器官移植临床案例分析一.doc

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CaseNum 213 PtName Heidi Maryam Address 2202 SW Sam Jackson Age 59 Height 6' 0" Weight 198 lb Sex F Race White Allergies NKDA SectionName Organ Transplantation CaseName Cardiac Transplantation ChiefComplaint 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. PastMedicalHx Unstable angina Status post cerebrovascular accident Anemia Depression Ingrown right first toenail Gout Herpes zoster Ventricular arrhythmia SocialHx Smoking for 20 years No illicit drug use Married with five children FamilyHx 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 2 CHEST: Respirations are even and unlabored LUNGS: Clear to auscultation. No accessory muscle use noted. No retractions noted. CARDIAC: S1, S2, irregular rate and rhythm irregular, rubs and significant gallops GI: 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. LabsAndDxTests Sodium 141 mEq/L Potassium 4.1 mEq/L Chloride 102 mEq/L CO2 24 mEq/L Glucose 99 mg/L Albumin 3.7 g/L HCT 41% Hemoglobin 10.6 g/dL Diagnosis Heart transplantation RxRecord Date 6/1 6/1 6/1 8/10 5/2 5/2 6/1 10/1 10/1 Rx No D245536 D455537 D244538 D246539 D246555 D246555 D346876 D368654 D468762 Physician @ @ @ @ @ @ @ @ @ Drug and Strength Cellcept Cyclosporine 100 mg Prednisone 5 mg Prevacid 30 mg Zocor 40 mg Capoten 12.5 mg Zenapax 1 mg/kg Tacrolimus 1 mg Mycelex Quantity 100 300 500 60 30 100 @ 400 140 Sig 1 g po bid 2 po bid 2 po q am 1 po bid 1 po qd 1 po bid q 14 days for a total of 5 doses 2 mg po bid 10 mg po qid Refills 3 2 3 1 6 6 0 6 3 RPhNotes None available CaseNum 213 QuestNum 2121 Question 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 azathioprine CorrectAnswer D Explanation 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 1.2.2 K-Type CaseNum 213 QuestNum 2122 Question Cyclosporine trough concentrations should be monitored for: I. efficacy. II. toxicity. III. compliance. AnswerChoiceA I only AnswerChoiceB III only AnswerChoiceC I and II only AnswerChoiceD II and III only AnswerChoiceE I, II, and III CorrectAnswer D Explanation Therapeutic monitoring is used to avoid toxicity and to assessácompliance. Patients with therapeutic blood concentrations are at a lower risk of acute rejection. CompetencyStmt 1.1.4 K-Type K CaseNum 213 QuestNum 2123 Question 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 mofetil AnswerChoiceB Tacrolimus AnswerChoiceC Sirolimus AnswerChoiceD Azathioprine AnswerChoiceE Simulect CorrectAnswer B Explanation 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 1.2.4 K-Type CaseNum 213 QuestNum 2124 Question 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. AnswerChoiceB 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 A Explanation Patient and allograft survival of kidney, heart, and liver transplant under tacrolimus protocols are similar to those of cyclosporine. CompetencyStmt 1.3.1 K-Type CaseNum 213 QuestNum 2125 Question Which of the following transplant recipients appear to be at greater risk for nephrotoxicity? AnswerChoiceA Liver transplant AnswerChoiceB Kidney transplant AnswerChoiceC Heart transplant AnswerChoiceD Bone marrow transplant AnswerChoiceE Liver and heart transplant CorrectAnswer B Explanation 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 1.3.1 K-Type CaseNum 213 QuestNum 2126 Question Which of the following agents is a monoclonal antibody that inhibits IL-2 receptors? AnswerChoiceA Cyclosporine AnswerChoiceB Tacrolimus AnswerChoiceC Daclizumab AnswerChoiceD Sirolimus AnswerChoiceE Azathioprine CorrectAnswer C Explanation Daclizumab is a humanized IL-2 receptor antagonist that can be used to reduce acute rejection following transplantation. CompetencyStmt 1.2.1 K-Type CaseNum 213 QuestNum 2127 Question Which of the following agents consists of 90% human and 10% murine amino acid sequences? AnswerChoiceA Basiliximab AnswerChoiceB Daclizumab AnswerChoiceC Mycophenolate AnswerChoiceD Tacrolimus AnswerChoiceE Cyclosporine CorrectAnswer B Explanation Daclizumab is a humanized (90% human and 10% murine) IL-2 receptor antagonist that can be used to reduce acute rejection. CompetencyStmt 1.2.1 K-Type CaseNum 213 QuestNum 2128 Question Which of following is a major side effect of daclizumab? AnswerChoiceA Hypertension AnswerChoiceB Flu-like syndrome AnswerChoiceC Nephrotoxicity AnswerChoiceD Hyperlipidemia AnswerChoiceE No major clinical side effects have been reported with the use of daclizumab CorrectAnswer E Explanation 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 1.1.4 K-Type CaseNum 213 QuestNum 2129 Question 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. CorrectAnswer B Explanation Mycophenolate mofetil is a pro-drug of mycophenolaic acid that blocks the proliferation of both B- and T-cells. CompetencyStmt 1.3.2 K-Type CaseNum 213 QuestNum 2130 Question 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 B Explanation 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 1.3.1 K-Type 213 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。现病史海蒂·麦尔彦，59岁，女性，白种人。1999年诊断患有病毒性心肌炎，在过去两年内有心力衰竭的迹象，症状包括呼吸急促，水肿，严重的活动受限，目前主要依靠多巴酚丁胺和硝普盐来维持。尝试弃去收缩器未能成功。3周前考虑心脏移植。既往病史有抑郁，痛风，带状疱疹。在找到合适的供体后，患者实施心脏移植手术。既往史不稳定性心绞痛脑血管中风后遗症贫血抑郁右侧第一指甲内翻痛风带状疱疹室性心律失常社会史患者已婚，有5个子女，20年的吸烟史，未服用违禁药品。家族史她的父亲母亲健在，无关于病毒性心肌炎或心肌梗塞的家族病史。整体评价患者无发热，寒颤，背痛头晕，虚弱，胸痛，呼吸急促或疹。患者有些疲劳。无胃食管返流，吞咽困难，吞咽痛，下肢水肿或胃肠出血等症状。她有临时下肢感觉异常。无腹部胀气或绞痛。目前遗留重要的问题是无捐献者。体格检查女性，59岁，无急性痛。生命迹象稳定。血压：158/79 mmHg，心率：93bmp，呼吸频率：20rmp，体温：37.1℃，室内空气氧饱和98%。移植手术后两天：胸：呼吸平稳肺：两侧听诊呼吸音清无副肌肉使用。无取消记录。心血管病与营养对照：S1S2心率不齐节律不规整。胃肠：存在肠鸣音。无器官巨大症。四肢：病人正常状态下下肢凹陷性水肿，足背双侧脉搏2+。神经系统：无震颤，无神经系统疾病。实验室和诊断检查钠 141 mEq/L 钾 4.1 mEq/L 氯 102 mEq/L CO2 24 mEq/L 葡萄糖 99 mg/dL 白蛋白 3.7 g/dL 血细胞比容 41% 血红蛋白 10.6 g/dL 诊断心脏移植用药记录日期 6/1 6/1 6/1 8/10 5/2 5/2 6/1 10/1 10/1 处方号 D245536 D455537 D244538 D246539 D246555 D246555 D346876 D368654 D468762 医师 @ @ @ @ @ @ @ @ @ 药物和剂量骁息环孢素A 100 mg 泼尼松 5 mg 兰索拉唑缓释胶囊30 mg 辛伐他汀 40 mg 开博通 12.5 mg 赛尼哌 1 mg/kg 他克莫司 1 mg 菌丝体数量 100 300 500 60 30 100 @ 400 140 用法 1 g po bid 2 po bid 2 po q am 1 po bid 1 po qd 1 po bid q 14 days for a total of 5 doses 2 mg po bid 10 mg po qid Refills 3 2 3 1 6 6 0 6 3 药师记录和其他病人信息无问题 1．淋巴细胞激活需要神经钙蛋白酶，下列哪两种因子抑制神经钙蛋白酶？ A：达珠单抗和巴利昔单抗， B：他克莫司和麦考酚酸吗乙酯 C：环孢素A和麦考酚酸吗乙酯 D：他克莫司和环孢素A E：环孢素A和依木兰正确答案：D 解释：环孢素A和他克莫司通过抑制神经钙蛋白酶而抑制胸腺依赖性淋巴细胞增殖。环孢素A是通过结合靶受体抑制神经钙蛋白酶，为他克莫司通过结合FKPB-12抑制神经钙蛋白酶。 2．环孢素A血药浓度需要被监测是因为： Ⅰ功效 Ⅱ毒性 Ⅲ顺从性 A：Ⅰ， B：Ⅲ， C：I and II， D：II and III， E：I, II, and III 正确答案：D 解释：治疗监测用于避免毒性和评估顺从性。患者血药浓度在有效范围内可以降低急性排斥反应发生率。 3．为了避免如多毛症，面部粗化和牙龈增生等副作用，环孢素A可以被下列哪种同种类药物替换？ A：麦考酚酸吗乙酯 B：他克莫司 C：西罗莫司 D：依木兰 E：舒莱正确答案：B 解释：他克莫司和环孢素A的副作用比较相似，但是诸如多毛症，牙龈增生等还未见报道。 4．下列哪些关于他克莫司与环孢素A的比较是错误的？ A：他克莫司用于改善一年内术后存活者和降低死亡率 B：他克莫司较少发生排斥反应 C：他克莫司排斥反应轻微并且对皮质激素敏感 D：他克莫司对于逆转排斥反应效果较好 E：他克莫司广泛肝代谢正确答案:A 解释：使用他克莫司进行肾脏、心脏、肝脏移植的患者的存活率与使用环孢素A的存活率是相似的。 5．下列哪种移植受体有肾毒性的危险较大？ A：肝移植 B：肾移植 C：心脏移植 D：骨髓移植 E：肝和心脏移植正确答案：B 解释：与其他器官移植相比，肾移植患有肾毒性的可能性较大。急性肾小管坏死是移植后主要病变（30%）。年龄较大的供体和24小时以上局部缺血者有很高的患急性肾小管坏死的几率。所以，如果肾移植患者肾毒性发展，剂量需要调整。 6．下列哪些是抑制白细胞介素-2受体的单克隆抗体？ A：环孢素A B：他克莫司 C: 达珠单抗 D: 西罗莫司 E：依木兰正确答案：C 解释：达珠单抗是人化白细胞介素-2受体的抑制物，用来减少移植后急性排斥反应。 7．下列哪种包含90%人和10%鼠氨基酸序列？ A：巴利昔单抗 B：达珠单抗 C：霉酚酸酯 D：他克莫司 E：环孢素A 正确答案：B 解释：达珠单抗是一种人化（90%人和10%鼠）的白细胞介素-2受体抑制物，可以用来减少急性排斥反应。 8．下列哪种是达珠单抗最主要的副作用？ A：高血压 B：类流感综合症 C：肾毒性 D：高血脂 E：未见报道主要的临床副作用正确答案：E 解释：未见关于使用达珠单抗的主要药物毒性报道。感染率和癌症率与安慰组结果相似。 9．下列哪些关于麦考酚酸吗乙酯的描述是正确的？ A：一种神经钙蛋白抑制剂 B：抑制嘌呤合成，从而抑制T细胞和B细胞DNA和RNA的合成。 C：IL-2受体拮抗剂 D：抑制m-TOR的诱导 E：人化IL-2受体抑制物正确答案：B 解释：麦考酚酸吗乙酯是麦考酚酸酯的前药，阻碍T细胞和B细胞的增殖。 10．麦考酚酸吗乙酯与依木兰相比，下列哪些阐述是错误的? A：麦考酚酸吗乙酯胃肠副作用和淋巴细胞增生症发生率较高 B：麦考酚酸吗乙酯每天3g，耐受性比依木兰好 C：麦考酚酸吗乙酯较少发生嗜中性白血球减少症 D：麦考酚酸吗乙酯较少合用抗淋巴细胞治疗 E：麦考酚酸吗乙酯减少排斥反应发生率正确答案：B 解释：每天3g麦考酚酸吗乙酯的临床研究是有限的。在每天3g的剂量下，麦考酚酸吗乙酯胃肠副作用发生率较高。病例213 器官移植 1.答案 D 2.答案D 3.答案B 4.答案A 5.答案B 6.答案C 7.答案B 8.答案E 9.答案B 10.答案B 12

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