Organ Transplant

Solid Organ Transplant Patient

Transplant Pts Don’t Follow Rules

  • Any organ transplant patient is immunosuppressed for life
  • Abnormal innervation and anastomosis of transplanted organs = pain unreliable
  • Can’t rely on “well appearing” gestalt
  • Lower threshold for testing, imaging, consultation
  • High risk for drug-drug interactions with any new drug

Long Term Complications

  • Cardiovascular disease
  • Hypertension
  • DM
  • Cancers (due to immunosuppression)

Anatomic complications

  • Within first 6 mo usually – Consult Surgery within first 6 mo of transplant
  • Vascular
    • Venous thrombosis – tender/swollen graft – Emergent US
    • Arterial thrombosis/stenosis – drop off in urine output
  • Non-vascular leaks/obstruction
  • Surgical technique problems – wound infection, ureteral stent migration, hematoma, lymphocele etc.

CV Complications

  • Transplanted organs very sensitive to hypotension
  • ESRD patients very high risk for CAD

Immunosuppression and Drug-Drug Problems

  • Most regimens most intense in first 6-12 mo and then ideally taper down to low dose
  • Cyclosporine/Tacroliums (calcineurin inhibitors)
    • Nephrotoxicity
    • HTN
    • High risk for drug-drug interactions
  • Imuran (anti-metabolite)
    • Bone marrow suppression
    • Azothioprine and allopurinol interaction – Bone Marrow Failure and Death
  • Steroid
  • Antinfective PPX – if on steroids, usually on Bactrim for PJP, Toxoplasmosis and Nocardia as well as antifungal for candida
  • Antiviral if high risk for CMV or has had HSV/VZV

Infectious Complications

  • Major cause of mortality
  • Normal responses are blunted – Relative leukocytosis or subtle temp elevations are important
  • First Month Post – Surgical site and other nosocomial infections, also viral reactivations
  • 2-6 months Post –
    • Opportunistic infections: PJP, Listeria, Fungal, TB, histo/blasto, strongy
    • CMV – Insidious flu like illnesss 1-3 mo post transplant affecting multiple organ systems
    • Atypical presentations of diverticulitis
    • Nocardia
  • >6 months
    • CMV retinitis or colitis
    • Endemic fungi
    • Community acquired infections

Rejection

  • Hyperacute – rare immediate post op
  • Acute – first couple of months, most common, presents like infection, only proven on biopsy – can happen anytime someone stops taking medication
  • Chronic – gradual organ failure over years

 

Organ Specific Considerations

Cardiac

  • Vagus nerve denervated so baseline tachycardia is expected
  • Endogenous catechols work and B-receptors are up regulated
  • Classic teaching is atropine doesn’t work – but it actually might, worth a try
  • Adenosine – more sensitive – 3 mg initial dose probably reasonable
  • Accelerated atherosclerosis does occur –  no CP symptoms in ACS/ischemia due to denervation

Lung

  • Highest risk for infection of all solid organ transplants
  • Gram negs most common but also high risk for fungal
  • Acute rejection looks like PNA – clinical impression of infection wrong ~50% of the time
  • Median survival for adults is 5.6 yrs

Liver

  • Bile leaks and strictures
  • Rejection w/ lab findings as well as pain, fever, malaise
  • US with doppler flow to evaluate

Renal

  • CV mortality leading cause of death
  • Pyelo common in first month after surgery
  • Any UTI with renal transplant needs IV Abx and admission
  • Get an ultrasound in almost all cases