CaseNum214PtName Amy FarrahAddress10 SW Merlin CourtAge68Height5' 11"Weight125 lbSex FRace WhiteAllergies CodeineSectionName Organ TransplantationCaseName Cardiac TransplantationChiefComplaint Transfer from St. Andrew Medical Center in cardiogenic shock HxPresIllness AF is a 68-year-old woman with coronary artery disease admitted 10 days ago with chest pain for about 3 hours, diaphoresis, and shortness of breath, which was preceded by about 3 days of shortness of breath, dyspnea on exertion, wheezing, and orthopnea. On presentation, she was tachycardic and normotensive, and EKG revealed loss of R waves across the anterior precordium with no acute ST or T wave changes. Chest x-ray revealed pulmonary edema. Initial CK was 505. She was found to have normal renal function and normal hematocrit. An echocardiogram revealed anteroseptal akinesis, a laminar clot, posterior and inferior right ventricular hypokinesis, severe tricuspid regurg, and mild mitral regurg. She had a cardiac index of 1.4. The patient is on 100% nonrebreather mask while plans are underway for heart transplantation.PastMedicalHxCHF; going for HHTx todayParkinson's disease which is felt to be mild, managed only with Artane which controls a mild tremorHiatal herniaEndometrial cancerGERDSevere kyphosis and scoliosisSocialHx She lives independently. She is married with very supportive family, church, and husband. She is active and drives. She is a retired secretary.FamilyHx Includes a history of coronary artery diseaseReviewOfSystems VS: Temperature 37.5°C, blood pressure initially 155/85 mmHg, decreasing to 110-120/40-60, heart rate 85-90, respirations 10/10 on a ventilatorShe came with an intraaortic balloon pump 1:1. Initial Swan numbers revealed a cardiac index of 1.49, a cardiac output of 2.55, a CVP of 10, a pulmonary artery wedge pressure of 22, systemic venous resistance of 1474, anda pulmonary vascular resistance of 188 at the time of transfer to transplantation.PhysicalExam GEN: In general, she is sedated and quickly became more awake and alert as propofol was decreased. She was intubated and ventilated.HEENT: PERRLACARDIOVASCULAR: S1, S2. Balloon pump made heart sounds difficult to assess further. LUNGS: Bilateral crackles to bilateral bases but bilateral exchange throughout. ABDOMEN: Bowel sounds were active. Abdomen was soft. There was no obvious hepatosplenomegaly.EXTREMITIES: Cool but pink. Distal pulses were palpable. There was no edema. LabsAndDxTests Sodium 137 mEq/LPotassium 3.6 mEq/LChloride 94 mEq/LHCO330 mEq/LBUN 28 mg/LCreatinine 1.1 mg/LMg 2 mg/dLWBC 7500/mm3Hematocrit 32.7%Platelets 158 x 109/LDiagnosis Cardiogenic shock and heart transplantationRxRecordRPhNotes New admit for heart transplantCaseNum214QuestNum2131Question When monitoring serum concentration of tacrolimus, the recommended range for a trough level is:AnswerChoiceA2-3 ng/mL.AnswerChoiceB5-15 ng/mL.AnswerChoiceC150-250 ng/mL.AnswerChoiceD250-500 ng/mL.AnswerChoiceE greater than 500 ng/mL.CorrectAnswer BExplanation Following oral administration, approximately 20% of the dose is absorbed in the GI tract. Tacrolimus concentration can be measured in both plasma and blood. Whole blood is the preferred method for measuring tacrolimus blood concentration. Tacrolimus levels should be maintained in a range of 5-15 ng/mL. Levels greater than 20 ng/mL have been associated with nephrotoxicity, neurotoxicity, and diabetogenicity.CompetencyStmt 1.2.6K-TypeCaseNum214QuestNum2132Question Which of the following medications require close plasma therapeutic monitoring?<br>I.áAzathioprine<br>II.áSteroids<br>III. TacrolimusAnswerChoiceA I onlyAnswerChoiceB III onlyAnswerChoiceC I and II onlyAnswerChoiceD II and III onlyAnswerChoiceE I, II, and IIICorrectAnswer BExplanation Tacrolimus trough levels should be maintained in a range of 5-15 ng/mL. Clinical pharmacokinetic studies do not suggest a strong correlation between plasma concentration and pharmacodynamic properties of steroids and azathioprine. Because of high interindividual variability and wider therapeutic indices in azathioprine and steroid plasma levels, therapeutic drug monitoring is not required in these agents.CompetencyStmt 1.2.6K-Type KCaseNum214qid<br>3<br>4/11<br>D429828<br>@<br>Fluconazole<br>12<br>100 mg po daily<br>0QuestNum2133Question Which of the following is the dose-limiting toxicity of tacrolimus? <br>I. Nephrotoxicity<br>II. Alopecia<br>III. DiarrheaAnswerChoiceA I onlyAnswerChoiceB III onlyAnswerChoiceC I and II onlyAnswerChoiceD II and III onlyAnswerChoiceE I, II, and IIICorrectAnswer AExplanation A variety of adverse drug reactions have been reported with the use of tacrolimus. Evidence suggests that tacrolimus-induced adverse drug reactions are typically associated with a highblood concentration. Alopecia and diarrhea have been reported in patients with low troughátacrolimus levels.CompetencyStmt 1.2.4K-Type KCaseNum214QuestNum2134Question How would you monitor a patient taking tacrolimus? <br>I. Serum creatinine, cardiac function tests<br>II. Blood pressure, diabetes<br>III. Plasma therapeutic concentrationAnswerChoiceA I onlyAnswerChoiceB III onlyAnswerChoiceC I and II onlyAnswerChoiceD II and III onlyAnswerChoiceE I, II, and IIICorrectAnswer EExplanation Clinical pharmacokinetic studies do suggest a strong correlation between plasma concentration and toxicity of tacrolimus. Plasma concentration of tacrolimus should be monitored very closely to avoid toxicity. However, some patients may experience adverse drug reactions despite normal tacrolimus level. Therefore, it is essential to monitor for blood pressure and diabetes following transplantation.CompetencyStmt 1.2.3K-Type KCaseNum214QuestNum2135Question The primary criteria for selecting an immunosuppressive drug is: <br>I. patient's risk factors for acute rejection and infection.<br>II. efficacy and safety. <br>III. cost. AnswerChoiceA I onlyAnswerChoiceB III onlyAnswerChoiceC I and II onlyAnswerChoiceD II and III onlyAnswerChoiceE I, II, and IIICorrectAnswer CExplanation Risk factors of acute rejection, efficacy, and safety of immunosuppressive therapy should all be considered before formulating an immunosuppressive protocol for each individual patient. The focus of an immunosuppressive protocol should be on decreasing the risk of acute rejection and limiting adverse drug reactions. Although the cost is important, cost of immunosuppressive drugs are only 5% of the total cost of transplantation.CompetencyStmt 1.1.3K-Type KCaseNum214QuestNum2136Question The most likely cause of hypertension in this patient is: <br>I. sirolimus.<br>II. tacrolimus. <br>III. prednisone.AnswerChoiceA I onlyAnswerChoiceB III onlyAnswerChoiceC I and II onlyAnswerChoiceD II and III onlyAnswerChoiceE I, II, and IIICorrectAnswer DExplanation Several studies have shown that prednisone and tacrolimus can elevate blood pressure. The long-term effect of sirolimus on blood pressure remains unknown, but recent data indicate that sirolimus has a limited effect on blood pressure. Therefore, only II and III are correct.CompetencyStmt 1.2.3K-Type KeCaseNum214QuestNum2137Question Which of the following clinical tests are used for monitoring sirolimus therapy? <br>I. WBC (white blood counts)<br>II. Sirolimus level<br>III. Nephrotoxicity AnswerChoiceA I onlyAnswerChoiceB III onlyAnswerChoiceC I and II onlyAnswerChoiceD II and III onlyAnswerChoiceE I, II, and IIICorrectAnswer CExplanation Clinical pharmacokinetic studies suggest a strong correlation between plasma concentration of sirolimus and toxicity. Plasma sirolimus concentrations should be monitored very closely to avoid toxicity. However, some patients may develop hyperlipidemia and neutropenia despite normal sirolimus levels. Nephrotoxicity is not a common complication of sirolimus therapy.CompetencyStmt 1.2.3K-Type KCaseNum214QuestNum2138Question When monitoring serum concentrations of sirolimus, the recommended range for a trough level is:AnswerChoiceA1-2 ng/mL.AnswerChoiceB10-20 ng/mL.AnswerChoiceC40-50 ng/mL.AnswerChoiceD150-250 ng/mL.AnswerChoiceE greater than 250 ng/mL.CorrectAnswer BExplanation Like other agents with narrow therapeutic windows, sirolimus levels should be monitored very closely to avoid acute rejection or toxicities. Sirolimus levels should be maintained in a range of 10-20 ng/mL.CompetencyStmt 1.2.6K-TypeCaseNum214QuestNum2139Question The most common cause(s) of post-transplant hyperlipidemia is: <br>I. mycophenolate.<br>II. sirolimus.<br>III. prednisone.AnswerChoiceA I onlyAnswerChoiceB III onlyAnswerChoiceC I and II onlyAnswerChoiceD II and III onlyAnswerChoiceE I, II, and IIICorrectAnswer DExplanation Hyperlipidemia developing after heart transplantation is nearly universal, occurring in 70-80% of patients. Although the exact pathogenesis of hyperlipidemia following transplantation is still being determined, several studies have shown that both prednisone and sirolimus are independent risk factors for the development of hyperlipidemia. CompetencyStmt 1.3.1K-Type KCaseNum214QuestNum2140Question Which of the following immunosuppressive drugs is associated with causing gingival hyperplasia?AnswerChoiceA CyclosporineAnswerChoiceB TacrolimusAnswerChoiceC MycophenolateAnswerChoiceD Both cyclosporine and mycophenolateAnswerChoiceE Cyclosporine and tacrolimusCorrectAnswer AExplanation Gingival hyperplasia has been attributed to the use of cyclosporine only. Other commonly used drugs in transplant that might increase the risk of this cosmetic adverse reaction are Nifedipine and Dilantin.CompetencyStmt 1.2.2K-Type214 器官移植病人姓名：艾米·法拉地址：莫林院西南10号年龄：68身高：156cm性别：女性种族：白人体重：57Kg过敏史：可待因主诉转移来自安德鲁医疗中心心源性休克。