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Rosens > 183. Solid Organ Transplant Pt > Flashcards

183. Solid Organ Transplant Pt Flashcards

1
Q

Post solid organ transplantation: anatomic concerns/complications? List 3 general categories

A

vascular anastomoses complication (arterial worse than vein)
surgical wound complication
pseudo or mycotic aneurysms

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2
Q

What is the primary cause of mortality after solid organ transplantation?

A

infection

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3
Q

What is the early period considered post transplantation?

A

0-4weeks

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4
Q

Where do infections typically come from in the first month post solid organ transplant?

A

postop Intensive care, surgical site complications
-nosocomial, multidrgu R
-wound infection, pneumonia, UTI, cdiff
-bacteremia without signs of sepsis

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5
Q

Post solid organ transplant pt: concern for fever, how to work up in ED?

A

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

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6
Q

Post solid organ transplant pt: concern for anatomic issue, how to work up in ED at <30d post?

A

localizing sx in area of allograft
ddx vascular thrombosis leak vs stenosis vs imaging of transplanted organ

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7
Q

Post solid organ transplant pt: concern for anatomic issue, how to work up in ED at greater than 30d post?

A

ddx strictures, subacute thrombosis
- ct, doppler/us need for tp endocscopy (ERCP if biliary stricture)

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8
Q

Post solid organ transplant pt: concern for rejection issue issue, how to work up in ED?

A

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

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9
Q

Post solid organ transplant pt: concern for drug toxicity issue, how to work up in ED?

A

level of drug - meds and blood draq
Cr, LFT LE
Tremor and headache, seizure/PRES

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10
Q

What 3 viruses to look for sp that donor may have passed to recipient

A

cmv
ebv
hcv

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11
Q

Timeline of infections - early 0-4 weeks

A

MDR - MRSA, pseudmonas, VRE, cdiff, colitis

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12
Q

Timeline of infections IM 1-12mo

A

reactivation: fungi, cmv, hsv, zoster
relapsed: hep b
Opp: PJP

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13
Q

Timeline of infections: late

A

commnity acquired: aspergillus, endemic fungi, mycobacterium, resp viruses

late viral reactivation: cmv, hsv, zoster

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14
Q

Diagnosis if PJP?

A

best is a bronchoalveolar lavage fluid or sputum

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15
Q

PJP tx

A

septra 5mg/kg q6-8h

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16
Q

Which two organs are highest risk for fungal infection post transplant?

A

lung
liver

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17
Q

Disseminated strongyloides infection can cause what?

A

meningits
pneumonia
obstruction
sepsis

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18
Q

How does organ rejection occur?

A

T cell lead to cytotoxic actvity, b cell membory and antibody formationc lead to allograft cell death

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19
Q

What is hyperacute rejection?

A

immed postop perpoid: preformed abody against major histocompativility complex or ABO blood type ag

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20
Q

Most transplant immunosuppresive therapy is which 3 drugs?

A

calcineurin inhib (tacrolimus)
antimetabolite (mycophenolate)
steroids

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21
Q

What does a pretransplant desensitization regimen look like?

A

plasmaphresis to remove abodies
ritux to deplete b cells
bortezomib to reduce abody production
IVIG to trigger abx clearance
eculzimab to target complement cascade

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22
Q

Induction agents for immunosuppression in the pre or peri transplant period: name some

A

Antithymocyte globuin
alemtuzumab
both lymphocyte deleting agents

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23
Q

What is concern with tacrolimus?

A

narrow therapeutic window
variable pharmacokinetics
adverse SE

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24
Q

What is tacrolimus?

A

macrolide that binds to lymphocyte pro and inhibits ck synthesis

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25
Q

Tacrolimus common SE (or most adverse)

A

PRES
headache
neurotoxicity
tremor
with steroids - hyperglycemia

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26
Q

How does cyclosporine work?

A

inhibits cellular and humoral immunity by binding PRO inhibiting lymphocyte signal transduction

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27
Q

Cyclospoirin adverse effects

A

renal injury- tubular injury and direct vasospasm of artery

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28
Q

Mammalian target of rapamycin inhibitors: how so sirolimus and everolimus work?

A

MTO is key in T cell cloncal activation - they stop this

29
Q

mTOR drug adverse effects

A

delayed wound heal
hyperlidiemia
cytopenia
diarrhea
sirolumus induced lung injury

30
Q

Azathioprine: how does this work?

A

antimetabolite derivative that inhibits DNA and ribonucleic acid synthesis to suppress lymphocyte prolif

31
Q

How does mycophenolate work?

A

more potent and selective inhibition of lymphocyte proliferation through stopping dna and RNA

32
Q

Rixuximab black box warning

A

progressive multifocal luekoencephalopthy

33
Q

Heart: reasons for early post transplant admission:

A

cardiac dys
alllograft rejection
infection

34
Q

Heart: reasons for late post transplant admission:

A

cerebrovascular and allograft vasculopathy
renal dysfunc
diabetes

35
Q

Key anatomic considerations for heart transplant pt:

A
  1. Orthotopic: bicaval with single anastomis between donor and recip L atria, ao and pulmonary a anastomiies and 2 caval anastomosies
36
Q

Electricla changes in transplanted pt heart:

A
  • 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
37
Q

Infections of heart transplant pt:

A

mediastinitis
VAD infection

particular risk for toxo

38
Q

Toxo heart risk esp in transplant pt: how presents?

A

myocarditis
looking like rejection, pneumonia or meningoencephalitis

39
Q

How is cardiac allograft vasculopathy ID?

A

angio - diffuse concentric narrowing of coronaries

40
Q

Anatomic considerations of a kidney transplant:

A

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

41
Q

Anatomic complications of renal transplant

A

vessel anastomotic bleed
intra abdo hematomas
renal a anda v thrombosis
stent retention causing UTI, leak or stricture

42
Q

If worried about vascular stricture/stenosis in renal transplant pt, best test?

A

doppler u/s

43
Q

MC infections post renal transplant?

A

pyelo
perinpehric abscess, nephrolithiasis, residual ureteral stent, urinary retension

44
Q

Anatomic changes with liver transplant:

A

-surgical anastomoses at biliary and vascular sites
-risk for stenosis, obstruction, leak, rupture

45
Q

Liver transplant mc vascular complication?

A

hepatic artery thrombosis - fever jaundice RUQ pain without incr in LE or bili

if first month post op - screen for this with us!

46
Q

Complications of liver transplant:

A

-vessel: leak, rupture, stenosis, obstruction
-infection
- necrosis (biliary)

47
Q

Small for size syndrome in liver transplant:

A

living donor allograft may or may not be right size - assessed intraop and shunt formed, splenectomy

48
Q

Liver transplant: when likely to see sepsis early vs late cause?

A

two weeks post due to pretransplant RF or surgical complication

late: biliary stricture, preceding hepatic artery thrombosis

49
Q

NSAIDS in liver transplant?

A

not recommended

50
Q

Lung transplanation: anatomic factors

A

-single or bilateral
-anastamosis of bronchial or tracheal
-sequential lung transplant, lobar or heart and lung

51
Q

Lung transplant anatomic complications:

A

-bronchial stenosis, ischemia, tissue degen, dehiscence
-ptx
-mediastinitis
-vascular: ischemia, allograft fail, hemothorax
-pleural effusion
-empyema

52
Q

Community resp viruses can cause what kind of alograft dysfunction?

A

chronic

53
Q

Lung transplant pt infections risks/common issues?

A

gerd - aspiration
cmv pneumonia
pjp pneumonia rare if prophylaxis
donor derived: mycoplasma homini and ureaplasma urealuyticum - hyperammonia syndrome

54
Q

Pancreas transplant: how does this work?

A

The donor organ with its native duodenum is most often anasto- mosed to the recipient small intestine to allow for exocrine drainage

55
Q

Pancreas transplant: vascular anastomes: to which vessels?

A

R internal iliac

56
Q

Complications of pancreatic transplant:

A

vascular: bleed, thrombose, fistula, abscess
infections cmv, candida

57
Q

Intestinal and multivisceral transplantation: what is this?

A

for irrev intestinal failure
jejuno ileum
combined with liver

58
Q

MC infection Intestinal and multivisceral transplantation:

A

bacterial
abdo infection > catheter based > pneumonia > UTI

59
Q

Solid organ transplant recipient risk of malignancy

A

2-3x higher

60
Q

Cancers that pt with solid organ transplant are at higher risk for

A

lung
colon
skin
liver
lymphoma

61
Q

Why does post transplantation lymphoproliferative disorder

A

malignancy of Tc ell impairment results in unhibited monocloneal prolif of EBV infected B lymphocytes and transformation into immofrtal lymphoblastoid B cells

62
Q

GVHD risk ?-? weeks post solid organ transplantion

A

2-6wk

63
Q

Immediate contraindications to organ donation

A

creutzfeldt jakob disease
active malignancy

64
Q

Pregnancy and organ transplant: what changes?

A

mc miscarriage, preeclampsia, preterm delivery, need csection
MMF stopped, azathioprine reduced for fetal malformations
CS and tacrolimis incr risk gestdiabetes

65
Q
  1. 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

66
Q

. 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

A

C
Hyperammonemia syndrome affects 1% to 4% of lung transplant recipients, resulting from systemic infection with Myco- plasma hominis or Ureaplasma urealyticum.

67
Q
  1. 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
A

B

68
Q

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

A

D

69
Q

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

A

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.

Rosens (40 decks)

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