transplant emergencies

Now #1 in Everything!

TRANSPLANT

EMERGENCIESFor the non-transplant ED

Andrew Schmidt, DO, MPHUF Jax ED - TraumaOne

I have

NOTHING

to disclose

58% 21%

8% 5%Organ transplant numbers

What could possibly go wrong?

InfectionRejectionMedicationGraft vs Host …. And More!

Infection

Infection

25-80% in

first year

Infection

Most common

reason for

admission

Infection

Rejection

Immunosuppressants

Infection timeline

Donor-derivedBacteria (MRSA)

Fungi (Candida)

Parasite (Toxo)

Nosocomial/surgeryAsp pneumonia

Site infection

UTI

C-diff

1

M

O

N

T

H

ACUTE

Infection timeline


Fungi (Candida)

Parasite (Toxo)


Site infection

UTI

C-diff

OpportunisticPneumocystisHistoplasmaCryptococcusCMVTB

ReactivationCMV, HSV, EBV

1

M

O

N

T

H

6

M

O

N

T

H

S

ACUTE INTERMIDIATE

Infection timeline


Fungi (Candida)

Parasite (Toxo)


Site infection

UTI

C-diff

OpportunisticPneumocystisHistoplasmaCryptococcusCMVTB

ReactivationCMV, HSV, EBV

Community AcquiredResp virusesS PneumoLegionellaListeriaInfluenza

1

M

O

N

T

H

6

M

O

N

T

H

S

ACUTE INTERMIDIATE LATE

Infection timeline

Infection Pearls

FEVER is most common presentation…May be absent in ½ patients

Transplant patient tend to demonstrate LOWER temps and WBC counts

Tissue biopsies often needed for definitive dx

Infection management

Go BROAD

CBC, Lactate

Blood Cultures (Bacterial/fungal)

Urinalysis with culture

Viral PCR

Chest x-ray

No specified source


Go BROAD

Pulmonary CT if concern and CXR negative

Urine respiratory antigens

Sputum acid-fast bacilli

CMV PCR


Go BROAD

Diarrhea Stool for WBC, culture

Ova, parasites

C-diff


Go BROAD

CNS Head CT, MRI if negative

LP with CSF studies


Go BROAD

Diffuse Lymphadenopathy EBV, CMV PCR

Bartonella, Toxoplasmosis

CT neck/chest/abd/pelvis

REJECTION

Approximately

20% rejection

SIGNS/SYMPTOMSMay be asymptomatic

Fever, malaise, oliguria

Hypertension

20-70% rejection most in first 6 wks

SIGNS/SYMPTOMSHepatomegaly, ascites

Fever, malaise

Abd pain

Up to 30%

RejectionUsually acute

SIGNS/SYMPTOMSOrthopnea, periph edema

Dyspnea, palpitations

GI sxs (RV involve)

Dysrhythmias

Chest pain MAY be absent

due to denervation

Rejection

1/3 of rejections

in first year

Rejection

SIGNS/SYMPTOMSSOB, cough most common

Resp distress/failure

Stridor, wheezing

Rejection Treatment

MEDICATION

Medication timeline

Transplant Induction

Maintenance

• Triple therapy

• Followed by withdrawal of at least 1 med

3 mos 12 mos

Medication effects

Medication effects

Metabolic Syndrome is common

Medication effects

Insulin resistance

Hyperlipidemia

Hypertension

Obesity

Medication effects

Medication effects

Calcineurin InhibitorsCyclosporin

Tacromlius

P450

Cytochrome P450 interactionsIncreased nephrotoxicity

Calcium channel blockers

Amnioglycosides

Amiodarone

Antifungal

Cytochrome P450 interactionsIncreased clearance (rejection)

Carbamazepine

Phenytoin

Rifampin

Isoniazid

Cytochrome P450 interactionsRhabdomyolysis

Statins

GRAFT-vs-HOST

Graft-vs-Host

Primarily in hematopoietic stem cell transplantation

Can be majority of pts based on typeCan occur in solid organ transplant

Graft-vs-Host

Dermatitis

Hepatitis

Enteritis

100

Days

Graft-vs-Host

Dermatitis

• Usually first

• Maculopap

• Puritis/pain

Hepatitis

Enteritis

100

Days

Graft-vs-Host

Dermatitis

Hepatitis

• Jaundice

• Pruritus

• Coma rare

Enteritis

100

Days

Graft-vs-Host

Dermatitis

Hepatitis

Enteritis

• Diarrhea

• GI Bleed

• Abd pain n/v

• Ileus

100

Days

Graft-vs-Host

No specific acute treatmentProper prophylaxis is key

COMPLICATIONS

Complications

Complications

Urinary Tract Infection (MC)Early (1st 6 months) more dangerous

Common bugs are common

Flouroquinolones

Complications

Urinary Tract Infection (MC)

Asymptomatic Bacteriuria

Treat if within first 1-3 months

Otherwise avoid unless inc creatinine

Complications


Mild Symptomatic Bacteriuria

Empiric oral tx x 5-7 days

Flouroquinolone, Amox-Clav, 3rd Gen Cef

Complications


Mod Symptomatic Bacteriuria

Cipro, Ceftri, or Amp-Sul

Complete 14 days after Cx results

Complications


Sev Symptomatic Bacteriuria

Piper-Tazo, Cefipime

Consider MDR (VRE)

Complications

Renal Artery ThrombosisUsually immediately post-op

Sudden cessation

urine output

Diagnosis: CTA or dopp US

Complications

Peritransplant HematomaUsually early

Pain over site,

dec Hb, inc creatinine

Diagnosis: CT

Complications

Complications

Most common acute emergencies are

Mechanical

Complications

Hepatic artery thrombosisRejection

Artery kinkingAnastomotic failure

Complications

Hepatic artery thrombosis

High mortality

Complications

Hepatic artery thrombosis

VascularTransplant

Complications

Biliary complicationsLeaks

StonesStrictures

Complications

Biliary complications

Complications

Biliary complications

GITransplant

Complications

Within the first year

Graft failure

Rejection

Infection

Complications

After the first year

Vasculopathydue to rapid atheroscleorosis

Complications

After the first year

Complications

May have no symptoms

Baseline ECG abnormalities

Dysrhythmias

Complications

Complications

Complications

Premature Ventricular Complex

Most common post-op (up to 100%)

Complications

Atrial Fib / Flutter

Most common atrial arythmia

Complications

Dysrhythmias

Complications

TREATMENTBRADYCARDIA

Atropine may be effective

Temporary pacemaker

TACHYCARDIAS

Cardioversion if indicated

Cardiology consultation

TREATMENTSVT

Inc sensitivity to Adenosine

Do not give to ”uncover”

Start dose at 3mg

Cardiology consultation

Complications

Complications

Airway Causes

Bronchial stenosis/necrosis

Fistulapneumothorax

Tissue hyperplasia

Complications

Vascular Causes

Stenosis/kinking

Thrombosis

• Dyspnea, tachypnea

• Hypotension

• Edema

• Signs of R heart strain

Complications

Other Causes

Phrenic nerve dysfunctionMore common with combined cardiac-lung

• Dyspnea

• Hypoxia

• Tachypnea

• Atelectasis

• Elevated hemidiaphragm

Complications

Diagnosis

CT Scan

Bronchoscopy

US (right heart strain)

Complications

Complications

Otherwise, I will response as soon as I return.

Refs

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3487371/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4711495/

GVHDhttp://emedicine.medscape.com/article/429037-overview#a4

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3487371/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4711495/

http://emedicine.medscape.com/article/429037-overview#a4

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Adenosine in heart transplant

Rejection Tx (AJEM)

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