Immunosuppression Mastery
Which immunosuppressant is most commonly associated with nephrotoxicity and neurotoxicity in pediatric heart transplant patients?
Tacrolimus (Prograf)
What type of rejection is most common in the first few months post–heart transplant?
Acute cellular rejection
Which virus is closely monitored due to risk of post-transplant lymphoproliferative disorder (PTLD)?
Epstein–Barr virus (EBV)
Why do transplanted hearts often have a higher resting heart rate?
Denervation of the donor heart
A stable transplant patient has a rising lactate with normal vital signs. What should this prompt?
Concern for early graft dysfunction → escalate
A tacrolimus level is supratherapeutic. What electrolyte abnormality is most commonly associated?
Hyperkalemia (often with hypomagnesemia)
A subtle early sign of rejection in infants may include which finding?
Poor feeding, irritability, or tachycardia
Which medication is commonly used for Pneumocystis jirovecii pneumonia (PJP) prophylaxis?
Trimethoprim-sulfamethoxazole (Bactrim)
Which medication class is commonly used to treat post-transplant hypertension?
Calcium channel blockers or ACE inhibitors
Why is strict medication timing critical in transplant patients?
Small timing deviations significantly affect drug levels
Why are calcium channel blockers sometimes avoided or used cautiously in transplant patients on tacrolimus?
They inhibit CYP3A4 and can increase tacrolimus levels
What echocardiographic finding may suggest acute rejection?
Decreased ventricular function or new wall motion abnormalities
Why can transplant patients present with severe infection but minimal lab abnormalities?
Immunosuppression blunts inflammatory markers and WBC response
What hemodynamic change may suggest early graft dysfunction?
Rising filling pressures with decreased cardiac output
A patient vomits shortly after receiving tacrolimus. What is the priority nursing action?
Notify provider—do not automatically re-dose
Mycophenolate mofetil primarily suppresses which immune cell function?
Lymphocyte (T and B cell) proliferation
Why might transplant patients not mount a fever during rejection?
Immunosuppression blunts the inflammatory response
A CMV-positive donor and CMV-negative recipient places the patient at what level of risk?
High risk for CMV infection
Why are beta-blockers often less effective immediately post transplant?
Lack of autonomic innervation
What is more concerning than a single abnormal value in transplant patients?
Gradual trends over time
A transplant patient develops tremors, headache, hypertension, and rising creatinine. Which medication should be suspected?
Tacrolimus toxicity
Endomyocardial biopsy primarily evaluates for which type of rejection?
Acute cellular rejection
What is the most important nursing action when a transplant patient has new-onset diarrhea?
Notify transplant team and assess impact on immunosuppressant absorption/levels
A transplant patient develops sudden hypotension and low cardiac output. What must be ruled out urgently?
Acute rejection or primary graft dysfunction
Which scenario always warrants immediate escalation to the cardiac intensivist?
Any concern for rejection, graft dysfunction, or unexplained hemodynamic change