Power Review: Transplant Patient Management

Author: Amar Patel, MD (Resident Physician – EM, Penn State Hershey Medical Center) // Editor: Alex Koyfman, MD (@EMHighAK) & Justin Bright, MD

General Information
- Solid organ transplant patients presenting to the ED have complications that come in 4 varieties: anatomic, infection, rejection, drug toxicity. The most common of these being infection.

>6 months
- 3 groups for susceptibility
  - Healthy Transplant Patient: low-dose immunosuppression with slightly increased risk of community-acquired infections
  - Chronical Viral Infection Patient: progressive disease process (hepatocellular carcinoma or B-cell lymphoma via viral etiologies) or recurrent exacerbations of Varicella Zoster Virus and Herpes Simplex Virus
  - Chronic Rejection Patient: aggressive immunosuppression; patients are very susceptible to opportunistic infections

Mycophenolate mofetil
- Mild side effect profile: abdominal pain, nausea, diarrhea, leukopenia, thrombocytopenia
- Avoid Magnesium and Aluminum antacids

Corticosteroids
- Long list including not limited to: osteoporosis, cataracts, GI bleeding, adrenal suppression, glucose intolerance, AMS

Management of Specific Organ: all of the following should include basic labs, as well as, cultures including viral and fungal dependent on suspicion. Always contact transplant center! It is vital to know the new anatomy of the patient as well as medication regimen. Remember in the acute situation that rejection will not kill the patient but infection will; thus, important to manage infection and rule it out before initiation of rejection treatment which will normally be started by transplant center. In patients >1 year post-transplant, cancer should be on the differential; most commonly hepatocellular carcinoma, squamous cell carcinoma, and lymphoma.

Key Historical Inquires
- Recent temperature changes
- Any changes from baseline
- Rejection History
- Date of Transplant and Center
- Medication changes
- Immunization history
- Chronic infections
- Compliance to medications

Heart
- General: 60% of heart transplant patients presenting to the ED will be admitted. These patients will not have chest pain due to denervation and will have signs of CHF as an indication of ischemic disease as well as rejection. Stress can still increase heart rate and exogenous pressors will work as well as anti-hypertensive medications but atropine will not. Normal HR for these patients is between 90-100 and the EKG will show 2 distinct P waves, this is not 2^nd degree heart block.

Rejection
- Signs of CHF, dysrhythmias, decreased QRS voltage, new S₃
- Contact transplant center for treatment protocol for acute rejection but generally involves increased dose of steroids and OKT3

Liver
- General: most common vascular complication is hepatic artery thrombosis which will occur early after transplant so every patient presenting with dysfunction to the ED should get a formal ultrasound. Bile leaks and strictures are seen later and typically present with RUQ pain and elevated liver enzymes.

Kidney
- General: the kidney is transplanted in the retroperitoneal area of the anterior pelvis; most common and successful of all transplants. Basic labs should always be done paying special attention to Cr as well as cyclosporine and tacrolimus levels since both drugs are nephrotoxic.

Rejection
- Present with fever, LE swelling, tenderness over graft, HTN, and decreased urine output
- Subtle rise in Cr of >20% from baseline is a sign of rejection
- Prompt renal ultrasound and nephrology/transplant consult.

Summary
- The transplant patient is always sicker than they appear. It is important to be aggressive in these patients since they are severely immunocompromised which not only puts them at greater risk of infection but also blunts their normal signs to infection. Always contact the transplant team to help with management as many centers have specific protocols for treatment of rejection and infection. Often it is very difficult to differentiate between rejection and infection. In these cases, treat on the side of infection as it would be the greatest immediate threat to life in the patient.