Issue: Surveillance for long-term complications of immunosuppression (5).
Osteoporosis: monitor CMP, ALP, Vitamin D - rule out hyper-PTH, Vitamin-D deficiency (aim <75). DEXA annually for T<-1.5 or #, or high risk (e.g. steroids), otherwise 2 yearly. Encourage sun-exposure, regular WB exercise and falls prevention. Anti-resorptive.
Malignancy screening: ensure routine cancer screening is UTD + monthly self-skin examinations + 6 monthly exam by the clinician (BCC, SCC, melanoma, Merkel cell carcinoma). PTLD - regular hx + exam, if suspicious, do LDH + further radiology (e.g. PET).
CV risk factor Mx: target lipids, BP + HBA1C (specific to patients). NP - crucial spiel, diet (salt <2g, high-fibre, limit sat fats, dietician), exercise, weight loss, smoking & alcohol. Pharm - BP, Lipids (bring-out PCSK9i and why you would/wouldn’t use it), monitor postural BP, bradycardia, URTI/Rash/arthralgia (PCSK9i), monitor targets 3-6monthly.
Infection prophylaxis: avoid live vaccines, give influenza, pneumococcal, Hep A/B (if no Abs), VZV if (≥50yo)
Monitoring for drug toxicity: CNI levels, mTOR levels, FBC (anaemia, leukopenia), LFTs (Aza, MTX), EUCs (CNI toxicity) - 3-6 monthly.
4 types of rejection in transplants?
Hyperacute (1st 24 hours)
Acute cellular (T-cell mediated, more common): risk is highest in the 1st few months then falls thereafter
Humoral (antibody-mediated, less common)
Chronic
- Lung: BOS
- Cardiac: CAV
- Liver:
How do treatment differ for cell mediated vs ab-mediated acute rejection in transplants?
AMR: high-dose steroids, IVIG, PEX.
Agents - Rituximab, Bortezomib, Eculizumab (i.e. targeting B-cells or ABs)
Cellular: high-dose steroids (methyl), switch CsA to Tac. AZA to MMF. Consider ATG or Alemtuzumab (CD52, targeting lymphocytes)
Specific questions to ask regarding immediate complications of surgery of transplant? (5)
Anastomotic leak
Arterial leak
Venous leak
Damage to any other organs
Redo-operation
Names of specific rejections in organ transplants? (4)
Heart: CAV (cardiac allograft vasculopathy)
Lung: BOS
Liver: biliary stricture
Renal: CAN (chronic allograft nephropathy)
Monitoring transplant allograft function (Cardiac)?
- Hx + exam: HF, arrythmia, syncope, hepatic congestion
- Endomyocardial biopsy: 1-2-4 weekly in the first 3 months, then 3 monthly 1st year. Varies - after 1st year, continued biopsy surveillance is controversial.
- Coronary angiogram: annually for 5-years then dobutamine stress TTE thereafter.
- If eGFR <30 - annual dobutamine stress TTE instead, from the beginning.
- Can do MIBI instead of stress TTE.
- If abnormal → angiogram + intravascular USS
- ECG - look for new arrhythmia, ST/T changes, conduction issues.
Monitoring transplant allograft function (Lung)?
- Hx + exam: close communication with transplant nurse coordinator, keep on eye out for symptoms.
- Spirometry: FEV1 and FVC (also patient hand-held) - look for sustained decline of 10-15% in either parameters
- CXR
- Bronchoscopy
- BAL + transbronchial biopsy: 1st month, then 3, 6, 9, 12 months
- Long-term annual thereafter
- Lavage: viral resp PCR, MCS, cytology.
Monitoring transplant allograft function (Liver)?
- LFTs, INR, platelets
- USS Liver + doppler - if strong suspicion, proceed to ERCP or MRCP (if index of suspicion is low) → may need biopsy
- If anastomotic stricture: balloon dilatation, stent (plastic) - changed every 3 mohths
Monitoring transplant allograft function (Renal)?
- EUC and GFR
- K, PO4
- Proteinuria: UPCR/UACR (3 monthly 1st year then annually)
- Renal biopsy if UO decreases, proteinuric, renal impairment. Ability to work out a cause of allograft dysfunction without biopsy is notoriously low.
Any other side effects of CNIs other than diabetes, HTN, lipids, malignancy? (3)
- Seizure - PRES (posterior reversible encephalopathy)
- Hyperkalaemia
- Hypomagnesiemia
PTLD management? (3)
- Reduction of maintenance immunosuppression
- High-dose anti-viral therapy: Valganciclovir, Valaciclovir, Rituximab
- Chemotherapy
