器官移植临床案例分析一CaseNum213PtName Heidi MaryamAddress2202 SW Sam JacksonAge59Height6' 0"Weight198 lbSex FRace WhiteAllergies NKDASectionName Organ TransplantationCaseName Cardiac TransplantationChiefComplaint Orthotopic heart transplantation HxPresIllness HM is a 59-year-old Caucasian female with a history of viral cardiomyopathy diagnosed approximately in 1999. She has had progressive heart failure over the past 2 years with shortness of breath, edema, and severe limitation of activity and is currently maintained on dobutamine and nitroprusside. Attempts to wean off of her inotropic support were unsuccessful. Patient was listed and considered for heart transplantation 3 weeks ago. Past medical history is significant for severe depression, gout, and herpes zoster. After finding a suitable donor, patient underwent heart transplantation for viral cardiomyopathy.PastMedicalHxUnstable anginaStatus post cerebrovascular accident2AnemiaDepressionIngrown right first toenailGoutHerpes zosterVentricular arrhythmiaSocialHx Smoking for 20 years<br>No illicit drug use<br>Married with five childrenFamilyHx Her mother and father are alive, and she has no family history of viral cardiomyopathy or MI.ReviewOfSystems The patient denies any fever, chills, back pain, dizziness, weakness, chest pain, shortness of breath, or rash. She does have fatigue. No symptoms of gastroesophageal reflux, dysphagia, odynophagia, lower extremity edema, or gastrointestinal bleeding. She does have occasional lower extremity paresthesias. No abdominal bloating or cramping. The remainder of her review of systems is noncontributory.PhysicalExam A 59-year-old female in no acute distress. Vital signs are stable. Blood pressure 158/79 mmHg, heart rate 93, respiratory rate 20, temperature 37.1. Oxygen saturation at room air is 98%.Postoperative heart transplant day 2CHEST: Respirations are even and unlaboredLUNGS: Clear to auscultation. No accessory muscle use noted. No retractions noted. CARDIAC: S1, S2, irregular rate and rhythm irregular, rubs and significant gallopsGI: Bowel sounds are present. No masses or organomegaly noted.EXTREMITIES: There is noted lower extremity pitting edema bilaterally, which the patient states is her norm. Dorsalis pedis pulses 2+ bilaterally.NEUROLOGIC: Without asterixis. She has no focal neurological deficits.LabsAndDxTestsSodium 141 mEq/LPotassium 4.1 mEq/LChloride 102 mEq/LCO2 24 mEq/LGlucose 99 mg/LAlbumin 3.7 g/LHCT 41%3Hemoglobin 10.6 g/dLDiagnosis Heart transplantationRxRecordDate6/1 6/1 6/1 8/10 5/2 5/2 6/1 10/1 10/1Rx NoD245536 D455537 D244538 D246539 D246555 D246555 D346876 D368654 D468762 Physician@ @ @ @ @ @ @ @ @Drug and Strength Cellcept Cyclosporine100 mgPrednisone5 mgPrevacid30 mgZocor 40mgCapoten12.5 mgZenapax 1mg/kgTacrolimus1 mgMycelexQuantity100 300 500 60 30 100 @ 400 140Sig 1 g po bid 2 po bid 2 po q am 1 po bid 1 po qd 1 po bid q 14 daysfor a totalof 5 doses2 mg pobid10 mg poqidRefills3 2 3 1 6 6 0 6 3 RPhNotes None availableCaseNum213QuestNum2121Question Which two agents act by inhibiting the enzyme calcineurin, which is needed for T-cell activation?AnswerChoiceA Daclizumab and basiliximab AnswerChoiceB Tacrolimus and mycophenolate mofetil AnswerChoiceC Cyclosporine and mycophenolate mofetil AnswerChoiceD Tacrolimus and cyclosporine AnswerChoiceE Cyclosporine and azathioprine4CorrectAnswer DExplanation Both cyclosporine and tacrolimus inhibit T lymphocyte proliferation by inhibiting calcineurin. Cyclosporine inhibits calcineurin by binding to cyclophilin receptors while tacrolimus inhibits calcineurin by binding to FKPB-12.CompetencyStmt 1.2.2K-TypeCaseNum213QuestNum2122Question Cyclosporine trough concentrations should be monitored for:<br>I. efficacy.<br>II. toxicity.<br>III. compliance.AnswerChoiceA I onlyAnswerChoiceB III onlyAnswerChoiceC I and II onlyAnswerChoiceD II and III onlyAnswerChoiceE I, II, and IIICorrectAnswer DExplanation Therapeutic monitoring is used to avoid toxicity and to assessácompliance. Patients with therapeutic blood concentrations are at a lower risk of acute rejection.CompetencyStmt 1.1.4K-Type K5CaseNum213QuestNum2123Question To avoid cosmetic side effects such as hirsutism, coarsening of facial features and gingival hyperplasia, cyclosporine can be replaced with which of the following agents in the same class?AnswerChoiceA Mycophenolate mofetilAnswerChoiceB TacrolimusAnswerChoiceC SirolimusAnswerChoiceD AzathioprineAnswerChoiceE SimulectCorrectAnswer BExplanation The adverse drug reaction profile of tacrolimus is similar to cyclosporine. However, hirsutism and gingival hyperplasia have not been reported with the use of tacrolimus.CompetencyStmt 1.2.4K-TypeCaseNum213QuestNum2124Question Compared to cyclosporine, which of the following statements isáNOT true regarding tacrolimus?AnswerChoiceA Tacrolimus is associated with improvement in 1-year graft survival and mortality rate.6AnswerChoiceB Tacrolimus has fewer rejection episodes. AnswerChoiceC Rejection episodes associated with tacrolimus are milder and more responsive to corticosteroids.AnswerChoiceD Tacrolimus is better at reversing refractory rejection.AnswerChoiceE Tacrolimus is extensively metabolized through hepatic enzymes.CorrectAnswer AExplanation Patient and allograft survival of kidney, heart, and liver transplant under tacrolimus protocols are similar to those of cyclosporine. CompetencyStmt 1.3.1K-TypeCaseNum213QuestNum2125Question Which of the following transplant recipients appear to be at greater risk for nephrotoxicity?AnswerChoiceA Liver transplantAnswerChoiceB Kidney transplantAnswerChoiceC Heart transplantAnswerChoiceD Bone marrow transplant AnswerChoiceE Liver and heart transplant7CorrectAnswer BExplanation Kidney transplant patients are at a greater risk of nephrotoxicity compared to other transplant recipients. Acute tubular necrosis (ATN) is a common problem (30%) following transplantation caused by ischemic injury. Older donors and cold ischemic time greater 24 hours have been known as a risk factor for ATN. Therefore, dosage adjustment is required if nephrotoxicity develops in kidney transplant patients.CompetencyStmt 1.3.1K-TypeCaseNum213QuestNum2126Question Which of the following agents is a monoclonal antibody that inhibits IL-2 receptors?AnswerChoiceA CyclosporineAnswerChoiceB TacrolimusAnswerChoiceC DaclizumabAnswerChoiceD SirolimusAnswerChoiceE AzathioprineCorrectAnswer CExplanation Daclizumab is a humanized IL-2 receptor antagonist that can be used to reduce acute rejection following transplantation. CompetencyStmt 1.2.18K-TypeCaseNum213QuestNum2127Question Which of the following agents consists of 90% human and 10% murine amino acid sequences?AnswerChoiceA BasiliximabAnswerChoiceB DaclizumabAnswerChoiceC MycophenolateAnswerChoiceD TacrolimusAnswerChoiceE CyclosporineCorrectAnswer BExplanation Daclizumab is a humanized (90% human and 10% murine) IL-2 receptor antagonist that can be used to reduce acute rejection. CompetencyStmt 1.2.1K-TypeCaseNum213QuestNum2128Question Which of following is a major side effect of daclizumab? AnswerChoiceA Hypertension9AnswerChoiceB Flu-like syndromeAnswerChoiceC NephrotoxicityAnswerChoiceD HyperlipidemiaAnswerChoiceE No major clinical side effects have been reported with the use of daclizumabCorrectAnswer EExplanation No major drug toxicities have been associated with the use of daclizumab. The overall rate of infection or cancer is similar to the placebo group. CompetencyStmt 1.1.4K-TypeCaseNum213QuestNum2129Question Which of the following statements is true about mycophenolate mofetil (MMF)?AnswerChoiceA MMF is a calcineurin inhibitor.AnswerChoiceB MMF inhibits purine synthesis and thus inhibits DNA and RNA synthesis of T- and B-cells.AnswerChoiceC MMF is an IL-2 receptor antagonist. AnswerChoiceD MMF inhibits m-TOR induction. AnswerChoiceE MMF is a humanized IL-2 receptor inhibitor.10CorrectAnswer BExplanation Mycophenolate mofetil is a pro-drug of mycophenolaic acid that blocks the proliferation of both B- and T-cells.CompetencyStmt 1.3.2K-TypeCaseNum213QuestNum2130Question Compared to azathioprine, which of the following statements isáNOT true aboutámycophenolate mofetil (MMF)?AnswerChoiceA MMF may have a greater incidence of gastrointestinal side effects and lymphoproliferative disease.AnswerChoiceB MMF 3 g/day is better tolerated than azathioprine. AnswerChoiceC MMF is associated with less neutropenia.AnswerChoiceD MMF is associated with a lower use of antilymphocyte therapy.AnswerChoiceE MMF is associated with a reduced incidence of rejection. CorrectAnswer BExplanation Clinical studies with 3 g/day of mycophenolate are limited. At 3 g/day, mycophenolate is associated with a significantly higher risk of GI complications. CompetencyStmt 1.3.1K-Type11213 器官移植病人姓名：海蒂·麦尔彦地址：萨姆杰克森2202年龄：59身高：183cm性别：女性种族：白人体重：90Kg过敏史：无主诉常位心脏移植。