Transplant Complications

Question 1

What are common complications that occur post solid organ transplantation?

Answer 1

1. Hypertension
2. Post- transplant diabetes mellitus (PTDM)
3. Renal insufficiency
4. Hyperlipidemia
5. Bone Disease
6. Malignancy

Question 2

What causes and how do you treat post-transplant hypertension?

Answer 2

Causes: Preexisting HTN, calcineurin inhibitors, corticosteroids

Management: Optimize blood pressure according to current JNC guidelines

• Calcium channel blockers (CCB) are often used as they decease renal vascular resistance which may offset calcineurin induced vasoconstriction. Be aware of the patients baseline renal function and drug interactions when ordering antihypertensive therapy
• Success with single agent therapy is typically not effective. If the transplant recipient is kidney, hypotension should be avoided.

Question 3

What causes and how do you treat post-transplant diabetes mellitus?

Answer 3

The incidence is variable from 4-20% in the total transplant population

Causes: PTDM may be a direct side effect from the use of corticosteroids (enhanced glyconeogenesis) and to calcineurin inhibitors that may directed affect the release of insulin from beta cells.

• If patients are pre-diabetic prior to transplant it is expected they will become insulin dependent post transplant.

Management: Glucose control according to the EBM guidelines

Question 4

What causes and how do you treat post-transplant renal insufficiency?

Answer 4

can be seen in all transplant recipients, not just kidney. Close monitoring of renal function is key to avoid permanent renal injury and need for kidney transplantation

Causes: Etiology is most likely use of calcineurins but all co-morbidities must be assessed

Management: includes lowering dose of calcineurins (if possible), diabetes management, HTN management and avoidance of nephrotoxic drugs (NSAIDS, loop diuretics, certain antibiotics)

Question 5

What causes and how do you treat post-transplant hyperlipidemia?

Answer 5

Cause: occurs in 50% or more of transplant recipients due to the effect of immunosuppressive medications on lipids

Management: Lipid levels should be optimized by current EBM guidelines

Hyperlipidemia Increases the risk of cardiovascular disease including nephropathy

Question 6

What causes and how do you treat post-transplant bone disease?

Answer 6

Cause: Osteoporosis is a common complication after solid organ transplantation. It is directly related to corticosteroids with the maximum amount of bone loss occurring during the 3 months following surgery. Special attention should be given to tapering corticosteroids as allowed by protocol. Episodes of acute rejection requiring high dose steroid doses increase the incidence of bone disease.

Management: Baseline and annual bone scans. Corticosteroids should be minimized or discontinued according to transplant center protocol. Supplemental calcium, bisphosphonates and hormone replacements should be used if indicated.

Question 7

What causes and how do you treat post-transplant malignancy?

Answer 7

Causes: there is an increased incidence of lymphoma, skin cancer and Kaposi’s sarcoma in the post- transplant population. Can also be associated with higher doses of cyclosporine and tacrolimus. Target levels should be used to dose these medications, toxic levels should be addressed.

Management:

• Treatment consists of minimizing immunosuppressive medications, chemotherapy and radiation therapy
• The prognosis is poor

Question 8

What is the leading cause of death in solid organ transplant recipients?

Answer 8

• Infections are one of the leading causes of death in solid organ recipients.
• The risk is highest in the first 6 months after transplant and after enhancement of immunosuppressive medications to treat rejection