Primary Care for the Solid Organ Transplant Recipient

AFP February 1, 2016
– 50% of transplant-related deaths are due to immunosuppressive drugs, mostly infections
– Most immunosuppressive drugs are metabolized via cytochrome P450 3A4 – so lots of interactions
Transplant recipients have increased risk of CAD and cardiovascular death
HTN
– goal (expert recommendation) is less than 130/80 mmHg
– CCB reduce calcineurin-inhibitor-related vasoconstriction – reduce graft loss, but no effect on overall mortality
– NDHP CCBs can reduce dosage requirements and cost of calcineurin inhibitors
– ACEI/ARBs – first line in kidney recipients if Uprot > 1 g/day
– Thiazides good for calcineurin inhibitors, which can elevate sodium
HYPERLIPIDEMIA
– goal LDL < 100 mg/dL (expert recommendation) in liver recipients
– universal statin tx in kidney and heart recipients recommended
– start lower than usual dose – interact with calcineurin inhibitors
CHRONIC KIDNEY DISEASE
– prevent as with everyone else – BP control, glucose control, ACE/ARB.
DIABETES
– Screen per ADA
– Goal A1c < 7%
– new onset T2DM highest in first 3 mos after transplant
OBESITY
– 20-30% of recipients get obese!  Appetite better?
BONE DISEASE
– Osteopenia and osteoporosis common before transplant
– Manage PO4, PTH and vitamin D abnormalities as you would pre-transplant
– Use bisphosphonates  only in the first year post-kidney or -heart transplant
GRAFT DYSFUNCTION
– KIDNEY:  urine protein levels, serum Cr
– LIVER:  transaminases, bilirubin, alk phos
– LUNG:  bronch with biopsy, PFTs
– HEART:  endomyocardial bx
REPRODUCTIVE HEALTH:
– register your pregnant transplant recipients:  www.ntpr.giftoflifeinstitute.org
– men should bank sperm before rapamycin inhibitors
– pregnancy in the first year after transplant is a bad idea
IUD preferred method 
– transplant team consult prior to attempting to conceive ideal
– azathioprine, cyclosporine and tacrolimus have not been associated with birth defects
– high risk of SAb, gest hypertension, preeclampsia, GDM and preterm birth
– most women can breastfeed – follow baby’s drug levels for the first few weeks, stop BRF only if detectable levels
CANCER SCREENING:
– 2x higher rate of common CA:  colon, lung, breast, prostate
– uncommon CA (Kaposi’s, NHL, non-melanoma skin, etc.) up to 20x higher!
– consider more aggressive cervical cancer screening in transplant recipients
skin cancers (SCC, BCC) occur younger and metastasize more often – be aggressive with AKs, have derm check skin yearly
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