1.Immunosuppressant Medications a.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 2.Infection Prophylaxis Medications a.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 900 mg po qd x 6 months (if D-/R-then acyclovir qd x 6mos); c.if Liver/Kidney then 450 mg po qd x 6 mos d.Anti-fungal—Nystatin 500,000 units po qid x 3 mos 3.Common Calcineurin Inhibitor Drug Interactions* a.Azole anti-fungals b.Protease inhibitors c.Grapefruit d.Erythromycin/Macrolides e.Diltiazem/Verapamil f.Statins will require lower starting dose g.CYP450 medications can alter CNI levels * Not an exhaustive list 1. Surgical Complications a.Vascular i. Stenosis –can be managed by interventional radiology or surgical intervention if necessary—should be done at transplant center preferably ii. Hepatic Artery a. US to assess for hepatic artery thrombosis day around 12 b.Wound i. Dehiscence and infections most common in the first three months—more prevalent in diabetics, obese population. 2.Biliary Complications a. Stenosis – ERCP usually indicated b. Ischemic cholangiopathy i. ERCP for management and may need to be relisted 2.Medical Complications a.Hypertension b.Hyperlipidemia c.Chronic kidney disease d.Malignancies e.Anemia f.Leukopenia b.Non-Alcoholic Steatohepatitis 3.Infectious Complications a.Pneumocystis pneumonia b.Cytomegalovirus c.Fungal d.BK virus e.Varicella zoster f.Urinary tract infections 1. Visit Frequency a.Surgeon – within one week of discharge b.RN visit 2-3x/week for first 2 weeks c.Hepatologist – 1 month, 3 months, 6 months then annually and prn d.If Liver kidney/then follow both liver and kidney schedules e.Primary Care Provider - annually 2.Laboratory Frequency – see chart 3.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 Common Medications in Abdominal Transplantation Post-Transplant Complications Post-Transplant Care/Management Reference: Lucey, M. R., Terrault, N., Ojo, L., Hay, J. E., Neuberger, J., Blumberg, E. and Teperman, L. W. (2013), Long‐term management of the successful adult liver transplant: 2012 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Liver Transpl, 19: 3–26. doi: 10.1002/lt.23566
*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 - If patient is a combined liver and kidney patient then please follow both this protocol and the post kidney protocol Liver Transplant Standard of Care (SOC) Labs Laboratory Test0-1 months1-2 months2-3 months3-6 monthsAfter 6 months Comp Chem3x/week2x/week M, Th1x/week2x/monthMonthly CBC with diff3x/week2x/week; M, Th1x/week2x/monthMonthly Drug level (FK, Csa, Sirolimus, Everolimus) 3x/week2x/week; M, Th1x/week2x/monthMonthly LipidsOnceQ 6months Magnesium level3x/week2x/week M, Th1x/week 1/week if still on beyond 6 mos Serum pregnancy test*First visitOne month3 months6monthsAnnually HBV DNA PCR Quant; HBsAg At month 3Q3monthsQ3 months until 1 year then q 6 months
NOSOCOMIAL TECHNICAL DONOR/RECIPIENT Activation of Latent Infections, Relapsed, Residual, Opportunistic Infections COMMUNITY ACQUIRED 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) TRANSPLANTATION DYNAMIC ASSESSMENT OF INFECTIOUS RISK < 4 WEEKS1-6 MONTHS> 6 MONTHS Donor- Derived Recipient- Derived The Timeline of Post-Transplant Infections Modified from 1-3
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