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NAPLEX 2024 > 56. Transplant > Flashcards

56. Transplant Flashcards

1
Q

Blood type ___ is considered “universal donor” while blood type ___ is considered “universal receiver”

A

O
AB

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2
Q

____ is the transplant of an organ or tissue from one individual to another of the space species with a different genotype

A

Allograft (allogenic transplant)

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3
Q

____ is the transplant of an organ from a genetically identical donor (such as an identical twin)

A

Isograft

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4
Q

____ is a transplant in the same patient, from one site to another (e.g. autologous stem cell transplant or skin graftin)

A

Autograft

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5
Q

Prior to any transplant, tissue typing or crossmatching is performed to assess donor-recipient compatibility for ____ and ___

A

human leukocyte antigen (HLA)
ABO blood group

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6
Q

A commonly used induction drug is ___, an IL-2 receptor antagonist

A

Basiliximab

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7
Q

MOA basiliximab

A

IL-2 receptor antagonist
IL-2 receptor is expressed on activated T-lymphocytes and is a critical pathway for activating T-lymphocytes to attack and reject the organ

Note: does not deplete immature T-lymphocytes and therefore cannot be used to treat rejection (only for prevention)

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8
Q

Why is basiliximab only used for prevention of rejection (induction) but not treatment?

A

Does not deplete immature T-lymphocytes

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9
Q

For patients at higher risk of rejection, what is an alternative to basiliximab?

A

Antithymocyte globulin (Atgam- Equine) (Thymoglobulin - Rabbit)

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10
Q

Which induction immunosuppression agents can be used for both prevention (induction) and treatment for rejection?

A

Antithymocyte globulins b/c they deplete both mature and immature T-lymphocytes

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11
Q

T/F: Induction immunosuppression may not be required if the transplant is from an identical twin

A

True

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12
Q

Boxed warnings for Antithymocyte Globulin

A

Anaphylaxis can occur; intradermal skin testing recommended prior to 1st dose of Atgam
Must be administered under supervision of a physician with immunosuppressive experience

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13
Q

Side effects for antithymocyte globulin

A

Infusion related reactions
Others: cytokine release syndrome (fever, chills, pruritis, rash, decreased BP; more common with first dose), infections, leukopenia, thrombocytopenia, chest pain, increased BP, edema

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14
Q

What can lessen infusion-related reactions with antithymocyte globulins?

A

Premedication - diphenhydramine, APAP, and steroids

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15
Q

Maintenance immunosuppression is generally provided by the combination of _____

A

Calcineurin inhibitor (CNI) + antiproliferative agent ± steroids

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16
Q

What is the first line CNI agent?

A

Tacrolimus
Other options: cyclosporine or belatacept

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17
Q

What is the first line antiproliferative agent for most protocols?

A

Mycophenolate
Other options: azathioprine, mTOR inhibitors (everolimus and sirolimus)

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18
Q

What steroid is typically used in transplant patients?

A

Prednisone

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19
Q

What is the rationale behind immunosuppression using multiple mechanisms with different drug classes?

A

Lower toxicity risk and reduce risk of graft rejection

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20
Q

CNI (Cyclosporine, Tacrolimus) MOA

A

Calcineurin inhibitors, inhibits T-lymphocyte activation

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21
Q

mTORi (everolimus, cirolimus) MOA

A

mammalian target of rapamycin (mTOR) kinase inhibitors
Inhibits T-lymphocyte activation/proliferation (may be synergistic with CNIs)

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22
Q

Antiproliferative agents (mycophenolate, azathioprine) MOA

A

Inhibit T- and B-lymphocyte proliferation by altering purine nucleotide synthesis

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23
Q

Basiliximab MOA

A

IL-2 receptor inhibitor

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24
Q

Betalacept MOA

A

CD80/86 (on antigen) inhibitor, blocking costimulation with CD28 (on T-lymphocytes)

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25
Q

Boxed warnings for cyclosporine

A

Nephrotoxicity, increased risk of lymphoma and other malignancies (includes skin cancer)
Increase risk of infection
Can increase BP

Only experience providers should prescribe cyclosporine, cyclosporine (modified - Gengraf/Neoral) has 20-50% greater BA compared to cyclosporine (non-modified - Sandimmune) and cannot be used interchangeably

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26
Q

Which cyclosporine formulations have 20-50% greater bioavailability? Can cyclosporine formulations be used interchangeably?

A

Gengraf/Neoral (modified) > Sandimmue (non-modified
Cannot be used interchangeably

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27
Q

Side effects for cyclosporine

A

Increased BP, nephropathy, hyperkalemia, hypomagnesemia, hirsutism, gingival hyperplasia, edema, increase BG, neurotoxicity (tremor, HA, paresthesia), QT prolongation
Others: GI upset, increased TG, viral infections

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28
Q

Monitoring for cyclosporine

A

Trough levels, serum electrolytes (K and Mg), renal function, LFTs, BP, BG, lipid profile

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29
Q

Drug interactions for cyclosporine

A

Many drug interactions: CYP3A4 inhibitor and CYP3A4 and P-gp substrate
Inducers of either enzyme (e.g. carbamazepine, nafcillin, rifampin) decrease CNI conc and inhibitors (e.g. azole antifungals, diltiazem, erythromycin) increase CNI conc

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30
Q

For oral liquid of cyclosporine, what types of cups should be avoided?

A

Plastic or styrofoam cups

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31
Q

Boxed warning for tacrolimus (Prograf)

A

Increased susceptibility to infection
Possible development of lymphoma

Note: ER tacrolimus (Astagraf XL) a/w increased mortality in female liver transplant recipients

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32
Q

What tacrolimus formulation is a/w increased mortality in female liver transplant recipients?

A

ER tacrolimus (Astagraf XL)

33
Q

Side effects for tacrolimus

A

Increased BP, Increased BG, nephrotoxicity, neurotoxicity (tremor, HA, dizziness, paresthesia), hypo/hyperkalemia, hyperlipidemia, QT prolongation, alopecia

Others: hypomagnesemia, hypo/hyperphosphatemia, edema, chest pain, insomnia, generalized pain, rash/pruritis, diarrhea, abdominal pain, nausea, dyspepsia, anorexia, constipation, UTI, anemia, leukopenia, leukocytosis, thrombocytopenia, elevated liver enzymes, arthralgia

34
Q

Monitoring for tacrolimus

A

Specific trough level goal (usually within 3-15 ng/mL) varies based on type of transplant
Serum electrolytes (K, Phos, Mg), renal function, LFTs, BP, BG, lipid profile

35
Q

Are XL and IR tacrolimus interchangeable?

A

No

36
Q

Notes for IV tacrolimus

A

Continuous infusion
Must use non-PVC bag and tubing

37
Q

Drug interactions for tacrolimus

A

Many drug interactions: CYP3A4 and P-gp substrate
Note: tacrolimus absorption is decreased by food

38
Q

Boxed warnings for Mycophenolate Mofetil (CellCept) // Mycophenolic Acid (Myfortic)

A

Increased risk of infection, lymphoma and skin malignancies
Increased risk of congenital malformations and spontaneous abortions when used in pregnancy

39
Q

Side effects for Mycophenolate Mofetil (CellCept) // Mycophenolic Acid (Myfortic)

A

Diarrhea, GI upset

Others: vomiting, leukopenia, increased/decreased BP, edema, tachycardia, pain, increased BG, hypo/hyperkalemia, hypomagnesemia, hypocalcemia, hypercholesterolemia, tremor, acne, infections

40
Q

Is CellCept and Myfortic interchangeable?

A

No (differences in absorption CellCept 500mg = ~Myfortic 360mg)

41
Q

Which mycophenolate formulation is enteric coated to decrease diarrhea?

A

Myfortic (Mycophenolic Acid) (1% absolute diff with CellCept vs Myfortic)

42
Q

CellCept IV is stable in ____ only.

A

D5W

43
Q

What is the drug interaction between mycophenolate and oral contraceptives?

A

Mycophenolate decreases efficacy of oral contraceptives

44
Q

Warning for Azathioprine (Azasan, Imuran)

A

Patients with deficiency of TPMT are at higher risk for myelosuppression and may require lower dose
GI (severe N/G/D), hematologic (leukopenia, thrombocytopenia, anemia) and hepatotoxicity

45
Q

Which mTOR is not recommended in heart transplant? Liver or lung transplant?

A

Heart = Everolimus (Zortress)
Liver/Lung = Sirolimus (Rapamune)

46
Q

Warnings for everolimus (Zortress)

A

HLD, impaired wound healing
Others: Hypertriglyceridemia, angioedemia, fluid accumulation, pneumonitis (d/c if this develops), proteinuria, anemia, lymphocytopenia, thrombocytopenia, new-onset DM, male infertility

47
Q

Side effects for everolimus (Zortress)

A

Peripheral edema, increased BP, risk of renal and hepatic artery thrombosis (do NOT use within 30 days of transplant)
Others: N/V/D, constipation, HA, increased BG, fatigue, fever, rash/pruritus, xeroderma, acne, onychoclasis (nail disease), abdominal discomfort, stomatitis, dysgeusia, weight loss, dry mouth

48
Q

Monitoring for everolimus (Zortress)

A

Trough levels
Others: renal function, LFTs, lipids, BG, BP, CBC, s/sx infection

49
Q

Drug interactions for everolimus (Zortress)

A

Many - CYP3A4 and P-gp substrate

50
Q

Warnings for sirolimus (Rapamune)

A

Impaired wound healing, HLD

Others: angioedema, fluid accumulation, decline in renal fxn, latent viral infections, increased risk of hemolytic uremic syndrome when used with CNI

51
Q

Side effects for sirolimus (Rapamune)

A

Irreversible pneumonitis/bronchitis/cough (d/c if this develops)
Increased BG, peripheral edema

Other: increased BP, HA, pain, insomnia, acne, constipation, abdominal pain, diarrhea, nausea, anemia, thrombocytopenia, arthralgia

52
Q

Monitoring for sirolimus (Rapamune)

A

Trough levels
Others: renal function, LFTs, lipids, BG, BP, CBC, s/sx infection

53
Q

T/F: sirolimus tabs and oral solution are bioequivalent

A

False - not bioequivalent

54
Q

Drug interactions for sirolimus

A

Numerous drug interactions - CYP3A4 and P-gp substrates

55
Q

Short-term side effects of prednisone

A

Fluid retention, stomach upset, emotional instability (euphoria, mood swings, irritability), insomnia, increased appetite, weight gain, acute rise in BG and BP with high doses

56
Q

Longer-term side effects of prednisone

A

Adrenal suppression/Cushing’s syndrome, impaired wound healing, increased BP, DM, acne, osteoporosis, impaired growth in children

57
Q

Boxed warnings for Belatacept (Bulojix)

A

Increased risk of post-transplant lymphoproliferative disorder (PTLD) (highest risk in pts w/o immunity to Epstein-Barr Virus (EBV)
Use in EBV seropositive patients only

58
Q

Which transplant med should be used in EBV seropositive pts only?

A

Belatacept (Bulojix)

59
Q

Warnings for Belatacept

A

Increased risk for TB - test for latent TB prior to initiation and treat latent TB prior to use

60
Q

Which transplant drugs are used for induction?

A

Basiliximab (IL-2 receptor antagonist)
Antithymocyte globulin in pts at higher risk of rejection
High dose IV steroids

61
Q

Which transplant drugs are used for maintenance?

A

CNI (tacrolimus (primarily) or cyclosporine) // belatacept as an alt to CNI
Antiproliferative agents (mycophenolate or azathioprine) or mTORi (everolimus, sirolimus)
Steroids at lower or tapering doses

62
Q

Which transplant med absorption is decreased by food?

A

Tacrolimus

63
Q

Azathioprine is metabolized by xanthine oxidase. Avoid using azathioprine with xanthine oxidase inhibitors (____or ___)

A

Allopurinol or febuxostat

64
Q

Which transplant meds should be avoided with grapefruit juice and St. John’s wort

A

CNIs

65
Q

Which transplants meds should providers use caution with additive drugs that are nephrotoxic?

A

CNIs

66
Q

Which transplants meds should providers use caution with additive drugs that raise BG?

A

Steroids, CNIs, mTORi

67
Q

Which transplants meds should providers use caution with additive drugs that worsen lipids ?

A

mTORi, steroids, cyclosporine

68
Q

Which transplants meds should providers use caution with additive drugs that increase BP ?

A

Steroids and CNIs

69
Q

What are common boxed warnings that are found for many transplant meds?

A

Infection risk
Cancer risk
“Only experience prescribers”

70
Q

All transplant recipients must self-monitor for s/sx infection. What are some things you can counsel on?

A

Fever 100.4ºF (38ºC) or higher (lower if elderly), chills
Cough, more sputum or change in color, sore throat
Pain with passing urine, ear, or sinus pain
Mouth sores or wound that does not heal

71
Q

Acute rejection of a transplanted oran arises from either ___ or ___ mediated mechanisms. Both types can occur simultaneously. Distinguishing the type of rejection via ___ is essential to determine treatmet

A

T-cell (cellular)
B-cell (humoral or antibody)
biopsy

72
Q

An initial approach to treating acute cellular rejection (ACR) is the administration of ____ and increased levels of maintenance immunosuppression

A

High-dose steroids

73
Q

Is acute cellular rejection (ACR) or antibody-mediated rejection (AMR) more difficult to treat?

A

AMR - antibodies against the graft must be removed and then suppressed from recurring (by plasmapheresis and use of IVIG + rituximab)

74
Q

Important vaccines for transplant recipients

A

Influenza (inactive, not live) annually
Pneumococcal vaccine in adults ≥19 yo (either PCV20 x1 or PCV15 x1 + PPSV23 x1 ≥ 8 weeks late)
Varicella (vaccinate pre-transplant + close contacts; if vaccinated household contact develops a rash avoid contact + contact physician; if transplant pt develops rash, must be seen right away)

75
Q

What kind of cancer is common following a transplant and what do you recommend?

A

Skin cancer
Sunscreen must be used routinely

76
Q

T/F: transplant meds can cause metabolic syndrome

A

True

77
Q

What is the frequency for XL or XR tacrolimus formulations?

A

every 12 hours or once daily in the morning on empty stomach

78
Q

Important things to note when giving cyclosporin oral solution

A

Use syringe provided
Do NOT rinse syringe before/after use
Use compatible diluent (e.g. orange juice) at room temp
Do NOT administer from plastic/styrofoam cup, use glass
Administer/drink immediately, rinse container with extra diluent to ensure total dose is take

NAPLEX 2024 (74 decks)

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