Lecture 2 - Transplant Complications Flashcards
What makes you think rejection
Bump SCr = kidney
Bump LFTs = liver
HF symptoms, fluid overload = heart
Shortness of Breath = lungs
1st line for Acute Cellular rejection streatment
Steroids
Pulse dosing, based on organ
Generally 3 days +/- taper
2nd line therapy for Acute Cellular rejection treatment
usually refractory, used for severe rejection
Doses range based on organ
Last line for Acute Cellular rejection treatment
Alemtuzumab
For persistent severe rejection
Methylpred to Prednisone conversion
4:5
Corticosteroid monitoring when using for rejection treatment
watch Blood sugar, may req insulin
Trouble sleeping
Blood pressure
Admin high doses at least 18hrs apart
Treatment of AMR w/ Pulse steroids, Thymoglobulin, Belatacept works on…
T cell
APC
Treatment of AMR w/ Rituximab works on…
B cell
Treatment of AMR w/ Bortezomib works on…
Plasma cell
Treatment of ARM w/ Plasmapheresis works on…
antibodies
essentially removing antibodies
Treatment of ARM w/ Ecolizumab works on….
complement system
Treatment of ARM w/ IVIG works on…
all the parts
IVIG Adverse reactions
infusion reactions so need to premedicate
Hemolytic anemia when pts are non-O blood type
Rituximab dosing info
weight based dosing
Pre-medicate
Monitor for HepB reactivation
Bortezomib dosing info
Does m2
IV push has to be over 3-5 sec
SubCu can avoid infusion related reactions
Bortezomib monitoring
Hepatic function
Myelosuppression
Peripheral sensory/motor neuropathy
Eculizumab dosing info
varies depending on organ
IV infusion over 30 min
Eculizumab dosing info
varies depending on organ
IV infusion over 30 min
Eculizumab monitoring
Has REMS, pts req vaccination with meningitis vaccines or prophylaxis with abx for duration after therapy
Pharmacy concerns Eculizumab
$$$$$
commonly non-formulary
Special order from drug company
REMS program
2 way street to prevent infections
Screen recipient and donor
Pneumocystis (PJP)
Risk related to time post transplant
All organs get prophylaxis initially
Duration organ/center specific
Preferred agent is bactrim
PJP 1st line agent
Bactrim
SS QD or BS MWF
False SCr elevation, leukopenia
PJP 2nd line agent
Atovaquone
1500mg QD
$$$$
“yellow paint” liquid
No renal dosing
PJP 3rd line agent
Dapsone
100mg QD
No renal dosing
Check G6PD, risk for methemoglobinemia
High hematologic toxicities
CMV Risk factors
D+/R- = 56-80%
D-/R+ = 0-27%
D+/R+ = 27-39%
D-/R- = < 10%
small bowel,liver,lung at highest risk
CMV prevention
minimum of 200 days = Valganciclovir = renal dose adjustment
CMV symptoms
Flue-like = Diarrhea,fever, malaise
Leukopenia** viral phenotype
Colitis** most common CMV disease
1st line for CMV
Gamciclovir = IV, use if concern for oral absorption
Valganciclovir = oral
most common SE Thrombocytopenia/Neutropenia
1st line in UL97 resistant CMV
Foscarnet
Foscarnet info
extremely nephrotoxicity
aggressively pre-hydrate
monitor for electrolyte abnormalities
Treatment of CMV
reduce immunosuppression = d/c dose of mycophenolate if possible
Monitor CMV viral loads weekly
Renal dose adjustments in all 4 drugs
Letermovir info
doesn’t cover HSV, use with Acyclovir
CYP3A4 inhib*** = tacrolimus lvls
role emerging for prophylaxis CMV in pt who cant tolerate valganciclovir
AE = GI + Peripheral edema
Maribavir info
oral, weak inhib of CYP3A4
Doesn’t cross BBB but does cross blood-retinal barrier
ADE: Dysgeusia, Diarrhea, Nausea, Vomiting, Fatigue
Typically for treatment resistance disease
Prophylaxis CMV treatment
start valganciclovir
if leukopenia concern, watchful waiting vs letermovir
avoid maribravir and wait for CMV vaccine
Treatment-Viremia CMV
1st line ganciclovir/valganciclovir
monitor response if concern for resistance consider new agents
Treatment - Resistant Disease CMV
consider Maribravir depending on disease dissemination
Candida fungal prophylaxis
Nystatin = 1st line for oral
Fluconazole as backp
Aspergillus fungal prophylaxis
Oral azole
close monitoring of tacrolimus
1st line therapy or severe fungal infection
liposomal ampotericin
Ritonavir w/Tacrolimus when treating COVID w/ Paxlovid
Ritonavir effects Tacrolimus so have to hold immunosuppression once starting therapy such as paxlovid
vaccines that should be avoided in immunocompromised patients?
Live vaccines are CI post transplant
Give pre-transplant
Infection prevention living tips
frequent hand washing
avoid smoking
avoiding well water
no raw/undercooked foods
avoid public buffets or street food
avoid cleaning animal cages
transplant Hypertension treatment of choice?
CCB = amlodipine/nifedipine
ACE/ARB consider if proteinuria/DM, 1yr out and more stable
Transplant Hyperlipidemia treatment of choice?
Cyclosporine has more effects with statins than tacrolimus
Only can use pravastatin with cyclosporine
atorvastatin ok with tacrolimus
What pain med should be avoided after transplant?
Avoid NSAIDs, just Tylenol/acetaminophen
New onset diabetes after transplant info
Renal dosing of therapeutic agents
Insulin = new regiment for pts
Consider SGLT-2 inhibitors
Hypoglycemia risk with decrementing steroids
Osteoporosis post transplant info
renal dosing for therapeutic agents
Calcium supplements, but that affects Myclophenolate absorption
Gout post transplant info
DI:
Taco inc colchicine conc*
allopurinol/Azathio also interact* Allo is CI
Febuxostat
Avoid NSAIDs
Pulse steroids typically treatment for gout attack
