Transplant

allograft

transplant from one individual to another

ograftis

transplant from a genetically identical donor (such as identical twin)

autograft

transplant from same patient from one site to another (also called autologous transplant)

HLA stands for

human leukocyte antigen

a mismatch in either ____ or ____ would lead to an acute, fast rejection of a transplant

HLA or ABO blood group

a High PRA score correlates to

likelihood of graft rejection (could necessitate desensitation protocol prior to transplant

Type O blood =

universal donor

can be given to any blood type without causing an immune response

People with type O blood can receive:

only type O blood

Type AB blood =

universal receiver

People with type AB blood can receive:

Type A, Type B, or type AB, or Type O blood

People with type A blood will react against _______

People with type B will react against:

A will react against: B or AB

B will react against A or AB

Induction immunosuppression is given ______ in order to

given before or at time of transplant

in order to prevent acute rejection during early post-transplant period

Induction immunosuppression usually consists of

poly/monoclonal antibodies, high-dose IV steroids

Basiliximab is a ____(class)

interleukin-2 (IL-2) receptor antagonist

IL-2 receptor is expressed on

activated T-lymphocytes and is responsible for activated t-lymphocytes to attack and reject an organ

T/F: Basiliximab depletes T-lymphocytes

false: IT does NOT therefore it cannot be used to treat rejection, only for prevention

basiliximab can be used for _____ ONLY, not for _____

prevention only, not for treatment

Basilixmab (-ximab) is humanized, so

infusion-related reactions are unlikely

an alternative to basiliximab for patients at higher risk of rejection is

antithymocyte globulin

t/f: antithymocyte globulin depletes T-lymphocytes

true

T/F: Antithymocyte globulin can be used for both treatment and induction

true

leukemia and MS drug used off-label for induction

alemtuzumab

Atgam is brand name _____ derived from _____

antithymocyte globulin

from horse

thymoglobulin is brand name ______ derived from

antithymocyte globulin

from rabbit

side effects of antithymocyte globulin

infusion-erlated reactions

notes on Atgam

premedicate to lessen infusion reactions

Maintenance immunosuppression is provided by

combo of calcineurin inhibitor (i.e. tacro first line)

antiproliferative (i.e. mycophenolate or azathioprine)

with or without steroids (typically prednisone)

Prednisone short term side effects include

fluid retention

stomach upset

emotional instability (mood swings)

insomnia

increased appetite, weight gain, acute rigse in BG, BP

Cellcept boxed warning

(mycophenolate)

increased risk of infection, lymphoma and skin malignancies

increased risk of congenital malformations and spontaneous abortions

side effects of Myfortic

diarrhea, GI upset

T/F: Cellcept and Myfortic are not interchangeable

true

Difference between myfortic and cellcept

myfortic is enteric coated to decrease diarrhea

Cellcept IV is stable in ____ only

D5W

mycophenolate drug interactions considerations

reduce efficacy of oral contraception

Mycophenolate works by

inhibiting T- and B-lymphocyte proliferation by altering purine nucleotide synthesis

Azathioprine warnings

patients with genetic deficiency of thiopurine methyltransferase (TPMT) are at increased risk for myelosuppression

A patient tells you they are deficient in TMPT. They may need a decreased dose of:

azathioprine

Prograf boxed warnings

(tacrolimus)

increased susceptibility to infection

side effects of prograf

(tacrolimus)

increased BP

nephrotoxicity

increased BG

neurotoxicity

hyperkalemia

hyperlipidemia

QT prolongation

alopecia

tacrolimus is monitored by

trough level goal

(electrolytes are monitored as well as renal fxn, LFTs, BG, BP, lipids)

T/F: Tacrolium XL and IR are not interchangeable

true

Tacrolimus is a CYP_____ ____

CYP450 3A4 and P-gp substrate

Tacroliumus IV considerations

must use a non-PVC bag

Cyclosporine brand names include:

gengraf, neoral, sandimmune, restasis (eye drops)

Gengraf boxed warning

nephrotoxicity, increased risk of lymphoma and other malignancies, skin cancer, increased risk of infection, increased BP

Difference between Gengraf/Neoral and Sandimmune

Gengraf/Neoral are modified formulations of cyclosporine with greater bioavailability compared to non-modified Sandimmune

do not interchange them

Monitor cyclosporine with

trough levels, eletrolytes, renal function, BP, BG, lipids

Cyclosporine is a CYP_____

Cyp3A4 inhibitor, CYP3A4 and P-gp substrate

Considerations with oral liquid cyclosporine

do not administer from a plastic or styrofoam cup

mTOR kinase inhibitors include

everolimus and sirolimus

mTOR kinase inhibitors work by

inhibiting T-lymphocyte activation/proliferation; synergistic w/ CNIs

Zortress warnings

(everolimus)

hyperlipidemia, impaired wound healing

side effects of everolimus

peripheral edema, thrombosis

Everolimus should not be used within ____ days of transplant

30 days

everolimus and sirolimus are monitored at

trough level

everolimus and sirolimus are CYP____

CYP3A4 and pGP substrates

warnings with rapamune

(sirolimus)

hyperlipidemia, impaired wound healing

T/F: Sirolimus oral liquid and tablets are equivalent

false

belatacept (nulojix) boxed warning

increased risk of post-transplant lymphoproliferative disorder (PtlD)

use in EBV seropositive patients only

drug that should be used in EBV seropositive patients only

belatacept

Prednisone long-term side effects include

adrenal suppression/cushing's syndrome, impaired wound healing, increased BP, diabetes, acne, osteoporosis, impaired growth in children

Warnings with belatacept

treat latent TB prior to use

Primary used calcineurin inhibitor

tacrolimus, cyclosproine is sometimes used

drug sometimes used as an alternative to a CNI

belatacept

Inducers of p-GP or CYP3A4 decrease ____ concentration and inhibitors like azoles increase _____ concentration (class)

CNIs

Avoid using azathioprine with ______

xanthine oxidase inhibitors: allopurinol or febuxostat

A patient is taking allopurinol for gout. which drug should you check that is not part of their transplant regimen due to interactions

azathioprine

Grapefruit juice and st. john's wort will interact with

CNIs

drugs that are nephrotoxic should be used cautiously due to additive risk with

tacro and cyclo

drugs that worsen blood glucose, lipids, or BP should be used with caution due to:

steroids, cyclosporine, and tacrolimus

trough levels should be drawn ______

30 minutes before scheduled dose

Nephrotoxicity is most associated with which maintenance IS meds

tacrolimus and cyclosporine

worsening or new-onset DM is most associated with which IS meds

tacrolimus, steroids, cyclosporine

worsening lipid parameters is most associated with which transplant meds

mTOR inhibitors

(also steroids and cyclosporine)

hypertension is associated w/ which IS meds

steroids, cyclosporine, tacrolimus

T/F: All transplant patients should monitor for sx of infection

true

symptoms of infection include

fever of 100.4 of higher

chills

cough, sore throat

pain with urine, ear, sinus pain

mouth sores, wound not healing

Initial approach to treating acute cellular rejection (ACR) is

high-dose steroids

(and increased IS maintenance meds)

If a patient develops humoral antibody rejection against their graft, what can be used?

IVIG, plasmapheresis, rituximab to prevent new antibodies

T/F: Patients with transplant can still receive live vaccines

false. Post-transplant patients CANNOT receive live vaccines

For vaccines, patients should be counseled

to get live vaccines prior to transplant for coverage against vaccine-preventable illnesses if possible

T/F: prophylaxis against opportunistic infections is important for transplant patients

true

Counseling for transplant patients regarding cancer

regular cancer screening

skin cancer is common

sunscreen must be used routinely

T/F: Transplant patients are at high risk for developing metabolic syndromes due to their medication profiles

true

Inactivated transplants can be given

3-6 months post-transplant

(must have an immune system to develop an adequate response to the vaccine)

Important vaccines for transplant patients include:

influenze (inactivated)

pneumococcal in adults 19+

-PCV20 once

-OR PCV 15 (vaxneuvance once followed by PPSCV23 x 1 8 weeks later

T/F: Close contacts of transplant patients should also be vaccinated for varicella

true

Avoid taking antacids and vitamins at the same time as this IS med

mycophenolate

this IS med is teratogenic and also decreases efficacy of birth control pills

mycophenolate

Tacrolimus XR and XL are taken every

non XR/XL formulations are taken

once daily

non xr/xl are taken every 12H

tacrolimus should be taken

on an empty stomach