Immunology Review
This signal involves antigen-presenting cells binding to the T-cell receptor.
What is Signal 1?
This is the maximum single dose of thymoglobulin
150 mg
Name 3 factors that affect induction agent selection
Younger recipient age, number of HLA mismatches, older donor age, African-American ethnicity, PRA >0%, presence of DSA, blood group incompatibility, delayed graft function, cold ischemia time >24 hours
This medication is always given regardless of induction regimen and involves a tapering schedule.
What is methylprednisolone?
An endocrinology fellow asked to schedule insulin NPH to be given with the patient's daily steroid dose. Currently the patient is POD1 and has methylprednisolone scheduled at 1300 before their thymoglobulin dose at 1400 on POD1 and POD2, but their prednisone taper starting POD3 is set to be given daily @0900. What would you do?
Do NOT re-time the methylprednisolone to 0900 as they need to be given 1 hour prior to thymoglobulin infusions. Schedule NPH at 0900 daily or can do one time doses at 1300 on POD1 and POD2 the start daily 0900 NPH on POD3.
These antibodies are directed specifically against donor antigens and increase rejection risk.
What are donor-specific antibodies (DSA)?
What are the two thymoglobulin products that are available and which one do we use for induction at HFH?
Rabbit and horse. We use the rabbit thymoglublin.
These kidney transplant recipients should receive no induction
Living Related Donor Transplants that are:
This medication has immunosuppressant effects that can last anywhere from 6 months to a year and requires frequent monitoring during the infusion.
What is thymoglobulin?
A patient is currently POD1 in the SICU post kidney transplant and their induction regimen is 2 dose thymoglobulin via central line. The SICU team wants to remove the central line. What should you recommend?
Change the current central t
Expressed as a percentage, this lab test measures the level of sensitizing antibodies in a patient's blood to determine how likely they are to reject a transplant.
What is Panel Reactive Antibody (or PRA)?
These are the pre-meds required for thymoglobulin
Diphenhydramine 50 mg IV, methylprednisolone 250 mg IV, and acetaminophen 650 mg PO given 1 hour before each dose
These kidney transplant recipients should receive basiliximab induction
Non-African American patients with cPRA <20% that are:
Non-African American patients with cPRA ≥20% that have:
What is basiliximab?
A doctor from the OR calls central pharmacy saying they placed a stat order for thymoglobulin for a kidney transplant that is happening now. They ask you to tube the thymoglobulin to tube station 508. What do you do?
Tell them you will make it in the IV room stat and that unfortunately the medication cannot be tubed so please send someone to come to the pharmacy to pick it up.
These are the differences between induction and maintenance immunosuppression.
Induction is high-intensity immunosuppression, administered intra-op and immediately post-transplant to prevent rejection when patients are at the highest risk. While maintenance is less intense lifelong immunosuppression to prevent organ rejection long term.
If rituximab and thymoglobulin are both indicated for a patient what are the administration considerations?
Rituximab infusion should be administered prior to thymoglobulin if both are indicated. Rituximab and thymoglobulin should NOT be given through the same IV access.
These kidney transplant recipients should receive 2 doses of thymoglobulin
Deceased donor transplants who are:
This induction agent that depletes both T and B cells is only available through a direct distribution from the manufacturer
What is alemtuzumab?
The transplant team wants to discharge a patient on POD3 because they are stable to go home. They received basiliximab 20 mg IV induction on POD0. What are the next steps?
Administer a second dose of basiliximab 20 mg IV on POD3 before the patient leaves.
This cytokine is central to T-cell proliferation and is the downstream target of multiple induction agents.
What is IL-2?
How must thymoglobulin be administered peripherally?
Infuse over 12 hours via a large bore peripheral IV (18 g or greater is preferred). A back-up peripheral IV site must be present in the event that the peripheral IV develops phlebitis or infiltrates. Use a 0.22-micron filter.
These kidney transplant recipients should receive 3 doses of thymoglobulin
This induction agent binds to CD20 to deplete mature B cells by various mechanisms such as mediation of antibody-dependent cellular cytotoxicity, complement-dependent cytotoxicity, and B-cell apoptosis
What is rituximab?
A planned A2/A2B kidney transplant is planned and the provider orders Truxima (rituximab-abbs). What are your next steps?
Truxima (rituximab-abbs) is only approved for ambulatory use on our formulary, so ask the provider to change the order to Ruxience (rituximab-pvvr).