Transplant Immunosuppression

Question 1

Formula to calculate ALC

Answer 1

WBC (K) x Lymphs,auto (%)

Question 2

Common induction agents in Kidney…liver

Answer 2

Kidney
 -methylprednisolone 
 -MMF
 -basiliximab
Liver
 -methylprednisolone

Question 3

Where do steroids work on T-cells?

Answer 3

in the nucleus

Question 4

Where do CSA/TAC work on T-Cells?

Answer 4

Calcinurin

-Prevent dephos of NFAT-P

Question 5

Induction for high risk kidney transplant

Answer 5

For PSA above 30 or hx above 50,

-ATG (total 6mg/kg) over 3 doses

Question 6

Where does ATG work on T-cells?

Answer 6

on the surface

Question 7

mTOR inhibitors

Answer 7

Sirolimus and Everolimus

• inhibition downstream of IL-2 R
• inhibits cell cycle in all rapidly dividing cells

Question 8

Which drug is an APS co-stimulation blocker

Answer 8

belatacept

Question 9

Formula for all dose adjustments

Answer 9

New dose = 
 current dose (target conc/act conc)

Question 10

Target CSA maint levels

Answer 10

Day 1-29 300-350
30-89 250-300
90-365 200-250
Over 1yr 100-150

Question 11

Drugs that have 3A4 metabolism

Answer 11

CSA

TAC

Question 12

CSA ADEs

Answer 12

Hyperlipidemia
Gingival Hyperplasia
Hirsutism
+Nephrotox, HTN, Elec, CNS

Question 13

Target TAC maint levels

Answer 13

Day 1-29 10-12
30-89 8-10
90+ 5-8

Question 14

Normal starting dose for CSA

Answer 14

250-350mg BID

Question 15

Normal starting dose for TAC

Answer 15

3-6mg BID

Question 16

TAC ADEs

Answer 16

Diabetes
Allopecia
CNS
+GI, nephro, HTN, electro

Question 17

Common Cyp3A4 INHIBITORS

Answer 17

CCB's -use nifedipine/monitor
Azoles -50%
 except TAC/vori 66%
Macrolides -use azith
HIV (avirs) - monitor
Sirolimus - sep dose if CSA
Grapefruit - avoid

Question 18

Common 3A4 INDUCERS

Answer 18

Monitor All except SJW (avoid)
Rifampin
Barbiturates
Phenytoin
Carbamazepine
SJW - Avoid

Question 19

Other drugs to avoid with CNI

Answer 19

Calcinurin Inh + monitor kidney
 -NSAIDS, aminoglycosides, ampho
Take di-trivalent cations 2 hrs later
 -antacids
Statins
Contrast - hold CNI

Question 20

PC for AZA

Answer 20

Pts also taking allopurinol should decrease dose of AZA by 75%

Question 21

Where does AZA work on T-cell?

Answer 21

between G and S phase

Question 22

Where does MMF work on T-cell?

Answer 22

between G and S phase

guanine, no salvage for T-lymphocytes

Question 23

Which drug is a selective inhibitor of lymphocyte proliferation?

Answer 23

MMF

Blocks guanine, T-cells have no alt path

Question 24

Which drug is always adjunctive? …used with?

Answer 24

MMF

-used with CNI and Prednisone

Question 25

Main MMF ADE

Answer 25

GI

-diarrhea

Question 26

How do mTOR inhibitors work?

Answer 26

Block last stage downstream from IL-2R

Inhibit proliferation of ALL rapidly dividing cells

Question 27

Target Sirolimus levels

Answer 27

As primary:
12-24

With CSA/TAC:
5-15

Question 28

Dose adjustments for Sirolimus

Answer 28

wait 14 days

Question 29

Target Everolimus levels

Answer 29

3-8

With CSA, target CSA levels:
-up to 1 mo     100-200
2-3 mo           75-150
4th mo            50-100
6-12 mo         25-50

Question 30

Belatacept use

Answer 30

EBV+ and Kidney ONLY
Must be used with:
 -basiliximab
 -MMF
 -CSA/TAC

Question 31

Belatcept MOA

Answer 31

Signal 2 blocker

• blocks secret handshake/co-signal
  
  • CD80/86 on APC

Question 32

Common immunosuppressant regimens

Answer 32

***TAC/MMF/Pred
DM risk CSA/MMF/Pred
CVA risk Belatacept/MMF/Pred

Question 33

Drugs with NODAT tox

Answer 33

TAC

Prednisone