Download What Every Non-hepatologist Should Know About Caring For

What Every Non-hepatologist Should
Know About Caring For Transplanted
Patients
Gia Tyson, MD, MPH
Ochsner Health System
March 31, 2017
Agenda
• Liver transplant statistics
• Post-transplant patient information
• Medications
• Guideline recommendations
• Frequently Asked Questions
Liver Transplantation- Statistics
• 1988-2017 about 150,000 liver transplants1
• 2015 about 7,000 liver transplants1
Graft failure after deceased donor liver transplantation2
1https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/#
2OPTN/SRTR
2015 Annual Data Report: Liver Report
Liver transplantation- Causes of death
• Peri-operative issues
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Bleeding
Infection
Cardiovascular events
Pulmonary embolus
• >1 year post-transplant
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Infections
Cardiovascular disease
Renal insufficiency
Malignancy
Recurrent liver disease
Rejection is an
uncommon cause of
death
Liver transplantation - Complications
AASLD Long-term Management Adult Liver Transplant. Hepatology. 2012
Patient Information
Safe Living- Step 1 Hand washing
Safe Living- Step 2 Infection Awareness
• Education about immunosuppression and increased risk
of infections
▫ Avoid contact with people recently ill
▫ Avoid large crowds within 6 months of transplant or recent
treatment for rejection
▫ Early evaluation for a fever (≥100.4 F) or cold longer than 3
days
▫ Quickly wash scraps and cuts; apply antibiotic ointment
• Staying up to date on needed immunizations
▫ Wait until 6 months post-transplant to receive vaccines
▫ Only dead viruses, no live viruses
▫ Wait 7-10 days to have contact with someone who received
a live virus
Safe Living- Step 3 Best Daily Action
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Do not eat after other people
Only pasteurized and fully cooked foods
Peel cooked foods
Limit time outdoors or in the sun
▫ Insect repellent especially for mosquitoes
▫ Sunscreen
• Pets needs shots up to date, avoid cleaning up
after them
• Wear work gloves when gardening or yard work
• Wear metal mesh gloves when fishing
Health Maintenance
Prevention
• Dental cleaning twice a year
• Avoid tobacco
• Cancer screening
▫ Skin cancers: Use SPF ≥30, cover skin, yearly
dermatologic exam
▫ Routine cancer screening for males and females
Immunosuppressive Medications
• Primary immunosuppression can NEVER be
stopped
Immunosuppressive Medications
• Secondary immunosuppression can be stopped
and is usually tapered
▫ Need to discuss with transplant team
Immunosuppressive Medications*
• Tacrolimus (Prograf)
▫ Renal insufficiency
▫ Tremor, neuropathy, headaches, seizures or other
neurologic symptoms
▫ Elevated blood sugars
▫ Elevated blood pressure
▫ Elevated potassium
▫ Low magnesium
▫ Vision changes or hair loss
*Infection is a risk associated with all immunosuppressive medications
Immunosuppressive Medications
• Cyclosporine(Neoral)
▫ Similar side effects to
tacrolimus
▫ Increased hair growth on
face and upper trunk
▫ Gingival hyperplasia
▫ Flushing
▫ Elevated cholesterol
• Sirolimus (Rapamune)
▫ Elevated cholesterol and
triglycerides
▫ Poor wound healing
 Needs to be stopped 2
weeks before and after
surgery
▫ Nausea, vomiting, diarrhea
▫ Mouth ulcers
▫ Leukopenia
▫ Joint pains
▫ Rash or acne
Immunosuppressive Medications
• Mycophenolate mofetil
(CellCept)
▫ Leukopenia
▫ Diarrhea, stomach cramps,
nausea
▫ Birth defects
• Mycophenolate sodium
(Myfortic)
▫ Fewer GI side effects
• Prednisone
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Thrush
Elevated blood sugars
Sodium and fluid retention
Gastrointestinal bleeding
Acne
Moon facies
Stretch marks
Anxiety, mood swings, sleep
disturbance
▫ Nocturnal diaphoresis
Preventative Medications
• P. jirovecii (previously PCP)
prophylaxis for 6 months after
transplant
• Bactrim
▫ Leukopenia
▫ Elevated potassium
▫ Cholestasis
• Dapsone
▫ Hemolytic anemia
• Pentamidine
▫ Shortness of breath
▫ Cough
▫ Chest tightness
• Atovaquone
• CMV prophylaxis for 3 or 6
months after transplant
• Valcyte
▫ Leukopenia
▫ Birth defects
• Acyclovir
• Fungal prophylaxis while on
steroids
▫ Nystatin
▫ Fluconazole
• Aspirin-indefinite to improve
hepatic artery blood flow
These medications are restarted after inpatient treatment of acute rejection
Medication interactions
• Tacrolimus, Cyclosporine, Sirolimus
• Decreased levels
• Increased levels
Cholestyramine
St. John’s wart
Efavirenz
Phenytoin, carbamazepine,
phenobarbital
– Rifampin
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–
–
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– Azithromycin,
erythromycin,
clarithromycin
– Fluconazole ,
itraconazole,
ketoconazole,
voriconazole
– Diltiazem, verapamil
– Grapefruit and
pomegranate
– Amiodarone
– Protease inhibitors
Medication Interactions
• Mycophenolate
▫ Decrease absorption with antacids (Magnesium
and Calcium) and cholestyramine
• Caution when using statins and cyclosporine
▫ Increased risk of rhabdomyolysis
 Pravastatin ≤ 20mg/day
 Rosuvastatin ≤ 5mg/day
 Fluvastatin ≤ 20mg/day
Safe Antibiotics
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Amoxicillin
Augmentin
Cephalosporins
Ciprofloxacin
Clindamycin
Doxycycline
Levaquin
Azithromycin (Z) pack
Hepatitis C Medications
Recommendations
• Grade 1
▫ Level A
 Smoking cessation-strong association of lung, head and neck
cancers
 Treatment of hypertension to goal ≤130/80
 Annual dermatologic exam
 If osteopenic need to evaluate for causes, i.e. vitamin D levels,
calcium intake, thyroid
 Attention to risk of cardiovascular disease and cancers
▫ Level B
 Goal hemoglobin A1C <7.0%
 Annual influenza vaccine
▫ Level C
 Ongoing dietary counseling to avoid obesity
Recommendations
• Grade 2 Level B
▫ Bone mineral density (BMD) yearly for 5 years
after transplant if patient is osteopenic and every
2-3 years is previous normal BMD
▫ Annual lipid panel; LDL goal ≤100
▫ History of primary sclerosing cholangitis with
ulcerative colitis need annual colonoscopy with
biopsies
Frequently Asked Questions
1. Do I need antibiotics before dental procedures
-No, antibiotics should be given according to
the American Heart Association guidelines
2. Do I need to wear a mask in crowds?
-No, it will not protect from colds
3. When can sexual activity be resumed?
-Around 4 weeks after transplant
4. Can patients have Tylenol?
-Tylenol (max 2 grams) is safer than
nonsteroidal anti-inflammatory drugs
Thank You