Transplant

Question 1

How is hepatopulmonary syndrome diagnosed?

Answer 1

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

Question 2

When to consider liver transplant in HPS?

Answer 2

PaO2 <50

Question 3

What is the primary graft dysfunction grading system?

Answer 3

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

Question 4

What are risk factors for primary graft dysfunction?

Answer 4

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

Question 5

What are some referral criteria for CF for lung transplant?

Answer 5

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

Question 6

What is the mechanism and findings for acute cellular rejection?

Answer 6

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.

Question 7

What is the mechanism and findings for antibody mediated rejection?

Answer 7

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

Question 8

What are the features of Posttransplant lymphoproliferative disorder?

Answer 8

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

Question 9

How does a TIPS affect hepatopulmonary syndrome?

Answer 9

Can worsen it due to increased pulmonary vasodilation, shunt, and hypoxemia.

Question 10

What meds can affect tacrolimus levels?

Answer 10

Meds that increase levels- CYP3A4 inhibitors, azoles, antivirals

Meds that decrease levels- CYP3A4 inducers, rifamycin, phenytoin, trikafta, phenobarb, St John’s wart

Question 11

Describe the CLAD staging

Answer 11

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

Question 12

What is seen on pathology for CLAD due to restrictive allograft syndrome?

Answer 12

Alveolar damage, interstitial fibrosis, interlobular septal and visceral pleural fibroelastosis w/wo obliterative bronchiolitis lesions, and bronchiectasis

Question 13

What are the leading causes of mortality in lung transplant recipients?

Answer 13

In the first year, infection. Afterwards, CLAD. 50% of patients after 4.5 years develop CLAD.

Question 14

What are the indications for heart-lung transplants?

Answer 14

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

Question 15

Of bacterial infections in lung transplant recipients, which sites and bugs predominate?

Answer 15

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

Question 16

Which virus is most common and associated with ACR, AMR, and CLAD?

Answer 16

CMV. But also every other virus can be seen

Question 17

What are the features of CMV infection vs disease?

Answer 17

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-

Question 18

What is the most common fungal infection in transplant recipients?

Answer 18

Aspergillus, more common earlier post-transplant (first year). Has association with CLAD. Can also see endemic fungi, and emerging infections with scedosporidium and fusarium

Question 19

What are the early and late airway complications post-transplant?

Answer 19

Early- (under 8 weeks) infection, dehiscence

Late (over 8 weeks)- stenosis, bronchomalacia

Question 20

Which primary diseases can see recurrence after lung transplantation?

Answer 20

Sarcoid, LAM, GIP, diffuse panbronchiolitis, DIP, BAC, EG, PAP, IPH

Question 21

Table for transplant drugs and common side effects

Answer 21

Question 22

When can one start to see improvement in hypoxemia due to HPS after liver transplantation?

Answer 22

6-12 months, but 20% may not have any improvement at all