i bc27f85be50b71b1 (219 page)

unresponsive to treannenr and removal of the rejected organ is the

only way to stOp the reaction. Therefore, the recipient will need

immediate retransplantation to survive.6,12,21

2.

ACllte rejection is a treatable and reversible form of rejec-

tion that occurs within the fi rst year after transplantation. Almost

every patient has some degree of acute rejection after transplantation. T lymphocytes detect foreign antigens from the graft, become

Table 12-1. Immunosuppressive Drugs Used in Organ Transplanrarion

C!

...

immunosuppressive Drug

Action

Possible Adverse Effects

>

Corticosteroids (methylinhibit gene transcription for

Muscle loss and weakness, hypertension, hyperglycemia,

�

prednisolone [Solucytokines, which affect all

delayed wound healing, osteoporosis, weight gain, peptic

�

'"

Medral], prednisone)

immune responses

ulcers, cataracts, hypokalemia, mood swings, congestive

'"

Inhibit T-cell activation

heart failure

r

>

Used to reverse early rejection

6

Cydosporine (Neoral,

Inhibits immune responses by

Hypertension, elevated cholesterol, renal dysfunction, [remOl;

g

Sandimmune)

inhibiting T-ceil lymphokinc

sodium retention, hyperkalemia, hyperglycemia, pares

'"

production and cell-mediated

thesias, hepatic dysfunction, seizures, hirsmism, gum

"

"

immunity by blocking

hyperplasia, malignancy; long-term side effects: diabetic

:t

transcription of early

neurotoxicity, decreased bone density

i2i

activation genes

n

>

Used to prevent, rather than

,...

reverse, acme rejection

Tacrolimus (FK506,

Inhibits T-Iymphocyte activation

Tremors, headache, hepatotoxicity, hypertension,

>

�

Prograf)

Used to prevent acute rejection

hyperglycemia, hyperkalemia, constipation, diarrhea,

�

nausea, vomiting, renal dysfunction, mental status changes

Azathioprine Omuran)

Inhibits lymphocyte proliferation

Bone marrow suppression, heparotoxicity,

leukopenia,

Inhibits DNA and RNA synthesis

pancreatitis, cholestasis

Blocks antibody production

Suppresses emire immune system

Mycophenolare mofetil

Inhibits T· and B-Iymphocyte

Nausea, vomiting, diarrhea, leukopenia, neutropenia, sepsis,

(CelICepr)

proliferarion

abdominal pain

Suppresses anribody formation

Inhibits de novo parhway for

purine synthesis

Muromonab-CD3

Inhibits T-cell function and

Chest pain, fever, nausea, vomiting, diarrhea, pulmonary

(Orrhodone OKT3)

proliferation

edema, dyspnea, malignant lymphoma, rigors, malaise,

Used only for acute rejection that

meningitis

is refractory to other agents

Sources: Adapted from JM Black, E Marassarin-Jacobs (eds). Medical-Surgical Nursing: Clinical Management for Continuity of Care (5rh ed).

Philadelphia: Saunders, 1997;644-645; L Bucher, S Melander. Crirical Care Nursing. Philadelphia: Saunders, 1999;343; and data from E

Winkel, VJ DiSesa, MR Costanzo. Advances in heart rransplantarion. Dis Man 1999;45(3):77-79.

o

,.

C)

,.

Z

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�

!;:

� o z

Cl

706

ACUTE CARE HANDBOOK FOR PHYSICAL TIIERAPISI"S

sensitized, and set the immune response into action. Phagocytes,

which are attracted to the graft site by the T lymphocytes, damage

the inner lining of small blood vessels in the organ. This causes

thrombosis of the vessels, resulting in tissue ischemia and eventual

death of the graft if left untreated '

The fi rst signs of acute rejection may be detected within 4 to 10

days postOperatively.6,7.9 The actual manifestations of rejection vary

with the affected organ. General signs and symptOlllS of acute rejection include the following9:

• Sudden weight gain (6 Ib in less than 3 day )

• Peripheral edema

• Fever, chills, sweating, malaise

• Dyspnea

• Decreased urine output, increased blood urea nitrogen (BUN)

and serum creatinine levels

• Electrolyte imbalances

• Increased blood pressure

• Swelling and tenderness at the graft site

Early intervention is the key to reversal of acute rejection. Depending on the severity of rejection, treatment varies from a new dose of intravenous steroids, to a change in current immuno uppressive therapy, to a to-day course of the murine monoclonal antibody muromonab-CD 3 (Orthoclone OKT3). '9 Some immunosuppressant

medications used to treat acute rejection include corticosteroids

(prednisone), cyclosporine (Neoral), tacrolimus (Prograf), azathioprine (Imuran), muromonab-CD 3 (Orthoclone OKT3), cyclophosphamide, anti thymocyte globulin, and antilymphocyte globulin.'

3.

Chrol1ie reieetioll of the graft occurs after the first year of

transplantation. It is believed to resulr from immune complexes of

immunoglobulin M and complement that form in the blood vessels

of rhe organ. Deterioration of the graft is gradual and progressive.

Immunosuppressive drugs do not stOp this type of rejection. The

more frequent and severe the rejection episode, the poorer the prognosis. Increasing immunosuppressive medications may slow the pro-