© 2014 Direct One Communications, Inc. All rights reserved. 1 Best Practices in the Management of...

© 2014 Direct One Communications, Inc. All rights reserved. 1

Best Practices in the Management of Chronic Care Issues Post Transplant

Robert R. Redfield, MD

University of Wisconsin–Madison School of Medicine and Public Health, Madison, Wisconsin

A REPORT FROM THE 2014 WORLD TRANSPLANT CONGRESS


Minimizing the Risk of Cancer


Epidemiology

Immunosuppression is the primary risk factor for cancer among the transplant population, who have a cancer profile similar to that of individuals infected with HIV or who have AIDS.

When matched for both age and gender, solid-organ transplant recipients have a two- to threefold increased risk of cancer compared with the general population.

Cancer rates in transplant recipients are similar to those of people who are 20–30 years older who did not receive a transplant.

Grulich AE et al. Lancet. 2007;370:59; Engels EA et al. JAMA. 2011;306:1891; Giordano TP et al. JAMA. 2007;297:2010; Webster AC et al. Am J Transplant. 2007;7:2140


Epidemiology continued

When compared with the general population, children who have undergone an organ transplant have 15–30 times the risk of malignancy, whereas organ-transplant recipients > 65 years of age have twice the risk.

Lung-transplant recipients have a higher risk of cancer than do heart- or liver-transplant recipients, due to intensity of immunosuppression they receive.

Several studies also have shown that the use of induction therapy with depleting antibodies increases the risk of cancer post transplant.

Na R et al. Am J Transplant. 2013;13:174; Collett D et al. Am J Transplant. 2010;10:1889; Euvrard S et al. J Am Acad Dermatol. 1995;33:222; Ong CS et al. J Am Acad Dermatol. 1999;40:27; Opelz G, Dohler B. Am J Transplant. 2004;4:222


Epidemiology continued

Cancer risk post transplant varies by cancer site and type, compared with the risk of the same cancers in the general population, and

is especially high with cancers that can be traced to viral exposure.

Grulich AE et al. Lancet. 2007;370:59; Webster AC et al. Am J Transplant. 2007;7:2140


Screening and Prevention

All transplant recipients should be cautioned about the risks of sun exposure and should be examined regularly by a dermatologist and for removal of suspicious lesions.

Patients with anogenital cancers should be offered vaccination, be counseled on safe sexual practices, and undergo cervical screening.

Transplant recipients should avoid tobacco smoking to minimize the risk of lung cancer and undergo a routine colonoscopy for colon cancer screening.

Patients with ulcerative or primary sclerosing colitis should be screened more frequently.


Screening and Prevention continued

The intensity of immunosuppression should be minimized, if possible.

Because azathioprine therapy has been associated with an increased risk for developing non-melanoma skin cancers, lip cancer, and non-Hodgkin’s lymphoma, discontinuation of azathioprine therapy should be considered if these cancers develop.

Treatment with sirolimus has antineoplastic effects and should be considered in patients with a history of malignancy.

Stallone G et al. N Engl J Med. 2005;352:1317


Hypertension, Hyperglycemia, and the Metabolic Syndrome


Definition and Epidemiology

The term metabolic syndrome describes a collection of modifiable risk factors for cardiovascular disease characterized by obesity, physical inactivity, and insulin resistance:

Pagadala M et al. Liver Transplant. 2009;15:1662

The incidence of metabolic syndrome following transplant is as high as 50%.


Impact on Graft Survival and CHD

The effect of metabolic syndrome during 12 months post transplant on long-term kidney allograft survival (left) and freedom from coronary heart disease (right)

Israni AK et al; PORT Investigators. Transpl Int. 2012;25:748


Screening and Prevention

Because most routine immunosuppressive therapies may induce glucose intolerance, hypertension, and hyperlipidemia, preoperative assessment of patients for the presence of metabolic syndrome is important.

Screening and identification of these cardiovascular disease risk factors both before and after transplant is crucial to optimizing post-transplant care.

Control of weight gain is central to managing metabolic syndrome and for treating dyslipidemia, hypertension, and diabetes; in addition to aggressive lifestyle modifications and pharmacotherapy, bariatric surgery should be considered.

Laish I et al. Liver Transplant. 2011;17:15; Hricik DE. Clin J Am Soc Nephrol. 2011;6:1781; Modanlou KA et al. Transplantation. 2009;87:1167


Management

Once the metabolic syndrome is identified, medical interventions should be used, along with aggressive lifestyle modifications, to reduce weight and blood pressure and improve lipid and glucose levels to:

Hricik DE. Clin J Am Soc Nephrol. 2011;6:1781

Hemoglobin A1c level < 7% Fasting blood sugar level = 70–130 mg/dL

(3.9–7.2 mmol/L) Blood pressure < 140/90 mm Hg in

nondiabetic patients or < 130/80 mm Hg in diabetic patients

Low-density lipoprotein cholesterol level < 130–160 mg/dL (3.4–4.2 mmol/L)


Avoiding Infection When Traveling


Overview

Prophylaxis of infection in immunocompromised transplant recipients is extremely important, especially when they are traveling abroad.

Overall considerations for vaccine recommendations, such as destination and likely risk of exposure to disease, are the same for immunocompromised patients as for any other traveler.

In general, live vaccines are contraindicated in solid-organ transplant recipients on immunosuppressive therapy, but their use is usually safe in close household contacts who are immunocompetent.

Boggild AK et al. J Travel Med. 2004;11:37; Kotton CN et al. Am J Transplant. 2005;5:8; Ryan ET, Kain KC. N Engl J Med. 2000;342:1716


Overview continued

Intravenous administration of immunoglobulin may provide protection against measles, mumps, rubella, varicella, hepatitis A, and rabies when vaccination is contraindicated or time to develop immunity is insufficient.

Travelers who cannot tolerate recommended immunizations or prophylaxis should consider deferring their trip.

For solid-organ transplants, the risk of infection is highest during the first year after transplant, so transplant patients should consider postponing travel to high-risk destinations until after that time.

Boggild AK et al. J Travel Med. 2004;11:37; Kotton CN et al. Am J Transplant. 2005;5:8; Ryan ET, Kain KC. N Engl J Med. 2000;342:1716


Vaccine Recommendations

Recommended and contraindicated vaccinations for solid-organ transplant recipients

Kotton CN et al. Am J Transplant. 2005;5:8


Vaccine Recommendations continued

Vaccination of transplant recipients may result in a less vigorous immunologic response, especially early after surgery, when the immunosuppressive load is highest.

Guidelines from the AST’s Infectious Diseases Community of Practice suggest that vaccinations be withheld for 3–6 months after transplant.

It is still generally worthwhile to vaccinate, however, since many patients develop some type of response and, thus, protection against disease.

There is no evidence that vaccines increase the risk of allograft rejection.


Hepatitis A and Typhoid Fever

Hepatitis A can be a devastating illness in transplant recipients; therefore, patients should be vaccinated against this virus before traveling.

If transplant patients do not have time or do not respond to active immunization against hepatitis A, they should receive immunoglobulin before traveling.

The majority of Salmonella typhi infections are related to international travel; transplant patients may have severe complications during infection with S typhi and should be immunized against typhoid fever before any travel to endemic areas.


Poliomyelitis

Poliomyelitis essentially has been eradicated from the Western hemisphere; however, wild-type poliovirus still exists in sub-Saharan Africa and South Asia, and transplant recipients need protection when traveling to those areas.

Childhood polio vaccination should be adequate; however, if 10 years have passed since the last dose of polio vaccine was given, booster immunization is advisable, especially for travelers to endemic areas.

Immunity appears to be well maintained after transplant patients are revaccinated with polio vaccine.

Ljungman P et al. Bone Marrow Transplant. 2004;34:1067


Meningitis and Yellow Fever

Meningococcal vaccine is indicated for transplant recipients traveling to areas with known outbreaks of meningococcal disease (eg, sub-Saharan Africa).

Yellow fever is a mosquito-borne illness endemic to South America and sub-Saharan Africa; the fatality rate from this infection is high, and no specific treatment exists.

Only a live attenuated vaccine is available; transplant patients should be cautious about traveling to endemic areas.

If travel is mandatory, it should be avoided during peak infection months.


Rabies and Japanese Encephalitis

Pre-exposure rabies immunization may be indicated for travelers expecting to be exposed to animals that might be infected; however, transplant recipients receiving immunosuppression may not mount an adequate antibody response to the rabies vaccine.

Human rabies immunoglobulin should be given to transplant patients after all risk exposures.

Immunization against Japanese encephalitis is appropriate for individuals traveling to rural, endemic areas of Asia, especially during periods of increased transmission.

Gibbons RV, Rupprecht CE. JAMA. 2001;285:1574


Malaria

Malaria is a significant risk for transplant recipients traveling to endemic areas.

There is no evidence that the incidence of malarial infection is higher or that the severity of the disease is worse in immunocompromised patients other than asplenic patients

Asplenic patients should be aware of their increased risk of morbidity and mortality from malaria; otherwise, standard prophylactic precautions should be taken.


Traveler’s Diarrhea

Travelers’ diarrhea can be life-threatening for transplant patients.

Travelers who have undergone transplant surgery should carry ciprofloxacin or azithromycin for self-treatment of symptoms lasting more than a few days.

Patients who experience fever, vomiting, or bloody stools while traveling should consider seeking medical attention.

Travelers should be counseled about food and water precautions; in general, they should drink bottled or boiled water and avoid consuming drinks containing ice and raw foods that cannot be peeled.

© 2014 Direct One Communications, Inc. All rights reserved. 1 Best Practices in the Management of...

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