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Chapter 297: The Transplant Patient

J. Hayes Calvert

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.

TABLE 297-1Key Historical Elements Specific to Transplant Patients
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TABLE 297-1 Key Historical Elements Specific to Transplant Patients
Historical Item Significance
Recent temperature increase or decrease from baseline Potential clue to onset of infection or rejection.
Changes from baseline function

Decreased urine may signify rejection in renal transplant patients or acute dehydration.

Decreased exercise tolerance may signify rejection in heart transplant patients.

Change in skin color (jaundice specifically) may signify rejection in liver transplant patients or graft-versus-host disease.
Date of transplant surgery The date from transplant helps to predict typical infections and types of posttransplant complications (i.e., graft-versus-host disease).
Graft source for solid-organ transplant, special features of graft if any, prior infections; donor living related vs cadaveric These details predict the potential for certain infections and rejection.
Graft source for hematopoietic stem cell transplant: autologous, degree of match, related donor These details predict potential graft-versus-host disease.
Rejection history May predict current rejection if similar presentation and difficulty in controlling a current episode of rejection.
Recent changes in dosages of antirejection and other medications Although a planned part ...

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