Transplant medicine

Question 1

What is the role of diltiazem in treating patients taking cyclosporin?

Answer 1

It dramatically inhibits the metabolism of cyclosporin and allows for lower doses of cyclosporin to be used.

Question 2

What are the important side effects of tacrolimus and cyclosporin A?

Answer 2

Nephrotoxicity - tubular dysfunction. Rarely a TMA.
Hypertension - caused by renal vasoconstriction and sodium retention
Neurotoxicity - tremor is common. Rarely, severe headache with seizures and visual abnormalities. PRESS has been associated with severe dysfucntion. Akinetic mutism and encephalopathy have been seen.
Pain syndrome with associated bone marrow oedema.
Metabolic - glucose intolerance and diabetes. Hyperlipidaemia. Hyperuricaemia. Hyperkalaemia. Hypomagnesaemia.
Infections - viral (esp. CMV) most often, but bacterial and fungal important.
Malignancy - SCC and lymphoproliferative disorders
GI - anorexia, nausea, vomiting, raised ALT/AST

Question 3

What’s the big issue with cyclosporin A compared with tacrolimus given they have so many of the same side effects?

Answer 3

Gingival hyperplasia and hirsutism occur with Cyc A but not tacro. Also, the combination of cyclosporin and the older mTOR (sirolimus) has been demonstrated to be associated with an increased risk of graft failures and thrombi, episodes of HUS, and worse mortality. The same is not true for tacrolimus and everolimus.

Question 4

What are the important adverse effects of mTOR inhibitors?

Answer 4

Leukopoenia
Thrombocytopoenia
Anaemia
Hypercholesterolaemia/triglyceridaemia
Diarrhoea
Haemolytic uraemic syndrome (when sirolimus used in combined with cyclosporin A)
Mouth ulcers
Interstiial pneumonitis
Teratogen
Kidney dysfunction

Question 5

How often are routine cardiomyocyte biopsies done for heart transplant recipients?

Answer 5

6 monthly