Term
| What are contraindications to liver transplantation? |
|
Definition
- Active alcohol
- infection
- Cardiac medical condition
- Metastatic cancer
- Must be able to afford and comply w/ regimen
- Uncontrolled psych |
|
|
Term
|
Definition
| How to rank someone for a liver transplant |
|
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Term
| What grafts are more and less likely to survive? |
|
Definition
| Kidney is the most likely, heart and lung are the least |
|
|
Term
| What are common indications for kidney transplant? |
|
Definition
|
|
Term
| What are contraindications for kidney transplant? |
|
Definition
- Metastatic cancer
- Severe CHF
- CAD
- must be able to adhere to regimen |
|
|
Term
| Which type of transplant is not orthotopic? |
|
Definition
|
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Term
| How is acute cellular reaction graded? |
|
Definition
| BANFF grade - 1 is least severe. |
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Term
| What drugs are used for induction? |
|
Definition
- Polyclonal antibodies - ATGAM/thymoglobulin (preferred)
- anti-IL2 - Basiliximab/simulect
- anti-CD52 - Alemtuzumab/Campath
- Costim inhibition - Belatacept/Nulojix |
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|
Term
| What drugs are used for maintenence of transplants? |
|
Definition
- Calcineurin inhibitors - Tacrolimus/prograf or CsA/Gengraf or Neoral or Sandimmune
- Purine analogs - Mycophenolate/Cellcept or AZA/Imuran
- Corticosteroids - Prednisone/Deltasone or Methylprednisolone/Solu-medrol
- mTOR inhibitors - Sirolimus/Rapamune or Everolimus/Zortress |
|
|
Term
| What are different regimens used for immunosuppression? |
|
Definition
Triple regimen - most common
Dual regimen - for low risk of rejection
Single regimen - liver transplant only. Induction not used in liver |
|
|
Term
| What IL-2 receptor antagonists are used for induction? |
|
Definition
Basiliximab/Simulect
Good for kidneys, low risk of cancer/infection |
|
|
Term
| How are polyclonal antibodies used for induction? |
|
Definition
| - Thymoglobulin - decreases ACR in high risk and steroid resistant pts. Pancytopenia is the most common rxn. Also cancer, infection, infusion rxn. |
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|
Term
| How is thymoglobulin administered? |
|
Definition
| Via central line, premedicate w/ APAP/benadryl/steroid |
|
|
Term
| When can Belatacep/Nulojix be used? |
|
Definition
Only in kidney transplants and ONLY if epstein-barr virus positive.
Dose: 10mg/kg on day 3, eventually 5 mg/kg
AE: infection |
|
|
Term
| How is Alemtuzumab/Campath used? |
|
Definition
anti-CD52 MAB for induction and tx of ACR
AE: infusion rxns |
|
|
Term
| What calcineurin inhibitors are used for maintenence? |
|
Definition
- Tacrolimus/Prograf - usually oral, IV rarely used. TAC trough monitored
- CsA/Gengraf or Neoral or Sandimmune - sandimmune abs is erratic, rarely used anymore. Oral is preferred.
**Badly nephrotoxic. TAC is neurotoxic, watch for these symptoms (shaking, coma, blindness, HA). Some CV, LFTs (hepatitis), cancer.
CsA - gingival hyperplasia, acne.
Q12H |
|
|
Term
| What are drug interactions with calcineurin inhibitors? |
|
Definition
- Increase levels: Macrolides, Amiodarone, CCBs, Azoles, grapefruit juice, protease inhibitors
- Decrease levels - Carbamazepine, Phenobarb, Phenytoin, Rifampin, St. John's wort
**Toxicity: NSAIDs, aminoglycosides, amphotericin, contrast dye
** Diuretics - increase hyperkalemia
** Statins - incr rhabdo |
|
|
Term
| What are purine antagonists used for maintenance? |
|
Definition
- Mycophenolate/Cellcept or MMF - Inhibits IMPDH. Less side effects than AZA. GI side effects, Anemia, Leukopenia
- AZA/Imuran - synthetic MPA. Interacts w/ allopurinol. AE: Anemia, thrombocytopenia |
|
|
Term
| How are steroids used for maintenence? |
|
Definition
| First line Tx of ACR, part of many regimens, may need to be long term. |
|
|
Term
| What agents are mTOR inhibitors for maintenence? |
|
Definition
Sirolimus/Rapamune - daily levels not required. Same interactions as calcineurins. For kidney transplants. DELAYED WOUND HEALING, lipids
Everolimus/Zortress |
|
|
Term
| How is acute cellular reaction diagnosed? |
|
Definition
- Liver - Tbili, AST/ALT, AP, GGT, INR
- Kidney - Scr, decr urine
- Pancreas - amylase, glucose
Biopsy is definitive |
|
|
Term
|
Definition
- High dose steroids
- Switch to tacrolimus, add MMF or prednisone
Steroids resistance: Thymoglobulin |
|
|
Term
| How is antibody mediated rejection treated? |
|
Definition
Less common, C4d positive on biopsy
- IVIG binds antibodies, then plasmapheresis to remove |
|
|
Term
| What anti-infectives are used post-SOT? |
|
Definition
- Anti-bacterial - PJP prevention. Bactrim first line. If allergy: Mepron, dapsone
- Anti-viral - CMV and HSV virus - Valganciclovir for 3-6 months or acyclovir. Renal dosing
- Anti-fungal - thrush. Nystatin, clotrimazole troche, fluconazole for high risk |
|
|
Term
| What is the most common maintenance IS agent? |
|
Definition
Tacrolimus/Prograf
TAC/MMF/Prednisone is a common regimen |
|
|
Term
| When is induction not necessary? |
|
Definition
In liver transplant.
Use basiliximab if renally compromised |
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