Emory Transplant Center



Weeks1-4Weeks5-810th Week12thWeek4th mo.5th mo.6th mo. 7th mo.8th mo.9th mo.12th mo.>12 mo.Visits & Reports:Weekly Visit w/ LabsWeek 1Week 2Week 6Week 10Hepatology▲▲▲▲▲▲▲AnnualLabs Only: Three weeklyTwice weekly Weekly MonthlyUNOS Report▲ (Hospital D/C)▲▲AnnualImmunosuppression:Prednisone10 mg daily at day 305mg daily at day 60Off at day 90 except in autoimmune which may benefit from continuation of steroids.Patients with PSC or PBC should be off steroids in 6 months.Tacrolimus (Prograf)(target level) *See risk indicators8-12 ng/mlMycophenolate mofetil (MMF, CellCept)1000 mg BIDBasiliximab (Simulect)(Renal Sparing) All patients with renal insufficiency ( Cr Cl<60 ml/min, SCr > 1.5) 20 mg after reperfusion, then 20 mg post op day 4Alloantibody Screen ▲▲▲Annual for liver/kidInfection Prophylaxis/MonitoringCMV ProphylaxisNone. Preemptive therapy. Weekly CMV PCR months 0-3. Qother week CMV PCR months 4-6 Annual CMV PCRPCP ProphylaxisBactrim SS dailyPolyoma BK Virus (liver/kidney only)Week 4Week 8▲▲▲▲▲▲Cardiovascular Risk ReductionBMI Goal < 25B/P <130/80Cholesterol < 200▲ ▲AnnualLipid Profile▲AnnualDiabetes Management Hgb A1C (if on steroid)OphthalmologyIf blood glucose consistently > 150, obtain endocrine consult▲▲▲▲▲q 3 months AnnualVaccinations (starting 3 months after transplant) Influenza AnnualPneumococcalEvery 5 yearsBone Disease ManagementBone Density Scan (DEXA)If PSC, PBC or AIH obtain dexa scan at 6 months▲Annual DentalRoutine check ups▲Every 6 monthsAnnualCancer Screening and ProphylaxisGeneral ExamsExams by PCP; Breast (>40 yrs)- Cervical (>18 yrs); and Prostate (>40 yrs)AnnualDermatology ScreenAnnualSigmoidoscopy or ColonoscopyColorectal screening: Colonoscopy prior to or at 1 year post OLT, if negative, FOBT in5 yearsColorectal cancer screening: If negative, repeat colonoscopy 10 years after previousNegative colonoscopyPSC and UC: annual colonoscopy and surveillance biopsies; maintain breast, cervical and prostate examsEvery 5-10 YearsPatient Education MaterialsA Journey for Life & Pathway Document▲On going educational materials at clinic visits as dictated by medical conditionAssessmentsDieticianAnnualSocial WorkerAnnualLiver Transplant Program Post Transplant Management ProtocolLiver transplantation in the hepatitis C patient: Special considerations4 weeks12 weeks24 weeks36 weeks1 year2 yearsEvaluation Liver BiopsyNote: Whenever clinically indicated▲▲▲HCV RNA by PCR(if on treatment)▲▲▲▲▲ImmunosuppressionPrednisoneUse will be minimized in HCV ptsAcute Cellular Rejection in HCV patients will be assessed and treated only after deliberation by liver leadershipPrografStandard therapyMMFStandard therapy Monoclonal antibodiesPer renal sparing protocolTreatmentPegylated Interferon alpha 2aStandard therapy of 180 mcg weekly desirable. Usual 12 week stop analysis does not apply in these patients. Treatment is generally continued for 48 weeks.RibavirinDose of 400 mg BID advisable due to risk of anemia. Treatment continues for 48 weeksGrowth factorsUse of growth factors usually necessary and generally considered safe. Should be considered for Hgb <10 grams and neutrophil count below 2.5.Approach to Cellcept AdjustmentIndications for Dose Reduction/dosing interval changeApproach to ReinstitutionDiarrhea refractory to RxUpon Resolution of symptomsDyspepsia Refractory to RxMethod: stepwise by 250 mg increments to 1gm b.i.d.WBC <2.0Women should not become pregnant on MMFViral/Fungal InfectionM.D. Discretion Immunosuppressive Reductions Drug0-3 months3-6 months6-12 months> 1 yearPRIVATE "TYPE=PICT;ALT="PRIVATE "TYPE=PICT;ALT="Tacrolimus (Prograf)levels 8-12ng/mllevels 6-12ng/mllevels 4-10levels 3-8PRIVATE "TYPE=PICT;ALT="PRIVATE "TYPE=PICT;ALT="Cyclosporine (Gengraf)levels 150-180levels 100-150levels 75-125levels 50-100PRIVATE "TYPE=PICT;ALT="PRIVATE "TYPE=PICT;ALT="MMF (Cellcept)1000mg BID1000mg BID1000mg BID1000mg BIDPRIVATE "TYPE=PICT;ALT="PRIVATE "TYPE=PICT;ALT="Sirolimus (Rapamune)not used < 1 month;Level 8-12levels 6-12levels 4-10levels 3-8PRIVATE "TYPE=PICT;ALT="PRIVATE "TYPE=PICT;ALT="PRIVATE "TYPE=PICT;ALT="PRIVATE "TYPE=PICT;ALT="PRIVATE "TYPE=PICT;ALT="PRIVATE "TYPE=PICT;ALT="PRIVATE "TYPE=PICT;ALT="PRIVATE "TYPE=PICT;ALT="PRIVATE "TYPE=PICT;ALT="Prednisone15 days1 month2 months3 months6 months> 1 yearEtOH, NASH, NAFLD, HBV, Crypto20mg QAM10mg QAM5mg QAMOff at 3 monthsoffPRIVATE "TYPE=PICT;ALT="offPSC, PBCAIH20mg QAM20mg QAM10mg QAM10mg QAM5 mg QAM5mg QAMOff at 3 months5mg QAMoff5mg QAMoff5mg QAM Emory Liver Transplant ProgramRev. 06.10.11For Questions Contact 1-888-295-8907 or 404-712-7731 ................
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