ABTC CCTN cheat sheet

Immunosuppression maintenance typically combines a calcineurin inhibitor (tacrolimus or cyclosporine), an antimetabolite (mycophenolate or azathioprine), and a corticosteroid; each targets a different step of T-cell activation.

Tacrolimus trough targets commonly range 5-15 ng/mL depending on time post-transplant and rejection risk; whole-blood trough is drawn just before the next dose.

Mycophenolate is teratogenic: pregnancy must be excluded before initiation and two forms of contraception used; it is generally avoided in pregnancy.

Calcineurin inhibitors are nephrotoxic and cause dose-dependent tremor, hypertension, hyperkalemia, hypomagnesemia, and new-onset diabetes.

Cytomegalovirus prophylaxis (e.g., valganciclovir) is standard for CMV-seronegative recipients of seropositive organs and for seropositive recipients on lymphocyte-depleting induction.

Live vaccines (MMR, varicella, live attenuated influenza, yellow fever) are contraindicated after transplant; inactivated vaccines are safe but may have reduced response.

Acute cellular rejection is treated with high-dose IV corticosteroids; antibody-mediated rejection may require plasmapheresis, IVIG, and/or rituximab.

Therapeutic drug monitoring is required for tacrolimus, cyclosporine, sirolimus, and everolimus because of narrow therapeutic indices and drug-drug interactions via CYP3A4 and P-glycoprotein.

ABO compatibility is required for most solid organ transplants; HLA matching is most critical for kidney and is largely irrelevant for liver and heart allocation.

Panel-reactive antibody (PRA) quantifies the breadth of preformed anti-HLA antibodies; a positive crossmatch generally contraindicates kidney transplant due to hyperacute rejection risk.

Absolute contraindications to solid organ transplant commonly include active malignancy (outside remission windows), active untreated infection, and active substance use without engagement in treatment.

Cardiac evaluation before non-cardiac transplant includes ECG, echocardiography, and stress testing when risk factors are present; pulmonary function tests guide lung and some heart evaluations.

Psychosocial evaluation screens for adherence history, social support, mental health, and substance use, as these predict post-transplant outcomes.

Pretransplant vaccination should be completed before immunosuppression when feasible; live vaccines must be given before transplant or avoided afterward.

The MELD-Na score (bilirubin, INR, creatinine, sodium, with exception points) prioritizes liver candidates; higher scores reflect greater 90-day mortality risk.

Living donor evaluation confirms voluntary consent, ABO compatibility, adequate donor GFR, and absence of transmissible disease and coercion.

Hyperacute rejection occurs within minutes to hours from preformed antibodies and requires immediate graft removal; it is largely prevented by crossmatch.

Acute rejection most often occurs in the first 6 months; presentation includes rising creatinine (kidney), fever, graft tenderness, or elevated liver enzymes.

Infection risk follows a timeline: early (surgical, nosocomial), 1-6 months (opportunistic: CMV, Pneumocystis, fungal), and late (community-acquired).

BK polyomavirus nephropathy causes rising creatinine with BK viremia; management is reduction of immunosuppression, not increased therapy.

Post-transplant lymphoproliferative disorder (PTLD) is associated with Epstein-Barr virus and intensified immunosuppression; treatment includes reducing immunosuppression.

Graft-versus-host disease is a major complication of hematopoietic stem cell transplant; skin, GI tract, and liver are classic targets.

Chronic allograft dysfunction manifests as interstitial fibrosis and tubular atrophy (kidney), cardiac allograft vasculopathy (heart), or bronchiolitis obliterans (lung).

Pneumocystis jirovecii prophylaxis (e.g., trimethoprim-sulfamethoxazole) is typically given for at least 6-12 months post-transplant and longer with ongoing immunosuppression.

Organ allocation in the United States follows OPTN/UNOS policy; the 'final rule' requires allocation by medical criteria, not by ability to pay or social worth.

The dead donor rule holds that vital organs may only be recovered after death is declared by neurologic or circulatory criteria; organ recovery must not cause death.

Informed consent for transplant and for living donation must disclose risks, benefits, alternatives, and the voluntary nature of donation free of coercion.

Living donors must be medically and psychosocially evaluated by a team independent of the recipient's care to avoid conflicts of interest.

Confidentiality applies to donor and recipient health information; directed donation is permitted under OPTN rules with appropriate disclosure.

Transplant coordinators must verify informed consent, document education, and confirm UNOS/OPTN data entry accuracy for waitlist and post-transplant reporting.

Patient education should use teach-back and health literacy–appropriate materials; adherence education begins pretransplant and continues lifelong.

Ethical allocation considers urgency, utility (expected outcome), and justice; geographic and pediatric prioritization rules are set by OPTN policy.

Induction therapy (e.g., basiliximab, antithymocyte globulin) is given at transplant to reduce early rejection; lymphocyte-depleting agents increase infection risk.

Tacrolimus and cyclosporine are CYP3A4 substrates; azole antifungals, macrolides, and grapefruit increase levels, while rifampin and some anticonvulsants decrease them.

Sirolimus and everolimus (mTOR inhibitors) impair wound healing and are often avoided immediately post-transplant; they can cause proteinuria and hyperlipidemia.

Corticosteroid side effects include hyperglycemia, hypertension, osteoporosis, weight gain, and infection risk; tapering is common but not universal.

Ganciclovir/valganciclovir require dose adjustment for renal function and cause myelosuppression; monitor CBC during CMV prophylaxis or treatment.

Rejection surveillance includes protocol biopsies (kidney, heart) and serial labs (creatinine, liver enzymes, donor-specific antibody testing).

Donor-specific antibody (DSA) monitoring identifies patients at risk for antibody-mediated rejection; de novo DSA warrants evaluation and possible treatment.

Drug levels are interpreted with timing of last dose; trough levels drawn at incorrect times can mislead dosing decisions.

Kidney allocation uses the Kidney Allocation System (KAS), incorporating EPTS (expected post-transplant survival), dialysis time, and HLA/age matching.

Heart allocation prioritizes status based on acuity (e.g., ECMO, inotropes, ventricular assist device) under current OPTN tiers.

Lung allocation uses the Lung Allocation Score (LAS), balancing waitlist urgency against post-transplant survival benefit.

Coronary angiography is commonly required before kidney or liver transplant in candidates with significant cardiac risk factors.

Obesity (often BMI >35-40) may be a relative contraindication depending on center protocol due to wound and outcome risks.

Tobacco and substance use counseling and cessation are required pretransplant; active smoking increases pulmonary and wound complications.

Serologic screening before transplant includes HIV, hepatitis B and C, CMV, EBV, and syphilis; results guide prophylaxis and donor matching.

Informed consent for waitlisting includes discussion of waiting time, organ offers, alternative treatments, and the option to decline an organ.

Fever in a transplant recipient requires prompt evaluation for infection and rejection; empiric broad-spectrum antibiotics are often started after cultures.

CMV disease presents as fever, leukopenia, hepatitis, or colitis; diagnosis uses CMV DNA PCR (viral load) and treatment is IV ganciclovir.

Post-transplant diabetes mellitus is common with tacrolimus and steroids; management includes glucose monitoring and possible immunosuppression adjustment.

Cardiovascular disease is a leading cause of late death after transplant; blood pressure, lipids, and glucose require ongoing management.

Malignancy risk rises with chronic immunosuppression (skin cancer, PTLD, Kaposi sarcoma); sun protection and skin surveillance are recommended.

Renal dysfunction after non-renal transplant often reflects calcineurin inhibitor toxicity; dose reduction or conversion may be considered with monitoring.

Adherence to immunosuppression is critical; missed doses and erratic timing increase rejection and graft loss risk.

Vaccination after transplant should use inactivated vaccines; response may be blunted, and household members should be vaccinated to reduce exposure.

The OPTN is operated under federal contract; UNOS is the current contractor, and its policies govern listing, allocation, and data submission.

Mandatory UNOS data reporting includes waitlist updates, transplant events, and post-transplant follow-up at defined intervals.

Transplant centers must have written policies for informed consent, living donation, and conflict-of-interest management.

Cultural humility and interpreter services are required for equitable education; consent must be in a language the patient understands.

Mandatory reporting includes communicable disease transmission events and adverse outcomes per OPTN policy.

Professional boundaries and confidentiality apply to social media; patient identifiers must not be shared.

Quality improvement uses metrics such as graft survival, patient survival, and waitlist mortality to guide program evaluation.

Ethical dilemmas (e.g., nonadherence, re-transplantation) should be addressed through team discussion and ethics consultation when needed.

Hyperkalemia and hypomagnesemia are common with tacrolimus and cyclosporine; monitor electrolytes and ECG changes.

Antithymocyte globulin (ATG) can cause cytokine release syndrome and serum sickness; premedication and monitoring are used.

Basiliximab is an IL-2 receptor antagonist given as induction; it does not deplete lymphocytes broadly and has a favorable safety profile.

Mycophenolate causes GI upset and leukopenia; enteric-coated formulations may improve tolerability.

Azathioprine is metabolized by TPMT; TPMT deficiency increases myelosuppression risk, and allopurinol interaction is dangerous.

Pregnancy after transplant requires pre-conception planning and medication review; mycophenolate and mTOR inhibitors are typically avoided.

Infection prophylaxis after transplant may include trimethoprim-sulfamethoxazole for Pneumocystis and nystatin or clotrimazole for oral candidiasis.

Patient education on immunosuppression includes timing, missed-dose instructions, interactions, and reporting of fever or rejection symptoms.

A positive virtual crossmatch based on unacceptable HLA antigens can limit organ offers; unacceptable antigen lists are entered into UNOS.

Donor and recipient size matching matters for heart, lung, and liver transplants; a graft too small may be inadequate and too large may impair closure.

Hepatitis C–positive donors may be used for negative recipients with informed consent and direct-acting antiviral prophylaxis or treatment in many centers.

HIV-positive candidates may be transplant candidates when viral load is suppressed and CD4 count is adequate, per center protocols.

Nutritional assessment pretransplant identifies malnutrition and obesity, both of which affect post-transplant outcomes.

Frailty and functional status predict post-transplant morbidity and mortality and should be assessed in older candidates.

Financial and insurance evaluation is part of transplant workup because lifelong immunosuppression and follow-up are costly.

Caregiver support and transportation plans are assessed pretransplant because they affect adherence and follow-up feasibility.

Surgical complications early post-transplant include bleeding, vascular thrombosis, anastomotic leaks, and wound infection.

Liver transplant complications include biliary strictures and leaks, hepatic artery thrombosis, and rejection; imaging and liver enzymes guide evaluation.

Heart transplant surveillance includes endomyocardial biopsy and coronary angiography or CT for cardiac allograft vasculopathy.

Lung transplant recipients are at risk for bronchiolitis obliterans syndrome and airway anastomotic complications; spirometry is monitored.

Hematopoietic stem cell transplant complications include sinusoidal obstruction syndrome, infections, and GVHD; engraftment is monitored by CBC.

Osteoporosis and avascular necrosis are long-term complications related to corticosteroids; bone density monitoring is recommended.

Depression and anxiety are common after transplant and affect adherence; screening and treatment improve outcomes.

Return to work and sexual health counseling are part of comprehensive post-transplant care.

The principle of utility in allocation weighs expected survival benefit; justice weighs fair access across populations.

Altruistic (non-directed) donation is permitted; donors must be screened for coercion and financial inducement.

Financial incentives for organ donation are prohibited in the United States under the National Organ Transplant Act.

Research involving transplant patients requires IRB approval and informed consent; vulnerable populations need additional protections.

Documentation of patient education includes content, comprehension check, and patient questions answered.

Transplant team communication uses structured handoffs and shared decision-making with patients and families.

Advocacy includes identifying barriers to waitlisting and addressing disparities in referral and access.

Continuing education and certification maintenance are professional obligations for transplant coordinators.

Trough monitoring for tacrolimus should use the same assay method consistently because results differ between methods.

Cyclosporine can cause gingival hyperplasia and hirsutism; these are reversible with dose adjustment or discontinuation.

mTOR inhibitors can cause aphthous ulcers, pneumonitis, and edema; monitor for respiratory symptoms.

Corticosteroid stress dosing may be needed during acute illness or surgery in patients on chronic steroids.

Drug interaction review should occur at every visit; over-the-counter supplements and herbals (e.g., St. John's wort) can alter levels.

Rejection treatment increases infection risk; prophylaxis and monitoring should be intensified after treatment.

Vaccine response may be improved by timing inactivated vaccines before intensification of immunosuppression when possible.

Patient self-management includes a medication list, emergency contact, and knowledge of when to call the transplant team.

Dental evaluation and treatment of active infection are completed before transplant to reduce post-transplant infection risk.

Age alone is not an absolute contraindication; physiologic reserve and comorbidity guide candidacy.

Pulmonary hypertension and right heart function are assessed before liver and kidney transplant because they affect perioperative risk.

Substance use treatment (e.g., alcohol for liver disease) may be required before listing, depending on center and etiology.

Informed consent for living donation includes risks of surgery, long-term health effects, and the right to withdraw at any time.

Donor-derived infection screening includes serologies and, when indicated, nucleic acid testing for HIV, HBV, and HCV.

Waitlist status must be updated when clinical status changes; inactive status may be used while evaluation is completed.

Transplant candidates should be educated on organ offer acceptance and the possibility of declining an offer.

Graft tenderness, decreased urine output, and fever should prompt urgent evaluation for rejection or infection.

Protocol monitoring after kidney transplant includes creatinine, drug levels, and urinalysis at scheduled intervals.

Anemia and thrombocytopenia after transplant may reflect infection, drug toxicity, or rejection; evaluate cause.

Hyperuricemia and gout are common after transplant, especially with cyclosporine; management considers drug interactions.

Post-transplant hypertension is common; ACE inhibitors and ARBs require monitoring of potassium and renal function.

Skin cancer screening is recommended annually; squamous cell carcinoma risk is elevated with chronic immunosuppression.

Patient education on infection prevention includes hand hygiene, food safety, and avoiding sick contacts.

Transition of care from inpatient to outpatient should include medication reconciliation and follow-up scheduling.

Informed refusal must be respected; patients may decline transplant or an offered organ without penalty to future care.

Conflicts of interest in living donation are managed by separating donor and recipient evaluation teams.

Data privacy laws (e.g., HIPAA) govern sharing of transplant information; minimum necessary disclosure applies.

Transplant programs participate in quality reporting; outcomes are publicly reported and used for oversight.

Education for patients with low health literacy uses plain language, visual aids, and teach-back.

Ethical use of social media includes no patient identifiers and no clinical advice outside appropriate channels.

Team-based care includes pharmacists, social workers, dietitians, and coordinators to address whole-person needs.

Professionalism includes honesty in documentation, timely reporting, and respectful communication with donors and recipients.

Tacrolimus is preferred over cyclosporine in many protocols due to lower rejection rates, but it has higher rates of new-onset diabetes.

Sirolimus and everolimus require therapeutic monitoring; trough targets vary by protocol and indication.

Antimetabolite dosing is adjusted for renal function and bone marrow suppression; leukopenia requires dose reduction.

Induction choice depends on immunologic risk; high PRA or prior rejection may warrant lymphocyte-depleting induction.

Prophylaxis for fungal infection may include fluconazole or other azoles, which interact with calcineurin inhibitors.

Patient education should include recognition of rejection signs and symptoms and when to seek emergency care.

Medication adherence tools include pillboxes, reminders, and pharmacy coordination; nonadherence is a leading cause of late graft loss.

Routine monitoring includes blood counts, renal and liver function, drug levels, and infection surveillance.

Cardiac catheterization findings guide risk stratification; significant coronary disease may require intervention before transplant.

Sleep apnea and obesity hypoventilation are assessed because they affect perioperative and post-transplant outcomes.

Prior sensitization (pregnancy, transfusion, prior transplant) increases PRA and complicates matching.

Desensitization protocols may be used for highly sensitized candidates, with risks of infection and rejection.

Informed consent includes discussion of immunosuppression risks, including infection, malignancy, and nephrotoxicity.

Vaccination status should be documented and updated before transplant, including hepatitis B, pneumococcal, and influenza vaccines.

Substance use and mental health treatment engagement may be required before listing per center policy.

Waitlist candidates should be reassessed periodically for changes in clinical status.

Fever with neutropenia requires urgent evaluation and empiric antibiotics; cultures should be obtained promptly.

CMV and EBV viral loads are monitored in high-risk patients; rising levels may prompt preemptive treatment.

Post-transplant lymphoproliferative disorder may present as lymphadenopathy, fever, or mass lesions; biopsy is diagnostic.

Renal replacement therapy may be needed temporarily after transplant; drug dosing must be adjusted for dialysis.

Wound care and monitoring for dehiscence are important, especially with mTOR inhibitors or steroids.

Physical activity and rehabilitation are encouraged to improve functional recovery and cardiovascular health.

Sexual health counseling includes contraception and prevention of sexually transmitted infections.

Caregiver support and respite are part of comprehensive post-transplant care.

Transplant coordinators must maintain competency through continuing education and certification.

Ethical allocation decisions should be transparent and documented; appeals processes exist for patients.

Informed consent for research includes risks, benefits, alternatives, and the right to withdraw.

Cultural and religious beliefs should be respected and accommodated in care planning.

Mandatory reporting of adverse events supports system learning and patient safety.

Advocacy for equitable access includes addressing language, transportation, and financial barriers.

Professional communication includes timely response to patient concerns and clear explanations.

Documentation should be accurate, timely, and reflect patient education and shared decision-making.

Cyclosporine and tacrolimus levels are affected by grapefruit juice; patients should be counseled to avoid it.

Antifungal azoles and macrolide antibiotics increase calcineurin inhibitor levels; dose adjustment and monitoring are required.

Rifampin and some anticonvulsants decrease calcineurin inhibitor levels; monitor and adjust doses.

Corticosteroid withdrawal may be considered in low-risk patients but increases rejection risk in some.

mTOR inhibitors are associated with impaired wound healing; avoid in the early postoperative period when possible.

Patient education includes avoiding herbal supplements that interact with immunosuppressants.

Rejection surveillance includes donor-specific antibody testing and protocol biopsies in some programs.

Infection prevention includes avoiding live vaccines and practicing food and hand hygiene.

HLA typing identifies donor and recipient antigens; mismatches affect rejection risk, especially in kidney transplant.

Crossmatch testing detects preformed antibodies; a positive crossmatch generally precludes kidney transplant.

PRA and unacceptable antigen lists guide organ offers and reduce risk of hyperacute rejection.

Medical evaluation includes cardiac, pulmonary, renal, hepatic, and infectious disease assessments.

Psychosocial evaluation assesses adherence, support, mental health, and substance use.

Nutritional and functional assessment guide candidacy and post-transplant planning.

Vaccination before transplant reduces preventable infections after immunosuppression.

Informed consent includes discussion of waiting time, organ offers, and alternatives.

Hyperacute rejection is prevented by crossmatching; it presents with immediate graft dysfunction.

Acute rejection is treated with corticosteroids or antibody therapy depending on severity and type.

Chronic rejection leads to progressive graft dysfunction and fibrosis; management focuses on risk factor control.

Infection risk is highest in the first 6 months and with intensified immunosuppression.

CMV prophylaxis and monitoring reduce disease in high-risk recipients.

BK virus nephropathy requires reduction of immunosuppression; increasing therapy worsens outcomes.

PTLD is associated with EBV and immunosuppression; treatment includes reduction of immunosuppression.

Cardiovascular risk factor management is essential for long-term survival.

OPTN/UNOS policies govern allocation, listing, and reporting; coordinators must follow them.

The dead donor rule requires death declaration before organ recovery.

Informed consent must be voluntary and free of coercion, especially for living donors.

Confidentiality applies to donor and recipient information.

Living donor evaluation is independent of the recipient team to avoid conflicts.

Patient education uses teach-back and health literacy–appropriate materials.

Ethical allocation balances urgency, utility, and justice.

Professional development includes continuing education and certification maintenance.

Tacrolimus and cyclosporine require therapeutic drug monitoring due to narrow therapeutic index.

Drug interactions via CYP3A4 and P-glycoprotein are common; review all medications and supplements.

Mycophenolate is teratogenic; pregnancy prevention is required.

Corticosteroids cause hyperglycemia, hypertension, and osteoporosis; monitor and manage.

mTOR inhibitors impair wound healing and can cause proteinuria and hyperlipidemia.

Infection prophylaxis includes Pneumocystis and CMV prevention in high-risk patients.

Live vaccines are contraindicated after transplant.

Adherence support is essential to prevent rejection and graft loss.

ABO compatibility is required for most solid organ transplants.

HLA matching is most critical for kidney transplant.

PRA quantifies sensitization and guides organ offers.

Active malignancy and untreated infection are common contraindications.

Cardiac evaluation includes ECG, echocardiography, and stress testing when indicated.

Psychosocial evaluation predicts post-transplant outcomes.

Vaccination should be completed before immunosuppression when possible.

MELD-Na prioritizes liver candidates by mortality risk.

Fever after transplant requires prompt evaluation for infection and rejection.

CMV disease is diagnosed by PCR and treated with ganciclovir.

BK virus nephropathy is managed by reducing immunosuppression.

PTLD is associated with EBV and immunosuppression.

Cardiovascular disease is a leading cause of late death.

Malignancy risk increases with chronic immunosuppression.

Adherence to immunosuppression prevents rejection and graft loss.

Inactivated vaccines are safe after transplant; live vaccines are not.

OPTN/UNOS policies govern listing, allocation, and reporting.

The dead donor rule requires death declaration before organ recovery.

Informed consent must be voluntary and free of coercion.

Confidentiality applies to donor and recipient information.

Living donor evaluation is independent of the recipient team.

Patient education uses teach-back and plain language.

Ethical allocation balances urgency, utility, and justice.

Continuing education and certification maintenance are professional obligations.