Transplant 2 Flashcards
What are the pros of kidney transplantation? (5)
- No more dialysis
- Less dietary restrictions
- Avoid dialysis related complications
- Increased mortality
- Economics
What are the cons of kidney transplantation? (2)
- Complicated regimen of immunosuppressant therapy
- Risks of immunosuppression
Who is eligible for a kidney transplant? (4)
- Referral for evaluation usually happens prior to dialysis
- Generally not listed until GFR <= 20ml/min
- Pre-emptive transplant possible
- Some patients are listed for kidney + pancreas
What are some common indications for a kidney transplant? (5)
- Diabetes
- Hypertension
- Glomerulonephritis
- Polycystic kidney disease
- Other
How do we monitor for rejection in kidney transplant?
Routine bloodwork including SCr, urea, lytes, drug levels can help us to monitor for rejection
What are acute symptoms of kidney rejection? (7)
- Abrupt increase in SCr >30% baseline
- Fever
- Decreased urine output
- Weight gain
- HTN
- Edema
- Pain over the kidney
What are the chronic symptoms of kidney rejection? (3)
- HTN
- Proteinuria
- Progressive decline in renal function
What are 3 “other” issues that can happen with kidney transplant?
- Delayed Graft Function (DGF)
- Original cause of renal failure can be an issue
- BK Virus/polyoma virus
What is delayed graft function (DGF)?
The need for dialysis in the first week post transplant
What is BK virus/polyoma virus and why is it an issue with kidney transplant?
- Opportunistic infection which is a major cause of graft loss
- Associated with increased levels of immunosuppression
Who is eligible for liver transplant?
Pts with advanced disease with impaired, non-reversible liver disease (decompensated)
What are some common indications for a liver transplant? (7)
- Chronic viral hepatitis C and B
- Autoimmune hepatitis
- Primary biliary cirrhosis (PBC)
- Primary sclerosing cholangitis (PSC)
- Alcoholic liver disease
- Hepatocellular carcinoma
- Kids: biliary atresia (congenital condition - failure of bile ducts to develop and drain bile)
Describe the immunosuppression regimen of a liver transplant (3)
- The liver is the least immunogenic organ
- Complete steroid weaning is almost always the goal
- While induction and triple therapy is used initially, it is often possible to taper this to one agent over time (ex TAC)
- Steroid usually weaned first
- Mycophenolic acid derivative usually tapered around 1 year
How do we monitor for rejection of a liver transplant?
Routine bloodwork including liver enzyme tests can help us monitor for rejection (ALP, AST, ALP, GGT)
What are some symptoms of acute liver transplant rejection? (3)
- Increased bilirubin
- Increased liver enzymes
- Leukocytosis
What are some symptoms of chronic liver transplant rejection? (4)
- ‘Vanishing bile duct syndrome’
- Increased liver enzymes
- Increased bilirubin leading to jaundice
- Itching
What are some “other” issues that may arise with a liver transplant?
Recurrence of disease is possible with some conditions
- Ex. Hepatitis B&C, primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), autoimmune hepatitis
Who is eligible for a heart transplant?
Advanced heart failure, non-responsive to medical therapy, but otherwise healthy
What are some common indications for a heart transplant? (3)
- Cardiomyopathy
- Severe coronary artery disease with scar tissue
- Congenital defects
What is the 5-year survival rate for a kidney transplant?
5-year survival kidney transplant is roughly 80% for deceased donor, 90% for living
What is the 5-year survival rate for a liver transplant?
82-87%
What is the 5-year survival rate for a heart transplant?
~75%
Describe the immunosuppression regimen for a heart transplant (2)
- In general they follow the normal regimen, i.e., biologic therapy for induction + maintenance triple therapy
- IS levels are similar to kidneys but prednisone is eventually often tapered
What are some “other” issues that arise with a heart transplant? (4)
The transplanted heart is denervated
- Increased resting heart rate (90-110bpm), decreasing ability to rise quickly with exercise
- MI may be asymptomatic
- Altered response to drugs that work via the autonomic nervous system
What medications should adult heart transplant patients get for cardioprotection and prevention of CVD?
All adult patients should receive a statin, (regardless of LDL) to prevent CVD, plus ASA & ACE inhibitor for cardioprotection
How to monitor for rejection of a heart transplant? (2)
- No great way to monitor! Labs are not helpful
- Protocol biopsies are scheduled depending on the time post transplant
What are the acute rejection symptoms of a heart transplant? (6)
- Majority of episodes are asymptomatic
- Fever
- Malaise
- Decreased exercise tolerance
- Hypotension
- CHF symptoms
What are the chronic rejection symptoms of a heart transplant? (2)
- “Coronary graft vasculopathy”
- Specific pathology unique to transplanted vessels
Who is eligible for lung transplant? (2)
- Healthy younger patients with chronic, end-stage lung disease who are failing maximal medical therapy.
- Potential candidates should be well informed and demonstrate adequate health behavior and a willingness to adhere to health care guidelines
What are some common indications for lung transplant? (4)
- Cystic fibrosis
- COPD
- Pulmonary fibrosis
- Pulmonary hypertension
What is the 5-year survival rate for a lung transplant?
65%
What is the immunosuppression regimen for a lung transplant? (2)
- High levels of immunosuppressants are necessary to prevent rejection
- Induction therapy + triple therapy maintenance is almost always necessary (sometimes even quadruple therapy used)
How do we monitor for rejection in a lung transplant?
Routine pulmonary function tests can help us to monitor for rejection, bloodwork can help us monitor for toxicity
What are the acute symptoms of rejection in a lung transplant? (7)
- Fever
- Flu-like symptoms
- Chest pain
- Cough
- SOB
- Decreased pulmonary function tests
- Changes in body weight
What is the main chronic symptom of rejection in a lung transplant? How is it treated/prevented?
- Termed ‘Chronic Lung Allograft Dysfunction (CLAD)’
- Bronchiolitis obilterans syndrome (BOS) form most prevalent
- Also Restrictive Allograft syndrome
- Occurs in up to 64% by 5 years - Azithromycin 250mg EOD
Lung transplants have additional susceptibility compared to other organs. Why? (3)
- Exposure via direct inhalation
- High IS load
- Denervation which inhibits cough reflex
Suppressing the immune system will of course result in an increased risk of infection. When is risk greatest? How is immune response altered?
- Risk is related to overall level of immunosuppression & is generally > in the first 3 months post transplant & following treatment for acute rejection
- Pts may not exhibit normal immune responses as in the general population
What are the treatment principles for infections in transplant pts? (2)
- Infections need to be treated aggressively and sx’s such as fever, diarrhea should be promptly investigated
- Pts must report any signs/symptoms of infection! Fever, chills, sore throat, dysuria, skin infections, diarrhea etc.
Prophylaxis is required for common opportunistic pathogens post transplant. Such as? (7)
- CMV (cytomegalovirus)
- Pneumocystis jirovecii pneumonia (PJP)
- Herpes simplex reactivation
- Epstein Barr Virus
- Fungal - candida, aspergillus
- Polyoma BK virus
- Other (covid, west nile, etc.)
What is the most common opportunistic infection post transplant?
CMV
What does CMV risk depend on?
Donor/recipient serology
D+R- > D+R+ > D-R-
How does CMV present? (5)
- Viremia (flu-like symptoms, decreased WBC, decreased platelets)
- Enteritis
- Pneumonitis
- Hepatitis
- Retinitis
What drug is used in CMV prophylaxis?
Valganciclovir x100-200 days (or screening with CMV PCR and pre-emptive treatment)
What drugs are used in CMV treatment? (2)
1. PO valganciclovir
2. IV ganciclovir
What is given in PJP prophylaxis? How long?
Co-trimoxazole x 6-12 months (perhaps indefinitely in the lungs)
What is EBV a major cause of?
Post transplant hypoproliferative disorder (PTLD)
- Prophylaxis or monitoring is common for D+R-
Polyoma BK virus is associated with ___________ and _____ ____
nephropathy; graft loss
How does rate of malignancy compare for a transplant pt compared to the general population? What kinds specifically?
- Increased risk (3-4x general pop)
- Skin, cervical & anorectal cancer, lymphoma, PTLD
How do we try to prevent malignancy for transplant patient? (4)
- Encourage routine screening & lifestyle factors:
- Protect from sun/sunscreen
- Regular pap & colonoscopy
- Regular dermatologic exams
Which population is PTLD highest risk in? Why?
Pediatrics
- Unlikely they’ve been exposed to EBV, which is the cause
How might PTLD be treated? (2)
- Decrease immunosuppression
- Rituximab??
Osteoporosis/osteopenia is a metabolic complication of transplantation. How to prevent and treat? (3)
- Regular bone densities
- Optimize Vitamin D & calcium
- Targeted treatment for high risk patients (ie: bisphosphonate)
H2RAs and PPIs in transplant patients. Yay or nay?
Yay
- H2RA or PPI for dyspepsia or to minimize side effects from intensive immunosuppression
- PPI prophylaxis routine in many centers
CVD is a major cause of morbidity and mortality in transplant patients. What can we do to prevent? (5)
Decrease risk factors
- Control BP and diabetes
- Stop smoking
- Weight loss
- Manage hyperlipidemia
In terms of GI side effects, which of the transplant drug classes has the highest rate of s/e?
How does TAC compare to CSA?
What does sirolimus cause?
What do steroids cause?
- MPA highest GI s/e
- TAC > CSA
- SRL = mouth ulcers
- Steroids = ulcerogenic
Between CSA, TAC, and SRL, which has the most effect on lipids?
SRL > > CSA, TAC
How do we treat hyperlipidemia in transplant patient?
Statins, just like general population, but increased risk of myopathy/rhabdomyolysis
What sort of DIs might there be seen with statins in transplant pts? (3)
- Increased levels of statins, start at 1/2 dose & titrate pending effect and tolerance
- Cholestyramine/colestipol adversely affect absorption of MMF, CSA
- Ezetimibe in combo with CSA can increase levels of both drugs - caution with CNIs!
Which transplant meds are known for causing HTN?
CSA, TAC
ACEi/ARB for HTN in transplant patient. Yay or nay?
Yay, but may affect renal function so be careful
CCBs for HTN in transplant patients. Yay or nay?
Yay, but be careful. Verapamil & diltiazem can increase CNI levels, peripheral edema, gingival hyperplasia
Diuretics for HTN in transplant patients. Yay or nay?
Yay, but again, be careful. Decreased renal function if hypovolemic, decreased potassium, increased uric acid
What HTN med NEEDS to be avoided in a transplant patient?
Aliskerin - 5x AUC in combo with CSA
What transplant drugs may contribute to anemia? (2)
- MPA
- SRL
How to treat anemia in transplant patient?
Same as normal - iron, erythropoietin or darbopoietin
True or False. Renal insufficiency is not an issue with transplant patients
False - complication of all solid organ transplants. CKD affects 30-50% of non-renal transplants too.
New onset diabetes after transplant (NODAT) is most likely to occur when?
Within the first year of the transplant
Between TAC and CSA, which increases blood sugar more?
TAC - can try switching to CSA if it’s a problem
Between TAC and CSA which is worse in terms of causing gout?
CSA > TAC
What is the treatment of gout in transplant pts? (3)
- Avoid NSAIDs
- Counsel on diet
- May use steroids, colchicine or allopurinol but dose adjust based on renal function & manufacturer recommendation
How are electrolyte disturbances treated in transplant pts?
Oral or IV supplementation
- Correct underlying problem if possible
In transplant patients, should know whether the following are typically high or low:
Magnesium
Phosphate
Potassium
Calcium
Mg - low
PO4 - low
K - high
Ca - high
Pregnancy and transplant recipient. What’s the deal? (3)
- Pregnancy should NOT be considered without consultation from transplanting center
- Pregnancy may pose risk to mother and organ
- Improved health post transplant may lead to return to fertility
Immunizations and transplant patients. What’s the deal? (3)
- No live vaccines!
- Vaccine response post transplanted is often blunted
- Influenza yearly is recommended for all patients
There are MANY drug interactions when it comes to transplants. How can we do our due diligence to make sure it’s safe for the pt? (3)
- Always check, consider expected as well as reported
- Avoid NSAIDs and other potential nephrotoxic meds
- If unsure double check with the transplanting center
Herbal products and transplants. Yay or nay?
- Generally avoid
- Anything that stimulates the immune system is a problem
Nay
The most common cause of graft loss is? What population at high risk?
Non-adherence
Adolescents
How can we help with adherence of transplant meds? (4)
- Regular clinic visits
- Addressing side effects
- PIP
- Simplifying medication scheduling
