Pneumocystis carinii

Pneumocystis carinii pneumonia can cause significant morbidity and mortality in transplant recipients. Effective prophylaxis against this organism is achieved with trimethoprim-sulfamethoxazole-DS, one tablet on Monday, Wednesday, and Friday once oral intake starts or nebulized pentamidine (in sulfa allergic patients). Active disease rarely occurs in patients receiving prophylaxis. The diagnosis of Pneumocystis carinii infection is established by bronchoscopic washings and is treated with parenteral trimethoprim-sulfamethoxazole, trimethoprim-dapsone, or pentamidine in sulfa allergic patients.


Most programs rely on a "triple-drug" protocol that combines cyclosporine, azathioprine and corticosteroids.41 Recent additions to the armamentarium include tacrolimus, sirolimus and mycophenolate mofetil. A typical strategy consists of:

a. Pre-transplant:

azathioprine 1.5-2 mg/kg intravenously just prior to transplantation b. Post-transplant

• Cyclosporine 3-5 mg/hr intravenously, later converted to an oral dose (twice daily to maintain blood levels in the range of 250-300 ng/ml. Some centers prefer to avoid early intravenous cyclosporine due to its potential for renal toxicity.

• Azathioprine 2 mg/kg intravenously daily (initially), later converted to 2 mg/kg orally daily, adjusted to maintain a white blood cell count greater than 3500/dl

• Corticosteroids:

- Methylprednisolone 10-15 mg/kg intravenously before graft reperfusion.

- Then 0.5 mg/kg intravenously daily,

- Then, convert to Prednisone, (0.5 mg/kg orally daily, tapered to 15 mg p.o. daily at 1 year.

• Anti-thymocyte globulin (ATGAM) 15 mg/kg intravenously over 8-24 hrs for 1 week (usually from the 1st-8th post-operative days).

Primary immunosuppression trials comparing cyclosporine with tacrolimus in lung transplant recipients have shown fewer acute rejection episodes in patients taking tacrolimus.42,43

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