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Common Medications in Abdominal Transplantation 1. a. b. c. d. 2. Immunosuppressant Medications Calcineurin Inhibitors (CNI) i. Prograf/Tacrolimus/Hecoria ii. Neoral/Cyclosporine/Gengraf mTor Inhibitors i. Rapamune/Sirolimus ii. Zortress/Everolimus Prednisone Anti-proliferative medications i. Myfortic/Mycophenolic acid (enteric coated) ii. Cellcept/Mycophenolate mofetil iii.Imuran/Azathioprine Infection Prophylaxis Medications a. PCP Prophylaxis i. Bactrim SS/SMTZ SS QD i. After one year can be changed to TIW OR ii. Mepron/Atovaquon (sulfa allergy) – stopped after one year b. CMV prophylaxis – Valcyte 450 mg po qd x 6 months (if D-/R-then acyclovir) c. Anti-fungal—Mycelex troche bid x 3 mos 3. a. b. c. d. e. f. g. Common Calcineurin Inhibitor Drug Interactions* Azole anti-fungals Protease inhibitors Grapefruit Erthromycin/Macrolides Diltiazem/Verapamil Statins will require lower starting dose CYP450 medications can alter CNI levels Post-Transplant Complications 1. 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—require fluid analysis i. Urinoma ii. Lymphocele iii.Seroma 2. 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 a. Months 1, 3, 12, annually and prn 2. a. Laboratory Frequency SEE CHART on OTHER SIDE a. Protocol Kidney Biopsy Schedule Month 3, 12 and 24 and prn 3. 4. 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 5. 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 three 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, blood; 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+ 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): Aspergilus, Pseudomonas With PCP and antiviral (CMV, HBV, Prophylaxis: • BK Polyomavirus Nephropathy • C. difficile colitis • Hepatitis C virus • Adenovirus, Influenza • Crytococcus neoformans • M. tuberculosis Anastamotic complications Without Prophylaxis Add: Penumocystis Herpesviruses (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)