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As of the end of 2006, there were 173,339 patients in the U.S. living with solid-organ transplants, and an additional 27,578 U.S. transplants in 2007.1 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. In 2008, there were 4300 hematopoietic stem cell transplants (HSCTs) (bone marrow transplants) in the U.S.2

Most transplant patients require lifelong immunosuppression. Transplant patients present to the EDs with 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 and complications of altered physiology secondary to the transplanted organ. Frequently, transplant patients present with common medical problems that require unique management due to their immunosuppression or altered physiology. Finally, transplant patients are at risk for presenting with symptoms of a new malignancy due to their extended immunosuppression.


The largest study of transplant patients presenting to the ED was published in 2009 (1251 visits),3 adding to previously published studies of liver transplant patients (290 ED visits),4 heart transplant patients (131 ED visits),5 and renal transplant patients (78 ED visits).6 With multiple diagnoses possible per patient, the most common diagnosis in all studies was infection (39%) followed by noninfectious GI/GU pathology (15%), dehydration (15%), electrolyte disturbances (10%), cardiopulmonary pathology (10%) or injury (8%), and rejection in 6%. Acute graft-versus-host disease occurs in 20% to 80% of patients post-HSCT, depending on the degree of major histocompatability complex mismatch, and rarely occurs post–solid-organ mismatch, depending on the amount of lymphoid tissue transplanted.7

Initial Evaluation: Clinical Features

Pertinent History and Comorbidities

The initial history may reveal other immediate patient concerns (Table 295-1).

Table 295-1 Key Historical Elements Specific to Transplant Patients

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