Special considerations/Current conditions Flashcards
Infection risk is increased, due to…
Suppression of the immune system
Risk of infection is related to…
Overall level of immunosuppression
Greater in three months post transplant, and after treatment for acute rejection
Infections related to transplant/immunosuppressed individuals need to be…
Treated aggressively - any signs/symptoms should be promptly reported and investigated
Due to immunosuppression, ____ is required for…
Prophylaxis - common opportunistic pathogens
The most common opportunistic infection post transplant is…
Cytomegalovirus (CMV)
CMV risk is dependent on ____.
Donor/recipient serology
D+R- > D+R+ > D-R-
CMV infection may present as…
Viremia (flu-like sx’s, decrease in WBC, platelets)
Enteritis, pneumonitis, hepatitis, retinitis
Prophylaxis for CMV is usually with…
Valganciclovir
Depends on risk level (serology) - this would also be used for treatment
Pneumocystis Jiroveci Pneumonia (PJP) is common in immunosuppression, therefore prophylaxis is…
Co-trimoxazole - various dosing regimens
Herpes with immunocompromised patients…
May experience reactivation
Epstein-Barr virus is a major cause of…
Post transplant hypoproliferative disorder
Prophylaxis/monitoring for Epstein-barr is done…
When?
Based on serology - commonly done for D+R-
Primarily for children - exposure likely already taken place in adults
Polyoma BK virus is associated with…
Nephropathy, graft lost in kidney transplants
Higher levels of immunosuppression
Other noteworthy infections that may be more common in transplant patients include…
Flu, Covid
Fungal infection
Malignancy rates are ____ in transplant patients - most common types include…
Increased; most commonly present as skin, cervical, anorectal, lymphoma
PTLD
Post-transplant lymphoproliferative disorder (PTLD) may present as…
Has a varied clinical presentation - may be nodal/extrandoal, localized in allograft or disseminated, or may be indistinguishable from other lymphomas
If a patient presents with PTLD, we should…
Decrease immunosuppresion
Consider rituximab
Osteoporosis/osteopenia treatment includes…
Getting regular bone density testing
Optimizing Vitamin D + Calcium
Targeting treatment with bisphosphonates for high risk patients
These medications can help minimize GI side effects…
H2RA or PPI for dyspepsia/GI AE’s - PPI prophylaxis is routine in many centers
If a patient is experiencing GI AE’s, we should consider drug causes, including…
Immunosuppressive therapies: Mycophenolate > Tacrolimus > Cyclosporine
Sirolimus - mouth ulcers
Steroids - GI upset, ulcerogenic
Consider antibiotics, antihyperglycemics, certain supplements, etc.
These immunosuppressive drugs may cause hyperlipidemia…
Sirolimus > Cyclosporine - Tacrolimus
1st line medications for hyperlipidemia for transplant are ____, however…
Statins - however, increased risk for myopathy/rhabdomyolysis
Treating hyperlipidemia often introduces drug interactions such as….
Increased statin levels (start at 1/2, titrate)
Cholestyramine will adversely affect absorption of mycophenolate + cyclosporine
Ezetimibe + CNI will increase level of both drugs, caution
Optimal BP for transplant patients…
Is unknown - extract from general population and treat as a high-risk patient (?130/80)
Often, a lower target is better than a higher target
ACEI/ARB’s in transplant may affect…
Renal function
CCB’s in transplant may affect…
Increased CNI levels, especially with verapamil + diltiazem - increased risk of peripheral edema, gingival hyperplasia
Check for DI’s and AE’s
Diuretics in transplant may affect…
Lowering renal function if patient is hypovolemia
Decrease in potassium
Increase in uric acid
Anemia developing post-transplant may be a result of ____ and may contribute to…
Mycophenolate, sirolimus; may contribute to CV disease
Treated same as general population
Renal insufficiency is a complication of all solid organ transplants: we should aim to….
Usually due to CNI’s
Modify medications/procedures to minimize renal adverse effects
New onset diabetes after transplant increases risk of…
CVD, CKD
Lowered graft function
Lowered survival rates
Most cases in first year
New onset diabetes after transplant may be caused by…
Treated with??
CNI’s (Tacrolimus more than cyclosporine)
Corticosteroids
Similar population - oral hypoglycemics, insulin
Gout may be precipitated by…
CNI’s - cyclosporine more than tacrolimus
Gout treatment during transplant can include…
Altered steroid dose, colchicine, allopurinol - dose adjust based on renal function
AVOID NSAID’s
Counsel on diet
Electrolyte disturbances can be resolved via…
Oral or IV supplementation - often gets better with time
These electrolytes are usually low…
Magnesium
Phosphate
Watch for trends
These electrolytes are usually high…
Potassium
Calcium
Watch for trends
Pregnancy should not be considered without…
Consultation from transplanting center - pregnancy may pose a risk to mother + organ
Improved health post-transplant may lead to return to fertility
When a new medication is added onto pre-existing regimen, we should always check for…
DI’s - consider expected as well as reported
If unsure, check with transplant center
PD interactions that need to be considered in a transplant regimen include…
NSAID’s, other potential nephrotoxic medications
We should generally avoid ____, or anything that stimulates…
Herbal products - anything that stimulates the immune system
A common cause of graft loss is…
Non-adherence
Adherence can be maximized via…
Regular clinic visits
Addressing AE’s
Checking PIP
Simplifying medications scheduling as much as possible
