Transplant Flashcards
How is hepatopulmonary syndrome diagnosed?
Platypnea, orthodeoxia, clubbing, elevated A-a gradient, +bubble study at 4-6 beats, V/Q scan showing uptake over the brain/kidneys. Pulmonary capillaries enlarge from 15micrometers to up to 500
When to consider liver transplant in HPS?
PaO2 <50
What is the primary graft dysfunction grading system?
Grade 0- no pulmonary edema and p/f >300
Grade 1- edema and p/f >300
Grade 2- edema and p/f 200-300
Grade 3- edema and p/f <200
Assessed at time of reperfusion, and at 24/48/72hrs following graft
What are risk factors for primary graft dysfunction?
Occurs within 72hrs post-transplant
Donor smoking, donor aspiration, chest trauma/contusion, ETOH, undersized donor, bypass need, large volume transfusions, delayed chest closure, prolonged ischemic times, increasing reperfusion FiO2, abnormal recipient body weight, mod-severe PAH, pre-transplant Dx other than COPD/CF
What are some referral criteria for CF for lung transplant?
FEV1 50% or less with rapid decline (more than 20% in 12 months), 40% or less with markers of shortened survival, or less than 30%.
Also with BMI under 18 and FEV1 under 40 when working to improve nutrition, FEV1 under 40% with more than 2 exacerbations/massive hemoptysis requiring ICU or embolization/PTX
Special consideration for women especially if younger due to poorer outcomes
What is the mechanism and findings for acute cellular rejection?
T-cell mediated direct attack against donor antigens. See 10%+ decrease in FEV1, perihilar infiltrates and/or pleural effusions, decrease in oxygen sats, lymphocytic vasculitis on TBBx.
Patients can experience fever, SOB, dry cough.
Tx- high dose steroids followed by a taper. Refractory cases are given lymphocytic immunosuppressive agents.
What is the mechanism and findings for antibody mediated rejection?
Antibodies (made by B cells) directed against donor HLA. See DSA in lab work, sometimes endothelial C4d deposition in alveolar capillaries. Patients experience fever, cough, DOE, hypoxemia, hemoptysis, resp failure.
Tx- steroids, rituximab, IVIG, plasmaphoresis
What are the features of Posttransplant lymphoproliferative disorder?
The most common malignancy following nonmelanoma skin cancers in lung transplant recipients. B cell proliferation due to EBV+. Risk factors include +donor/-recipient mismatch, seroconversion, episodes of rejection requiring increased immunosuppression. Incidence higher in the first year likely due to the higher immunosuppression. Most commonly in the lung, but can also be skin, colon, CNS.
Tx- reduce immunosuppression, rituximab, may need full CHOP
How does a TIPS affect hepatopulmonary syndrome?
Can worsen it due to increased pulmonary vasodilation, shunt, and hypoxemia.
What meds can affect tacrolimus levels?
Meds that increase levels- CYP3A4 inhibitors, azoles, antivirals
Meds that decrease levels- CYP3A4 inducers, rifamycin, phenytoin, trikafta, phenobarb, St John’s wart
Describe the CLAD staging
0- current FEV1 greater than 80% of baseline
1- current FEV1 65-80% of baseline
2- current FEV1 50-65% of baseline
3- current FEV1 35-50% of baseline
4- current FEV1 <35% of baseline
What is seen on pathology for CLAD due to restrictive allograft syndrome?
Alveolar damage, interstitial fibrosis, interlobular septal and visceral pleural fibroelastosis w/wo obliterative bronchiolitis lesions, and bronchiectasis
What are the leading causes of mortality in lung transplant recipients?
In the first year, infection. Afterwards, CLAD. 50% of patients after 4.5 years develop CLAD.
What are the indications for heart-lung transplants?
Not amenable to isolated transplants, irreversible myocardial dysfunction or congenital defects in conjunction with intrinsic lung disease or severe PAH
Severe PAH in a heart transplant candidate (increase PVR, PVRI, and TPG)
Most candidates with isolated PAH with RVH undergo just lung transplant
Of bacterial infections in lung transplant recipients, which sites and bugs predominate?
Most common in the upper and lower airway (anastomosis infection, bronchitis, PNA) but also wound, pleura, GI (CDiff), UTI
PA and Staph most common, but have increasing concern for steno, acinobacter, MDR infections
Which virus is most common and associated with ACR, AMR, and CLAD?
CMV. But also every other virus can be seen
What are the features of CMV infection vs disease?
Infection- replication of CMV with or without symptoms
Disease- varies depending on organ infection, can have acute viral illness but may also have organ specific disease (pneumonitis, hepatitis, gastroenteritis, colitis, retinitis, pancreatitis), may need biopsy to prove CMV disease
High risk is D+/R-. Intermediate is D+/R+ or D-/R+, low risk is D-/R-
What is the most common fungal infection in transplant recipients?
Aspergillus, more common earlier post-transplant (first year). Has association with CLAD. Can also see endemic fungi, and emerging infections with scedosporidium and fusarium
What are the early and late airway complications post-transplant?
Early- (under 8 weeks) infection, dehiscence
Late (over 8 weeks)- stenosis, bronchomalacia
Which primary diseases can see recurrence after lung transplantation?
Sarcoid, LAM, GIP, diffuse panbronchiolitis, DIP, BAC, EG, PAP, IPH
Table for transplant drugs and common side effects
When can one start to see improvement in hypoxemia due to HPS after liver transplantation?
6-12 months, but 20% may not have any improvement at all
