Published December 2020
Yilin Zhang, MD, Brandon Fainstad, MD
Expert review pending
Objectives
- Describe the constant balance of weighing the value of immunosupression against the risks of cancer, infection and drug toxicity.Â
- Identify common immunosupression drug combinations and timing following solid organ transplant.Â
- Develop a framework for common complications after transplantation based on time out from transplantÂ
Teaching Instructions
Plan to spend at least 30-60 minutes preparing for this talk by using the Interactive Board for Learning/Preparing and clicking through the graphics animations to become familiar with the flow and content of the talk. Print out copies of the Learner’s Handout so learners can take notes.
Begin with reviewing the objectives for the session. All clickable elements are indicated by a cursor element as well as with shading. Some elements can be clicked more than once. The cursor will disappear when all clickable elements are completed. A toolbox will appear next to key tests used in the evaluation of anemia.Â
- Objective 1Â – Review the core principles of balancing immunosuppression. Click on each of the “overimmunosupression” and “underimmunosuppresion” buttons. Have your learners guess which transplants are associated require the highest level of immunosuppresion (most likely to reject) and which require the least. Click anywhere to reveal the answer.
- Objective 2Â – Review the allogenicity of a patient following their time from transplant. Tie this into the type and degree of immunosuppression that is required. Overall, patients are at highest risk of rejection in the first month after transplant, thus they are treated with very strong immunosuppressants such as anti-lymphocyte antibodies and pulse dose steroids. Anti-lymphocyte antibodies and anti-IL2 inhibitors used in transplant result in profound and prolonged immunosuppression.
- Bonus: Antibody therapy for induction can be further separated into T-cell depleting and non-depleting agents (which are then subdivided into polyclonal and monoclonal agents). T-cell depleting agents include OKT3, alemtuzumab, ATG. T-cell non-depleting agents include basiliximab, daclizumab. Differentiating between these medications are outside the scope of this talk, however, T-cell depleting agents are typically associated with more prolonged immunosuppression that can last for several months and are also used for treatment of acute rejection.
- Objective 3 – Several complications can occur after transplant and can roughly be separated by time from transplant (<1 month, 1-6 months, and > 6 months). These complications can be divided into a few broad categories – rejection, medication side effects, infection, malignancy, and surgical complications. Click on each of these sections to reveal more about them.
Estimated time to present: 45 minutes
Printouts
Interactive Boards
For Learning
Use for self-directed learning and for preparing to present
For Teaching
Use for Presenting – there is less text and fewer pop-ups
Take Home Points
- Managing immunosuppression following solid organ transplant is the balance of decreasing the risk of rejection by increasing the immunosupression at the cost of increased risk for infections, cancer and drug side effects.
- Assuming good medication compliance, the first of event of acute rejection is highly unlikely at more than 6 months out from transplant.
- The reactivation infections most commonly associated with immunosupression are most likely to occur between 1 to 6 months out from transplant.
References
- Enderby C & Keller CA. An Overview of Immunosuppresion in Solid Organ Transplantation. AJMC. 2015. 21(1): S12-S23.
- Fishman JA. Infection in solid-organ transplant recipients. N Engl J Med 2007; 357:2601.
- Â Freidberg JW & Aster JC. Epidemiology, clinical manifestations and diagnosis of post-transplant lymphoproliferative disorders. In UpToDate, Freedman SA & Brennan DC (Eds); UpToDate. Waltham, MA. Accessed
- Â Brennan DC, et al. Development of malignancy following solid organ transplantation. In UpToDate, Murphy B (ed). UpToDate. Waltham, MA. Accessed
