Transplant Flashcards
DRILL = Heart Transplant history questions
- Brief summary of underlying condition / indication
- How long did they wait / any bridging with mechanical support
- Transplant date
○ Donor / matching
○ CMV status - Procedural complications / ICU stay
- Post Tx Course
○ Rejection
○ Current cardiac function on monitoring
○ Current symptoms and IMPACT on QoL - Current immunosuppression
- Complications of Immunosuppression
○ Infections and prophylaxis / vaccines
○ Malignancies
○ Specific drug effects (NODAT / AKI)
CV RFs
How would you monitor this person’s immunosuppression?
GENERAL
- Monitoring therapeutic level
a. Drug levels (tacro) - Monitoring for Adverse effects of specific agents
a. Renal impairment
b. Cytopaenias
c. Diabetes
d. Metabolic risk - Longer term risks of immunosuppression
a. Opportunistic infection
b. Malignancy
i. Skin checks
Ix: - FBE, UEC, LFT, CMP, Glucose, Lipid profile - CNI and/or mTOR TDM - CMV viral load 3 monthly
What needs to be monitored on calcineurin inhibitors?
Cyclosporine - AEs to monitor for: ○ More HTN / dyslipidaemia -> regular checks and management ○ Less DM -> regular HbA1c ○ Nephrotoxicity -> regular UEC ○ Electrolyte disturbance -> CMP ○ Neurotoxicity (seizures, tremors)
Tacrolimus - AEs to monitor for: ○ Less HTN / dyslipidaemia -> regular checks and management ○ More DM -> regular HbA1c ○ Nephrotoxicity -> regular UEC ○ Electrolyte disturbance -> CMP ○ Neurotoxicity (headaches, tremors)
What needs to be monitored on mTOR inhibitors?
- Oedema + poor wound healing
- Can worsen CNI nephrotoxicity -> regular UEC
- Dyslipidaemia -> screening
- Lung toxicity (pneumonitis)
- Cytopaenias -> FBE
What needs to be monitored on MMF?
○ GI disturbance
○ Myelosuppression -> check FBE
What needs to be monitored on Azathioprine?
○ Bone marrow suppression -> FBE
○ Liver toxicity -> LFTs
○ Skin cancer -> skin checks
What needs to be monitored on steroids?
STEROIDS
- Patient education -> Sick day plan and vigilance for infection
Monitoring:
- Bone health -> regular DEXA, Vit D, Ca
○ Treat pre-emptively if osteopenia + >7.5 mg pred for >3 months
- Proximal myopathy -> check strength, encourage exercise
- Metabolic issues
○ HTN + dyslipidaemia -> regular checks and treat
○ SIDM -> screen with HbA1c regularly
- Eyes -> regular Ophthal review
- Mood -> regular screening for depression
How will you monitor graft function of cardiac transplant?
- Monitoring for any change in clinical status is incredibly important, with regular review and encouraging early reporting of symptoms
○ Volume overload = SOB, PND, orthopnea,
○ Fatigue / syncope
○ New arrhythmias- Acute cellular rejection can develop without obvious symptoms, so particularly in early period post transplant when highest risk, regular endomyocardial biopsies will be important to screen
- Regular TTEs for cardiac function
- Later on in course -> concern for cardiac allograft vasculopathy (can be silent ischaemia due to denervation)
○ Can perform annual angiography if renal function tolerates, otherwise do a stress echo
What immunisations will you give post SCT?
Regular Fluvax Pneumovax DTP Haemophilus Meningococcal Hep B
This person has declining function of their cardiac allograft. What are your differentials?
Will depend on time course and initial indication for Tx
- Rejection -> biopsy
- Cardiac allograft vasculopathy -> angio
- Infection (CMV) -> CMV viral load / biopsy
- Tachycardic cardiomyopathy due to denenervation -> ECG / Holter
- Recurrence of underlying pathology (e.g. amyloid) -> biopsy
How would you manage this person’s CMV status peri-transplant?
- I would review the donor and recipient’s antibody status
○ High risk would be donor +ve and recipient -ve
○ Intermediate risk would be recipient positive, and donor positive or negative
○ Low risk is both negative- All circumstances apart from neg/neg status require CMV prophylaxis with valganciclovir
- Duration can be variable, and I would discuss this with the Transplant Team
How will you monitor this person for malignancy?
Malignancies are much higher risk in this population, and regular screening is essential to early detection
- Annual skin checks
- Age-appropriate screening with FOBT/ Mammography / HPV
- Be alert to possibility of PLTD depending on EBV status also, which can present heterogeneously
How are you going to manage this person’s risk of infection in light of their immunocompromised state?
- Quantify risk of infection ○ Previous hx ○ Medical / skin barriers - Appropriately treat current infection - Fix anatomical issues ○ Blood supply ○ Urinary flow ○ Foreign bodies - Optimise host defences ○ Improve skin and mucosal integrity ○ Nutrition - Prevention ○ Non-pharmacological § Patient education § Avoidance of exposures ○ Pharm § Emergency antibiotics § Guidelines for Px ○ Immunological § Vaccines to household § Check Igs Finally, review immunosuppression with Transplant team
Is this person a transplant candidate?
In this person, they have advanced organ failure that will lead to their early death without a transplant.
However there are a number of barriers to consider:
- Can they safely have surgery? ○ Obesity / Malnutrition ○ Anaesthetic risk - Do they have another serious co-morbidity that is affecting their life expectancy? ○ Advanced age ○ Other organ failure - Safe to immunosuppress? ○ Infections / uncontrolled DM ○ Malignancy - Can they adhere to regimen? ○ Psychosocial support ○ Psychiatric illness ○ Inability to engage in rehab
