Transplant Flashcards
Test that are performed in the donor and recipient before transplant is performed
Human leukocyte antigen (HLA)
and ABO blood group
Allograft
transplant of an organ or tissue from one individual to another with a different genotype
Which blood type is the universal donor?
Type O
Hyperacute rejections
Happens w/in hours
Usually in the operating room
organ must be removed ASAP
Induction immunotherapy consist of….
IV agent (biologic or monocloncal antibody) sometimes combined w/ high-dose IV steroids
Organ transplant complications
CVD (drugs cause metabolic syndrome)
Cancer
Incr risk of infection
What cancer is more common in transplant pts?
Skin cancer
wear sunscreen daily
calcineurin inhibitors also cause photosensitiviy
General symptoms of acute rejection:
chills body aches nausea cough SOB
flu like symptoms
transplant drugs that can cause nephrotoxicity
tacrolimus
cyclosporine
transplant drugs that can cause worsening/new onset diabetes
tacrolimus
cyclosporin
steroids
transplant drugs that cause hypertension
steroids
cyclosporine
tacrolimus
Can live vaccines be given to transplant pts??
HELL NO
Transplant pts are at increased risk for varicella, should they receive the vaccine?
They should receive it prior to transplant only
varicella vaccine is live
Pneumococcal vaccine recommendations
for adults 19 and older:
PCV13 fisrt
PPSV23 (at least 8 weeks later)
then PPSV23 every 5 years per most facilities
MOA of antithymocyte globulin
bind to antigens on T-lymphocytes (killer cells)
antithymocyte globulin brand names
ATGAM (made from horses)
Thymoglobulin (made from Rabbit)
antithymocyte globulin side effects
infusion-related reactions (fever, chills, rash, hypotension)
leukopenia
thromobocytopenia
Meds used to pre-medicate for antithymocyte globulin infusion reaction:
Benadyrl
APAP
Steroids
basiliximab MOA
IL-2 receptor antagonist
binds to IL-2 receptors on activated t-lymphocytes
basiliximab brand
Simulect
basiliximab and antithymocyte globulin can both be used to treat organ rejection (t/f)
False
Only antithymocyte globulin can be used for rejection treatment
Preferred induction agent
basiliximab (better side effect profile)
basiliximab dosing
20 mg IV post-op day 1
repeat dose 4 days after transplant
Drugs used for maintenance therapy:
Steroids (prednisone) Antiproliferative agents (mycopehnolate) Calineurin inhibitors (tacrolimus)
Cellcept
mycophenolate mofetil
Myfortic
mycophenolic acid
Cellcept/Myfortic boxed warnings
incr risk of infection
incr risk of lymphoma and skin cancers
congenital abnormalties in pregnancy
Cellcept/Myfortic side effects
diarrhea
GI upset
vomiting
leukopenia
Cellcept/Myfortic administration
take BID on an empty stomach
which form of mycophenolate is available IV?
CellCept IV
MOA of mycophenolate/azathioprine:
inhibit t cell proliferation by altering purine synthesis
azathioprine brands
Imuran
Azasan
azathioprine side effects
n/v/d
myelosuppression
rash
incr LFTs
azathioprine renal dosing
crcl < 50
Calcineurin inhibitors MOA
inhibit t-lymphocyte activation
Tacrolimus brands
Prograf (usually given BID)
Astagraf XL
Envarsus XR
usual tacrolimus initial dose
0.1-0.2 mg/kg/day
Tacrolimus side effects
htn nephrotoxictiy hyperglycemia neurotoxicity hyperkalemia hypomagnesemia QT prolongation
what levels of Tacrolimus are measured?
trough levels
goal levels vary by pt
Tacrolimus metabolism
3A4 p-gp substrate
Tacrolimus admin with food?
Prograf: with or w/o food, but be consistent
Astagraf: qam on empty stomach
Envarsus: qam on empty stomach
Prograf PO:IV conversion
4:1
IV 1/4 the dose of PO
cyclosporine modified brands
Neoral
Gengraf
cyclosporine non-modified brand
Sandimmune
Different side effects of cyclosporine
causes hirsutism (tacro causes alopecia) gingival hyperplasia
Sandimmune PO:IV conversion
3:1 (PO:IV)
what form of cyclosporine has higher bio availability?
Modified (neoral and gengraf)
Available mTOR inhibitors:
everolimus
sirolimus
mTOR inhibitors cannot be used with CNIs (t/f):
False
can be used together as synergy
Everolimus brand
Zortress
Everolimus side effects
peripheral edema HTN constipation N/v/d hyperglycemia
Everolimus clinical pearl
do not use within 30 days of transplant
Rapamune
sirolimus
sirolimus is not recommended in which transplants….
liver and lungs
L’s
SIrolimus main side effects
Irreversible pneumonitis (d/c immediately if cough develops) hyperglycemia
Nulojix
Belatacept
belatacept MOA
binds to CD80 and 86: block T-cell constimulation and production and production of inflammatory mediators
belatacept clinical pearl
can only be used in epstein-barr virus (EBV) seropositive pts
increased risk of cancer in pts without immunity to EBV
Benefit to giving belatacept
less frequent dosing
given q 2 weeks post transplant\
eventually monthly
IV injection
1 metabolism pathway for most transplant drugs (tacrolimus, cyclosporine, etc.)
CYP 3A4
be aware of 3A4 inducers and inhibitors
Main interactions with azathioprine
allopurinol: reduce azathioprine dose by 75% if used together
ACEi: do not use together; risk of severe anemia
Mycophenolate can decr levels of this class of drugs that some pts might also be taking
decr levels of birth control
mycophenolate is CI during pregnancy; woman of childbearing age should be on birth control and use secondary protection
Treatment of t-cell (cellular) acute rejection:
Usually high-dose steroids
If steroids don’t work: antithymocyte globulin
alemtuzumab (off-label)
Treatment or b-cell (humoral or antibody) rejection
plasmaphersis +
IVIG +
Rituximab
(in that order)
