Organ Transplant Case

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QUESTION

Team Assignment
You are the pharmacist for the local family practice clinic. Today a patient came into the emergency room and was seen by a physician from your practice group. He has asked you to see the patient and give him guidance on medications. You go to the emergency room to read the chart and then visit with the patient. When you get to the chart, you find the following note from your physician partner.
History of Present Illness
PP is a 44 year old, CMV+ black female who complains of difficulty breathing and severe diarrhea. The difficulty breathing has been slowly getting worse over the last 24 hours, she has become dizzy when she stands and is very sleepy. Cramps and diarrhea have been present since the last transplant, but has gotten worse over the last 2 weeks.
PP received a 2 antigen match CMV- cadaveric kidney transplant 20 years ago. The kidney was rejected within 48 hours of transplant and did not respond to OKT3 or Atgam. On the first dose of OKT3, she had a terrible reaction which was related to HAMA and was switched to Atgam. The kidney was surgically removed and she returned to dialysis. Fourteen years ago, she received a 5 antigen match, CMV- cadaveric kidney transplant. That kidney remained healthy, but 3 years ago, she was hospitalized with a resistant gram negative infection for which she received high dose gentamicin, causing severe nephrotoxicity and failure of the allograph. That allograft was surgically removed and she again returned to dialysis. Two months ago, a 6 antigen, CMV+ match was made available and PP received the transplant with no complications at Big Time Medical Center, 250 miles away. The kidney was slow to function and the return to normal serum creatinine level has not yet occurred. She returned home within a week of surgery and has been managed by her local nephrologist for the last 7 weeks. Her nephrologist is currently out of town and unavailable.
Three weeks ago, the nephrologist became concerned that the serum creatinine was still high and changed the immunosuppression. He reduced the dose of tacrolimus (5 mg / twice a day to 2 mg twice a day), increased the dose of mycophenolate (1 gm PO twice a day to 1.5 gm PO twice a day and increased the dose of prednisone (1 mg / day to 15 mg twice a day).
Patient also complains of painful abdominal cramps and severe diarrhea for the last several weeks. She has been taking acetaminophen to decrease pain. She occasionally takes ibuprofen when acetaminophen does not control pain.
PP says she takes her medications religiously because she doesn’t want to lose this kidney like the last 2 transplants. She only takes medications that are approved by her doctor. She does not use over the counter medication except for acetaminophen and does not take alternative therapy.
Past Medical History
Poorly controlled hypertension x 22 years
Dialysis x 3 years
Allergies: horse
Family history:
Father: alive and well
Mother: seizures controlled by medication
Social history
Employed as a 5th grade teacher
Alcohol: Occasional glass of wine with friends
Smoking history: non-smoker
Current medications include:
Tacrolimus 2 mg PO twice a day
Mycophenolate 1.5 gm PO twice a day
Prednisone 15 mg PO twice a day
Bactrim DS 1 tablet PO daily
Magnesium 400 mg PO twice a day
Nystatin swish and swallow 5 ml four times a day
Hydrochlorothiazide: 50 mg PO daily
Lisinopril 20 mg PO daily
Inderal LA 160 mg PO daily
Acetaminophen 325 mg PO every 6 hours as needed for painful hemorrhoids
Vancomycin 125 mg PO four times a day
Physical Exam
Height: 5 ft. 7 in.
Weight: 167 lbs.
Vital signs:
Temperature: 98.60 F
Pulse: 110 BPM
RR: 22 BPM
Blood Pressure: 102 / 58
Pulse Oximetry: 88%
Neuro: Reflexes normal
Lethargic
Oriented X2
EENT: Eyes sunken
No evidence of thrush in throat
Lips blue
Membranes are dry
Cardiac: Within normal limits
No murmurs
Tachycardia / normal rhythm
Lungs: Labored breathing
Clear to auscultation
No sputum production
Abdomen:
Surgical scar present on abdomen
Abdomen raised over mass (transplanted kidney) in left lower quadrant
Abdomen not distended
No pain over transplanted kidney when percussed
Rapid bowel sounds
Extremities: dialysis fistula on left forearm
Poor skin turgor
Skin dusky colored
Fingernails blueish color
Labs Performed
Serum tests
Na 132 mEq/L WBC 8.6 × 103/mm3
K 3.1 mEq/L Hgb 12.6 g/dL
Cl 95mEq/L Hct 38.5%
CO2 23 mEq/L Plt 410 × 103/mm3
BUN 83 mg/dL Total cholesterol 250 mg/dL
SCr 2.9mg/dL LDL 180 mg/dL
Glu 101 mg/dL HDL 32 mg/dL
Ca 8.6 mg/dL Triglycerides 210 mg/dL
Mg 3.1 mg/dL COVID antibody negative
Phos 2.3 mg/dL Tacrolimus level (whole blood) 14.5 ng/ml

Urinalysis
Specific Gravity: 1.018 Blood: negative
Color: yellow to amber Glucose: negative
pH: 6.8 Protein: negative
Leukocytes: negative Cells: negative

Sputum culture
Gram stain No cells seen in gram stain
Culture Pending
Antibiotic sensitivities Pending

Chest x-ray
Heart normal size, lungs appear normal
Summary:
Patient presents to emergency room with difficulty breathing, cyanosis and pulse oximetry 88%. Chest clear to auscultation. Neuro exam reveals decreasing mentation. Temperature normal, but taking acetaminophen for severe abdominal cramping. Gram stain on sputum sample is negative for bacteria. Concerned that patient has mycoplasma pneumonia. Will start doxycycline 100 mg IV every 12 hours. Will also discontinue prednisone to allow the immune system to fight the infection.
COVID antibody test negative, but must consider infection and will administer an experimental anti-COVID antibody from mouse source that is available in hospital.
Patient complains of severe cramps, abdominal pain with watery diarrhea. Will place patient on NPO (nothing by mouth), check patient for lactose intolerance as well as a bulk laxative to firm up stool. Will discontinue oral magnesium due to potential to cause diarrhea.
Plan
Admit to hospital
Provisional Diagnosis:
Mycoplasma pneumonia – begin doxycycline
Severe infectious diarrhea – rule out Clostridium difficle
Labs
CBC with diff daily
Chem 7 daily
Tacrolimus level weekly
Sputum culture and gram stain daily
Stool culture
Serum Clostridium difficle toxin
Medication
Doxycycline 100 mg IV piggyback every 12 hours
Tacrolimus 2 mg PO twice a day
Mycophenolate 1.5 gm PO twice a day
Prednisone 10 mg PO twice a day – discontinue
Magnesium 400 mg PO twice a day – discontinue
Nystatin swish and swallow 5 ml four times a day – discontinue
Hydrochlorothiazide: 50 mg PO daily
Lisinopril 20 mg PO daily
Hydralazine 50 mg PO twice daily
Inderal LA 160 mg PO daily
Metamucil 5 gms PO three times a day
Mouse anti-COVID antibody 0.5 ml IM one time only

Consultation: Gastroenterology to evaluate for lactose intolerance
After meeting the patient, performing your own physical exam and reviewing medication history, you suspect multiple oversights. List 6 findings that you have detected and justify why you think it needs to be addressed with your physician.

Finding (1 pt each) Justification For Review (1 pt each)
1.
2.
3.
4.
5.
6.

When you have completed this exercise, upload your document into Canvas. I will grade your submission and add any comments that might be helpful to your learning.

Have fun with the exercise. Hopefully, it won’t take you long.

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