Chapter 102: Solid Organ Transplantation: Kidney—Don’t Fail Me Now! Level III

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LEARNING OBJECTIVES

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

• 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.

PATIENT PRESENTATION

Chief Complaint

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

HPI

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.

PMH

• 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

FH

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.

SH

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

ROS

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.

Meds

• 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

All

Sulfa (rash)

Physical Examination

Gen

WDWN man in NAD

VS

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″

Skin

Warm and dry

HEENT

PERRLA; EOMI