Organ Transplant/Rejection

Factors required for successful transplant

Deceased or living donors (i.e., kidney, liver). Most come from deceased donors.

Matched based on a number of factors. ABO blood, HLA typing, medical urgency, time on waiting list and geographic location.

Immunosuppressive drugs prevent the recipient’s immune system from building are response against the transplanted organ.

The better the HLA match, the better the long-term survival of the transplant.

Rejection S/S

Fever, chills, body aches, N/V, pain at transplant site.

Hyperacute Rejection

Within 24 after transplantation

No treatment, organ is removed

Acute Rejection

First 6 months after transplantation

Immunosuppressive therapy

Chronic Rejection

Over months or years, irreversible

Supportive therapy, poor prognosis

Immunosuppressants

Increases risk for infection and cancers (watch for signs in the patient)

Calcineurin inhibitors (cyclosporine, tacrolimus)

Act on T helper cells

SE: nephrotoxic, risk for infection, neurotoxicity (seizures, tremors),

hepatoxicity, lymphoma, hypertension

hirsutism, leukopenia, gingival hyperplasia.

No grapefruit/grapefruit juice →prevents metabolism, can lead to toxicity.

Usually in combo with corticosteroids, mycophenolate mofetil, and sirolimus.

Corticosteroids (prednisone, methylprednisolone)

Suppress inflammatory response

SE: PUD, hypertension, osteoporosis

Na and H20 retention, weakness, easy bruising

delayed healing, hyperglycemia, risk for infection

Cytotoxic (Antiproliferative) Mycophenolate mofetil (Cellcept)

Inhibits purine synthesis

SE: N/V/D, neutropenia, thrombocytopenia, increased risk of infections, cancers

IV only reconstitute with D5W, do not give as bolus, over 2 hours or more Azathioprine (Imuran)

Sirolimus (Cytotoxic)

Suppresses T cell activation and proliferation) in combo with steroids, cyclosporine and/or tacrolimus

SE: increased risk for infection, leukopenia, anemia, thrombocytopenia, hyperlipidemia, arthralgias, diarrhea, and increased cancer risk.

Monoclonal antibodies

Prevent and treat acute rejection

SE: Flu like symptoms-fever, chills, H/A, myalgias and GI problems

To decrease give acetaminophen, diphenhydramine and methylprednisolone before.

Alemtuzumab (Campath, Lemtrada) (Monoclonal)

SE: fever, chills, CP, N/V, neutropenia, thrombocytopenia, and anemia, increased risk for infection.

Basiliximab (Simulect) (Monoclonal)

Hypersensitivity and anaphylaxis.

Polyclonal Antibodies

Derived from animals (horse and rabbit) induce immunosuppression and treat acute rejection.

SE: fever, chills, dyspnea, myalgia, chest pain, N/V, anaphylaxis, leukopenia, thrombocytopenia, rash, increased risk of infection

Immunosuppressive Therapy Concerns

Compliance, life long

Meds need to be changed

Acute rejection - increase or add other immune

Increase risk of infection, cancer, anaphylaxis

Rejection is similar to infection symptoms

GVHD

In transplant rejection-host rejects organ, GVHD-the graft (donated tissue) rejects the host tissue. Common in stem cell transplants.

May begin within 7 to 30 days after transplantation

GVHD Areas Affected

Skin (maculopapular, itching, or painful rash that progresses to generalized erythema to shedding of a layer of the skin)

Liver (jaundice with elevated LFTS to hepatic coma)

GI tract (mild to severe diarrhea, severe abdominal pain, GI bleeding, and malabsorption)

GVHD Treatment

No adequate treatment- high-dose corticosteroids are used.

Immunosuppressive agents- best preventative measure rather than treatment.

Radiation of blood products before they are administered is another measure to prevent T cell replication.