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26 Cards in this Set
- Front
- Back
What is the risk of infection in a transplant patient related to?
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Infection and rejection are the 2 primary complications of immunosuppression. Risk of infection is directly related to epidemiologic exposure and net state of immunosuppression. The greatest risk is in the first 3-6 months after transplantation. At one year, risk of infection is about that of the general population.
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What things contribute to the net state of immunosuppression?
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1. immunosuppressive therapy
2. underlying immune deficiency 3. skin intergrity (catheters) 4. devitalized tissue, fluid collections (from surgery) 5. neutropenia, lymphopenia 6. metabolic conditions 7. infection with immunomodulating viruses |
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What common infections are seen within 1 month of transplant?
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-pneumonia is most common
-UTIs -herpes simplex virus -oral candidiasis -infection conveyed with the donor allograft -infections present in the recipient prior to transplant |
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What common infections are seen from 2-6 months after transplant?
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-Viral infections (CMV, HSV, EBV, HBV, HCV, VZV)
-Opportunistic infections (PCP, Listeria, Aspergillus, Nocardia) -Endemic fungi (Histoplasmosis, Blastomycosis) |
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What common infections are seen over 6 months after transplant?
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-CMV retinitis
-Cryptococcus -BKV -MTB |
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What are common fungal prophylaxis regimens post transplant?
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They are focues on preventing oral candidiasis
-Nystatin suspension (swish and swallow 5mls TID for 3 months) (liver at UAMS) OR -Clotrimazole 10mg troches (TID for 3 months) (Kidney at UAMS) -fluconazole is only used is you are worried about candidemia |
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What is the risk of developing PCP post transplant?
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-5-15% risk without prophylaxis
-risk drops to about 0% with proper prophylaxis development of PCP can be a great indicator of poor compliance |
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How does PCP present itself?
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1. progressive dsypnea
2. tachypnea 3. cyanosis 4. nonproductive cough 5. low-grade fever 6. sweats 7. systemic flu-like symptoms Usually presents 6-8 weeks after the initiation of immunosuppressive therapy |
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What is typical PCP prophylaxis?
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Bactrim (SMX/TMP)
-kidney: single strength daily for 1 year -liver: single strength on MWF for 1 year *Bactrim also reduces risk of nocardia, listeria, UTIs |
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PCP prophylaxis for patients with sulfa allergies?
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-pentamidine inhalation 300mg monthly for 1 year
-dapsone 50-100mg daily for 1 year (check for patient with G6PD deficiency - can lead to hemolysis) -atovaquone 1500mg daily for 1 year |
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What are the main viral diseases in the transplant recipient?
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Herpes simplex viruses
Epstein-Barr virus Cytomegalovirus BK virus JC virus SV40 virus |
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How do we denote donor/recipient viral status? Which status is the highest risk to spread infection?
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Viral status is reported in the Donor/Recipient format (+/+, -/-, etc.). The highest risk is (+/-). The lowest risk is (-/-). (+/+) and (-/+) are intermediate risk.
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What is the most important infection occurring in transplant recipients?
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cytomegalovirus
The immunosuppressive regimens that inhibit T-cell proliferation suppress the means by which a person would fight CMV. Infection primarily occurs in the first 3 months post-transplant. |
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What constitutes CMV disease in the post-transplant patient?
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CMV disease is evidence of infection plus symptoms. Symptoms include fever, malaise, possible leukopenia, thrombocytopenia, and tissue invasive disease.
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What is the difference between primary and recurrent CMV infection?
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Primary infection is when a CMV seronegative recipient (no CMV antibodies) receives a CMV seropositive organ. A recurrent infection is when the latent virus reactivates in a seropositive recipient. A superinfection is a different CMV strain.
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What are risk factors for CMV disease in transplant recipients?
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-donor CMV-seropositive and recipient CMV-seronegative
-use of ATG or OKT-2 (T-cell depleters) |
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Indirect effects of CMV disease.
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CMV has immunomodulatory properties which have been shown to be independent risk factors for several other types of infections and rejection.
-EBV-PTLD (post transplant lymphoproliferative disease) -HCV - chronic liver disease -60% of rejection cases are linked to CMV -chronic rejection -systemic immunosuppression -opportunistic infection |
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What are the effects of immunosuppression on CMV?
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ATG and other polycolonal antibodies (ATGAM, OKT-3) are potent activators of CMV
Mycophenolate and azathiprine are mild CMV activators Calcineurin inhbitors are CMV proliferators |
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CMV prophylaxis
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Valganciclovir
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Treatment of CMV
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IV ganciclovir
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Treatment of ganciclovir resistant CMV
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foscarnet and cidofovir (both are extremely nephrotoxic)
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Epstein-Barr prophylaxis
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acyclovir 200mg TID for 3 months
(if CMV status is (-/-) you must use antiviral prophylaxis for EBV) |
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PTLD treatment
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reduction in immunosuppression (responds poorly to chemotherapy)
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Presentation of BK polyomavirus?
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1. gradual decline in kidney function
2. hematuria 3. proteinuria 4. obstruction |
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Natural progression of BK virus?
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1. Viruria
2. Viremia 3. Nephropathy (50-70% will lost the allograft at this point) |
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Treatment of BK Polyoma virus?
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Decreasing immunosuppression
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