Transplant LC

Question 1

Indications for PJP prophylaxis

Answer 1

First 6-12 months post-transplant (lifelong in lung transplant)

Steroid dose >20mg daily for >1/12 + second cause of immunosupression

Alemtuzumab

ALL

Temozolomide + RTx

Allogenieic HCT for duration of immunosupressive therapy

Autologous HCT (selected patients)

Purine analogue (i.e. fludarabine) + cyclophosphamide

Primary immunodeficiencies (i.e. SCID)

Question 2

Major side effects and monitoring of rituximab

Answer 2

S/Es:

• infusion reactions (pre-medication with methylpred 100mg/antihistamine/panadol)
• infections
• PML
• cytopenias
• HBV reactivation (inc. HbcAb +ve, HbsAg -ve)

Monitoring:

• HBV, HCV and TB before starting
• all patients need continuous monitoring during infusion
• 2-4 monthly CBC + platelets
• B cell subsets

Question 3

Major side effects and monitoring of azathioprine

Pregnancy?

Answer 3

S/Es

• HAEM: macrocytosis, lymphopenia, bone marrow suppression (low TPMT)
• GI: GI upset, hepatotoxicity (high TPMT)
• hypersensitivity reactions
• infection

Monitoring

• TPMT levels prior to starting
• 3 monthly FBE + LFTs once on maintenance
• 6-TGN levels if concerns re thiopurine toxicity (i.e. low TPMT) and 6-MMP if concerns re hepatotoxcicity (i.e. high TPMT)

C/I in pregnancy

Question 4

Major side effects and monitoring of mycophenylate

Pregnancy?

Answer 4

Side effects

• GI upset
• bone marrow supression and cytopenias
• infections
• increased risk of lymphoproliferative disorders (inc. PML)
• hypersensitivity reactions

Monitoring

• monthly FBE once stable on therapy
• monitor skin for cancers and B symptoms for lymphoma

Avoid in pregnancy (risk of congenital malformations)

Question 5

Major side effects and monitoring of tacrolimus

Pregnancy?

Answer 5

S/Es

• Nephrotoxicity
• Metabolic: HTN, hypercholesterolemia, diabetes (TACRO>CYC)
• Neurotoxicity (TACRO>CYC)
• Gingival hyperplasia
• AVN
• Hepatoxicity
• infection

Monitoring

• UEs, LFTs, CBC
• Tacro levels
• BSL + BP
• Fasting lipids

Frequency varies depending on stability

Can be used in pregnancy

Question 6

Monitoring on prednisolone

Answer 6

Metabolic:
- BP, weight

Bones:
- BMD

UEs
Educate about risk of PUD (malena)
VA (cataracts)
Sick day plan with prolonged therapy (double or triple the dose for 3-5 days)

Question 7

Major side effects and monitoring of methotrexate

Pregnancy?

Answer 7

S/Es

• HAEM: cytopenias, macrocytosis
• GI: nausea, mouth ulcers, hepatoxicity
• Infection
• ILD (lower zone)

Monitoring

• FBE, UEC, LFT monthly for 6 months then every 2/12
• Liver Bx if ↑ ALT/AST after cessation of Rx
• Prior to starting: CXR, HBV, HCV, HIV serology

Pregnancy
- contraindicated in trimester 1; avoid in T2 and T3 if possible