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LEARNING OBJECTIVES

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

  • Develop a patient-specific care 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 strategies 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

5 months S/P living kidney transplant from his wife. He is CMV seronegative; his wife (the donor) was CMV seropositive.

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.

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)

ROS

He has pain in the left lower quadrant of his abdomen (at the site of his kidney transplant) and bilateral lower extremity edema. He reports mild pain and tingling in both legs, primarily in his feet. He also notes that his total daily urine output has decreased over the past week; he estimates that he is now producing about 1.5 L of urine/day, compared to more ...

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