183. Solid Organ Transplant Pt Flashcards
Post solid organ transplantation: anatomic concerns/complications? List 3 general categories
vascular anastomoses complication (arterial worse than vein)
surgical wound complication
pseudo or mycotic aneurysms
What is the primary cause of mortality after solid organ transplantation?
infection
What is the early period considered post transplantation?
0-4weeks
Where do infections typically come from in the first month post solid organ transplant?
postop Intensive care, surgical site complications
-nosocomial, multidrgu R
-wound infection, pneumonia, UTI, cdiff
-bacteremia without signs of sepsis
Post solid organ transplant pt: concern for fever, how to work up in ED?
cbc
chem 10
urinalysis and urine culture
cxr
cxrp
if resp - cxr, ct chest without contrast if lung
abdo - LFT, LE, lipase imaging, ciarrhea = cdfif, stol pathogen and serum cmv
kidney: urinalysis and culture
skin rash/lesion - swab
Post solid organ transplant pt: concern for anatomic issue, how to work up in ED at <30d post?
localizing sx in area of allograft
ddx vascular thrombosis leak vs stenosis vs imaging of transplanted organ
Post solid organ transplant pt: concern for anatomic issue, how to work up in ED at greater than 30d post?
ddx strictures, subacute thrombosis
- ct, doppler/us need for tp endocscopy (ERCP if biliary stricture)
Post solid organ transplant pt: concern for rejection issue issue, how to work up in ED?
recent tx for rejection - risk infxn (look there)
ask about adherence to immsupp
new drugs
serum tacrolimus or cyclosporine
organ sp testing
consider adm for bx of organ
Post solid organ transplant pt: concern for drug toxicity issue, how to work up in ED?
level of drug - meds and blood draq
Cr, LFT LE
Tremor and headache, seizure/PRES
What 3 viruses to look for sp that donor may have passed to recipient
cmv
ebv
hcv
Timeline of infections - early 0-4 weeks
MDR - MRSA, pseudmonas, VRE, cdiff, colitis
Timeline of infections IM 1-12mo
reactivation: fungi, cmv, hsv, zoster
relapsed: hep b
Opp: PJP
Timeline of infections: late
commnity acquired: aspergillus, endemic fungi, mycobacterium, resp viruses
late viral reactivation: cmv, hsv, zoster
Diagnosis if PJP?
best is a bronchoalveolar lavage fluid or sputum
PJP tx
septra 5mg/kg q6-8h
Which two organs are highest risk for fungal infection post transplant?
lung
liver
Disseminated strongyloides infection can cause what?
meningits
pneumonia
obstruction
sepsis
How does organ rejection occur?
T cell lead to cytotoxic actvity, b cell membory and antibody formationc lead to allograft cell death
What is hyperacute rejection?
immed postop perpoid: preformed abody against major histocompativility complex or ABO blood type ag
Most transplant immunosuppresive therapy is which 3 drugs?
calcineurin inhib (tacrolimus)
antimetabolite (mycophenolate)
steroids
What does a pretransplant desensitization regimen look like?
plasmaphresis to remove abodies
ritux to deplete b cells
bortezomib to reduce abody production
IVIG to trigger abx clearance
eculzimab to target complement cascade
Induction agents for immunosuppression in the pre or peri transplant period: name some
Antithymocyte globuin
alemtuzumab
both lymphocyte deleting agents
What is concern with tacrolimus?
narrow therapeutic window
variable pharmacokinetics
adverse SE
What is tacrolimus?
macrolide that binds to lymphocyte pro and inhibits ck synthesis
Tacrolimus common SE (or most adverse)
PRES
headache
neurotoxicity
tremor
with steroids - hyperglycemia
How does cyclosporine work?
inhibits cellular and humoral immunity by binding PRO inhibiting lymphocyte signal transduction
Cyclospoirin adverse effects
renal injury- tubular injury and direct vasospasm of artery
Mammalian target of rapamycin inhibitors: how so sirolimus and everolimus work?
MTO is key in T cell cloncal activation - they stop this
mTOR drug adverse effects
delayed wound heal
hyperlidiemia
cytopenia
diarrhea
sirolumus induced lung injury
Azathioprine: how does this work?
antimetabolite derivative that inhibits DNA and ribonucleic acid synthesis to suppress lymphocyte prolif
How does mycophenolate work?
more potent and selective inhibition of lymphocyte proliferation through stopping dna and RNA
Rixuximab black box warning
progressive multifocal luekoencephalopthy
Heart: reasons for early post transplant admission:
cardiac dys
alllograft rejection
infection
Heart: reasons for late post transplant admission:
cerebrovascular and allograft vasculopathy
renal dysfunc
diabetes
Key anatomic considerations for heart transplant pt:
- Orthotopic: bicaval with single anastomis between donor and recip L atria, ao and pulmonary a anastomiies and 2 caval anastomosies
Electricla changes in transplanted pt heart:
- loss of PNS and SNS so rests around 95-110, decr one year to mean 92
- reduce adenosine dose by half as ++ sens
- won’t experience classic angina, HF as denerved
Infections of heart transplant pt:
mediastinitis
VAD infection
particular risk for toxo
Toxo heart risk esp in transplant pt: how presents?
myocarditis
looking like rejection, pneumonia or meningoencephalitis
How is cardiac allograft vasculopathy ID?
angio - diffuse concentric narrowing of coronaries
Anatomic considerations of a kidney transplant:
transplant with allograft into R or L iliac fossa, native kidneys and ureters in situ
abdo pain from pyelo may be lower abdo; denervation can prevent pain altogether
Anatomic complications of renal transplant
vessel anastomotic bleed
intra abdo hematomas
renal a anda v thrombosis
stent retention causing UTI, leak or stricture
If worried about vascular stricture/stenosis in renal transplant pt, best test?
doppler u/s
MC infections post renal transplant?
pyelo
perinpehric abscess, nephrolithiasis, residual ureteral stent, urinary retension
Anatomic changes with liver transplant:
-surgical anastomoses at biliary and vascular sites
-risk for stenosis, obstruction, leak, rupture
Liver transplant mc vascular complication?
hepatic artery thrombosis - fever jaundice RUQ pain without incr in LE or bili
if first month post op - screen for this with us!
Complications of liver transplant:
-vessel: leak, rupture, stenosis, obstruction
-infection
- necrosis (biliary)
Small for size syndrome in liver transplant:
living donor allograft may or may not be right size - assessed intraop and shunt formed, splenectomy
Liver transplant: when likely to see sepsis early vs late cause?
two weeks post due to pretransplant RF or surgical complication
late: biliary stricture, preceding hepatic artery thrombosis
NSAIDS in liver transplant?
not recommended
Lung transplanation: anatomic factors
-single or bilateral
-anastamosis of bronchial or tracheal
-sequential lung transplant, lobar or heart and lung
Lung transplant anatomic complications:
-bronchial stenosis, ischemia, tissue degen, dehiscence
-ptx
-mediastinitis
-vascular: ischemia, allograft fail, hemothorax
-pleural effusion
-empyema
Community resp viruses can cause what kind of alograft dysfunction?
chronic
Lung transplant pt infections risks/common issues?
gerd - aspiration
cmv pneumonia
pjp pneumonia rare if prophylaxis
donor derived: mycoplasma homini and ureaplasma urealuyticum - hyperammonia syndrome
Pancreas transplant: how does this work?
The donor organ with its native duodenum is most often anasto- mosed to the recipient small intestine to allow for exocrine drainage
Pancreas transplant: vascular anastomes: to which vessels?
R internal iliac
Complications of pancreatic transplant:
vascular: bleed, thrombose, fistula, abscess
infections cmv, candida
Intestinal and multivisceral transplantation: what is this?
for irrev intestinal failure
jejuno ileum
combined with liver
MC infection Intestinal and multivisceral transplantation:
bacterial
abdo infection > catheter based > pneumonia > UTI
Solid organ transplant recipient risk of malignancy
2-3x higher
Cancers that pt with solid organ transplant are at higher risk for
lung
colon
skin
liver
lymphoma
Why does post transplantation lymphoproliferative disorder
malignancy of Tc ell impairment results in unhibited monocloneal prolif of EBV infected B lymphocytes and transformation into immofrtal lymphoblastoid B cells
GVHD risk ?-? weeks post solid organ transplantion
2-6wk
Immediate contraindications to organ donation
creutzfeldt jakob disease
active malignancy
Pregnancy and organ transplant: what changes?
mc miscarriage, preeclampsia, preterm delivery, need csection
MMF stopped, azathioprine reduced for fetal malformations
CS and tacrolimis incr risk gestdiabetes
- A 42-year-old man presents from home with a 3-day history of fever, cough, and shortness of breath. He underwent orthotopic heart transplantation 5 years ago, has never experienced rejection, and is maintained on minimal doses of prednisone and tacroli- mus. He takes trimethoprim-sulfamethoxazole for antimicrobial prophylaxis. Chest radiograph reveals a diffuse interstitial pattern. What is the most likely cause of his pneumonia?
a. Community-acquiredrespiratoryvirus b. Cytomegalovirus
c. Pneumocystisjirovecii
d. Nocardia
A
. A 35-year-old woman with cystic fibrosis status post bilateral lung transplantation 2 weeks ago is brought to the ED by her husband. He reports that she was discharged several days prior to presen- tation with confusion attributed to intensive care unit delirium. Instead, she has developed worsening episodes of alternating agita- tion and lethargy. She is afebrile and normotensive on presentation, with a 2-liter oxygen requirement to maintain saturations above 90%. No leukocytosis or abnormalities of liver or kidney function are noted. A blood gas test does not demonstrate hypercarbia. What is the next best test?
a. Lumbarpuncture
b. Magnetic resonance imaging c. Serumammonia
d. Electroencephalography
C
Hyperammonemia syndrome affects 1% to 4% of lung transplant recipients, resulting from systemic infection with Myco- plasma hominis or Ureaplasma urealyticum.
- A 57-year-old deceased donor kidney transplant recipient is sent to the ED from her primary care physician’s office 3 months postop- eratively because routine blood work revealed a creatinine of 3.45 (baseline creatinine 1.0). Which of the following medications may be responsible for her acute kidney injury?
a. Albuterol
b. Tacrolimus c. Pancrelipase d. Prednisone
B
A 30-year-old liver transplant recipient presents to the ED 10 days post-transplantation with fevers, right upper quadrant pain, and jaundice. Laboratory evaluation reveals leukocytosis, transaminase elevations, and hyperbilirubinemia, which have all worsened since hospital discharge. Which of the conditions responsible for this pre- sentation is most important to diagnose emergently?
a. Rejection
b. Cholangitis
c. Donor-derived hepatitis B infection d. Hepatic artery thrombosis
D
A 53-year-old intestinal transplant recipient with a history of Crohn disease status post multiple bowel resections resulting in short gut syndrome has been maintained on tacrolimus and prednisone for the last 2 years since transplantation without previous significant infection complications. He presents to the ED with 5 days of nau- sea, vomiting, cramping abdominal pain, and diarrhea, and states that his 2-year-old son had been ill with similar symptoms that have since resolved. The recipient has not been able to consistently take his medications for the last 3 days. He is febrile and hypotensive with blood pressures in the 80s/50s. His lab work is significant for acute kidney injury and hyponatremia. Which of the following is unlikely to contribute to this patient’s clinical presentation?
a. Community-acquiredgastroenteritis b. Acute rejection
c. Adrenalinsufficiency
d. CMV enteritis
D. Intestinal transplant recipients may develop diarrhea from a wide variety of causes and, in fact, dehydration is the most common reason for recurrent presentations to the ED and readmission in this population. While rejection, bacterial overgrowth, and CMV infection are common reasons for diarrhea in the first year after transplant, later causes for diarrhea are more likely to be community-acquired. This patient’s history of an exposure to a child with a like illness suggests a new infection with a typical pathogen. Acute rejection can be precip- itated by the inability to ingest and absorb immunosuppressive drugs and could now be a part of this patient’s disease process. Given the use of chronic corticosteroids in this population, endogenous steroid pro- duction by the adrenal glands is often impaired and seemingly minor insults such as viral infections and hypovolemia may lead to signs of adrenal insufficiency. CMV is unlikely to emerge as a new infection this late post-transplant.
