Chapter 297: The Transplant Patient

INTRODUCTION

As of the beginning of 2013, there were 76,047 active candidates waiting for solid-organ transplants in the United States, with the kidney transplant waitlist being the largest at 57,903 candidates.¹ The kidney is the most commonly transplanted organ (58%), followed by liver (21%), heart (8%), lung (5%), pancreas (5%), and, less commonly, combined organ transplants and intestine transplants. Annually, there are around 18,000 hematopoietic stem cell transplants in the United States, with about one third of these transplants being allogenic transplants and two thirds being autologous transplants.²

Most transplant patients require lifelong immunosuppression. Transplant patients can develop a number of acute to life-threatening emergencies, including (1) transplant-related infection, (2) medication side effects, (3) rejection, (4) graft-versus-host disease, and (5) postoperative complications or complications of altered physiology secondary to the transplanted organ. Transplant patients may also have common medical problems that require unique management. Adverse outcomes often are directly proportional to increasing age of the recipient and the donor organ.³

The most common acute disorders prompting ED visits are infection (39%) followed by noninfectious GI/GU pathology (15%), dehydration (15%), electrolyte disturbances (10%), cardiopulmonary pathology (10%) or injury (8%), and rejection (6%).^4,5,6,7 Acute graft-versus-host disease is an important complication, especially in those with hematopoietic stem cell transplantation.⁸ Coronary artery disease, sudden cardiac death, and heart failure are results of premature cardiovascular disease in solid-organ recipients, due to underlying comorbidities and metabolic effects of immunosuppression.⁹ Preoperative and regular postoperative cardiovascular assessment identifies risk factors and enables treatment to mitigate risk effects.¹⁰

GENERAL APPROACH TO EVALUATION

HISTORY AND COMORBIDITIES

Key historical elements for the management of transplant patients are listed in Table 297-1.