Chapter 56: Transplant Flashcards
Prior to any transplant, tissue typing or crossmatching is performed to assess donor-recipient compatibility for
HLA and ABO blood group
Transplant of an organ or tissue from one individual to another
allograft
Transplant from a genetically identical donor (such as an identical twin) is called
isograft
Transplant in the same patient, from one site to another (e.g., stem cell or skin grafting)
Autograft
_____ immunosuppression is given before or at the time of transplant to ______
Induction
to prevent acute rejection during the early post-transplant period
Most commonly used induction drug
Basiliximab
Basiliximab drug class
IL-2 receptor antagonist
Patients at higher risk of rejection can receive which drug class
antithymocyte globulin
antithymocyte globulins can be used for which stages of transplant
induction
and
treatment or rejection
antithymocyte globulin brand names
Atgam (equine)
Thymoglobulin (rabbit)
antithymocyte globulin MOA
binds to T-lymphocytes and interferes with their function
antithymocyte globulin boxed warning
anaphylaxis
antithymocyte globulin side effects
infusion-related reactions (premedicate)
What is the first line calcineurin inhibitor (CNI)
Tacrolimus
What is the first line antiproliferative agent
Mycophenolate
Suppressing the immune system via multiple mechanisms through different drug classes has what 2 benefits
lowers toxicity risk of individual immunosuppressants
reduces risk of graft rejection
Mycophenolate mofetil brand name
CellCept
Mycophenolic acid brand name
Myfortic
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
Mycophenolate side effects
Diarrhea
GI upset
T/F: CellCept and Myfortic are NOT interchangeable
True
Which brand of mycophenolate is enteric coated to decrease diarrhea
Myfortic
CellCept IV is stable in ____ only
D5W
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
Tacrolimus monitoring
Trough levels
serum electrolytes (K, phos, Mg)
renal function
LFTs
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
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 monitoring
Trough levels
Everolimus is a ___ substrate
3A4
Sirolimus warnings
impaired wound healing
hyperlipidemia
Sirolimus SE
irreversible pneumonitis/bronchitis/cough (d/c therapy if this develops)
increased BG
peripheral edema
Sirolimus monitoring
Trough levels
Sirolimus tablets and oral solution are not
bioequivalent
Sirolimus is a ____ substrate
3A4
Belatacept MOA
binds to CD80 & CD86 to block T-cell costimulstion
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
Xanthine oxidase inhibitors (allopurinol or febuxostat)
____ & ____ 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
BG
Caution with additive drugs that raise ____ with tacrolimus, steroids, & cyclosporine
BP
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
