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TABLE 12.5 Immunosuppression table 108

Drug names Typical dose Important side effects Nursing considerations
Calcineurin antagonists Maintenance
Cyclosporin 5–10 mg/kg/day (target Renal impairment Monitor renal and liver function.
blood levels) Hypertension
Tacrolimus 0.2–0.5 mg/kg/day (target Hypercholesterolaemia Mix oral liquid cyclosporin with
blood levels) Abnormal liver function orange juice or milk in glass.
Headaches Do not crush tablets.
Gingival hypertrophy Time sampling of serum drug levels
(cyclosporin only) with dosage times.
Hirsutism (cyclosporin only)
Diabetes (tacrolimus only)
Corticosteroids Maintenance
Prednisolone/prednisone 0.2–0.5 mg/kg/day Mood change Monitor blood glucose levels.
Augmentation for rejection Weight gain
‘Pulse’ of 2 g over 3 days for Glucose intolerance
acute rejection Osteopenia
Muscle weakness
Antiproliferative Maintenance
cytotoxic agents 1–2 mg/kg/day Bone marrow suppression Cytotoxic: take full precautions when
Azathioprine 2–3 g/day (adult) Gastrointestinal tract irritation preparing, administering and
Mycophenolate mofetil (especially mycophenolate disposing of drugs.
mofetil)
Rapamycin Starting at 0.03 mg/kg/day
(target blood levels) Bone marrow suppression Minimise dietary cholesterol.
Hypercholesterolaemia Monitor platelets and serum
Hypokalaemia potassium.
Interleukin-2 receptor Induction of
antagonist immunosuppression: Few and infrequent These drugs are often used in patients
Basiliximab 20 mg/kg preoperatively with preexisting renal dysfunction.
Daclizumab and day 4 Other immunosuppression agents
1 mg/kg preoperatively and may be delayed with the use of
days 14, 28, 42, 56 these agents.
Little information about
compatibilities: avoid concurrent
administration.
Antilymphocyte Induction or augmentation
preparations for rejection Anaphylaxis Premed of paracetamol, promethazine
ATGAM/OKT3 Various, may target T Sterile meningitis and hydrocortisone 30 min prior to
lymphocyte levels Pulmonary oedema slow infusion.
Serum sickness

crushed for naso-gastric administration. In addition, as atrial flutter or fibrillation. 98,107 More severe forms of
blood levels of some immunosuppression agents (e.g. acute rejection are suspected when signs and symptoms
cyclosporine, sirolimus) are taken regularly to assess effi- of varying degrees of heart failure emerge. If patients are
cacy, nurses need to be aware of timing blood sampling awake and alert, they may complain of severe fatigue,
to dosage times in order to obtain accurate data to inform sudden onset of dyspnoea during minimal physical effort,
doses. syncope or orthopnoea. Physical assessment and haemo-
dynamic monitoring will reveal clinical signs of left and
right cardiac failure (see Chapter 9).
Nursing practice
Nurses have an important role in detecting acute rejec-
tion, as it is diagnosed by clinical signs and supported by Infection
histological findings from an endomyocardial biopsy. Infection is a major risk factor for transplant recipients
Low-grade rejection can be suspected when non-specific due to their immunosuppressed state. The periods of
signs such as malaise, lethargy, low-grade fever and mood greatest risk for patients are the first 3 months after trans-
changes are present. Acute rejection causing cardiac irrita- plantation, and after episodes of acute rejection when
tion is revealed by a sinus tachycardia greater than 120 immunosuppression agents are increased. 108,109 In addi-
beats/min; a pericardial friction rub; or new-onset atrial tion to the nosocomial bacterial infections that all surgi-
dysrhythmias such as premature atrial contractions, cal patients are exposed to in critical care (see Chapter 6),