Chapter 56: Transplant

Question 1

Induction Supression

Answer 1

Given at or before transplant to prevent acute rejection during early post-transplant period

Question 2

Basiliximab

Answer 2

IL2 receptor antagonist

Does not deplete immature t-lymphocytes and cannot be used to treat rejection (only prevention)

Question 3

Anithymocyte globulin

Answer 3

Depletes lymphocytes
Can be used for induction and tx of rejection
Infusion related reactions

Question 4

Maintenance Immunosuppression includes

Answer 4

• Calcineurin inhibitor (CNI) (tacrolimus preferred)
• Antiproliferative agent (mycophenolate 1st line)
• With or without steroids

Question 5

Prednisone Short-Term Side Effects

Answer 5

• Fluid retention
• stomach upset
• emotional instability
• insomnia
• increased appetite
• weight gain
• acute rise in blood glucose and BP

Question 6

Prednisone Long-Term Side Effects

Answer 6

• Adrenal Suppression/Cushing’s syndrome
• impaired wound healing
• increased BP
• diabetes
• acne
• osteoporosis
• impaired growth in children

Question 7

Mycophenolate mofetil

Answer 7

Cellcept

IV stable in D5W only

Question 8

Mycophenolic acid

Answer 8

Myfortic

EC to decrease diarrhea

Question 9

Mycophenolate Boxed Warnings

Answer 9

• Increased risk of infection
• increased development of lymphoma and skin malignancies
• increased risk of congenital malformations and spontaneous abortions

Question 10

Mycophenolate SE and Notes

Answer 10

SE: diarrhea, GI upset
Notes: Cellcept and Myfortic are not interchangeable
Decreases efficacy of oral contraceptive

Question 11

Azathioprine Warnings

Answer 11

(antiproliferative agent)
Warnings: patients with genetic deficiency of thiopurine methytransferase (TPMT) are at increased risk of myelosuppression

Question 12

Tacrolimus Boxed Warnings and SE

Answer 12

Boxed warnings: Increased susceptibility to infections, possible development of lymphoma
SE: Increased BP and BG, nephrotoxicity, hyperkalemia, hyperlipidemia, QT prolongation

Question 13

Tacrolimus Monitoring and Notes

Answer 13

Monitoring: trough level, serum electrolytes (k, phos, mg), and renal function, LFTs, BP, BG, lipids
Notes: Do not interchange, IV in non-PVC bag, drug interactions (Cyp3A4 and P-gp substrate)

Question 14

Cyclosporine Boxed Warnings

Answer 14

Boxed warnings: renal impairment with high doses, increased risk of lymphoma and other malignancies including skin cancer, increased risk of infection, increased BP
Modified has 20-50% greater bioavailability then non-modified. Cannot be interchanged

Question 15

Cyclosporine SE, Monitoring, and Notes

Answer 15

SE: Increased BP, nephropathy, hyperkalemia, hypomagnesemia, hirsutism, gingival hyperplasia, edema, increased BG, neurotoxicity, QT prolongation
Monitoring: Trough level, serum electrolytes, renal function, BP, BG, lipids
Notes: Drug interaction (Cyp3A4 inhibitor, substrate and P-gp substrate)
Do not administer oral liquid in a plastic or styrofoam cup

Question 16

Everolimus Warnings, SE, Monitoring, Notes

Answer 16

Zortress (mtor kinase inhibitor)
Warnings: hyperlipidemia
SE: Peripheral edema, increase BP, do not use within 30 days of transplant
Monitoring: trough
Notes: Cyp3A4 substrate

Question 17

Sirolimus Warnings, SE, Monitoring, Notes

Answer 17

Rapamune (mtor kinase inhibitor)
Warnings: impaired wound healing, hyperlipidemia
SE: Irreversible pneumonitis/bronchitis/cough (d/c if happens), increased BG, peripheral edema
Monitoring: trough level
Notes: tabs and oral solution are not bioequivalent, cyp3A4 substrate

Question 18

Belatacept Boxed Warnings

Answer 18

Nulojix (binds to CD80 and 86 to block t-cell costimulation and production of inflammatory mediators)

Boxed Warnings: increased risk of post-transplant lymphoproliferative disorder, use in EBV seropositive patients only. Treat latent TP prior to use.

Question 19

Induction Immunosuppressants

Answer 19

• basiliximap (IL-2 receptor antagonist)
• Antithymocyte globulin (in pts at higher risk of rejection)
• Maintenance drugs at higher doses)

Question 20

Maintenance Immunosuppresants

Answer 20

• CNIs (tac or cyclosporine)
• adjuvant meds (antiproliferative agents [mycophenolate or azathioprine]) (mTOR kinase inhibitors [everolimus or serolimus]) (belatacept)
• Steroids

Question 21

Vaccines

Answer 21

Flu
Pneumonia
Varicella