Infection Prophylaxis/Tx in Transplant Patients

Question 1

What puts a patient at risk for CMV?

Answer 1

Latent reactivation

Donor transmission

Question 2

What is the risk category for +/-

Answer 2

Donor/recipient

Highest risk

Question 3

What is the risk for +/+ or -/+ ?

Answer 3

medium risk

Question 4

What is the risk for -/-

Answer 4

lowest risk

Question 5

What is the clinical presentation of CMV?

Answer 5

non-specific febrile syndrome- fever, low WBC, abdominal pain, nausea, vomiting, diarrhea, arthralgia
Tissue invasive infection- hepatitis, pneumonitis, enteritis
Graft injury

Question 6

What are the prophylactic treatments for CMV?

Answer 6

Duration dependent on risk- usually 3-6 months
Valganciclovir
Ganciclovir
Acyclovir

Question 7

What is the treatment of CMV?

Answer 7

valganciclovir/ganciclovir at higher doses
CMV IVIg- Cytogam
treat for 2 weeks min, until serology undetectable/symptoms resolved

Question 8

What are some side effects of CMV tx?

Answer 8

needs to be renally adjusted

Bone marrow supression

Question 9

What puts a patient at risk for pneumocystis pneumonia?

Answer 9

Immunosuppression- transplant, chemo, HIV, chronic steroid therapy, neutropenia

Question 10

What is the clinical presentation of pneumocystis pneumonia?

Answer 10

Fever, cough, dyspne, hypoxemia, abnormal chest X-ray

Question 11

What are the agents for the prophylactic treatment of pneumocystis pneumonia?

Answer 11

Sulfa/trimethoprim - Bactrim/Spetra
Dapsone
Pentamidine (if sulfa allergy)
Atovaquone (if sulfa allergy)

Question 12

What are the drugs for the treatment of pneumocystis pneumonia?

Answer 12

Same meds as prophylaxis just higher doses

Question 13

What are the risks for the herpes simplex virus?

Answer 13

Past serostatus
reactivation
new infection

Question 14

What is the clinical presentation of herpes?

Answer 14

orolabial, genital or perianal local warts
cutaneous, esophagitis, hepatitis, pneumonia
fever, leukopenia

Question 15

How is HSV detected?

Answer 15

PCR to check for herpese DNA

Question 16

What are the agents for the prophylaxis of herpes?

Answer 16

ganciclovir, valganciclovir, acyclovir

Continue for a month post transplant

Question 17

What drugs are used in the treatment of herpes?

Answer 17

Acyclovir IV or acyclovir, famcyclovir or valacyclovir PO
Doses need to be adjusted for renal insufficiency
Continue treatment till lesions are gone

Question 18

What puts a patient at risk for candida?

Answer 18

mucocutaneous infection

type of transplant, acute renal failure

Question 19

How does candida present clinically?

Answer 19

candidemia, UTIs, pulmonary

Question 20

what are the agents used for the prophylaxis of candida?

Answer 20

Prophylaxis is controversial
can be universal or targeted
Antifungals at least 14 days post transplantation
Fluconazole, amphotericin B

Question 21

What agents are used in the treatment of candida?

Answer 21

amphotericin B
fluconazole
itraconazole
voriconazole
fungins

Question 22

What viral infection does not have a prophylactic treatment?

Answer 22

BK virus

Question 23

What is the BK virus?

Answer 23

a childhood infection that is asymptomatic/dormant in genitourinary tract. Can cause nephrotoxicity in kidney transplant patients

Question 24

How do you diagnose BK?

Answer 24

routine screening, detection by urine or blood OCR

Biopsy for neuropathy

Question 25

How do we treat BK virus?

Answer 25

minimize immunosupression add leflunomide (Arava) add Cipro Add Iv Ig

Question 26

What vaccinations should be given pre-transplant?

Answer 26

Complete vaccination series and boosters before transplant Live and inactivated vaccines safe annual influenza/pneumococcal

Question 27

When can patients receive vaccines after transplant?

Answer 27

inactivated vaccines safe, avoid live | can give 3-6 months after transplant

Question 28

Which vaccines cannot be given to a transplant patient?

Answer 28

``` MMR Varicella Zostavax Nasal Influenza all live ```

Question 29

What are metabolic complications post transplant?

Answer 29

hyperlipidemia

Question 30

What causes hyperlipidemia in a transplant patient?

Answer 30

immunosupressives, diet, obesity, diabetes, age, meds

Question 31

What meds can cause HLD in a transplant patient?

Answer 31

cyclosporine, tactolimus, sirolimus, prednisone

Question 32

What is the consequence of HLD in transplant patients?

Answer 32

cardiovascular disease and chronic allograft rejection

Question 33

What is the treatment for HLD in transplant patients?

Answer 33

lifestyle mods, immunosupression adjustments, lipid lowering therapy

Question 34

What is the drug of choice for HLD in transplant patients?

Answer 34

Statins, low to moderate intensity

Question 35

What immunosupressive does statins interact with?

Answer 35

calcineurin inhibitors

Question 36

What percentage of patients get post op HTN?

Answer 36

90%

Question 37

What are the causes of HTN in transplant patients?

Answer 37

immunosupression meds kidney dysfunction vascular compromise

Question 38

How do you treat HTN in transplant patients?

Answer 38

lifestyle mods, chance cyclosporine to tacrolomist | Antihypertensives

Question 39

What HTN drugs do CNI/mtor drugs interact with?

Answer 39

Diltiazem | Verapemil

Question 40

How do we treat new onset diabetes after transplant?

Answer 40

follow American diabetes association criteria

Question 41

What are the risk factors for gout in transplant patients?

Answer 41

serum uric acid > 7mg/dL | obesity, HTN, alcohol, diuretics, cyclosporine

Question 42

What is the treatment of gout in transplant patients?

Answer 42

steroids colchicine - monitor for GI side effects, nephrotoxicity Avoid NSAIDs - nephrotoxicity allourinol, febuxostat

Question 43

What are the causes of osteoporosis in transplant patients?

Answer 43

CNIs, steroids, kidney dysfunction, alcoholsim, age, smoking, nutrition, immobiliztion

Question 44

What is the treatment for osteoporosis?

Answer 44

Exercise Calcium, vitamin D, bisphosphonates- hard on kidneys modify immunosupressants

Question 45

What are the risk factors for malignancy in transplant patients?

Answer 45

pre-existing conditions, viral infections, sun exposure, smorking

Question 46

What is post transplant lymphoprolifertative disorder?

Answer 46

Usually associated with EBV Can be uncomplicated mononucleosis to full malignancy Localized and slow or widspread with sepsis

Question 47

What are the risk factors for PTLD?

Answer 47

primary EBV, intestinal transplant, young recipient, polyclonal anti-lymphocyte antibodies

Question 48

What are the risk factors for PTLD?

Answer 48

primary EBV, intestinal transplant, young recipient, polyclonal anti-lymphocyte antibodies

Question 49

Which skin cancer is most common in transplant patients?

Answer 49

Basal cell and squamous cell

Question 50

What OTC meds should you caution patients against?

Answer 50

NSAIDs- nephrotoxicity Decongestants- increase BP Herbals - increase/decrease CNI or mTOR inhibitor concentration