Therapeutics Iii Exam 3 - Post Tranplant Infectious Diseases Questions

Front 1

What is the risk of infection in a transplant patient related to?

Back 1

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.

Front 2

What things contribute to the net state of immunosuppression?

Back 2

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

Front 3

What common infections are seen within 1 month of transplant?

Back 3

-pneumonia is most common
-UTIs
-herpes simplex virus
-oral candidiasis
-infection conveyed with the donor allograft
-infections present in the recipient prior to transplant

Front 4

What common infections are seen from 2-6 months after transplant?

Back 4

-Viral infections (CMV, HSV, EBV, HBV, HCV, VZV)
-Opportunistic infections (PCP, Listeria, Aspergillus, Nocardia)
-Endemic fungi (Histoplasmosis, Blastomycosis)

Front 5

What common infections are seen over 6 months after transplant?

Back 5

-CMV retinitis
-Cryptococcus
-BKV
-MTB

Front 6

What are common fungal prophylaxis regimens post transplant?

Back 6

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

Front 7

What is the risk of developing PCP post transplant?

Back 7

-5-15% risk without prophylaxis
-risk drops to about 0% with proper prophylaxis
development of PCP can be a great indicator of poor compliance

Front 8

How does PCP present itself?

Back 8

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

Front 9

What is typical PCP prophylaxis?

Back 9

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

Front 10

PCP prophylaxis for patients with sulfa allergies?

Back 10

-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

Front 11

What are the main viral diseases in the transplant recipient?

Back 11

Herpes simplex viruses
Epstein-Barr virus
Cytomegalovirus
BK virus
JC virus
SV40 virus

Front 12

How do we denote donor/recipient viral status? Which status is the highest risk to spread infection?

Back 12

Viral status is reported in the Donor/Recipient format (+/+, -/-, etc.). The highest risk is (+/-). The lowest risk is (-/-). (+/+) and (-/+) are intermediate risk.

Front 13

What is the most important infection occurring in transplant recipients?

Back 13

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.

Front 14

What constitutes CMV disease in the post-transplant patient?

Back 14

CMV disease is evidence of infection plus symptoms. Symptoms include fever, malaise, possible leukopenia, thrombocytopenia, and tissue invasive disease.

Front 15

What is the difference between primary and recurrent CMV infection?

Back 15

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.

Front 16

What are risk factors for CMV disease in transplant recipients?

Back 16

-donor CMV-seropositive and recipient CMV-seronegative
-use of ATG or OKT-2 (T-cell depleters)

Front 17

Indirect effects of CMV disease.

Back 17

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

Front 18

What are the effects of immunosuppression on CMV?

Back 18

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

Front 19

CMV prophylaxis

Back 19

Valganciclovir

Front 20

Treatment of CMV

Back 20

IV ganciclovir

Front 21

Treatment of ganciclovir resistant CMV

Back 21

foscarnet and cidofovir (both are extremely nephrotoxic)

Front 22

Epstein-Barr prophylaxis

Back 22

acyclovir 200mg TID for 3 months
(if CMV status is (-/-) you must use antiviral prophylaxis for EBV)

Front 23

PTLD treatment

Back 23

reduction in immunosuppression (responds poorly to chemotherapy)

Front 24

Presentation of BK polyomavirus?

Back 24

1. gradual decline in kidney function
2. hematuria
3. proteinuria
4. obstruction

Front 25

Natural progression of BK virus?

Back 25

1. Viruria
2. Viremia
3. Nephropathy (50-70% will lost the allograft at this point)

Front 26

Treatment of BK Polyoma virus?

Back 26

Decreasing immunosuppression