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Role of Primary Care in Transplant Patient Management

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Section 1: Transplant Patient Management

What is the role of a primary care physician after intestinal transplant?


Due to the increase in intestinal and multivisceral transplants' success, more patients will be returning home and to their primary care providers for continued care. As more patients are expected to survive beyond the initial months after surgery, they can be expected to develop more conditions associated with their immunosuppressive therapy that primary care providers must identify, treat, or refer to a subspecialist if necessary. The primary healthcare professional is critical in coordinating the care of the transplant patient to maximize care, avoid errors, and minimize duplication of tests. Additionally, primary care professionals are key in helping patients adhere to complex transplant medication protocols and post-transplant lifestyles.




What are common conditions associated with immunmosuppressive therapy?


Conditions associated with immunosuppressive therapy include, but are not limited to:

  • Hypertension
  • Diabetes
  • Hyperlipidemia
  • Obesity
  • Cardiovascular disease
  • Cerebrovascular disease
  • Osteoporosis
  • Chronic kidney disease
  • Cancer Screening- Immunosuppression is associated with the increased risk of malignancy; transplant patients have at least 2-3 times higher risk of developing cancer compared to the general population, thus following regular cancer screening guidelines is vital.




Fluid and Electrolyte Management





Stoma Closure


The intestinal patient’s stoma is usually closed 6-12 months post-transplant. The site usually heals on its own, but wound infection or intestinal obstruction can occasionally complicate the procedure.




Chronic Kidney Disease Post-Transplant


It is well known that calcineurin inhibitors, like tacrolimus, have nephrotoxic effects. Since intestinal transplant patients are on high doses of these immunosuppressive agents, they are at high risk of kidney disease, dialysis, and ultimately kidney transplant. Since renal dysfunction is associated with poor outcomes after intestinal transplant, it is important to take maximal care when attempting to preserve native renal function. Weekly or bi-weekly monitoring of serum creatinine, GFR, and BUN levels is essential and prompt intervention is necessary when indicated.




Dental Health Post-Transplant


It is recommended that transplant patients receive routine dental cleanings. Prior to any dental work or cleaning transplant patients should receive antibiotic prophylaxis to avoid potential infection.




Monitoring for Allograft Dysfunction


As a primary caregiver, it is essential that you monitor the status of your patient’s graft on a regular basis. It is important that you understand and recognize the signs and symptoms that may indicate when something is wrong and should prompt a call to the transplant team. Once an intestinal patient leaves his or her respective transplant center, they will still be required to receive surveillance biopsies every 3-6 months or as a frequency indicated by their transplant team. Aside from surveillance biopsies, a biopsy should also be initiated when a patient reports signs and symptoms of possible acute rejection/ graft dysfunction, which include:

  • Increased or decreased stomal output.
  • Fever
  • Vomiting or high gastric residuals.
  • Abdominal pain or distention.
  • Changes in stomal color or perfusion.
Differential diagnosis to acute rejection includes:
  • Systemic viral or bacterial infection.
  • Infective enteritis.
  • PTLD
  • Intestinal perforation.
  • Intestinal obstruction.




Immunizations


Primary care providers should advise all patients to update all immunizations prior to transplant and avoid all live vaccines post-transplant. Killed and toxin derived vaccines are safe for transplant recipients, but many recipients are uninformed about immunizations, so proper education by the primary care provider is important for transplant patients. Safe Killed Vaccines

  • HPV
  • Hepatitis A
  • Hepatitis B
  • Influenza (injectable form)
  • Diphtheria toxoid
  • Tetanus toxoid
  • Pertussis
  • Hemophilus influenza type B (Hib)
  • Inactivated polio
  • Pneumococcal
  • Meningococcal
  • Rabies
  • Typhoid
  • Japanese encephalitis virus
Controlled Live Virus Vaccines
  • Varicella
  • Herpes zoster
  • Intranasal live attenuated influenza
  • MMR
  • Oral polio
  • Oral live attenuated typhoid
  • Calmett-Guerin bacillus (BCG)
  • Yellow Fever




Drug Interactions


Primary care providers must also be aware that many drugs commonly interact with immunosuppressive medications. The interactions can either have pharmacokinetic or pharmacodynamic effects, thus, it may increase or decrease the amount of the immunosuppression in the body. The calcineurin inhibitors (CNIs), cyclosporine and tacrolimus, are substrates for the cytochrome P450 3A4 (CYP 3A4) enzymes, a common pathway for the metabolism of many drugs, as a result, many pharmokinetic drug interactions are reported with CNIs. When selecting new medications for transplant patients, primary care healthcare professionals must judiciously consider all interactions to adjust immunosuppression dosage accordingly and consult with the transplant team if any uncertainty arises.




Mental Health Post-Transplant


Primary care healthcare professionals can play a vital role in screening and periodic assessment of depression and anxiety in transplant patients. Depression may appear at any stage of the transplant due to psychological stressors, medications (such as steroids), or physiological disturbances. Patients who were depressed have been found to have decreased compliance, thus early identification and treatment is crucial to avoid any detriment to the graft or patient.





Section 2: Additional Resources

Journal Article: Primary Care of the Solid Organ Transplant Recipient


Primary Care of the Solid Organ Transplant Recipient Authors: Francesca Cimino and Katherine Snyder, Year: 2016




Journal Article: Pediatric intestinal and multivisceral transplantation.


Pediatric intestinal and multivisceral transplantation: a new challenge for the pediatric intensivist. Authors: Hauser et al., Year: 2008




Helpful Website: American Society of Transplantation


American Society of Transplant Page for Non-Transplant Physicians: Although not specific to intestinal transplant, still a useful resources on managing transplant patients.




Page References


References here.