How should I monitor renal function and immunosuppressive therapy in a patient post-kidney transplant?

Following a kidney transplant, renal function should be closely monitored through regular measurement of serum creatinine, urea, electrolytes, and estimated glomerular filtration rate (eGFR) to detect early signs of graft dysfunction or acute kidney injury, with frequency tailored to clinical need but often daily in the immediate post-transplant period NICE NG148. Urine output monitoring is also essential to assess graft function and fluid balance NICE NG148. Urine dipstick testing for proteinuria and haematuria should be performed to identify potential causes of graft injury NICE NG148.

In addition to biochemical monitoring, clinical assessment for signs of rejection or infection is critical, including blood pressure monitoring given the high prevalence of post-transplant hypertension, especially in pediatric patients Seeman et al. 2023. Imaging such as ultrasound may be used selectively if obstruction or other complications are suspected NICE NG148.

Immunosuppressive therapy requires personalized monitoring to balance the risk of rejection against adverse effects. This includes regular assessment of drug levels (e.g., calcineurin inhibitors), renal function, and side effects, with dose adjustments guided by therapeutic drug monitoring and clinical response Cheung & Tang 2022. Subclinical acute rejection can occur despite therapeutic drug levels, so monitoring should also include clinical vigilance and possibly protocol biopsies in some centres Kuypers 2008.

Multidisciplinary collaboration involving nephrologists, pharmacists, and transplant specialists is recommended to optimize immunosuppressive regimens and renal function monitoring NICE NG148. Patient adherence and education are crucial to prevent rejection and complications Cheung & Tang 2022. Psychological assessment may be considered to identify factors that could affect adherence and outcomes NICE NG107.