Lung Transplant (Raf)

Question 1

Describe the immunosuppression for transplant

Answer 1

• Triple therapy:
• Calcineurin inhibitor—tacrolimus or cyclosporine. Tacrolimus is the most common
• Cell cycle inhibitor—azathioprine or MMF. MMF is used more commonly
• Corticosteroids
• Tacrolimus trough level is 10-20 mg/mL (which is higher than for other organ transplants)
• Prednisone starts at 0.5-1 mg/kg/day, which is hopefully weaned to 0.25-0.5 mg/kg by 3-4 months post transplant
• Induction immunosuppression at time of surgery with either:
  
  • Polyclonal agent - eg. anti lymphocyte or antithrombocyte globulin
  • IL2 receptor antagonist like basilimab

Question 2

S/E of immunosuppresive drugs in transplant

Answer 2

Tacrolimus and cyclosporine:

• Nephrotoxicity: acute increase in plasma creatinine
• Hypertension, which is related to nephrotoxicity
• Neurotoxicity: mild tremor. Severe headache, visual abnormality and seizure with posterior leukoencephalopathy on brain imaging, pain syndrome
• Glucose intolerance and diabetes
• Hyperlipidemia
• Risk of infection such as bacterial, viral (eg. CMV), fungal only write this down if you can’t think of anything else
• Risk of malignancy — Both cyclosporine and tacrolimus are associated with an increased risk of squamous cell skin cancer and benign or malignant lymphoproliferative disorders
• GI: anorexia, nausea, vomiting, diarrhea
• Cyclosporine: hirsutism and gingival hyperplasia

MMF (cellcept):

• Diarrhea – most common S/E
• Bone marrow suppression with cytopenia (eg. Leukopenia). Regular CBC (at least every 6-8 weeks)

Steroid side effects:
Steroids are associated with a number of side effects including diabetes, fluid retention, hypertension, emotional lability, hyperlipidemia, cosmetic changes (acne, buffalo hump, etc), poor wound healing, susceptibility to infection, visual changes, cataracts, and osteopenia, and they may cause adrenal suppression that may persist up to the time of weaning

Question 3

What are the contraindications to lung transplant?

Answer 3

BMI<5th percentile for children (but this is modifiable)

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