Chapter 56: Transplant Flashcards by Emily Jansen

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

HLA and ABO blood group

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Transplant of an organ or tissue from one individual to another

allograft

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Transplant from a genetically identical donor (such as an identical twin) is called

isograft

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Transplant in the same patient, from one site to another (e.g., stem cell or skin grafting)

Autograft

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____ immunosuppression is given before or at the time of transplant to ____

Induction
to prevent acute rejection during the early post-transplant period

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Most commonly used induction drug

Basiliximab

induction ONLY, not rejection

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Basiliximab drug class

IL-2 receptor antagonist

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Patients at higher risk of rejection can receive which drug class

antithymocyte globulin

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antithymocyte globulins can be used for which stages of transplant

induction and treatment or rejection

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antithymocyte globulin brand names

Atgam (equine)
Thymoglobulin (rabbit)

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antithymocyte globulin MOA

binds to T-lymphocytes and interferes with their function

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antithymocyte globulin boxed warning

anaphylaxis

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antithymocyte globulin side effects

infusion-related reactions (premedicate)

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What is the first line calcineurin inhibitor (CNI)

Tacrolimus

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What is the first line antiproliferative agent

Mycophenolate

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Suppressing the immune system via multiple mechanisms through different drug classes has what 2 benefits

lowers toxicity risk of individual immunosuppressants and reduces risk of graft rejection

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Mycophenolate mofetil brand name

CellCept

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Mycophenolic acid brand name

Myfortic

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Mycophenolate boxed warnings

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

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Mycophenolate side effects

Diarrhea, GI upset

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T/F: CellCept and Myfortic are NOT interchangeable

True

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Conversion from CellCept to Myfortic

CellCept 500 mg = Myfortic 360 mg

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Which brand of mycophenolate is enteric coated to decrease diarrhea

Myfortic

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CellCept IV is stable in ____ only

D5W

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Mycophenolate decreases efficacy of

oral contraceptives

Azathioprine warning

Patients with genetic deficiency of TMPT are at high risk for myelosuppression and may require lower dose

Tacrolimus drug class

Calcineurin inhibitor

Tacrolimus brand name

Prograf

Tacrolimus MOA

inhibits T-lymphocyte activation

Tacrolimus boxed warnings

Increased susceptibility to infection, possible development of lymphoma

Tacrolimus side effects

Increased BP, nephrotoxicity, increased BG, neurotoxicity, hyperkalemia, hyperlipidemia, QT prolongation, alopecia

Tacrolimus monitoring

Trough levels, serum electrolytes (K, phos, Mg), renal function, LFTs, BP, blood glucose, lipid profile

IV Tacrolimus is administered as a continuous infusion in a ____ container

non-PVC

Tacrolimus is a ______ & ______ substrate

3A4 & P-gp

Cyclosporine modified brand names

Gengraf, Neoral

Cyclosporine non-modified brand name

Sandimmune

Cyclosporine BW

renal impairment, increased risk of lymphoma and other malignancies, including skin cancer, increased risk of infection, can increase BP; modified has 20-50% greater bioavailability compared to non-modified

T/F: modified & non-modified Cyclosporine cannot be interchanged

true

Cyclosporine SE

Increased BP, nephropathy, hyperkalemia, hypomagnesemia, hirsutism, gingival hyperplasia, edema, increased BG, neurotoxicity, QT prolongation

Cyclosporine monitoring

Trough levels, serum electrolytes, renal fxn, BP, BG, lipid profile

Cyclosporine is a ___ inhibitor and ___ & ___ substrate

3A4 inhibitor 3A4 & P-gp substrate

Cyclosporine oral liquid should not be administered from

a plastic or styrofoam cup

mTOR kinase inhibitor MOA

inhibit T-lymphocyte activation & proliferation

Everolimus warning

hyperlipidemia, impaired wound healing

Everolimus side effects

Peripheral edema, increased BP, **do not use within 30 days of transplant** d/t increased risk of renal and hepatic artery thrombosis

Everolimus and sirolimus monitoring

Trough levels

Everolimus and sirolimus are substrates of ___

3A4 and pgp

Sirolimus warnings

impaired wound healing, hyperlipidemia

Sirolimus SE

irreversible pneumonitis/bronchitis/cough (d/c therapy if this develops), increased BG, peripheral edema

T/F: Sirolimus tablets and oral solution are bioequivalent

false, not bioequivalent

Belatacept MOA

binds to CD80 & CD86 to block T-cell costimulstion with CD28 and production of inflammatory mediators

Belatacept BW

increased risk of post-transplant lymphoproliferative disorder (PTLD) with highest risk in recipients without immunity to Epstein-Barr virus. Use in EBV seropositive patients only

Belatacept warings

Increased risk of TB - test for latent TB prior to initiation and treat latent TB prior to use *remember balatacept has the word lat in it for latent*

Which drug classes are used for maintenance therapy in transplant

- CNIs (tacrolimus primarily or cyclosporine) - Adjuvant therapy given with CNI (antiproliferative agents like mycophenolate or azathioprine, mTOR inhibitors like everlolimus or sirolimus, or belatacept) - Steroids

Azathioprine should be avoided with which drug class | what should you do if using these drugs?

Xanthine oxidase inhibitors (allopurinol or febuxostat) do not use with febuxostat decrease dose by 75% if starting allopurinol

____ & ____ should be avoided with both cyclosporine and tacrolimus

Grapefruit juice and St. John's Wort

Caution with additive drugs that worsen ____ with the mTOR inhibitors, steroids and cyclosporine

lipids

Caution with additive drugs that raise ____ with tacrolimus, steroids, cyclosporine & mTOR inhibitors

Caution with additive drugs that raise ____ with tacrolimus, steroids, & cyclosporine

Which maintenance immunosuppressants have the highest incidence of nephrotoxicity

tacrolimus and cyclospsorine

Which maintenance immunosuppressants have the highest incidence of worsening or new onset diabetes

tacrolimus, steroids and cyclosporine

Which maintenance immunosuppressant has the highest incidence of worsening lipid parameters

mTOR inhibitors

Which maintenance immunosuppressants have the highest incidence of HTN

steroids, cyclosporine, and tacrolimus

Acute rejection of the transplanted organ arises from either ___ or ___ mediated mechanisms

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

How can you distinguish the type of acute rejection of an organ

via biopsy

Initial approach for acute rejection

administering high-dose steroids

Which cancer is most common with transplant

Skin

Inactivated vaccines can be given post-transplant after how many months

3-6

Which vaccines cannot be given after transplant

live

Which vaccines are important for transplant recipients

- Influenza in adults 19+ years - Pneumococcal in adults 19+ years (PCV13 first then PPSV23 at least 8 weeks later - Varicella pre-transplant

Counseling point for ALL immunosuppressants

Take medication exactly as prescribed and stay consistent on how you take your medication

Tacrolimus should be taken every ___ hours

12 | *tacro 12*

Tacrolimus should be taken (with/without) food for best absorption

without