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957 Block 2 > 14. Transplant > Flashcards

14. Transplant Flashcards

1
Q

What are the important immune cells in transplant patients?

A
  • T cells

- APCs (B-cells, macrophages, dendritic cells)

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2
Q

What antigen/antibody interactions are important in transplant patients?

A
  • MHC class I and II
  • cytokine release
  • co-stimulatory molecules
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3
Q

What are the goals of immunosuppression therapy in transplants?

A
  • prevent acute rejection while minimizing toxicity
  • minimize the risk for infection
  • use lowest effective dose to prolong patient and graft survival
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4
Q

What are the phases of immunosuppression?

A
  • induction
  • maintenance
  • rejection
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5
Q

What are non-T cell depleting agents?

A

IL-2 receptor antagonists: Basiliximab

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6
Q

What are T-cell depleting agents?

A
  • antithymyocyte globulin

- alemtuzumab

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7
Q

Maintenance immunosuppression usually consists of __ medications from ______ _____.

A

2-3

different classes

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8
Q

What are some Maintenance immunosuppressive agent combos?

A
  • CNI + antiproliferative +/- steroids
  • mTOR inhibitor + CNI + steroids
  • mTOR inhibitor + antiproliferative + steroids
  • Co-stimulation blocker + antiproliferative + steroids
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9
Q

Immunosuppressants are frequently used off-label. (T/F)

A

True

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10
Q

What is a CNI and what does it do?

A
  • Calcineurin inhibitor
  • prevents the activation of nuclear factor of T-cells
  • activation normally leads to production of IL-2
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11
Q

What does IL-2 do?

A
  • potent growth factor for T-cells
  • activates T-cells
  • produced by T-cells
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12
Q

What is cyclosporine and what does it do?

A
  • calcinuerin inhibitor

- binds to cyclophilin

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13
Q

What is tacrolimus and what does it do?

A
  • calcinuerin inhibitor

- binds to FKBR- 12

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14
Q

What are the antiproliferative agents?

A

mycophenolate

azathioprine

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15
Q

What do mTOR inhibitors do and how to they work?

A
  • inhibits mammalian target of rapamycin

- inhibits T-cell proliferation influenced by IL-2

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16
Q

What are the mTOR inhibitor agents?

A

Sirolimus and Everolimus

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17
Q

Why are corticosteroids used for immunosuppression?

A
  • broad spectrum anti-inflammatory properties
  • block cytokine activation
  • inhibit IL-1,2,3,6
  • inhibit INF gamma
  • inhibit TNF alpha
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18
Q

What are the corticosteroid agents?

A
  • methylprednisolone

- prednisone

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19
Q

Both methylprednisolone and prednisone are converted to what?

A

prednisolone

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20
Q 
Calcineurin inhibitors are metabolized hepatically primarily via which CYP
enzyme? 
a. CYP 1A2 
b. CYP 2D6 
c. CYP 2E1 
d.CYP 3A4
A

d.CYP 3A4

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21
Q

Which of the following medications will potentially increase serum concentrations of mTOR inhibitors?

a. Rifampin
b. Diltiazem
c. Allopurinol
d. Ferrous sulfate

A

b. Diltiazem

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22
Q

A common adverse effect associated with high dose steroid use immediately after transplant includes

a. Hyperglycemia
b. Weight loss
c. Alopecia
d. Mouth ulcers

A

a. Hyperglycemia

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23
Q

Maintenance immunosuppressive regimens following transplant typically use two to three immunosuppressive agents. (T/F)

A

True

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24
Q

Less potent immunosuppression has lead to improved graft survival but increased susceptibility to infection among SOT recipients. (T/F)

A

False: more potent

25
Q

What are the 4 main categories of infections in SOT recipients?

A
  • donor derived
  • recipient derived
  • nosocomial
  • community acquired
26
Q

How long is the perioperative period?

A

day 0 - 30

27
Q

What are the major infection risks in the perioperative period?

A
  • nosocomial infections
  • surgical site infections
  • line and catheter infections
  • C.diff
28
Q

What are the major infection risks in months 1-6?

A
  • opportunistic infections

- community acquired infections

29
Q

What are the major infection risks > 6 months?

A
  • community acquired

- risk diminishes as immunosuppression is tapered off

30
Q

What antibiotics are used to prevent pneumocystis pneumonia?

A
  • Bactrim
  • Dapsone
  • inhaled pentamidine
  • atovaquone
31
Q

What are common perioperative period viral infections?

A
  • donor derived (HSV, HIV, West Nile, rabies)
  • reactivation (HSV)
  • viral dissemination (hepatitis, pancreatitis, pneumonia)
32
Q

What is the #1 cause of fever in the 1-6 month range?

A

viral pathogen

33
Q

What is CMV?

A

cytomegalovirus

34
Q

What solid organ transplants are most likely to get CMV?

A

lung and intestines

35
Q

EBV requires what alteration to immunosuppression?

A

de-escalation

36
Q

EBV can result in allograft ________.

A

neuropathy

37
Q

What virus is associated with post-transplant lymphoproliferative disorder (PTLD)?

A

EBV

38
Q

What virus antibody titer is take before transplant surgery?

A

VZV

39
Q

Transplant surgery can reactivate what virus to manifest what condition?

A

VZV

shingles

40
Q

What is the antiviral regimen for prophylaxis for low risk CMV?

A

acyclovir for 3 months

41
Q

What is the antiviral regimen for prophylaxis for moderate/high risk CMV?

A

valganciclovir 900 mg for 3 – 6 months

42
Q

Acyclovir prophylaxis covers what viruses?

A

HSV, VZV, EBV

43
Q

Valganciclovir prophylaxis covers what viruses?

A

CMV, HSV, VZV, EBV

44
Q

What is the antiviral regimen if a virus is contracted and requires treatment?

A
  • Ganciclovir 5 mg/kg IV q12h OR
    Valganciclovir 900 mg PO q12h for 14 – 21 days
  • followed by valganciclovir prophylaxis
45
Q

What viral infections are common after 6 months post-transplant?

A

community acquired infections

46
Q

What measures should be taken by transplant patient to avoid viral infections after 6 months post-surgery?

A
  • annual flu shot
  • avoiding sick contacts
  • good hygiene
47
Q

How can fungal infections be introduced in the perioperative period?

A
  • associated with transplant surgical technique

- donor derived

48
Q

What is the most common fungal infection that is associated with transplant surgical technique?

A

Candida albicans

49
Q

What fungal infections are commonly donor derived?

A
  • Aspergillosis
  • Histoplasmosis
  • Coccidioidomycosis
  • Cryptococcus
50
Q

Aside from surgical and donor derived infections, what other fungal infections are associated with the perioperative period?

A

thrush

candiduria

51
Q

What fungal infections are common in the 1-6 month period post-transplant?

A
  • Cryptococcus meningitis
  • Aspergillosis (pneumonia, CNS, GI tract)
  • Toxoplasmosis
  • Endemic mycoses: Histoplasmosis, Blastomycosis, Coccidioidomycosis
52
Q

What fungal infections are common > 6 months post-transplant?

A

community acquired pathogens

53
Q

What antifungal prophylaxis is recommended for pancreas or liver transplants?

A

fluconazole

54
Q

What antifungal prophylaxis is recommended for heart and lung transplants?

A
  • itraconazole
  • voriconazole
  • inhaled amphotericin
55
Q

What is recommended prophylaxis for mucocutaneous candida?

A
  • clotrimazole

- nystatin

56
Q

If a kidney transplant patient presents with a fever, what is the likely cause?

A

pylonephritis or BK virus

57
Q

If a liver transplant patient presents with a fever, what is the likely cause?

A

anastomotic leaks

intra-abdominal abscesses

58
Q

If a heart transplant patient presents with a fever, what is the likely cause?

A

pneumonia syndromes, sternal wound infections

59
Q

If a lung transplant patient presents with a fever, what is the likely cause?

A

pneumonia, aspiration

957 Block 2 (14 decks)

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