1. Immunosuppressant Medicationsa. Calcineurin Inhibitors (CNI)

i. Prograf/Tacrolimus/Hecoriaii. Neoral/Cyclosporine/Gengraf

b. mTor Inhibitorsiii.Rapamune/Sirolimusiv.Zortress/Everolimus

c. Prednisoned. Anti-proliferative medications

i. Myfortic/Mycophenolic acid (enteric coated)

ii. Cellcept/Mycophenolate mofetiliii.Imuran/Azathioprine

2. Infection Prophylaxis Medicationsa. PCP Prophylaxis

i. Bactrim SS/SMTZ SS QDi. After one year can be changed

to TIW ORii. Mepron/Atovaquon (sulfa allergy) –

stopped after one yearb. 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. Common Calcineurin Inhibitor Drug Interactions*

a. Azole anti-fungalsb. Protease inhibitorsc. Grapefruitd. Erthromycin/Macrolidese. Diltiazem/Verapamilf. Statins will require lower starting doseg. CYP450 medications can alter CNI levels* Not an exhaustive list

1. Surgical Complicationsa. 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 analysisi. Urinomaii. Lymphoceleiii.Seroma

2. Medical Complicationsa. Hypertensionb. Hyperlipidemiac. Chronic kidney diseased. Malignanciese. Anemiaf. Leukopenia

3. Infectious Complicationsa. Pneumocystis pneumoniab. Cytomegalovirusc. Fungald. BK viruse. Varicella zosterf. Urinary tract infections

1. Visit Frequencya. Months 1, 3, 12, annually and prn

2. Laboratory Frequencya. SEE CHART on OTHER SIDE

3. Protocol Kidney Biopsy Schedulea. Month 3, 12 and 24 and prn

4. Hepatitis B chronic/carrier statesi. Pre-transplant patients must be evaluated

and cleared by hepatologist at NMHii. 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 Schedulea. Vaccinations

i. No live vaccinesii. Annual seasonal influenzaiii. Pneumonia vaccine q5 yearsiv. Hepatitis A and B if not immune

i. Hepatitis B high-dose (40mg) day 0, 7, 28

b. Colonoscopy –per ACS guidelinesc. Pap Smear/HPV testing –annuallyd. Mammogram—per ACS guidelines

i. Annually (with risk assessment)e. Lipids

i. Q6-12 monthsf. Dermatology screening

i. Annually

Common Medications inAbdominal Transplantation

Post-TransplantComplications

Post-TransplantCare/Management

Reference: American Society of Transplantation, Guidelines for Post-Kidney Transplant Management in the Community Setting, 2009

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+

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 Once Yearly

Urine Dip Every clinic visit Every clinic visit Every clinic visit Every clinic visit Every clinic visit

BK screening 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

Cpeptide & A1c+ Once Every 3 months Every three months

Serum pregnancy test* First visit One month 3 months 6months Annually

HBV DNA PCR Quant; HBsAg

At month 3 Q3months Q6 months

NOSOCOMIALTECHNICAL

DONOR/RECIPIENT

Activation of Latent Infections, Relapsed, Residual,

Opportunistic Infections

COMMUNITYACQUIRED

Common Infections in Solid Organ Transplantation RecipientsAntimicrobial-resistant species• MRSA• VRE• Candida species (non-albicans)

AspirationsLine InfectionWound InfectionAnastamotic Leaks/IschemiaC. Difficile colitisDonor-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 complicationsWithout Prophylaxis Add:PenumocystisHerpesviruses (HSV, VZV, CMV, EBV)Hepatitis B virusListeria, Nocardia, ToxoplasmaStrongyloides, Leishmania, T.cruzi

Community Acquired Pneumonia Urinary Tract InfectionAspergillus, 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 WEEKS 1-6 MONTHS > 6 MONTHS

Donor-Derived

Recipient-Derived

The Timeline of Post-Transplant InfectionsModified from 1-3