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.
  • Infection Time Table
    • <1 month
      • Related to surgery, stents, catheters, intubations
      • Hospital-acquired infections prominent: full immunosuppression has not peaked
      • Organisms and treatment same as for any immunocompromised patient
        • MRSA, VRE, Candida species
  • 1 to 6 months
    • Cytomegalovirus (CMV)
      • Most common and affects multiple systems; usually pneumonitis
      • Can trigger rejection
      • May need bronchoalveolar lavage or biopsy to diagnose
      • Check for chorioretinitis: indicates a poor prognosis
      • Treatment: Ganciclovir or Immunoglobulin
    • Ebstein-Barr Virus (EBV)
      • Similar effects as CMV clinically
      • Can trigger rejection
      • B cell lymphoproliferative syndrome
    • Human Herpes Virus 6 (HHV-6)
      • BM suppression, pneumonia, encephalitis
    • Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), BK polyomavirus
    • Opportunistic infections: Pneumocystis, Listeria, Fungal species
  • >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
  • Drug toxicity of immunosuppression
    • Cyclosporine
      • Nephrotoxicity: dose-related
        • Adjust medication dosages for renal toxicity and check drug level before adding new medications
        • May cause renal artery vasospasm: treat HTN aggressively
      • May cause Gout
  • Tacrolimus
    • Nephrotoxic and Neurotoxic
    • Avoid macrolide antibiotics
  • Azathioprine
    • Bone marrow toxin: dose-related neutropenia
  • 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 2nd degree heart block.
  • Infection
    • Be aggressive with looking for source of fever.
      • Blood and urine cultures, +/-CT, +/-LP, +/-bronchoscopy, ECG, bedside TTE, basic labs
    • If your patient is septic and requires fluid resuscitation, don’t be timid
    • Most common skin infection will be herpes zoster
    • Nausea, vomiting, diarrhea: think CMV
    • Headache, fever, AMS, seizure
      • Cover for Listeria, Cryptococcal meningitis, Toxoplasma gondii, Norcardia, and Aspergillosis
  • 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.
  • Infection
    • > 1month
      • CMV, HSV (ulcers more common then vesicles)
      • Fungal: Aspergillus, Candida, Cryptococcus
      • Protozoan
      • Bacteria: Norcardia, Legionella, Listeria
    • Increased risk of ascending cholangitis and liver abscess
  • 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.
  • Infection
    • Pyelonephritis
      • 35% in 1st 4 months
    • HCV most common cause of hepatitis in renal transplant patients
      • Not seen till after 4 months
      • These patients have an increased risk of spontaneous bacterial peritonitis
  • 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.
  • References / Further Reading

-Marx JA, Hockberger RS, Walls RM. Rosen’s Emergency Medicine, Eighth Edition. 2014; 184: 2368-2377.
-Cline DM, Ma OJ, Cydulka RK, Meckler GD, Handel DA, Thomas SH. Tintinalli’s Emergency Medicine, Seventh Edition. 2012; ch295.


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