Transplant Immunosuppression on Step 1

Like any workaholic second-year medical student, I'm spending part of the holiday break studying for Step 1 of the boards (the standardized Big Test after the first two years of medical school).  But since it is supposed to be a vacation, I felt justified in studying a more familiar topic, so transplant immunosuppression it is.

Wow.  Everyone says that the textbooks and the exams are ten years behind the times, but it's really striking in a field that changes as fast as transplantation.  Also, the testable facts are based on FDA labeling and the approved indications, which are quite a bit more limited than clinical practice, especially for transplants that are done less commonly.  So, what I've "learned" is:

• Cyclosporine, azathioprine, and OKT3 are commonly used immunosuppressants.
• Cyclosporine is used for kidney, liver, and heart transplants; tacrolimus is used for kidney and liver transplants; everything else is used for kidney transplants only...so lung transplants must not need any immunosuppression at all!
• Daclizumab (Zenapax) is used as an antibody against the IL-2 receptor, even though it's no longer manufactured in the US since Simulect (basiliximab) is now preferred.
• Thymoglobulin, Campath (alemtuzumab), and belatacept don't exist (or rather, knowing them won't help me one bit on the test :-/).

Anyway, pretty obvious defense mechanisms in play with this post!  There's more to worry about than the anachronisms in the transplant immunosuppression section, like how much else there is to study, how out of date it may be (without me knowing it), and how much I'll have to unlearn or get a clue about before actually being able to take care of patients.

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Book Review: Intestinal Failure: Diagnosis, Management, and Transplantation

Intestinal transplantation is probably the most esoteric area of organ transplantation, so learning anything about it can be nearly impossible.  The occasional article or meeting isn't nearly enough to get an overall picture of the field, so I was glad to find a book about it called Intestinal Failure: Diagnosis, Management and Transplantation.

For transplantation, this book has it all.  Surgery, immunosuppression, rejection, infections, evaluation...all the usual topics in organ transplantation are included.  In particular, it discusses the different transplant options--isolated intestinal transplant, liver-intestine transplant, and multivisceral transplant--and describes the differences and indications for each.  Piecing this information together from individual articles isn't nearly as useful, since most of them report on one particular procedure at one center with the conclusion of "look how well it worked!"  There could be more detail on some general aspects of transplantation, such as immunology, but there are many other sources for that information, so this book stays focused on its niche and gives plenty of information to understand its topic.

Even though most people reading about intestinal transplantation have an extensive background (either professionally or personally), the book begins with general information about the gastrointestinal system and intestinal failure, which is great.  If I had to name a weakness, it would be the information on parenteral nutrition, which is pretty limited given how important it is in intestinal failure, and doesn't provide nearly enough detail to understand a PN prescription.  Of course, prescribing PN is a specialty in itself for physicians and for dietitians, so it's understandable if it can't be covered here.  Intestinal and multivisceral transplantation is only an interest for me, not something I deal with personally or professionally, so it's great to find a book that explains it well.

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