Transplant Flashcards
Imaging findings of PTLD?
- mediastinal lymphadenopathy
- pulmonary nodule - single or multiple**
- pulmonary mass
- pleural effusion
- consolidation
Symptoms and lab finginds of PTLD?
Symptoms:
- cough, fever, weight loss
- SOB, dyspnea
Lab findings:
- new EBV PCR positive
- persistently low lung function
Treatment of PTLD?
- reduce immunosuppression
- If CD20+, then rituximab
- additional chemotherapy like cyclophosphamide and prednisone
(Kendig’s does mention antiviral therapy, though uptodate does not)
Describe the immunosuppression for transplant
- Triple therapy:
- Calcineurin inhibitor—tacrolimus or cyclosporine. Tacrolimus is the most common
- Cell cycle inhibitor—azathioprine or MMF. MMF is used more commonly
- Corticosteroids
- Tacrolimus trough level is 10-20 mg/mL (which is higher than for other organ transplants)
- Prednisone starts at 0.5-1 mg/kg/day, which is hopefully weaned to 0.25-0.5 mg/kg by 3-4 months post transplant
- Induction immunosuppression at time of surgery with either:
- Polyclonal agent - eg. anti lymphocyte or antithrombocyte globulin
- IL2 receptor antagonist like basilimab
S/E of immunosuppresive drugs in transplant
Tacrolimus and cyclosporine:
- Nephrotoxicity: acute increase in plasma creatinine
- Hypertension, which is related to nephrotoxicity
- Neurotoxicity: mild tremor. Severe headache, visual abnormality and seizure with posterior leukoencephalopathy on brain imaging, pain syndrome
- Glucose intolerance and diabetes
- Hyperlipidemia
- Risk of infection such as bacterial, viral (eg. CMV), fungal only write this down if you can’t think of anything else
- Risk of malignancy — Both cyclosporine and tacrolimus are associated with an increased risk of squamous cell skin cancer and benign or malignant lymphoproliferative disorders
- GI: anorexia, nausea, vomiting, diarrhea
- Tacrollimus can cause TTP/HUS in <1% of patients
- Cyclosporine: hirsutism and gingival hyperplasia
MMF (cellcept):
- Diarrhea – most common S/E
- Bone marrow suppression with cytopenia (eg. Leukopenia). Regular CBC (at least every 6-8 weeks)
Steroid side effects:
Steroids are associated with a number of side effects including diabetes, fluid retention, hypertension, emotional lability, hyperlipidemia, cosmetic changes (acne, buffalo hump, etc), poor wound healing, susceptibility to infection, visual changes, cataracts, and osteopenia, and they may cause adrenal suppression that may persist up to the time of weaning
(similar to tac: hypertension, diabetes, hyperlipidemia)
Absolute and relative contraindications to lung transplant?
Absolute:
- multiple organ dysfunction
- HIV
- malignancy in last 2 years
- severe neuromuscular disease
- active TB
- sepsis
Relative:
- pleurodesis
- renal failure
- scoliosis
- markedly abnormal BMI
- poor controlled diabetes
- chronic airway infection with resistant organism
- fungal infection/colonization
Ways to increase donor pool?
- Lung bypass technology like ECMO
- EVLP:
- ex vivo diagnostics
- organ reconditioning–>antibiotics can be flushed through the lung, clots can be washed out
- outcomes are similar for EVLP and non-EVLP, but hopefully EVLP can be used on “marginal donor lungs”
- living donor lobar lung transplant–get 1 lobe each from different donors. Not commonly done in U.S, but this is done in Japan, where there are bigger challenges with access to organs
- Donor downsizing using linear stapling device
- Lobectomy and lobar transplant
survival after lung transplant?
50% at 5 years
complications in the immediate post transplant period?
- post op bleeding since patients are on bypass or ecmo for transplant. bleeding can happen in pleural space or at site of vascular anastomosis
- nerve injury: phrenic nerve injury–>diaphragm paralysis, recurrent laryngeal nerve injury–>vocal cord dysfunction
- dehiscence at either vascular or bronchial anastomoses–>patient may need to go back to OR
airway complications: strictures, granulation tissue, airway collapse (dehiscense)
* Hyperacute rejection: within hours of transplant
* not very common * due to recipient HLA antibodies * ideally, want to avoid donors with a related HLA antigen * even if there is a positive cross-match, plasmpheresis can be used to prevent hyperacute rejection * Primary graft dysfunction:
* MOST common complication in first week post transplant * due to reimplantation lung injury * Can be mild or severe with ARDS * Supportive care, may need ventilatory support
Complications starting at 1 week post transplant?
- Acute rejection–starts as early as 1 week, need biopsy to diagnose
- infection
- medication side effects
Complications at 1-6 months post transplant?
- acute rejection
- antibody mediated rejection
- infection
- medication side effects
Late complications at >6 months post transplant?
- infection
- antibody mediated rejection
- chronic lung allograft dysfunction (which can have the phenotype of BOS with obstruction or RAS = restrictive allograft syndrome)
- PTLD
- Renal dysfunction
- medication side effects
Diagnosis and treatment of acute rejection? Why is it especially important to monitor for acute rejection?
- rule out infection, transbronchial biopsy
- Treatment: IV methylpred 10 mg/kg x 3 days. If recurrent episodes, then ATG
- acute rejection increases risk for CLAD, which is the achilles heal of lung transplant
Investigations in a transplant patient with deteriorating lung function?
PFT’s (spiro with BDR, lung volumes) CXR Sputum sample CT chest BAL Transbronchial biopsy DSA (Donor Specific HLA antibodies) Open lung biopsy CMV/EBV
Treatment for chronic lung allograft dysfunction with phenotype of BOS?
o increase immunosuppression, ensure adherence
o may be benefit in addition of azithromycin 3x per week
o anti-lymphocyte agents like ATG
o photopheresis
o consider re-transplant if progressive decline in lung function
