caring for transplant patients
TRANSCRIPT
![Page 1: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/1.jpg)
Caring for transplant patients Silviana Marineci MD
1
![Page 2: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/2.jpg)
Case 1: infection • 65 yo M with PMH significant for LDKT in 2017 , on MMF 1.5 g ,
Tacrolimus 1.5 mg BID and Prednisone 5 mg , presented to ED with dysuria. BP of 90/60 mmHg, HR of 100. UA: WBC of 118, RBC of 15, pos for bacteria . Uc pending. He has leucocytosis with WBC of 26.000 mg/dl. After 3 L of NS his BP is still 90/60. He is started on Ceftriaxone 2 g and Levophed. What you will do with his immunosuppression:
• A. Hold Tacrolimus and give stress dose steroids
• B. Hold MMF , send tacrolimus level and give stress dose steroids
• C.Hold MMF, Tactrolims and give stress dose steroids
• D. Continue with the same immunosuppression
2
![Page 3: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/3.jpg)
Case 2: malignancy • 70 yo F with DDKT in 2016, on MMF 500 mg BID, Tacrolimus 1 mg BID,
presented to the hospital with intractable headache. A CT of the had was done. Patient is found with a brain tumor. What is the best answer regarding this patient tumor:
• A. This is PTLD, patient was EBV neg and he got an EBV pos. Kidney
• B. This is PTLD, patient was EBV neg and he got an EBV negative kidney
• C. This is PTLD, patient was EBV positive and he got an EBV positive kidney
• D. This is PTLD, patient was EBV positive and he got EBV negative kidney
• E. This is PTLD, EBV status dose not play a role in incidence of PTLD
• F. This is metastatic disease from of unknown cancer since she is on immunosuppression and this put her on increase risk of malignancy
3
![Page 4: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/4.jpg)
Case 3: pregnancy immunosuppression
• 25 yo F with LDKT in 2016 from her sister, on MMF and Tacrolimus was admitted to the hospital for bacterial pneumonia. She is ready to be discharge. While you are talking with her about discharger follow up, she tells you she plans to become pregnant. What do you think is the best advice for her:
• A.Is to soon after the transplant to be pregnant
• B. Please follow up with your transplant nephrologist to adjust your immunosuppression
• C. Explain that pregnancy will increase her risk for rejection
• D. Explain to her that Tacrolimus is associated with IUGR
• E. All of the above
• F. B,C and D
4
![Page 5: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/5.jpg)
Case 4: surgery and immunosuppression
• 78 yo M with PMH significant for LDKT 6 years ago, on Sirolimus, MMF 1 g BID and Prednisone 5 mg QD, came to the hospital with SBO. Initial conservative management failed, and the patient will need surgery. Witch of the following you will consider to change in the immunosuppression of this patient:
• A. Stop Sirolimus, consider to switch to Tacrolimus based on his immunologic risk
• B. Switch MMF to AZA
• C. Give stress dose steroids during surgery
• D. Give stress dose steroids and give MMF iv
• E. A and D
5
![Page 6: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/6.jpg)
Case 5: medication interaction
• 57 yo F with past medical history for DMT2, COPD,ESRD status post DDKT in 2014, came to ED with seizure after she stopped taking her Phenytoin. She is on Tacrolimus 1 mg BID and MMF 750 mg BID. When you examine her you notice tremor of the heads. No graft tenderness. On her labs her Cr is 2. She tells you she stop taking her Phenytoin one week ago. She noticed lately some decrease in her urinary output. You order UA, US of the transplanted kidney. What do you do next:
• A. Send Tacrolimus level and call IR / nephrology consult for possible kidney Bx thinking this is rejection because the Tacrolimus level decreased after stopped taking her Phenytoin
• B. Send Tacrolimus level, call nephrology consult and hold his next Tacrolimus dose, thinking this is Tacrolimus toxicity
• C. Send MMF level, call IR/nephrology consult for possible kidney Bx thinking MMF level was to low after stopping Phenytoin and patient has an acute rejection
• D. Send MMF level, call nephrology consult and hold MMF, thinking that this is MMF toxicity
6
![Page 7: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/7.jpg)
Case 6:Side effects of immunosuppression
• 55 yo AA F with PMH of DDKT in 2013, on Tacrolimus 3 mg BID MMF 750 mg BID and Prednisone 5 mg QD was admitted with HCAP. During her hospitalization she has been having elevated glucose. FS 250 mg most of the time. A Hg A1c was checked, and is 9. Witch of her medication makes diabetes worse.
• A. Prednisone
• B. MMF
• C. Tacrolimus
• D. A and B
• C. A and C
7
![Page 8: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/8.jpg)
Case 7: graft function • 55 yo F school teacher, with a SKPT in 2014 on Tacrolimus, MMF and Prednisone came
to the ED with diarrhea over the last 5 days. She was found with low BP of 90/60 mmHg, HR of 100 bit/min. On labs she has a Cr of 2 ( baseline one mo ago was 1) with BUN of 40 mg/dl. Her Na is 132 mg /dl, with bicarbonate of 20s. Stool studies found her with norovirus infection. She gets 2 L of NS.Her BP goes to 120s/70s. She feels much better. Her diarrhea persist. Next day you check her Cr. Is now 3. What do you do next:
• A. Give one dose of steroids, call IR to schedule a kidney Bx and call transplant /nephrology consult
• B. Send UA, Uc do an US of the kidney
• C. Check tacrolimus level
• D.Check MMF level
• E. B and C
• F. B and D
8
![Page 9: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/9.jpg)
Why is it important to know about transplant patients
• 739,437 transplants since January 1988 1
• 17935 organ transplants were performed in 2018 2
• On average 95 transplants take place each day in US 1
• 244 kidney transplant center in US
• 5534 registered hospitals in UA 3
91.OPTN 2.UNOS. 3.AHA
![Page 10: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/10.jpg)
Transplants by organ type Jan 1988-July 2018
10
1%5%
10%3%1%
22% 59%
UNOS
![Page 11: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/11.jpg)
Data from our hospital
• 47 transplanted patients in our hospital were admitted in 2018
11
![Page 12: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/12.jpg)
Question?
• Do we know what we don’t know?
12
![Page 13: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/13.jpg)
Particularities of transplanted patient
• Graft ( transplanted organ) - function
• Chronic immunosuppression
• Complex patients with multiple comorbidities
13
![Page 14: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/14.jpg)
Graft/kidney -function• Goal to keep the organ working as long as
possible
• LD kidney last approximatively 20 years
• DD kidney last approximatively 10-12 years
•
14
![Page 15: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/15.jpg)
Complex patient with multiple comorbidities
• Number one cause of ESRD is still T2DM
• Chronic immunosuppression more prone to infection and virus related malignancy
15
![Page 16: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/16.jpg)
Chronic immunsuppression
• Patient is on medication that comes with side effects that can be the cause of patient symptoms
• Predispose to infection, different forms of malignancy
16
![Page 17: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/17.jpg)
How do assess graft function
• What is the baseline Cr ?
• What is the maintenance immunosuppression regiment ?
• When was the last time when the patient took immunosuppression medication ?
17
![Page 18: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/18.jpg)
Cr elevated
• Is this a rejection ?
18
![Page 19: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/19.jpg)
Is this rejection?
• What is the risk of rejection ?
• Was the immunosuppression compromised by admission disease ?
19
![Page 20: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/20.jpg)
What is the risk of rejection for this patient
• How long ago was the transplant ?
• Other important factors: age of transplant, patient race , type of transplant , prior transplant, prior rejection
• High risk: 18-60 yo,Black, DD, previous transplant, combined transplant ( except liver), previous rejection, late rejection after transplant
• Other risk factor (unlikely to get them from the patient):HLA A,B, DR>1 mismatch
• Type of transplant: intestine>lung>heard>pancreas> kidney>liver
20
![Page 21: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/21.jpg)
Was the immunosuppression compromised by admission disease
• Recent change in medication that can interfere with metabolism of immunosuppression
• Inability to take their medication: nausea, vomiting, SBO.
• Pregnancy
21
![Page 22: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/22.jpg)
Immunosuppression
• What regiment it patient on ?
• Has he/she been taking her medication?
• When was the last dose?
22
![Page 23: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/23.jpg)
Immunosuppression • Immunosuppression medications by class
• Current most used maintenance immunosuppression therapy for kidney transplant
• Medication interaction
• Medication side effects
• Immunosuppression / graft function/ admission diagnosis interrelation
23
![Page 24: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/24.jpg)
Immunosuppression medication by class
24
Belatacept
mTOR Sirolimus and Everolimus
CNI Tacrolimus and Cyclosporine
Steroids Prednisone
Antimetabolite MMF and AZA
![Page 25: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/25.jpg)
How do they work
25
![Page 26: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/26.jpg)
Chronic immunosuppression protocols 2018
• Main protocol: MMF, CNI with or without Prednisone 0.1 mg /kg/day
• Other protocols: combination of antimetabolite with MTOR , Bellatacept, Prednisone and antimetabolite.
26
![Page 27: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/27.jpg)
Medication side effect by class
27
![Page 28: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/28.jpg)
Tacrolimus vs cyclosporine • Nephrotoxicity
• Hypertension (CSA >Tacro)
• Post-transplant DM ( Tacrolimus > CSA)
• Neurological ( Tacrolimus)
• Hirsutism ( CSA) / Alopecia ( Tacrolimus)
• HLD ( CSA> Tacrolimus) 28
![Page 29: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/29.jpg)
Sirolimus vs Everolimus • Acne/rash
• Mouth ulcers
• HLD
• anemia/thrombocytopenia
• Proteinuria ( rare) : Bx: FSGS, podocyte injury
• Pneumonitis ( 4-11%) Sirolimus > Everolimus
• Sirolimus: anemia, NODAT
29
![Page 30: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/30.jpg)
Belatacept
• EBV seronegative recipients have a 9 th fold increased risk of CNS PTLD .
• EBV sero-positive recipients treated with Belatacept still have an increase risk of PTLD compared with patients treated with Cyclosporine
30
![Page 31: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/31.jpg)
MMF vs Azotioprine
• Bone marrow toxicity (AZA >MMF)
• MMF birth defect
• MMF dose related nausea, gastritis and diarrhea
31
![Page 32: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/32.jpg)
Prednisone
• HTN
• DM
• Aseptic necrosis of the femoral head, osteoporosis.
• Other side effects: GI, skin, muscle, fracture
32
![Page 33: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/33.jpg)
Medication interaction with common used drugs
33
![Page 34: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/34.jpg)
Important CNI medication interaction
• Drug that increase CNI level
• Drug that decrease CNI level
• Other medication interaction
34
![Page 35: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/35.jpg)
Drugs that increase CNI level
• Ca channel blockers : Diltiazem, Verapamil, Amlodipine, Nicardipine (40% dose reduction)
• Antifungal agents: Ketoconazole, Fluconazole, Itraconazole, Voriconazole (80% dose reduction ).
• Antibiotics: Macrolide (Clarithromycin), Chloramphenicol (Tacrolimus), Erythromycin
• mTOR: increase CNI level
35
![Page 36: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/36.jpg)
Drugs that decreased CNI level
• Antituberculosis drugs: Rifampin, Rifabutin, Isoniazid
• Anticonvulsant: Barbiturates, Phenytoin, Carbamazepine
• Herbal preparation: St. John’s wort
• Cholestiramine ( decreased absorption)
36
![Page 37: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/37.jpg)
Exaggerate side effects of other medications
• Rhabdomyolysis: Lovastatin used with CSA ( 6 weeks to 16 mo after starting the therapy) . Recommended dose is 20 mg.
• Nephrotoxicity: Amphotericin, NSAID, ACE,ARB
• Hepatotoxicity: Ranitidine and CSA
37
![Page 38: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/38.jpg)
Elevated Cr
• Look for nephrotoxicity from CNI. Check 12 hours levels for Tacrolimus and CSP
• Look for drug interaction and inquire regarding change in medication
• Look for caused of change in drug levels : diarrhea increased tacrolimus level
38
![Page 39: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/39.jpg)
Admission diagnosis interrelation with chronic immusuppression
• Infection
• Malignancy
• Cardio vascular
• Diabetes
• Surgery
39
![Page 40: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/40.jpg)
Concepts in transplant patients with infection
• Patient is on chronic immunosuppression
• Screen for atypical infection: CMV , EBV, BK
• If you patient is septic : hold MMF, consider stress dose of steroids if you patient has been on Prednisone form more then 6 mo
• Consider longer treatment for infection, ID consult
• If recurrent infection contact the transplant center with regard to reduction in immunosuppression.
40
![Page 41: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/41.jpg)
Common infection
•
• Late infection
41 Fishman, NEJM 2007,357,2601-2614
![Page 42: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/42.jpg)
BKV• Polyomavirus present in the urinary tract
• Can cause nephropathy or urinary tract stenosis
• Dx: elevated Cr and BKVL >10.000. Kidney Bx
• Treatment :
• Prevention: BK screening mo for first 3 mo, then every mo until one year
• BK VL >10.000 copies, reduce immunsuppression
• Bx proven BK nephropathy: Tacrolimus level <6, switch MMF to Lefunomide
42 KIDIGO 2009 care of patient with transplant
![Page 43: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/43.jpg)
CMV• CMV disease: clinical signs and symptoms and CMV VL present in
plasma
• Manifested: viral illness with leucopenia and lymphocytosis or tissue invasion ( Pneumonitis, diarrhea)
• Treatment:
• Prophylactic: treatment with Valgancyclovir or Gancyclovir 3-6 mo after transplant. Exception CMV Donor neg /Rec. neg
• CMV disease: tissue invasion -iv Gancyclovir, non-invasive -iv Gancycolvir or po Valancyclovir , until CMV by NAT is negative.
• CMV VL by NAT will be checked weekly
43 KIDIGO 2009 care of patient with transplant
![Page 44: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/44.jpg)
EBV• High risk recipients: EBV negative with donor
EBV positive
• High risk recipients: monitor EBV VL every mo 3-6 mo, then every 3 mo until one year.
• Treatment:
• EBV VL increase, reduce immunosuppression
44 KIDIGO 2009 care of patient with transplant
![Page 45: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/45.jpg)
Malignancy risk
45
Increased incidence of cancer Much higher Higher Skin Uterine cervix Kaposi’s. Liver Vulvovaginal Lymphoma Kidney
Not diffrent Breast Prostate Testicular Ovarian Lung Colon
![Page 46: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/46.jpg)
Recurrent Skin cancer • Skin cancer incidence in transplant patients: SCC 100 % increased risk, BCC and
melanoma
• Risk factors: age at transplantation >55 yo, duration of immunosuppression (40-60% by 20 years), organ transplanted ( heart, kidney, liver)
• Treatment:
• Non-melanoma
1. Call transplant center since you patient can benefit from reduction in immunosuppression change in immunosuppression like switch form CNI to mTOR1
2. Use Acitretine topical 2
3. Nicotinamide 500 mg BID 3
• Melanoma: call your friend oncologist
46
1.Stallone G, NEJM 2005;352-1317 2.KIDIGO 2009
![Page 47: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/47.jpg)
PTLD • Lymphoma occurring post-transplant related to
immunosuppression
• EBV mediated (80%), or not mediated
• Most within 2 years post-transplant
• Increase risk with high immunosuppression
• Lesions within transplanted organs are common
• Treatment: Lower immunosuppression, Rituximab and Chemotherapy
47
![Page 48: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/48.jpg)
Cardio vascular • Number one cause of death with a functional graft
• Transplanted patients have an increase risk of cardiac death compared with general population
• Some of immunosuppression medication cause: HLD, DM
• Treatment:
• Consider managing at list as intensive as in general population 1
• ACE and ARB have been associated with post-transplant anemia
• HLD:mTOR, more with CSA >Tacrolimus
• mTOR could be anti-atherogenic
• Precaution with CNI and Lovastatine
48 KIDIGO 2009 care of patient with transplant
![Page 49: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/49.jpg)
Diabetes • NODAT / diabetes at the time of transplant
• Risk factors for NODAT : mTOR, Tacrolimus > CSA .
• NODAT increase risk of cardiovascular events
• Treatment:
• ASA 81 mg if DM /NODAT and age >40 yo, smoking, HLD,HTN, family history of CV disease
• Glycemic control: Hg A1c 7-7.5
• Consider modifying immunosuppression therapy to revers or ameliorate diabetes, after weighting the risk of rejection and other potential adverse effect
49 KIDIGO 2009 care of patient with transplant
![Page 50: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/50.jpg)
Surgery
• Switch immunosuppression to iv
• Switch mTOR to CSA or Tacrolimus
50
![Page 51: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/51.jpg)
51
Transplanted organ function
Diagnosis of admission
Meintanance immunosupresson
![Page 52: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/52.jpg)
Safe discharge • Call transplant coordinator and inform her about
the patient hospitalization and any new medication
• Have follow up on immunosuppression drug levels after hospital admission, if during the hospitalization there was any change in the patient medication or the drug levels were not at goal.
52
![Page 53: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/53.jpg)
Conclusions
• Transplant patient is complex
• Immunosuppression medication plays an important role in some of the common diseases requiring hospitalization
• The goal is to keep the patient alive and keep the graft functioning
53
![Page 54: Caring for transplant patients](https://reader031.vdocument.in/reader031/viewer/2022013101/61d1ca19f0d0d5332c2830d0/html5/thumbnails/54.jpg)
Thank you !
54