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Chapter 99: The Transplant Patient

Sarah E. Unterman

INTRODUCTION

Management of patients with transplanted organs in the emergency department (ED) involves three general areas: (1) disorders specific to certain transplanted organs, (2) disorders common to many different kinds of transplant patients due to an immunosuppressed state or antirejection medications, and (3) disorders not specifically related to a transplanted organ but where special care may be warranted due to associated medications or altered physiology. Disorders specific to the transplanted organ are manifestations of acute rejection, surgical complications specific to the procedure performed, and altered physiology (most important in cardiac transplantation). The most common conditions that prompt transplant patients to present to the ED are infections (39%), noninfectious gastrointestinal (GI) or genitourinary pathology (15%), dehydration (15%), electrolyte disturbances (10%), cardiopulmonary pathology (10%) or injury (8%), and rejection (6%).

POSTTRANSPLANT INFECTIOUS COMPLICATIONS

Posttransplant infections are the most common presenting diagnosis to the ED for this patient population, in part due to the ongoing immunosuppression required for transplant recipients. Additional infection risk factors include diabetes mellitus, advanced age, obesity, and other host factors. Table 99–1 lists the broad array of potential infections and the time after transplant they are most likely to occur.

Table 99-1

Infections Stratified by Posttransplant Period

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Table 99-1

Infections Stratified by Posttransplant Period
Period after Transplant/Conditions Infection Comments
<1 mo: resistant organisms

  • MRSA

  • Vancomycin-resistant Enterococcus faecalis

  • Candida species (including non-albicans)

 Opportunistic infections are generally absent during this period as full effect of immunosuppression not complete. MRSA important in HSCT patients.
<1 mo: complications of surgery and hospitalization

  • Aspiration

  • Catheter infection

  • Wound infection

  • Anastomotic leaks and ischemia

  • C. difficile colitis

 Clostridium difficile common during this period. Early graft injuries may abscess. Unexplained early signs of infection such as hepatitis, encephalitis, pneumonitis, or rash may be donor derived.
<1 mo: colonization of transplanted organ or HSCT neutropenia

  • Aspergillus

  • Pseudomonas

  • Klebsiella

  • Legionella

 Microbiologic analysis of aspirates or biopsy from surgery essential for therapeutic decisions.
<1 mo: HSCT-specific infections

  • Additional bacterial pathogens: Streptococcus viridans and enterococci

  • Viral infections include respiratory syncytial virus and HSV

 Neutropenia and mucocutaneous injury increase risk for HSCT patients. Lungs, bloodstream, and GI tract most commonly affected sites.
1–6 mo: in patients with Pneumocystis jirovecii pneumonia and antiviral (CMV, HBV) prophylaxis

  • Polyomavirus BK infection, nephropathy

  • C. difficile colitis

  • HCV infection

  • Adenovirus infection, influenza

  • Cryptococcus neoformans infection

  • Mycobacterium tuberculosis infection

  • Anastomotic complications

 Activation of latent infections, relapse, residual, and opportunistic infections occur during this period. Viral pathogens and allograft rejection cause the majority of febrile episodes during this period. Polyomavirus BK, adenovirus infections, and recurrent HCV are becoming more common.
1–6 mo: in patients without prophylaxis

  • Pneumocystis

  • Infection with herpesviruses (HSV, varicella-zoster virus, CMV, Epstein–Barr virus)

  • HBV infection

  • Infection with Listeria, Nocardia, Toxoplasma, Strongyloides, Leishmania, Trypanosoma cruzi

 Discontinuation of prophylaxis at the end of this period may prompt active infection, especially CMV. Graft-versus-host disease and mucocutaneous injury increase risk for HSCT patients.
>6 mo: general

  • Community-acquired ...

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