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Gastrointestinal mucormycosis is a rare infection in solid organ transplant recipients. Our patient, a 79-year-old male, presented with severe dysphagia and odynophagia about 2 weeks after receiving a renal transplant. An upper gastrointestinal (UGI) endoscopy revealed esophagitis and gastric ulceration, the cultures from which grew Rhizopus species. A usual treatment strategy should include Amphotericin B as monotherapy or in combination with Posaconazole or Isavuconazole for such infections. Our patient was treated with Isavuconazole monotherapy, in an effort to minimize renal toxicity from Amphotericin B to the new allograft. Unique to our case was a successful clinical response and resolution of UGI lesions with Isavuconazole monotherapy. Due to the vagueness of presenting symptoms, such infections can be easily missed in an immunocompromised patient which can have tragic outcomes. Prompt diagnosis and modulation of immunosuppression are essential to decrease mortality and morbidity. Isavuconazole is a novel agent and can be used as a monotherapy for such infections, especially in renal transplant recipients.

Abstract Purpose An institutional workflow developed by clinical pharmacists for initiation of directing-acting antiviral (DAA) therapy for patients who receive solid organ transplants from hepatitis C (HCV)–positive donors is described; programmatic challenges in providing pharmaceutical care to these patients are reviewed. Summary In recent years the introduction of new oral DAAs, coupled with faster screening of donor organs for HCV infection through use of a nucleic acid test (NAT), has facilitated transplants of organs from HCV-seropositive donors to HCV-seronegative recipients. The solid organ transplant program of a North Carolina health system began performing such transplants in December 2017. In the pharmacist-developed workflow, patients are initiated on DAA therapy in the outpatient clinic setting, and clinic pharmacists are consulted regarding drug selection. Prescriptions for DAA therapy are sent to an on-site specialty pharmacy, where pharmacists and pharmacy technicians work to obtain prior authorization and, if necessary, payment assistance through manufacturer-sponsored programs. The medical team is notified at the time of patient approval to begin treatment. Pharmacists provide counseling at the time of DAA therapy initiation and follow up with patients every 2 weeks to confirm adherence. As of June 2019, about 100 transplants of HCV NAT–positive organs had been performed (approximately 50% were kidney transplants; 15%, lung transplants; 20%, heart transplants; and 15%, liver transplants). Many challenges are encountered in the process of providing pharmaceutical care to this patient population, including challenges in patient selection and counseling, overcoming financial barriers and insurance restrictions, and coordinating with an internal specialty pharmacy to ensure timely delivery of medication to patients. Conclusion Within a solid organ transplantation program, clinical pharmacists and other pharmacy personnel can play vital roles in ensuring safe and effective DAA therapy for recipients of transplanted HCV NAT–positive organs.

Lung transplant recipients (LTRs) are at an increased risk for venous thromboembolism (VTE) after transplant, necessitating the use of anticoagulation. Guidelines recommend direct oral anticoagulants (DOACs) over warfarin for most patients and indications; however, many of the studies upon which these recommendations were made excluded high-risk patient populations, including transplant recipients. The purpose of this study was to compare rates of new or recurrent VTE and bleeding in patients receiving DOAC versus warfarin after lung transplant. Methods: This retrospective cohort study was approved by the local institutional review board. Adult lung transplant recipients transplanted at a single center from 2010 -2018 who received an oral anticoagulant for treatment of VTE were included. Re-transplants, patients with a diagnosis of atrial fibrillation/flutter, and those taking oral anticoagulation prior to transplant were excluded. The primary outcome was new or recurrent VTE within 1 year of starting oral anticoagulation, as determined by review of radiology reports. Safety was evaluated by assessment of 1-year rate of bleeding requiring emergency department visit or admission. Propensity matching in a 1:1 ratio using was used to control for confounders. Variables chosen for inclusion in the propensity score were sex, age, and chronic kidney disease. Clinical outcomes were assessed using chi-2 or Fisher's exact test. Results: 366 LTRs met inclusion criteria. Of these, 68 received DOACs and 298 received warfarin. The analysis cohort included 132 LTRs who were successfully propensity matched, 66 in each group. After matching, patient demographics and comorbidities were similar at baseline. In the 1-year follow up period, 17 patients (12.9%) experienced new or recurrent VTE. There was no difference in the rate of VTE between the DOAC and warfarin groups (13.6% vs 12.1%, p=0.80). Six total bleeding events requiring hospital visits were observed, 4 in the DOAC group and 2 in the warfarin group (p=0.68).

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