Solid Organ Transplant - Considerations in Selecting Immunosuppressive Regimens Post-Transplant Flashcards
What are factors to consider when choosing immunosuppressive regimens?
type of transplant; clinical trial data; type of induction used; comorbid conditions; patient intolerance; patient adherence; insurance coverage; clinician and institutional experience
What is the triple drug regimen?
calcineurin inhibitor: tacrolimus, cyclosporine
antimetabolite: mycophenolate, azathioprine
+/- corticosteroid: prednisone
What is a CNI avoidance/minimization regimen?
rationale: improved renal function; but increased incidence of acute rejection
sirolimus + mycophenolate or azathioprine + corticosteroids
everolimus + low-dose tacrolimus + corticosteroids
belatacept + mycophenolate + corticosteroids
What is a corticosteroid withdrawal or avoidance regimen?
rationale: goal to decrease long-term associated toxicity
CV risk, HTN, hyperlipidemia, glucose intolerance, weight gain, bone loss
What is the regimen for acute cellular rejection?
mild-mod: high dose corticosteroids - methylprednisolone
mod-severe or steroid resistant: T-lymphocyte depleting therapy - rabbit antithymoctye globulin, if refractory: alemtuzumab
What is the regimen for antibody mediated rejection?
steroids +/- rituximab +/- IVIG
Plasmapheresis in often performed in conjunction with medication therapy
What is the indication for rituximab?
Off-label use in SOT
Desensitization protocols - Transplant recipients with anti-HLA Class I and/or II antibodies against donor and/or ABO incompatible transplantation
Treatment of antibody-mediated rejection
What is the MOA of rituximab?
anti-CD20 chimeric monoclonal antibody
Binds to CD20 antigen on B lymphocytes producing cell lysis through complement-dependent cytotoxicity and antibody-dependent cellular mechanisms
What are the AEs of rituximab?
First dose “infusion reaction complex” - premedicate (30min prior) with acetaminophen, diphenhydramine, methylprednisolone
this can occur within 24hrs of infusion - hypoxia, ARDS, ventricular fibrillation, cardiogenic shock
What are the monitoring parameters for rituximab?
Blood pressure and heart rate every 15 minutes x 1 hr; then every 30 min x 2 hrs; then every 2 hrs
What is the indication for intravenous immune globulin (IVIG)?
- Desensitization protocols in SOT
- Treatment of antibody-mediated rejection
What is IVIG derived from?
- Derived from the pooled human plasma of thousands of donors
- Consists of intact immunoglobulin (Ig)G molecules
What are the AEs of IVIG?
infusion-related: fever, chills, flushing - premedicate with acetaminophen and diphenhydramine
HA, myalgia, back pain, hypotension, acute renal failure, renal dysfunction, hemolysis, hemolytic anemia
What is the monitoring for IVIG?
Vital signs should be taken prior to the start of the infusion, before any increase in the rate of the infusion, mid infusion, immediately post infusion
What are the donor derived infections?
nosocomial, technical (donor or recipient)
activation of latent infection (relapsed, residual, opportunistic)
community-acquired
What are common infections in solid-organ transplant recipients?
without prophylaxis: pneumocystis; infection with herpesviruses; HBV infection; infection with listeria, nocardia, toxoplasma, strongyloides, leishmania, T. cruzi
If a patient has an opportunistic infection from pneumocystic carinii (PCP) or pneumocystis jirovecci (PJP), what agent is used to treat it?
sulfamethoxazole-trimethoprim
If a patient has an opportunistic infection from cytomegalovirus, what agent is used to treat it?
valganciclovir = HSV, VZV, CMV
must consider the viral serostatus of the donor
If a patient has an opportunistic infection from yeasts/molds (aspergillus spp. especially lung transplant), what is the treatment?
posaconazole
