Transplant Flashcards
What 2 things are tested before a transplant to assess donor-recipient compatability
Human leukocyte antigen (HLA)
ABO blood type
Allograft vs isograft vs autograft
Allograft: transplant from one person to another
Isograft: transplant from a genetically identical donor to another
Autograft: transplant from the same patient
How to prevent rejection of a transplanted organ?
Immunosuppression
When to induce immunosuppression for a transplant
Before the transplant!!!
Antithymocyte Globulin (Atgam, Thymoglobulin) MOA, BBW, SE, notes
MOA: binds to antigens on T-lymphocytes (killer cells) and interferes with their function
BBW: anaphylaxis
SE: Infusion-related reactions
Notes: Premedicate (benadryl, APAP and steroids) to lessen infusion-related reactions
Can be used for induction of immunosuppression AND TREATMENT of rejection
Basilizimab MOA
MOA: monoclonal antibody that inhibits IL-2 receptor on the surface of activated T-lymphocyte preventing cell-mediated allograft rejection
What medications are clacineurin inhibitors (CNI)
Tacrolimus (Prograf)
Cyclosporin (Gengraf, Neoral, Sandimmune)
What medications are Antiproliferative agents
Mycophenolate Mofetil (CellCept), Azathioprine
Why is a combination of medications used for maintenance immunosuppression?
To lower toxicity risk of the individual immunosuppressants and to reduce the risk of graft rejection
Which systemic steroid is used for maintenance immunosuppression
Prednisone
Prednisone MOA, short-term SE, long-term SE
MOA: Naturally occurring hormones that prevent or suppress inflammation and humoral immune response
Short term SE: Fluid retention, stomach upset, emotional instability, insomnia, increased appetite, weight gain, acute rise in BP and BG
Long-term SE: Adrenal suppression/Cushing’s syndrome, impaired wound healing, increased BP, diabetes, acne, osteoporosis, impaired growth in children
What antiproliferative agents are used for maintenance immunosuppression?
Mycophenolate and azathioprine
Mycophenolate (CellCept, Myfortic) BBW, SE, Notes
BBW: Increased risk of infection, increased development of lymphoma and skin malignancies, increased risk of congenital malformations and spontaneous abortions
SE: Diarrhea, GI upset
Notes: REMS drug, decreased efficacy of oral contraceptives
Azathioprine warnings
Pts with genetic deficiency of thiopurine methyltransferase (TPMT) are at increased risk for myelosuppression
What medications are Calcineurin inhibitors
Tacrolimus (Prograf)
Cyclosporine (Gengraf, Neoral, Sandimmune)
Calcineurin inhibitor MOA
Suppress cellular immunity by inhibiting T-lymphocyte activation
Tacrolimus BBW, SE, monitoring
BBW: Increased susceptibility to infection, lymphoma risk
SE: Increased BP and BG, nephrotoxicity, neurotoxicity, hypo/hyperkalemia, hyperlipidemia, QT prolongation
Monitor: trough levels, serum electrolytes (K, phos, Mg), renal function, LFTs, BP, BG, lipid profile
LOTS of drug interactions
Cyclosporine BBW, SE, monitoring, notes
BBW: renal impairment, increased risk of lymphoma and other malignancies, increased risk of infection, increased BP
SE: increased BP, nephropathy, hyperkalemia, hypomagnesemia, hirsutism, gingival hyperplasia, edema, increased BG, neurotoxicity, QT prolongation
Monitor: trough level, serum electrolytes, renal function, BP, BG, lipid profile
LOTS of drug interactions
What mTOR kinase inhibitors are used to maintain immunosuppression? What is their MOA
MOA: inhibit T-lymphocyte activation and proliferation, may be synergistic with CNIs
Everolimus, Sirolimus
Everolimus warnings, SE, monitoring, notes
Warnings: Hyperlipidemia
SE: peripheral edema, increased BP, do not used within 30 days of transplant d/t risk of thrombosis
Monitoring: trough levels
Notes: LOTS of drug interactions
Sirolimus warnings, SE, monitoring, notes
Warnings: Impaired wound healing, hyperlipidemia
SE: Irreversible pneumonitis/bronchitis/cough (d/c if this develops), increased BG, peripheral edema
Monitor: trough levels
Notes: LOTS of drug interactions
Belatacept MOA, BBW, warnings
MOA: Binds CD80 and CD86 to block T-cell costimulation and production of inflammatory mediators
BBW: Increased risk of post-transplant lymphoproliferative disorder (PTLD), use in epstein-barr virus seropositive patients only
Warnings: treat latent TB prior to use
Which immunosuppressant should be used in epstein barr virus seropositive patients only?
Belatacept
What medications are used for induction of immunosuppression?
Basilizimab
Antithymocyte globulin in patients at higher risk of rejection
Maintenance drugs at higher doses
What medications are used as maintenance immunosuppressants
1) Calcineurin inhibitors (CNIs) - primarily tacrolimus
2) Adjuvant medications given with a CNI (antiproliferative agents, mTOR inhibitors, Belatacept)
3) +/- Steroids
What transplant medications should not be used with xanthine oxidase inhibitors?
Azathioprine b/c it is metabolized by xanthine oxidase
S/sx of acute rejection
flu-like symptoms (chills, body aches, nausea, cough, SOB
Which immunosuppressants can cause
nephrotoxicity
Tacrolimus
Cyclosporine
Which immunosuppressants can cause
worsening or new onset diabetes
Tacrolimus
Steroids
Cyclosporine
Which immunosuppressants can cause
worsening lipid parameters
mTOR inhibitors
Steroids
Cyclosporine
Which immunosuppressants can cause
HTN
Steroids
Cyclosporine
Tacrolimus
When to give live vaccines in a transplant patient
MUST be given before transplant - cannot be given when patient is immunosuppressed after transplant
What syndrome can many transplant medications cause?
Metabolic syndrome
How should Tacrolimus be taken?
On an empty stomach every 12 hours
With which immunosuppressant medications do you need to avoid grapefruit?
Tacrolimus (Progrf)
Cyclosporine
