Renal Transplant Case Study

Renal Transplant Case Study

The function of Prescribed Drugs

In this case study, AJ is a patient undergoing a renal transplant. AJ was prescribed many different types of medication that perform different functions in the body. Preoperatively this patient was given daclizumab; this medication prevents white blood cells from attacking the transplanted kidney by lowering the white blood cell count. It is a medication that is a genetically engineered human IgG1 monoclonal antibody that binds specifically to the chain of the interleukin­2 receptor (Vincenti, 1998). This, in turn, causes the patient’s immune system to become compromised. Mycophenolate and solumedrol were administered preoperatively as well. Mycophenolate is also a medication that lowers the body’s natural immunity in those who received or will be receiving an organ transplant (Mayo Clinic, 2018). Mycophenolate is used in conjunction with other medications, such as Solumedrol. Solumedrol, also known as methylprednisone, is a part of the glucocorticoid family. Corticosteroids such as solumedrol have immunosuppressive, anti­inflammatory and lymphocytic effects. These steroids decrease cytokine production, lymphocyte proliferation, and changes in cellular trafficking (Steiner, 2011). They may block proinflammatory TH1 (Steiner, 2011).

Reviewing the patient’s history, it is noted that AJ was prescribed erythropoietin alfa, sevelamer, furosemide, digoxin, phenytoin, and felodipine. Erythropoietin is a version of human erythropoietin, also known as EPO. EPO is naturally produced in the kidney, and it stimulates the bone marrow to produce red blood cells (Mayo Clinic, 2018). Without EPO, severe anaemia Occurs; EPO cannot be produced from kidneys that are not working properly; therefore, it is a popular medication prescribed to patients who are receiving dialysis and are in kidney failure. Furosemide also known as Lasix is a diuretic. According to the FDA, furosemide is extensively bound to plasma proteins, mainly to albumin and is indicated for the treatment of oedema associated with various diseases, including renal disease and nephrotic syndrome (Pharmacia & Upjohn CO, 2011).

After transplantation, AJ was again prescribed mycophenolate, prednisone and daclizumab. In addition to these medications, sirolimus and Tacrolimus were also prescribed. Tacrolimus is classified as a Calcineurin inhibitor and immunosuppressant. Its function in the body is to block the production of lymphocytes that attack foreign objects in the body. This medication is a big portion of the anti­rejection regimen in transplanted patients. Sirolimus also works similarly to Tacrolimus; however, it is used in combination with other medication and classified as Rapamycin. Sirolimus functions by preventing the white blood cells from getting rid of the transplanted organ.

With transplant medications, there are many adverse effects that can occur despite their benefits. The Corticosteroids, in this case, study, are prednisone and solumedrol, which can cause high blood pressure, high blood sugar levels, and water retention. Many patients who are started on these medications after transplant do need to start taking insulin therapy and are seen by a diabetes educator inpatient. The Calcineurin inhibitors, in this case, Tacrolimus adverse, include diabetes, high blood pressure, and increased risk of lymphoma, kidney damage and liver damage. Sirolimus has similar adverse effects in addition to slow healing of wounds, lung damage and anaemia. Mycophenolate can cause an increased risk of lymphoma as Tacrolimus does; nausea and vomiting are very common adverse effects with patients taking this medication. All of these medications lower white blood cell count and increase the risk of infections (Hertl, 2018).

As previously mentioned, pre­op medications are essential in preparing the patient’s body for the transplanted organ and avoiding acute rejection. Although beneficial pre­op, there could still be implications intraoperative and postoperatively due to the medication. The medication given to AJ preoperatively was mycophenolate, solumedrol and daclizumab. Immunosuppressant medication such as mycophenolate and daclizumab may have a negative effect on wound healing (Willems, 2016) due to and high risk for infection since their function is to lower the white blood cell count that is used to fight infection so that the cells will not attack the transplanted organ. Solumedrol also puts the patient at risk for impaired wound healing and makes one more susceptible to infection than a healthy person. Having a sterile technique and a sterile environment is crucial for the safety of AJ’s life in this operation.

In AJ’s medical history, he has noted natural therapies. AJ has been taking dandelion root, ginkgo, Echinacea and high-dose multivitamins. Dandelion root has a history of being used in traditional Native American, Chinese, and Arabic medical systems (NIH, 2016). Research shows the benefits and potential implications of the utilization of dandelion root, such as, for problems of the liver, gallbladder and bile ducts (NIH, 2016). The National Center for Complementary and Integrative Health states ginkgo is one of the oldest living tree species in the world, traditionally used in Chinese medicine (NIH, 2016). Historically, ginkgo is used for asthma, bronchitis and kidney and bladder disorders. There is a big risk of bleeding associated with ginkgo, studies have also shown ginkgo is associated with an increased risk of developing liver and thyroid cancer (NIH, 2016). This puts this patient at even greater risk, given that AJ was taking immunosuppressant medications preoperatively for infection and certain cancers.

The risk of bleeding should also be closely monitored. Contrary to ginkgo, Echinacea has been seen as an immunoenhancing herb (Miller, 2005). This is why it is a herb that is most commonly used to treat the common cold. The high-dose multivitamins AJ was taking are typically used for the treatment or prevention of chronic diseases (Hamishehkar, 2016). Despite their specific adverse effects, the UHN Multi­ Organ Transplant Program states that for people waiting for organ transplants or those who have had an organ transplant, the use of herbal and/or natural health products may cause serious health problems. The use of these products may lead to infection and even organ rejection.

In preparation for discharge, there is much education that should be done for AJ. AJ will be on many immunosuppressant medications and will be at high risk for infection. AJ should be thought to seek medical attention if signs and symptoms of infection, such as fever, chills, and malodorous drainage from the incision site, occur. Due to the lowered immune system, AJ should also be made aware of wearing a mask in crowded areas such as the mall and hospitals. AJ should also know to avoid contact with persons experiencing any communicable diseases. In addition, diet is a necessary key teaching point in order for AJ to remain healthy and free of infection. AJ should avoid raw foods, including sushi and steaks cooked rarely. Street food should also be avoided. Grapefruit also interacts negatively with Tacrolimus and should not be a part of AJ’s diet. If possible, AJ should also be seen by a diabetes educator due to the increased risk of hyperglycemia caused by corticosteroids. Natural herb therapy should not be taken in order to prevent the risk of organ rejection.

References

Epoetin Alfa (Injection Route) Description and Brand Names ­ Mayo Clinic. (2018). Mayoclinic.org. Retrieved 20 March 2018, from https://www.mayoclinic.org/drugs­supplements/epoetin­alfa­injection­route/description/drg­20068065

Ginkgo. (2018). NCCIH. Retrieved 20 March 2018, from https://nccih.nih.gov/health/ginkgo/ataglance.htm

Interleukin­2–Receptor Blockade with Daclizumab to Prevent Acute Rejection in Renal Transplantation | NEJM. (2018). New England Journal of Medicine. Retrieved 20 March 2018

Light, T., & Light, J. (2003). Acute Renal Transplant Rejection Possibly Related to Herbal Medications. American Journal Of Transplantation, 3(12), 1608­1609. http://dx.doi.org/10.1046/j.1600­6135.2003.00270.x

Miller, S. (2018). Echinacea: a Miracle Herb against Aging and Cancer? EvidenceIn vivoin Mice. Retrieved 20 March 2018,

Pharmacia & UpJohn CO. (2011). SOLU­MEDROL® For Intravenous or Intramuscular Administration. FDA.gov. Retrieved 20 March 2018, from https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/011856s103s104lbl.pdf

Sirolimus (By mouth) ­ National Library of Medicine ­ PubMed Health. (2018). PubMed Health. Retrieved 20 March 2018, from https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0012134/?report=details

Steiner, R., & Awdishu, L. (2018). Steroids in kidney transplant patients. Retrieved 20 March 2018,

(2018). Uhn.ca. Retrieved 20 March 2018, from http://www.uhn.ca/PatientsFamilies/Health_Information/Health_Topics/Documents/Usin g_Herbal_Natural_Health_Products_Transplant.pdf

Willems, M., Hendriks, T., Lomme, R., de Man, B., & van der Vliet, J. (2018). The Effect of Mycophenolate Mofetil on Early Wound Healing in a Rodent Model. Retrieved 20 March 2018

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Renal Transplant Case Study

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Case scenario

A 34-year-old Hispanic American male with end-stage renal disease received a kidney transplant from a cadaver donor, as no one in his family was a good match. His postoperative course was uneventful, and he was discharged with the antirejection drugs Tacrolimus (Prograf), Cyclosporine (Neoral), and Imuran (Azathioprine). He did well for three months and returned to his job as a policeman. Six months after his transplant, he began to gain weight, had decreased urine output, was very fatigued, and began to run temperatures up to 101˚F. He was evaluated by his nephrologist, who diagnosed acute kidney transplant rejection.