PHRM 542 Solid Organ Transplant Preventative Health, Comorbidities, ADEs

How can osteoporosis be prevented?

Calcium, vitamin D, phosphorus, annual bone densitometry

How can post-transplant anemia be prevented?

Evaluate medications

Prevent infections

How can post-transplant neutropenia be prevented?

Evaluate medications

How can CVD be prevented in transplant patients?

Aspirin 81 mg PO daily to prevent cardiac graft vasculopathy in those with CHD/PCI, etc.

Tobacco avoidance

Statin

How can malignancy be prevented in transplant patients?

Avoidance of sun/UV exposure, routine surveillance for skin cancers

What is the blood pressure goal for transplant patients?

First get the BP down to < 130 mmHg

Once you reach < 130 mmHg, work towards 120 mmHg

What are the drugs of choice for hypertension in transplant patients?

CCBs, then ACEi/ARBs

What is the risk of ASCVD in solid organ transplant patients?

High risk even though they are not in one of the 4 statin benefit groups

What is the target LDL for primary prevention in transplant patients?

< 100 mg/dL

What is the target LDL for renal transplantation patients?

< 70 mg/dL

What is the target LDL for secondary prevention in transplant patients?

< 55 mg/dL

How should statins be dosed in transplant patients?

Maximally tolerated statin PLUS non-statin therapies

What non-statin therapies can be added for secondary prevention of ASCVD in transplant patients?

Ezetimibe, PCSK9 inhibitor (PCSK9 inhibitor preferred if > 25% additional LDL-C lowering needed)

Bempedoic acid, inclisiran

What non-statin therapies can be added for primary prevention of ASCVD in transplant patients?

Most data for transplant is with EZETIMIBE

What should be added if a patient has persistent hypertriglyceridemia (fasting ≥ 150 mg/dL) despite maximally tolerated statin?

Icosapent ethyl (Vascepa)

Describe CMV screening and prevention in the setting of solid organ transplant

Recipients and donors prescreened

What does CMV status dictate in transplant patients?

Prophylaxis regimen and level of suspicion/reactivation or seroconversion

Risk for CMV mismatch

What should be done if CMV is suspected?

CMV PCR test

May require mucosal biopsy

Describe universal CMV prophylaxis treatment

(val)ganciclovir for donor and/or recipient CMV IgG seropositive for a finite period

Starting within 10 days after transplant and continuing for a finite period

Typically used for all patients who received an organ from a CMV seropositive donor

What is the recommended CMV and HSV prophylaxis for a D-/R- serostatus in kidney transplants?

Low risk

Prophylaxis = 6 months oral acyclovir

Monitor for clinical symptoms or preemptive therapy

What is the recommended CMV and HSV prophylaxis for a D+/R+ serotstatus in kidney transplants?

High risk

Prophylaxis = 6 months of valganciclovir 900 mg PO daily (alternative IV ganciclovir) or preemptive therapy

What is the recommended CMV and HSV prophylaxis for a D-/R+ serostatus in kidney transplants?

Intermediate risk

3 months of valganciclovir either 900 mg PO DAILY or half-dose 450 mg PO daily or preemptive therapy

With what CrCl is (val)ganciclovir not recommended?

CrCl < 10 mL/min

When can letermovir be used instead of (val)ganciclovir?

Cytopenias from valgan

DGF or unstable function where dosing of valgan is more complicated

What needs to be added when using letermovir?

Does not cover HSV, ADD acyclovir

Describe preemptive therapy (PET)

Used most commonly in D-/R-

Still give HSV prophylaxis

WEEKLY CMV PCR screening for 3-4 months for early detection

Describe EBV screening and prevention

Recipients and donors prescreened

What does EBV status dictate in the setting of solid organ transplant?

Prophylaxis regimen and level of suspicion/reactivation or seroconversion

Highest risk if EBV mismatch

What is the primary agent for PCP prophylaxis?

TMP-SMX (also effective against Listeria monocytogenes and Toxoplasma gondii)

What are alternative agents for PCP prophylaxis?

Atovaquone

Dapsone

Pentamidine

What is the duration of PCP prophylaxis for patients with a heart transplant?

While on steroids (6-24 months)

What is the duration of PCP prophylaxis for patients with a kidney transplant?

3-6 months

What is the duration of PCP prophylaxis for patients with a liver transplant?

6-12 months

What is the duration of PCP prophylaxis for patients with a lung or small bowel transplant?

Lifelong

What is the recommended post-transplant antifungal prophylaxis following a lung transplant?

Nebulized amphotericin B lipid complex for 1-6 months

What is the recommended post-transplant antifungal prophylaxis following a liver transplant?

Fluconazole (or another azole based on prevalence of other Candida spp.) for 1-4 weeks

In what other transplants is antifungal prophylaxis recommended?

Pancreas and intestine transplants

How long following a transplant should vaccines be delayed and what are the exceptions?

Delay for 3-6 months post transplant

EXCEPTIONS: COVID, influenza (delay 1 month)

Describe live vaccine administration following a transplant

Live vaccines are CONTRAINDICATED

When should vaccines be given pre-transplant?

At least 2 weeks before for inactivated vaccines

At least 4 weeks before for live vaccines