Download 6 months - Organ Donation Alliance

Common Medications in
Abdominal Transplantation
1.
Post-Transplant
Complications
Immunosuppressant Medications
Calcineurin Inhibitors (CNI)
i. Prograf/Tacrolimus/Hecoria
ii. Neoral/Cyclosporine/Gengraf
b. mTor Inhibitors
i. Rapamune/Sirolimus
ii. Zortress/Everolimus
c. Prednisone
d. Anti-proliferative medications
i. Myfortic/Mycophenolic acid (enteric
coated)
ii. Cellcept/Mycophenolate mofetil
iii.Imuran/Azathioprine
1.
Infection Prophylaxis Medications
PCP Prophylaxis
i. Bactrim SS/SMTZ SS QD
i. After one year can be changed to
TIW
OR
ii. Mepron/Atovaquone (sulfa allergy) –
stopped after one year
b. CMV prophylaxis – Valcyte 450 mg po qd x 6
months (if D-/R-then acyclovir qd x 6mos)
c. Anti-fungal—Mycelex troche bid x 3 mos
2.
a.
2.
a.
3.
a.
b.
c.
d.
e.
f.
g.
Common Calcineurin Inhibitor Drug
Interactions*
Azole anti-fungals
Protease inhibitors
Grapefruit
Erythromycin/Macrolides
Diltiazem/Verapamil
Statins will require lower starting dose
CYP450 medications can alter CNI levels
Surgical Complications
a. Vascular
i. Stenosis –can be managed by
interventional radiology or surgical
intervention if necessary—should be
done at NMH preferably
b. Wound—Dehiscence and infections
most common in the first three
months—more prevalent in diabetics,
obese population.
c. Fluid Collections—
c. May require fluid analysis
a.
b.
c.
d.
e.
f.
Medical Complications
Hypertension
Hyperlipidemia
Chronic kidney disease
Malignancies
Anemia
Leukopenia
a.
b.
c.
d.
e.
f.
Infectious Complications
Pneumocystis pneumonia
Cytomegalovirus
Fungal
BK virus
Varicella zoster
Urinary tract infections
3.
Post-Transplant
Care/Management
1.
Visit Frequency
Surgeon – within the first week, mos 6 & 12
RN – 2-3x/ week for the first week
Nephrologist – weekly for week 2-3, then
monthly x 3 months (until month 3), then
annually and prn
d. NMH Urology – Stent removal 6 weeks
e. If also kidney transplant then protocol Kidney
biopsy – month 3, 12, 24 and prn
f. Primary care provider/local neph – mos 3-4
a.
b.
c.
2.
Laboratory Frequency – see chart
3.
Hepatitis B chronic/carrier states
i. Pre-transplant patients must be evaluated and
cleared by hepatologist at NMH
ii. Carriers will be placed on treatment at the
time of transplant pending hepatology
recommendations
iii. Chronic or carrier HBV patients should remain
on treatment after transplant and follow-up
with NMH transplant hepatology at mos 3, 6,
9, 12
4.
Health Maintenance Schedule
a. Vaccinations
i. No live vaccines
ii. Annual seasonal influenza
iii. Pneumonia vaccine q5 years
iv. Hepatitis A and B if not immune
i. Hepatitis B high-dose (40mg) day 0,
7, 28
b. Colonoscopy –per ACS guidelines
c. Pap Smear/HPV testing –annually
d. Mammogram—per ACS guidelines
i. Annually (with risk assessment)
e. Lipids
i. Q6-12 months
f. Dermatology screening
i. Annually
* Not an exhaustive list
Reference: American Society of Transplantation, Guidelines for Post-Kidney Transplant Management in the Community Setting, 2009
Kidney, Kidney/Pancreas and Pancreas Alone Transplant Standard of Care (SOC) Labs
Laboratory Test
0-1 months
1-2 months
2-3 months
3-12 months
After 1 year
Basic Chem
3x/week
2x/week; M, Th
1x/week
2x/month
Monthly
Amylase and Lipase+
3x/week
2x/week; M, Th
1x/week
2x/month
Monthly
Comp Chem
Once
Yearly
Hepatic Panel/LFT’s^
Monthly
Monthly
Monthly
Monthly
Monthly
CBC with diff
3x/week
2x/week; M, Th
1x/week
2x/month
Monthly
Drug level (FK, Csa,
Sirolimus, Everolimus)
3x/week
2x/week; M, Th
1x/week
2x/month
Monthly
Lipids, iPTH, & UA
Urine Dip
Once
Every clinic visit
BK screening
Every clinic visit
Every clinic visit
Every clinic visit
Every clinic visit
Blood PCR
quant monthly
Blood PCR
quant monthly
Blood PCR quant
Q2 months (start
mo 4)
Blood PCR quant Q 3
months until 2 years
then annually/prn
Once
Every 3 months
Every 3 months
3 months
6months
Annually
At month 3
Q3months
Q6 months
Cpeptide & A1c+
Serum pregnancy test*
HBV DNA PCR Quant;
HBsAg
First visit
Yearly
One month
Urine Dip to include: Protein, leukocytes, nitrites, protein, blood, glucose; Reflex testing for Protein trace or >: order random urine protein
and creatinine; Reflex testing for Leukocyte and/or nitrate positive: Order urine C&S
+pancreas patients only; *only those child-bearing females (ages up to 60) on Myfortic, Cellcept, mycophenolate mofetil or mycophenolic
acid; ^for patients who are HBsAg+ or HBcAb+ or those who received a donor HBcAb + organ
The Timeline of Post-Transplant Infections
DonorDerived
Modified from 1-3
NOSOCOMIAL
TECHNICAL
DONOR/RECIPIENT
Activation of Latent Infections,
Relapsed, Residual,
Opportunistic Infections
COMMUNITY
ACQUIRED
TRANSPLANTATION
DYNAMIC ASSESSMENT OF INFECTIOUS RISK
RecipientDerived
< 4 WEEKS
1-6 MONTHS
> 6 MONTHS
Common Infections in Solid Organ Transplantation Recipients
Antimicrobial-resistant species
• MRSA
• VRE
• Candida species (non-albicans)
Aspirations
Line Infection
Wound Infection
Anastamotic Leaks/Ischemia
C. Difficile colitis
Donor-Derived (Uncommon):
HSV, LCMV, Rabies, West Nile
Recipient-Derived (colonization):
Aspergillus, Pseudomonas
With PCP and antiviral (CMV, HBV,
Prophylaxis:
• BK Polyomavirus Nephropathy
• C. difficile colitis
• Hepatitis C virus
• Adenovirus, Influenza
• Cryptococcus neoformans
• M. tuberculosis
Anastamotic complications
Without Prophylaxis Add:
Pneumocystis
Herpes viruses (HSV, VZV, CMV, EBV)
Hepatitis B virus
Listeria, Nocardia, Toxoplasma
Strongyloides, Leishmania, T.cruzi
Community Acquired Pneumonia
Urinary Tract Infection
Aspergillus, Atypical moulds, Mucor
species
Nocardia, Rhodococcus species Late
Viral:
• CMV (Colitis/Retinitis)
• Hepatitis (HBV, HCV)
• HSV encephalitis
• Community acquired (SARS,
West Nile)
• JC polyomavirus (PML) Skin
Cancer, Lymphoma (PTLD)