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pharmacy 358 > Transplant > Flashcards

Transplant Flashcards

1
Q

Most common transplant organ?

A

kidney

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2
Q

What is a autograft?

A

from self ie skin graft

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3
Q

What is allograft/

A

from same speciesq

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4
Q

What is a xenograft?

A

different species

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5
Q

What is isograft?

A

from twin

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6
Q

Why can you get less immunosuppression for liver transplants?

A

can regain so better at transplanting

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7
Q

What organ needs ALOT of immunosuppression?

A

lung

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8
Q

What is MHC/ HLA? Where are they found?

A

distinguishes self from non self
on antigen presenting cells (B cell, macrophage

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9
Q

What do APC’s do?

A

present antigen to T cells

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10
Q

What do CD4 or t helper cells do?

A

recog MHC class2 and stims B cells and t cells

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11
Q

What do CD8 or cytotoxic T cells do?

A

recog MHC class 1 and kill infected cells

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12
Q

What do B cells do?

A

forms antibodies

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13
Q

What do histocompatibility antigens do?

A

bind peptides and present them on cell surface for inspection of t cells

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14
Q

Why do we match HLA and not MHC?

A

HLA is more specific for human

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15
Q

What chromosome is HLA on?

A

Chromosome 6

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16
Q

What cells have HLA class 1?

A

most cells and platlets

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17
Q

What cells have class 2?

A

immune cells

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18
Q

What cells have class 3?

A

don’t worry no role in grafts

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19
Q

What is inheriting from haplotype mean? What’s the odds of being the same?

A

HLA genes are given as a group
1/4 siblings have the same

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20
Q

If perfect HLA match is there still a chance of rejection?

A

yes

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21
Q

What does signal 1 do?

A

recognition of MCH 2 and begin activation calcineurin pathway to make IL-2

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22
Q

What does signal 2 do?

A

Acitvate T cells by timing CD80 and 86 and 28

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23
Q

What does signal 3 do?

A

IL-2 released and binds on T cell for proliferation

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24
Q

Why are the signals of T cell an important target?

A

causes graft destruction
and activates calcineurin which is targeted

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25
Q

Do B cells play a role in matching?

A

yes by creating donor specific antibodies (DSA)
if due to this called humeral rejection

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26
Q

What is a PRA?

A

cross match blood sample with donors to see how much HLA antigens are present

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27
Q

What does a high PRA percentage mean?

A

bad because there is broad sensitization

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28
Q

Con of PRA?

A

doesn’t know strength of reaction

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29
Q

What is a lymphocyte cross match test mean?

A

directly tests reactivity between patient and donor cells if positive= BAD

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30
Q

What is the importance of ABO blood matching?

A

stops hyper acute reaction and destruction of the graft

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31
Q

Treatment of chronic rejection?

A

none hope immunosuppressants stop the beginning of process

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32
Q

What causes acute cellular rejection? When does this occur?

A

by t lymphocytes
can happen anytime

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33
Q

How long does induction therapy last?

A

1-3 months

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34
Q

What drugs must be given for induction?

A

Basiliximab OR Antithymocyte globulin
AND
corticosteroid
AND
Azathiprine OR Mycophenolate
AND
cyclosporine OR tacrolimus

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35
Q

How does basiliximab work?

A

Il-2 receptor antagonist

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36
Q

S/e of basiliximab?

A

hypersensitivity but VERY well tolerated

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37
Q

General dosing info on basiliximab?

A

everyone gets same dose

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38
Q

How does anti-thymocyte globulin work?

A

this antibody binds to T cells and depletes them

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39
Q

Main difference between basiliximab and antithymocyte?

A

Antithymocyet is a polyclonal antibody so binds more

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40
Q

S/e of antithymocyte?

A

bone marrow suppression, anaphylaxis, hepatic issues

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41
Q

Which agent can be used if rejection is happening?

A

antithymocyte

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42
Q

Short term s/e of corticosteroids and long term?

A

Short= insomnia, Gi, glucose, poor wound healing
long= osteoporosis, cataracts, moon face

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43
Q

Does CS cause hypo or hyper kalmia?

A

hypokalemia

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44
Q

How can we prevent osteoporosis?

A

routine bone tests, calcium, vitamin D, bisphosphonates

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45
Q

What other agent besides CS causes hyperglycaemia?

A

tacrolimus

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46
Q

MOA of azathioprine?

A

purine analoge that suppresses T and. B cells

47
Q

Main DI with azathioprine?

A

allopurinol- people often get gout
CAUSES MYELIN SUPPRESSION

48
Q

S/e of azathiprine?

A

alopecia, bone marrow suppression, skin lesion

49
Q

MOA of mychophenolic acid derivatives?

A

more specific ability than AZA to suppress B cells and T cells

50
Q

General dosing of MPA?

A

everyone gets the same dose

51
Q

Do you need blood tests for MPA?

A

NO

52
Q

S/e of MPA?

A

Gi is bad, neutropenia
teratogen for both males and females

53
Q

DI of MPA?

A

iron and calcium and other agents that cause neutropenia

54
Q

Can you give MPA with food?

A

yes to help with Gi just slows absorption NOT extent

55
Q

is it a good idea to divide doses of MPA foo help with gi?

A

helps but lowers adherence

56
Q

What agent causes bad neutropenia with MPA?

A

Valganciclovir

57
Q

If neutropenia happens with MPA what can we do?

A

filgrastim/GCSF to cause WBC proliferation

58
Q

How do cyclosporin and tacrolimus work?

A

binds calcineurin which stops T cell activation

59
Q

What is important about dosing with cyclosporin and tacrolimus?

A

narrow TI which is gets serum levels right

60
Q

What metabolizes cyclosporin/ tacrolimus?

A

CYP 34A

61
Q

How does the neural formulation of cyclosporin improve the drug?

A

less variable and improved BA

62
Q

How do you do blood levels of cyclosporin? Which method is better?

A

trough or 2 hour post dose
2 hours post is better for AUC but must be within 15 minutes of the 2 hours

63
Q

True or false Advagraf and prograf are bio equivalent?

A

FALSE prograf is BID and advagraft is ER

64
Q

How do you do blood levels of tacrolimus?

A

trough needs to be within 30 minutes of C0

65
Q

S/e of the calcineurin inhibitors?

A

nephrotoxicity, neurotoxicity- headache, fatigue
electrolytes issues (K increase)
gi
hepatic

66
Q

Which calcineurin inhibitors has worse gi?

A

tacrolimus, especially with MPA

67
Q

Unique s/e of tacrolimus?

A

alopecia

68
Q

unique s/e of cyclosporin?

A

more limipds and uricemia, acne, facial hair, gingival hyperplasia

69
Q

How to help with lipid s/e of cyclosporin?

A

statin BUT lowest dose due to DI causing more muscle pain

70
Q

DI with calcineurin inhibitors?

A

macrolide (NOT azithro), diltiazem, verapamil, fluconazole, grapfruit, other nephrotoxic agents

71
Q

MOA of sirolimus?

A

Macrolide antibiotic similar to tacrolimus that binds to FKBP and engages TOR which lowers proliferation

72
Q

Important PK info of sirolimus?

A

LOOOOONG half life (60 hours)
same DI as tacrolimus

73
Q

When would we use sirolimus?

A

to replace calcineurin agents due to low renal function, anti malignancy properties, add on

74
Q

S/e of sirolimus?

A

BAD hyper lipids, rash, mouth sores, edema, proteinuria, anemia

75
Q

What side effect must you stop siroliimus?

A

proteinuria

76
Q

Patient comes in complaining of edema and is on sirolimus. What agent can we give?

A

DIURETICS DO NOT WORK

77
Q

How to treat acute rejection?

A

HIGH dose CS
antithymocyte

78
Q

How to treat humeral rejection?

A

plasmapheresis (dialysis for antibodies), CS, antithymocyte, rituximab, tocilzumab, bortezomib

79
Q

How frequent is blood work for transplant patients?

A

minimum monthly forever

80
Q

How frequent is blood work for heart transplants?

A

prob q3 months due to no good biomarkers if stable

81
Q

Which drugs need level monitoring?

A

CNI, Sirolimus

82
Q

Should we use generic immunosuppressants?

A

Cheaper so yeah but LOTS more monitoring when switching so patient must be made aware

83
Q

Who is eligible for kidney transplant?

A

when GFR under 20

84
Q

What other transplant is common with kidney?

A

pancreas

85
Q

Signs of acute and chronic kidney rejection?

A

acute= abrupt >30% increase in SCr, low urine production, pain by kidney
Chronic= HTN, proteinuria and low renal function

86
Q

When do we need delayed graft function? and why?

A

if no pee after transplant need dialysis to kickstart kidney

87
Q

What is a common opportunistic infection with kidney grafts?

A

BK virus/polyoma virus due to so high immunosuppression

88
Q

Who is eligible for liver transplant? And what conditions are common?

A

advanced, nonreversible decompensated liver disease
causes= Hep C+B, PBC,PSC, alcohol

89
Q

How is immunosuppression different in Liver grafts?

A

can eventually taper off CS first then MPA after a year

90
Q

Signs of acute and chronic liver rejection?

A

Acute= increase in enzymes and bilirubin
chronic= LFTs, jaundice and itching

91
Q

What conditions can cause recurrent disease in liver?

A

Hep B and c, PBC and PSC

92
Q

Who is eligible for heart transplant?

A

advanced heart failure, non responsive to therapy, otherwise HEALTHY, but survival about 1 year

93
Q

How is immunosuppression different in heart grafts?

A

prednisone is eventually tapered off

94
Q

Issues with heart grafts?

A

higher resting rate, can’t tolerate exercise, MI can be asymptomatic

95
Q

If heart transplant what meds MUST be on board?

A

statin, ASA, ACE

96
Q

Signs of acute and chronic rejection of heart grafts?

A

Acute= mostly asymptomatic, heart failure sx
chronic= vasculopathy (plaque in grafted vessels

97
Q

Who is eligible of lung transplants?

A

HEALTHY,YOUNGER, end stage and failing max therapy, able to adhere

98
Q

Difference in immunosuppression in lung grafts?

A

possibly quad therapy

99
Q

signs of chronic rejection of lung graft?

A

CLAD- happens a lot after 5 years give azithro

100
Q

What is CMV and what is therapy?

A

most common virus and risk is highest with D+R-
give valganciclovir and screening with CMV PCR

101
Q

What is PJP prophylaxis?

A

SMX-TMP perhaps always if lung
sulpha allergy give dapsone or inhaled pentamadine

102
Q

What can we do for herpes simplex reactivation?

A

valganciclovir some help but usually therapy

103
Q

Why is Epstein Barr virus so bad?

A

can cause PTLD which is cancer and need prophylaxis and monitoring if D+R-

104
Q

How can we minimize malignancy risk?

A

sunscreen, pap and colonoscopy, term exams

105
Q

Who is most at risk of PTLD?

A

kids

106
Q

How do we treat PTLD?

A

lower immunosuppression or rituximab

107
Q

If bad gi issues on meds what can we do?

A

PPI

108
Q

What is blood pressure target for graft patients?

A

Lower is better but as tolerated

109
Q

Which is worse for renal grafts, ACE or diuretics?

A

diuretics

110
Q

Is CCB good for BP in graft patients?

A

use amlodipine but worse peripheral edema, gingival hyperplasia

111
Q

What can we do if anemia?

A

EPO dugh

112
Q

What drug is worse for gout in transplant therapy?

A

Cyclosporin

113
Q

What is paired exchange and altruistic donor?

A

Paired= if want to donate but no match go on registry for later
altruistic= stagner donating

pharmacy 358 (15 decks)

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