Review Flashcards
CNI
TACROLIMUS
CYCLOSPORINE
ANTIPROLIFERATIVE AGENTS/ANTIMETABOLITES
AZATHIOPRINE
MYCOPHENOLATE MOFETIL
MYCOPHENOLATE SODIUM
MTOR INHIBITORS
SIROLIMUS
EVEROLIMUS
ANTIBODIES
ATGAM THYMOGLOBULIN BASILIXIMAB RITUXIMAB ATEMTUXUMAB IVIG
PROTEASOME INHIBITOR
BORTEZOMIB
POLYCLONAL ANTIBODIES MOA
T-CELL DEPLETION
CYTOTOXIC ACTIVITIES
MODULATION OF T CELL ACTIVATION
POLYCLONAL ANTIBODIES ADVERSE REACTIONS
CYTOKINE RELEASE SYNDROME LEUKOPENIA/THROMBOCYTOPENIA SERUM SICKNESS ANAPHYLAXIS INFECTION MALIGNANCIES-PTLD
POLYCLONAL ADVANTAGES
STRONGER, CAN BE USED TO TREAT REJECTION
POLYCLONAL DISADVANTAGES
ACUTE SIDE EFFETS
HIGHER INFECTION RATES
HIGHER MALIGNANCY RATES
MONOCLONAL ADVANTAGES
NO ACUTE SIDE EFFECTS
NOT ASSOCIATED WITH HIGH INFECTION OR MALIGNANCY RATES
MONOCLONAL DISADVANTAGES
WEAKER, CANNOT BE USED TO TREAT REJECTION
TACROLIMUS DOSING
0.1-0.15 MG/KG/DAY PO DIVIDED BID
CYCLOSPORINE MOA
INHIBITS FIRST PHASE OF T CELL ACTIVATION
REDUCES LEVEL OF CIRCULATING T CELLS
CYCLOSPORINE DOSING
5-10 MG/KG/DAY DIVIDED BID
CNI NEPHROTOXICITY
TAC=CYCLO
CNI HYPETENSION
CYCLO>TAC
CNI DM
TAC>CYCLO
CNI NEUROTOXICITY
TAC>CYCLO
CNI COSMETIC EFFECTS
CYCLO>TAC
CNI GI EFFECTS
TAC>CYCLO
CNI HYPERKALEMIA
TAC>CYCLO
CNI HLD
CYCLO>TAC
CNI LOW MAG
CYCLO=TAC
THINGS THAT INCREASE CNI LEVELS
- ZOLES
- MYCINS
- GRAPEFRUIT/POMEGRANATE JUICE
- DILT, VERAPAMIL, AMIO
- FLUOXETINE
- PROTEASE INHIBITORS
- REGLAN
- SIMEPRAVIR
THINGS THAT DECREASE CNI LEVEL
- MG/AL ANTACIDS
- KAYEXOLATE/OCTREOTIDE
- CHOLESTRYAMINE
- ANTI-EPILEPTICS
- RIFAMPIN
- NAFCILLINE
- ISONIAZID
- CARBAMEZEPINE
- HERBS (ST. JOHNS WART)
MTOR MOA
INHIBITS T CELL ACTIVATION AND PROLIFERATION
SIROLIMUS DOSING
6-12 MG LOADING DOSE
2-5 MG MAINTENANCE DOSE
SIROLIMUS/EVEROLIMUS SIDE EFFECTS
- NEUTROPENIA, THROMBOCYTOPENIA, LEUKOPENIA
- INCREASE ANEMIA
- HLD, HYPERTRIGLYCERIDEMIA
- DELAYED WOUND HEALING
- N/V/D
- MOUTH ULCERS
- INTERSTITIAL PNEUMONITIS
- THROMBOTIC MYCROANGIOGRAPHY
- PROTEINUREA
- LYMPHOCELE/LYMPHODEMA
- BONE PAIN
SIROLIMUS BLACK BOX WARNING
- HEPATIC ARTERY STENOSIS
- BRONCHIAL ANASTOMOTIC DEHISCENCE
EVEROLIMUS DOSING
0.75 MG PO BID
AZATHIOPRINE DOSING
1-3 MG/KG/DAY
AZATHIOPRINE MOA
INHIBIT PURINE SYNTHESIS
INHIBIT T CELL PROLIFERATION
AZATHIOPRINE DRUG INTERACTIONS
ALLOPURINON-> PANCYTOPENIA-> DEATH
MYCOPHENOLATE MOFETIL-> BONE MARROW SUPPRESSION. SEPERATE MEDS BY 24 HOURS
MYCOPHENOLATE MOFETIL MOA
INHIBIT PURINE SYNTHESIS
INHIBIT T AND B CELL PROLIFERATION
MYCOPHENOLATE SIDE EFFECTS
- N/V/D
- ANEMIA, THROMBOCYTOPENIA
- INFECTION
- GASTRITIS, GI BLEED
- CMV TISSUE INVASIVE DISEASE
- MALIGNANCY
MYCOPHENOLATE MOFETIL DURG INTERACTIONS
- ANTIVIRALS/SIROLIMUS-> INCREASED BONE MARROW SUPPORESSION
- CYCLOSPONINE-> DECREASED LEVELS OF MPA
- AZATHIOPRINE-> BONE MARROW SUPPRESSION. SEPERATE BY 24 HOURS
- CHOLESTYRAMINE-> LOWERS DRUG LEVEL
- AL/MG-> DECREASE ABSORPTION. SEPERATE BYT 2-4 HOURS
CORTICOSTEROIDS MOA
BLOCKS LYMPHOCYTE PROLIFERATIONS
ANTIINFLAMMATORY
METHYLPREDNISONE DOSING FOR REJECTION
250-1000 MG IV X 3 DAYS
CORTICOSTEROID SIDE EFFECTS
- EUPHORIA/DEPRESSION/MOOD DISORDERS
- HTN
- HBP
- HBS
- INFECTION
- MYOPATHY
- IMPAIRED WOUND HEALING
- HIRSUTISM
- ACNE
- WEIGHT GAIN/INCREASED APPETITE
- CUSHINGOID FACE
- OSTEOPOROSIS
PLASMAPHERESIS
MECHANICAL REMOVAL OF AB. DOES NOT DO ANYTHING TO THE B CELLS
IVIG DOSE
1-2 GM/KG
IVIG SIDE EFFECTS
- BACK PAIN
- HA
- FEVER/CHILLS
- BRONCHOSPASM
- HYPOTENSION
RITUXIMAB MOA
MONOCLONAL AB TARGETED AGAINST CD20 ANTIGEN ON B LYMPHOCYTES
RITUXIMAB DOSING
PREVENTION OF REJECTION- 375 MG/M2
TREATMENT OF REJECTION- 375 MG/M2
TREATMENT OF PTLD- 375 MG/M2/DOSE EVERY WEEK X 4 DOSES
RITUXIMAB SIDE EFFECTS
- HYPOTENSION
- FEVERS/CHILLS
- BRONCHOSPAMS
- ARRYTHMIAS
CMV causes what in the liver?
Vanishing bile duct
CMV causes what in the heart?
Coronary artery vasculopathy
CMV causes what in the lung?
Bronchiolitis obliterans
CMV causes what in the kideny?
Glomerulopathy
Staph is a
Bacteria
c-diff is a
bacteria
Salmonella is a
bacteria
Psuedonomas is a
bacteria
Listeria is a
bacteria
Candida is a
Fungal
Aspergillus is a
Fungal
PCP is a
Fungal
Histoplasma is a
Fungal
Coccidio is a
Fungal
Blastomycosis is a
Fungal
Influenza is a
Virus
Herpes is a
Virus
EBV is a
virus
Varicella is a
Virus
CMV is a
Virus
Toxoplama is a
Parasite
Cryptosporidium is a
Parasite
What causes increased risk of CMV reactivation?
ATG
CMV causes
inflammation of organs
decreased WBC
Decreased Plts
Increased LFTs
EBV can cause
mononucleosis -> PTLD
What are the symptoms of PTLD?
- mono like
- fever
- abd pain
- jaundice
- gi bleed
- change in CNS
- renal dysfunction
- hepatic dysfunction
- splenomegaly
What is the main treatment for PTLD?
Stop or lower immunosuppresion
Treatment for varicella
varicella zoster immunoglobulin within 72 hours or IV acyclovir
Treatment for C-diff
Flagyl or oral vanco
How do you treat nocardia?
With sulfonamides and ceftriaxone
What are the symptoms of Nocardia in different organs?
Brain-HA, lethargy, confusion, seizures
Lungs- PNA, fever, cough, CP
Skin-cellulitis
Where is nocardia found?
In soil or water
Where is legionella found?
In water
What is the treatment for Legionella?
Quinolones, marcrolides, cipro, zithromycin, rifampin
What is the treatment for Hep B?
HBV immunoglobulin, enteravir, tenofovir
What are the two types of polyomarvirus?
BK and JC
What does BK affect?
-tubules and ureters
Biopsy shows tubules with epithelial cells containing the virus
What does JC cause?
Progressive multifocal leukoencephalopathy.
The virus infects and lyses oligodendrocytes which leads to multifocal demyelination in the brain.
Where is coccidomycosis found?
Az soil
Where is strongyloides found?
In tropical soil
Where is toxoplasmosis found?
In cat feces
Common post of complication for heart, heartlung
PNA d/t inactive phrenic nerve, long intubation times
Common post of complication for heart?
CMV leading to CMV pneumonitis and gastritis
Common post of complication for lung?
Colonization at the anastomosis site cause dehiscence, mediastinitis, bronchial stenosis.
Common post of complication for kidney?
UTI, lymphocele, secondary infection or urine leak
Common post of complication for Pancreas?
Sepsis
Common post of complication for Liver?
Nosocomial gram- candida. Also, CMV, EBV, pneuomocystitis, aspergillus about 1-6 months post transplant.
Common post of complication for intestine?
EBV-> PTLD
CMV most common
3 was the immune system protects us
- Defense
- Surveillance
- Homeostasis
What are cytokines?
- hormones
- 1st to respond
- T lymphocytes
- cell mediated
- responsible for allergic rxns
When do you get an updated pra in a senistized pt, recent blood tx, VAD pt, ped/retransplant and non sensitized pt?
- PRA >10% done monthly
- blood tx- 1-2 weeks after
- VAD pts- weekly
- peds/retransplant- 3 months
- no sensitization-6 months.
How is a CDC crossmatch done?
Recipient serum is mixed with donor lymphocytes and complement. If there is lysis present then it is positive.
How is a Flow cytometry cross match done?
Recipients serum is mixed with lymphocytes and fluorescein
Major sign of Hyperacute rejection?
Thrombosis
Major sign of acute ab mediated rejection?
Vasculitis
Histological findings for acute ab mediated rejection?
Capillary fragments Hemorrhage Infiltrates of neutrophils Macrophages intravascularly Edema Destruction of capillaries.
Treatment for ab mediated rejection? Asymptomatic, mild, severe
Asymptomatic: hold steroid taper, change immuno meds
Mild: increase steroids, ATG, IVIG, change immuno meds
Severe: increase steroids, plasmapheresis, ATG, IVIG, change immuno meds.
Histological changes seen in acute cellular rejection?
Hemorrhage Edema Interstitial inflammation Parenchymal damage Endothelialitus
Main symptoms of chronic rejections?
Vascular fibrosis
Kidney-nephropathy Arteriosclerosis Vanishing bile duct Interstitial fibrosis T-cell mediated Bronchiolitis obliterans.
Signs/symptoms of left sided heart failure
SOB, cough, wheezes, blood tinged sputum, tachycardia, cyanosis
Signs/symptoms of right sided heart failure
Fatige, JVD, anorexia, edema, ascites, enlarged liver and spleen.
Biopsy scale findings for antibody mediated rejection
0= no acute cellular rejection 1R= mild. Interstitial and or perivascular infiltrates with 1 focus of monocyte damage. 2R= Moderate. 2 or more foci 3R= Severe. Diffuse infiltrates
AB mediated rejection treatment based on phase
0 or 1R= no treatment, may adjust meds
2R= IV or oral steroids
3R= IV steroids. Thymo. Plasmapheresis. Mechanical support
S/S of chronic rejection in heart transplant
- CP
- Fatigue
- Dyspnea
Diagnosis and treatment of chronic rejection in heart
Stress test/left heart cath
PTCA or retransplant