially at high levels, may increase your creatinine.  If this occurs, it may be necessary for one of the transplant team members to decrease your dosage.  This is one of the major reasons why we will check your FK506 levels so much.
• Increased blood sugar:  some patients who are not diabetic before the transplant may develop difficulties controlling their blood sugars after the transplant.  We often have to administer oral medications and sometimes insulin to help control these high blood sugars.  This side effect is one that may go away with time.
• Increased potassium:  elevations in potassium levels can be seen in patients who are receiving FK506.  Potassium levels are monitored every time labs are drawn.  We can manage high potassium levels by lowering the FK506 dose (if possible) or administering a medication that acts to lower the potassium levels. 
• Decreased white blood cell count:  it is important that we maintain your white blood cell count, as it is one way to prevent you from getting an infection.
• High blood pressure:  high blood pressure is very common after transplantation.  FK506 can contribute to this.  Several medications are available for use in transplant patients with high blood pressure.
• High cholesterol: high cholesterol is very common after transplantation.  FK506 can contribute to this.  Several medications are available for use in transplant patients with high cholesterol.
• Stomach upset and/or diarrhea: stomach upset and diarrhea is common side effect with most medications.  In order to help prevent this, we will ask you to take FK506 with food.
• Hand tremor: FK506 can cause a fine hand tremor in several transplant patients and usually occurs in patients with a high blood level.  This tremor may go away with time, but if it occurs please let one of the transplant team members know and, if possible, we can lower the FK506 dose.
• Hair loss: hair loss occurs in about 20% of patients receiving FK506.  This side effect is generally seen within the 3 months post-transplant, and generally resolves on its own after approximately 6 months.

GENERIC NAME

Mycophenolate mofetil 

TRADE NAME

DESCRIPTION

What is CellCept? 

• CellCept suppresses the immune system, but works differently compared to FK506.
• 

DURATION

How long will I need to take CellCept? 

• You will need to take CellCept for as long as the transplanted kidney remains working.

DOSAGE

How much CellCept do I take?

• Most patients start taking between 1000 and 1500 mg twice a day.
• We generally start this medication either the night before the transplant or the day of the transplant.
• Doses may be decreased if you experience some side effects

DIRECTIONS

How do I take CellCept?

• Follow your transplant team’s instructions carefully.
• This medication is generally given twice a day (the best way to take it is every 12 hours), but it may be given three or four times a day.
• Even though, the manufacturer of this medication recommends taking it on an empty stomach, you will be asked to take this medication with food to help prevent stomach upset.

DRUG INTERACTIONS

Are there interactions between CellCept and other drugs?

• CellCept does not have as many drug interactions as FK506, however, there are still some medications that may interact with CellCept.  
• In particular, you will most likely be taking calcium carbonate as a calcium supplement after the transplant.  CellCept and calcium cannot be taken at the same time, because there is an interaction in the stomach that decreases the absorption of CellCept.  Because of this interaction, you will be instructed to take calcium supplements 1 hour before or 2 hours after taking the CellCept.
• Please consult with your transplant nephrologists or transplant pharmacist before starting any new medications because of the potential for drug interactions.

FOOD/BEVERAGE     INTERACTIONS

Are there interactions between CellCept and foods or beverages? 

• There are no known food or beverage interactions with CellCept.

SIDE EFFECTS

What are some of the more common side effects of CellCept?

• Decreased white blood cell count:  it is important that we maintain your white blood cell count, as it is one way to prevent you from getting an infection.  Decreased white blood cell counts are common in patients taking CellCept.  If this side effect occurs, it may require that we reduce your CellCept dosage.
• Stomach upset and/or diarrhea: stomach upset and diarrhea is the most common side effect with CellCept.  In order to help prevent this, we may ask you to take CellCept with food.  If this side effect occurs despite taking the CellCept with food, it may require that we split up the way we administer this medication (instead of two times a day, we may have you take smaller doses three or four times a day) or lower the total daily dose.  Some patients who cannot tolerate the stomach upset or diarrhea from CellCept may be changed to another transplant medication called Imuran (azathioprine) that may cause less gut irritation.

GENERIC NAME

Prednisone

TRADE NAME

• This drug is available as a generic and is no longer available as a trade name product. 
• Many pharmaceutical companies make a generic version of this medication; therefore, the pills are available in several different shapes and colors. In general, prednisone is available in 2.5, 5, 10 and 20 mg tablets.

DESCRIPTION

What is Prednisone? 

• Prednisone suppresses the immune system, but works differently compared to both FK506 and CellCept.
• Prednisone is known as a steroid.  You may be familiar with this medication, as it can also used to treat inflammation and pain.
• 

DURATION

How long will I need to take Prednisone? 

• The transplant team will let you know how long you will be taking this medication. Some patients need to take this medication for only a few days, while others need to take it for as long as the transplanted kidney is working.

DOSAGE

How much Prednisone do I take?

• It should be noted that in patients who need to take prednisone for longer than 5 days, the average daily doses of the prednisone that we use today are much smaller than those used for kidney transplant patients a few years ago.
• You will be given very high intravenous doses (up to 200 mg) of this medication during and after the transplant procedure.
• We will taper this dose down very quickly over the next few days after the transplant.  Most patients are taking 20 mg a day of prednisone 5 days after the transplant.
• Some patients can completely stop prednisone 5 – 7 days after the transplant.  Your transplant team will make the decision whether or not you are a good candidate to stop taking prednisone.

DIRECTIONS

How do I take Prednisone?

• Follow your transplant team’s instructions carefully.
• This medication is generally given once a day.
• You will be asked to take this medication with food to help prevent stomach upset.

DRUG INTERACTIONS

Are there interactions between Prednisone and other drugs?

• Prednisone can interact with many prescription and non-prescription medications, as well as some dietary supplements.  
• Please consult with your transplant nephrologists or transplant pharmacist before starting any new medications because of the potential for drug interactions.

FOOD/BEVERAGE      INTERACTIONS

Are there interactions between Prednisone and foods or beverages? 

• There are no known interactions with any foods or beverages.  However, prednisone may cause retention of sodium (salt), so try to keep your salt intake to a minimum.

SIDE EFFECTS

What are some of the more common side effects of Prednisone?

• It is important to note that most of the side effects listed below are seen in patients who continue taking prednisone after the transplant.  Most patients who are taken off prednisone 5 – 7 days after transplant experience few side effects from this medication.
• Increased blood sugar:  some patients who are not diabetic before the transplant may develop difficulties controlling their blood sugars after the transplant.  We often have to administer oral medications and sometimes insulin to help control these high blood sugars.  This side effect is one that may go away with time.
• High blood pressure:  high blood pressure is very common after transplantation.  Prednisone can contribute to this.  Several medications are available for use in transplant patients with high blood pressure.
• High cholesterol: high cholesterol is very common after transplantation.  Prednisone can contribute to this.  Several medications are available for use in transplant patients with high cholesterol.
• Stomach upset and/or diarrhea: stomach upset and diarrhea is common side effect with most medications.  In order to help prevent this, we will ask you to take prednisone with food.
• Weight gain:  prednisone can cause patients to gain weight by two mechanisms.  First, it makes people hold onto water; therefore, the more water they hold onto, the heavier they get.  Second, this medication can cause in increased appetite in approximately 3% of patients.
• Bone loss:  osteoporosis is a rare, yet serious side effect of prednisone.  Even as little as one dose of prednisone can cause bone loss.  If you are maintained on prednisone, we will periodically check your bone mineral density to check to see if prednisone is affecting your bones.  Also, you will be asked to take a calcium and vitamin D supplement after the transplant to help prevent osteoporosis.  Patients will be asked to receive a bone-mineral density test (also known as a DEXA scan) to determine the strength of their bones.  This test is usually performed every two to three years in patients who remain on prednisone after the transplant.
• Night sweats:  Some patients may experience night sweats while receiving prednisone.  This side effect usually takes place with higher doses and goes away with time.
• Mood changes:  We make a similar drug to prednisone in our bodies every night when we sleep called cortisol.  Cortisol helps us deal with stress and our emotions.  When prednisone is prescribed after the transplant, it is not uncommon to see patients develop rapid mood swings (i.e. happy to sad, laughing to crying).  This side effect generally disappears after about 5 days of being on the prednisone.  It is important that if you have had problems with depression or other psychiatric illnesses in the past that you let the transplant team know if the prednisone is making it worse.
• Cataracts:  you will be asked to make yearly visits to your eye doctor to make sure that this side effect does not take place.
• Acne:  a small percentage of patients may develop acne after the administration of prednisone.  Good skin hygiene is the best prevention for this, and over-the-counter acne medications may be helpful, but please consult with a transplant team member before starting any medications for acne.

GENERIC NAME

Sirolimus (we often call this medication rapamycin or just RAPA)

TRADE NAME

Rapamune- this drug is not currently available as a generic

DESCRIPTION

What is Rapamune? 

• Rapamune suppresses the immune system.
• This is necessary in kidney transplant patients to prevent organ rejection by the normal immune function of the body.
• 

DURATION

How long will I need to take Rapamune? 

• You will need to take Rapamune for as long as the transplanted kidney remains working.

DOSAGE

How much Rapamune do I take?

• Doses are different for each patient.
• We generally start this medication at a low dose after the transplant and then titrate the dose of the medication up so that we can achieve an adequate level of drug in your blood.
• You will be required to take blood tests so that we can adjust the dose according to how much of the drug is in your blood.
• Doses of this medication may change often.  It is important that you know how much of this medication you are taking at all times.

DIRECTIONS

How do I take Rapamune?

• Follow your transplant team’s instructions carefully.
• This medication is generally given once a day.
• You will be asked to take this medication with food to help prevent stomach upset.

TESTS

Tell me about the special blood test that I will need while I am taking Rapamune?

• In order to make sure that you get the appropriate dose of Rapamune, it is necessary for the transplant team to check how much of this drug is in your blood.
• We will check your Rapamune blood level every time you come to the outpatient transplant clinic for labs.
• To successfully check the Rapamune level in your blood you must follow several steps:

1.      Take all morning medications, except for the Rapamune, prior to coming to the clinic.

2.      Once you arrive in the clinic go to give a blood sample.

3.       After you have given the blood sample, take your morning dose of Rapamune.

4.       It takes up to 6 hours for us to get results back, so, if we need to change your Rapamune dose, we will call you at home and give you instructions on the dosing change.

DRUG INTERACTIONS

Are there interactions between Rapamune and other drugs?

• An interaction generally means that one drug may increase or decrease the effect of Rapamune.
• Also, the more medications a person takes, the more likely there will be a drug interaction.
• Rapamune interacts with many prescription and non-prescription medications, as well as some dietary supplements.  
• Please consult with your transplant nephrologists or transplant pharmacist before starting any new medications because of the potential for drug interactions.

FOOD/BEVERAGE INTERACTIONS

Are there interactions between Rapamune and foods or beverages? 

• It has been shown that grapefruit, grapefruit juice and other foods and beverages that contain grapefruit (for example, the soda Fresca has natural grapefruit juice in it) can increase the blood level of Rapamune.
• It is recommended that you avoid grapefruit, grapefruit juice and other foods and beverages that contain grapefruit while taking Rapamune.

SIDE EFFECTS

What are some of the more common side effects of Rapamune?

• Stomach upset and/or diarrhea: stomach upset and diarrhea is common side effect with most medications.  In order to help prevent this, we will ask you to take Rapamune with food.
• Decreased white blood cell count:  it is important that we maintain your white blood cell count, as it is one way to prevent you from getting an infection.
• Mouth ulcers:  ulcers on lips or in mouth can occur after starting Rapamune.  These will normally disappear on their own.  However, rinsing your mouth with salt water may help.  In rare cases, a prescription ointment can be applied to help decrease their size.
• Rash:  rarely, patients taking Rapamune develop a skin rash when first starting this medication.  This rash will normally disappear after a week or two.  In some cases, patients will receive a cream to help decrease the rash.  Tell your transplant nephrologist if the rash does not go away, or gets worse or becomes painful.
• High cholesterol: high cholesterol is very common after transplantation.  Rapamune can contribute to this.  In particular, Rapamune is associated with an increase in triglycerides.  Several medications are available for use in transplant patients with high cholesterol.
• Increased liver function tests: this medication has been shown to have a rare side effect where it may affect the function of the liver.  Routine tests are done in patients taking Rapamune to monitor for this potential side effect.
• Decreased wound healing: Rapamune may increase the risk of delayed wound healing in some patients.  Let your transplant nephrologist know if you ever have difficulty healing any wounds or are planning on undergoing any elective surgical procedures.

GENERIC NAME

Azathioprine

TRADE NAME

DESCRIPTION

What is Azathioprine?  

• Azathioprine suppresses the immune system, but works differently compared to FK506.
• 

DURATION

How long will I need to take Azathioprine? 

• You will need to take Azathioprine for as long as the transplanted kidney remains working.

DOSAGE

How much Azathioprine do I take?

• Most patients start taking between 50 and 200 mg once a day.
• Your transplant nephrologist and transplant pharmacist will decide the most appropriate starting dose for you.
• Doses may be decreased if you experience side effects.

DIRECTIONS

How do I take Azathioprine?

• Follow your transplant team’s instructions carefully.
• This medication is generally given once a day.
• You will be instructed to take this medication with food to help prevent stomach upset.

DRUG INTERACTIONS

Are there interactions between Azathioprine and other drugs?

• Azathioprine does not have as many drug interactions as FK506, however, there are still some medications that may interact with Azathioprine.  
• The two most common medications that interact with Azathioprine include allopurinol (a medication used to prevent gout) and a class of medications used to treat high blood pressure called the ACE inhibitors (common ACE inhibitors include lisinopril and enalapril).
• Please consult with your transplant nephrologists or transplant pharmacist before starting any new medications because of the potential for drug interactions.

FOOD/BEVERAGE INTERACTIONS

Are there interactions between Azathioprine and foods or beverages? 

• There are no known food or beverage interactions with Azathioprine.

SIDE EFFECTS

What are some of the more common side effects of Azathioprine?

• Decreased white blood cell count:  it is important that we maintain your white blood cell count, as it is one way to prevent you from getting an infection.  Decreased white blood cell counts are common in patients taking Azathioprine.  If this side effect occurs, it may require that we reduce your Azathioprine dosage.
• Stomach upset and/or diarrhea: stomach upset and diarrhea can occur with any of the transplant medications, but it is less common with Azathioprine compared to CellCept.