Patient Care and Monitoring

Early Management of Transplant Recipients

• Review any available diagnostic and laboratory data to evaluate the function of the allograft and the health of the recipient.

• Assess the patient's current medication regimen, including:

• Induction therapy agent:

• Assess for appropriate dose and duration of therapy

• Therapeutic monitoring parameters (organ function)

• Toxic monitoring parameters

• Maintenance immunosuppressive agents:

• Assess for appropriate dose and duration of therapy

• Therapeutic monitoring parameters (organ function)

• Toxic monitoring parameters

• Anti-infective prophylaxis:

• Assess suitability of chosen prophylactic agents (i.e., drug allergies, CMV donor and recipient serostatus)

• Therapeutic monitoring parameters

• Toxic monitoring parameters

• Medications used for comorbidities:

• Assess appropriate selection of these medications for pharmacokinetic and pharmacodynamic DDIs, need (i.e., do renal transplant recipients need to continue to take erythropoietin?), and efficacy.

• Therapeutic monitoring parameters

• Toxic monitoring parameters

• Evaluate the patient for the presence of adverse drug reactions, drug allergies or DDIs.

• Develop patient-specific short-term and long-term therapeutic goals.

• Provide patient education regarding the organ transplant, the complications associated with transplantation, the need for lifestyle modifications to reduce risk of complications (i.e., wear sunscreen, low-sodium diet) and drug therapy.

• Stress importance of adherence with therapeutic regimen. Outpatient Management of Transplant Recipients

• Obtain a thorough history of prescription, nonprescription, and complimentary and alternative medication use.

• Maintenance immunosuppressive agents:

• Assess for appropriate dose and duration of therapy

• Therapeutic monitoring parameters (organ function)

• Toxic monitoring parameters

• Anti-infective prophylaxis:

• Assess suitability of chosen prophylactic agents (i.e., drug allergies, CMV donor and recipient serostatus)

• Does the patient need continued prophylaxis therapy?

• When do you stop prophylaxis?

• Therapeutic monitoring parameters

• Toxic monitoring parameters

• Medications used for comorbidities:

• Assess appropriate selection of these medications for pharmacokinetic and pharmacodynamic DDIs, need and efficacy

• Therapeutic monitoring parameters (drug- and disease-specific)

• Toxic monitoring parameters (drug-specific)

• Evaluate the patient for the presence of adverse drug reactions, drug allergies, or DDIs.

• Reassess your patient-specific short-term and long-term therapeutic goals.

• Continue with patient education in regards to the complications associated with transplantation, the need for lifestyle modifications to reduce risk of the complications (i.e., wear sunscreen, low-sodium diet) and drug therapy.

• Re-emphasize the importance of adherence with their therapeutic regimen.

• Assess improvement in quality of life measures such as physical, psychological and social functioning, and well-being.

Abbreviations Introduced in This Chapter

6-MP

6-Mercaptopurine

ACE

Angiotensin converting enzyme

ALA

Antilymphocyt^ antibodies (includes OKT-3, eATQ,

and antithymocyte globulin)

ANF

Atrial natriuretic factor

A PC

Antigen-presenting cell

ARB

Angiotensin receptor blocker

AWP

Average wholesale pri.ee

BM1

Body mass index

BUN

Blood urea nitrogen

c,

Trough concentration

Drug concentration 2 hours postdose

CD4+

Helper T cells

CD8+

Cytotoxic T cells

CKD

Chronic kidney disease

CMV

Cytomegalovirus

CSA

Cyclosporine

CYP

Cytochrome P-450 system

CYP3A

Cytochrome P-450 system 3A isozyme

DC

Dendritic cell

DDI

Drug-drug interaction

DM

Diabetes mellitus

DOE

Dyspnea on exertion

DS

Double strength

eATG

Antithymoglobulin equine

EBV

Epstein-Barr virus

ESRD

End-stage renal disease

FBS

Fasting blood sugar

FEV

Forced expiratory volume

G6PD

Glucose-6-phosphate-dehydrogenase

GFR

Glomerular filtration late

HDL

High-density lipoproteins

HgAlc

Hemoglobin A

HLA

Human leukocyte antigen

HMG-CoA

3-Hydroxy-3-methylglutaryl coenzyme A

reductase

HPLC

High-performance liquid chromatography

HTN

Hypertension

IgG

Immunoglobulin G

IL-2

Interleukin-2

IL-2RA

Interleukin-2 receptor antagonist

IL-2R

Interleukin-2 receptor

JNC7

Joint National Committee Seventh Report

K

Potassium

LDL

Low-density lipoproteins

LDL-C

Calculated low-density lipoproteins

LFT

Liver function test

MACE

Major adverse cardiovascular events

Mg

Magnesium

MHC

Major histocompatibility complex

MMF

Mycophenolate mofeti 1

MPA

Mycoplienolic acid

MPAG

mAP-glucorinide

NCEP

National Cholesterol Education

Program

NFAT (NFAT-P)

Nuclear factors

NO DAT

New-onset diabetes raellitus after

transplantation

NSÀ1D

Nonsteroidal anti-inflammatory drug

NYHA

New York Heart Association

OKT-3

Muronoit)ab-CD3

P-glyœ protein

PKI)

Polycystic kidney disease

fJ°,

Phosphate

PRA

Panal of reactive antibodies

PTLD

Po s i-1 ra nsplant ly mp h o prol i fer at i ve

disorders

RATG

Rabbit antithymocyte immunoglobulin

RRF

Renal blood flow

SCr

Serum creatinine

son

Shortness of breath

SRi,

Si roll mus

SPK

Simultaneous panereas-kidney

SS

Single strength

TAC

Tacrolimus

TCR

T-cell receptor

ToR

Target of Rapamycin

Self-assessment questions and answers are available at ht-tp://www. mhpharmacotherapy. com/pp.html.

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