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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Develop a patient-specific therapeutic plan for acute cellular rejection following solid organ transplantation.

  • Assess a transplant medication regimen for potential drug interactions and develop a plan to resolve any identified interactions.

  • Describe possible adverse effects of immunosuppressive medications and prophylactic medications for solid organ transplant recipients and develop a plan to resolve these effects.

  • Counsel a transplant recipient on the importance of medication adherence and implement mechanisms to enhance adherence.

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PATIENT PRESENTATION

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Chief Complaint

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“I have pain over my kidney transplant, my legs are swollen, and my urine output is decreased.”

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HPI

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Brent Salston is a 42-year-old man who presents to the renal transplant clinic for evaluation of the above complaints. He states the symptoms began about 1 week ago and have gotten progressively worse.

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PMH

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  • 6 months S/P living kidney transplant from his wife

  • ESRD secondary to IgA nephropathy

  • HTN

  • Gout

  • Peripheral neuropathy, diagnosed 2 weeks ago by PCP

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FH

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Mother is alive with hypertension; father deceased from kidney disease. Two aunts and sister also have kidney disease. He is married with two children, Sarah and Justin, who are alive and well.

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SH

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He drinks beer occasionally with friends, but not since his transplant. He has no history of smoking or IVDA.

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ROS

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He has pain over his kidney and bilateral edema in his lower extremities. He reports mild pain and tingling in lower extremities. Urine output has decreased from baseline.

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Meds

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  • Tacrolimus 4 mg PO BID (last dose taken last night at 8:00 pm)

  • Mycophenolate mofetil 1000 mg PO BID

  • Dapsone 100 mg PO daily

  • Valganciclovir 900 mg PO daily

  • Aspirin 81 mg PO once daily

  • Metoprolol XL 100 mg PO daily

  • Amlodipine 10 mg PO daily

  • Magnesium chloride 64 mg PO BID

  • Allopurinol 100 mg PO daily

  • Carbamazepine 200 mg PO BID, started 2 weeks ago by PCP for neuropathy

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All

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Sulfa (rash)

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Physical Examination

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Gen
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WDWN man in NAD

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VS
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BP 169/92 mm Hg, P 66 reg, RR 14, T 37.4°C; Wt 87 kg (previous Wt 85 kg 2 weeks ago), Ht 5′10″

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Skin
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Warm and dry

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HEENT
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PERRLA; EOMI

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Chest
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CTA & P

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CV
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Normal S1 and S2; no MRG

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Abd
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Tenderness over kidney allograft; ...

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