organ transplantation

^[1]^[2]^[3]^[4]^[5]^[6]^[7]^[8]^[9]^[10]^[11]^[12]^[13]^[14]^[15]^[16]^[17]

Pathology

phase 1, pre-engraftment, 1st 30 days
- neutropenia, mucositis, acute graft vs host disease
phase 2, post-engraftment, 30-100 days
- impaired cell-mediated immunity
- acute & chronic graft vs host disease
phase 3, late phase, > 100 days
- impaired cell-mediated immunity
- impaired humoral immunity
- chronic graft vs host disease^[1]

Laboratory

Toxoplasma gondii serology IgG (all patients)
histoplasmosis serology
Strongyloides serology (ELISA) & stool ova & parasites
tuberculin skin testing
see ARUP consult^[4]

Radiology

chest X-ray as needed (rule out tuberculosis)

Complications

organ rejection:
- order of increasing tendency for organ rejection: liver > kidney > pancreas
- older organ tranplanted into younger patients results in highest rate of rejection
infection
- risk varies with
  - type of organ transplantation
  - immunosuppressive agents used
  - time after transplantation
  - recipient & donor characteristics (seropositivity)
  - post-transplantation complications
    - graft vs host disease
    - transplant rejection
- CMV
  - most common opportunistic organism in solid organ transplants
  - occurs most commonly in CMV-negative transplant recipient & CMV-positive organ donor
  - non-specific febrile illness vs pneumonitis, colitis, esophagitis, hepatitis, leukopenia &/or thrombocytopenia
- Epstein-Barr virus
  - associated with B-cell lymphoproliferative disease (seropositive donor, seronegative recipient)
- during the 1st month after transplantation:
  - most infections result from:
    - transmission from the donor organ
    - surgical complications
    - nosocomial exposures
    - similar to other types of surgery - C difficile
  - neutropenia & mucositis are major risk factors for bacterial & Candida infections
  - pathogens
    - Staphylococcus aureus including MRSA
    - nosocomial gram-negative infections
    - C difficile colitis
    - Candidiasis
    - aspergillosis
  - infections
- 1-6 months after transplantation
  - cytomegalovirus (CMV)
  - Epstein-Barr virus (EBV)^[1]
  - varicella zoster
  - Herpes simplex
  - Pneumocystis jirovecii
  - Toxoplasma gondii (CNS infection, cardiac infection)
  - polyomavirus BK virus in renal transplantation patients may cause nephropathy, organ rejection or urethral strictures
  - Listeria monocytogenes
  - Trypanosoma
  - Strongyloides
  - Aspergillus (lung transplantation, neutropenia)
  - Nocardia
  - hepatitis C virus, hepatitis B virus
  - reactivation of latent tuberculosis
  - Cryptococcal meningitis^[1]
- > 6 months after transplantation:
  - 75% at risk for same infections as general population
  - those transplant patients requiring increased immunosuppression remain at risk of opportunistic infections
  - pathogens
    - Epstein-Barr virus (EBV)^[1]
    - varicella zoster
    - polyomavirus (> 12 months after transplantation) - polyomavirus BK virus - polyomavirus JC virus
    - cytomegalovirus (CMV) (unless both donor & recipient seronegative)^[1]
  - infections
    - community-acquired pneumonia
    - urinary tract infection^[1]
- multidrug-resistant organisms including Pseudomonas species & MRSA are common
cancer, including skin cancer*
- recipients of solid organ transplants are at increased risk of cancer
  - kidney transplant, liver transplant, heart transplant, lung transplant
  - lymphoma & lung cancer are most common^[2]
  - EBV seronegative patients who receive transplant from EBV seropositive donor are at increased risk for post-transplant lymphoproliferative disease^[1]
- cancers may behave aggressively in transplant patients^[1]
- aggressive squamous cell carcinoma of the skin preferentially localized on the face (67%)^[15]

* non-melanoma skin cancer^[1]

Management

prescribe new medications with caution
- anti-rejection drug effects are wide
- drug interactions are common^[1]
immunizations prior to transplantation
- influenza virus vaccine (inactivated) annually
- tetanus-diphtheria-inactivated pertussis vaccine (Tdap)
  - immunize adults who received Tdap as child, regardless of pre vs post transplantation (immunity wanes)^[1]
- hepatitis A vaccine (prior to transplantation)
- hepatitis B vaccine (prior to transplantation)
- pneumonia vaccines: PCV13 followed in 8 weeks with PPSV23
- recombinant Herpes zoster vaccine (Shingrix) age 50 years (prior to transplantation)
- meningococcal polysaccharide vaccine (as per non-transplantation patients)^[1]
- inactivated polio vaccine
- in general, avoid live virus vaccines after organ transplantation
  - measles-mumps-rubella vaccine (MMR) <live virus vaccine>
    - contraindicated after solid organ transplantation
    - 24 months after hematopoietic stem cell transplantation (only 1-2 doses, no GVHD or immunosuppression)
  - varicella virus vaccine <live virus vaccine>
    - > 4 weeks prior to organ transplantation
    - contraindicated after solid organ transplantation
    - 24 months after hematopoietic stem cell transplantation (2 doses if seronegative, no GVHD or immunosuppression)
- Haemophilus influenzae type-B vaccine (hematopoietic stem cell transplantation)
- HPV vaccine (prior to transplantation as per non-transplantation patients)^[1]
immunizations for hematopoietic stem cell transplantation generally given 6-12 months after transplantation
- live virus vaccines contraindicated or given 24 months after transplantation if seronegative & no GVHD or immunosuppression^[1]
pharmaceuticals: immunosuppressive agents
- most transplantation centers use 3 drugs
- prednisone
- a calcineurin inhibitor
  - cyclosporine
  - tacrolimus
- an antimetabolite, generally mycophenolate mofetil^[1]
- other immunosuppressants
  - mTOR inhibitors
    - sirolimus
    - everolimus
  - other antimetabolites
  - lymphocyte-depleting antibodies
CMV prophylaxis
- indicated for transplant recipients at risk for CMV
  - seropositive donor or recipient
  - no need if donor & recipient seronegative^[1]
- ganciclovir, valganciclovir or high-dose acyclovir
- can reduce risk of lymphoproliferative disease
Bactrim is used for prophylaxis against & treatment of Pneumocystis pneumonia
prophylaxis with posaconazole for fungal infection for 1st few months in patients with hematopoietic stem cell transplantation^[1]
prophylaxis with fluconazole & a fluoroquinolone for neutropenic patients
treat Candida in the urine of renal transplantation patients
- suspect kidney infection
- fluconazole is usually effective against Candida sp except Candida glabrata & Candida krusei
treat Aspergillus early & aggressively
Strongyloides should be identified prior to transplantation
- Strongyloides hyperinfestation syndrome may occur during immunosuppression
- treat Strongyloides with thiabendazole or albendazole prior to transplantation

More general terms

transplantation

More specific terms

Additional terms

References

↑ ^1.00 ^1.01 ^1.02 ^1.03 ^1.04 ^1.05 ^1.06 ^1.07 ^1.08 ^1.09 ^1.10 ^1.11 ^1.12 ^1.13 ^1.14 ^1.15 ^1.16 ^1.17 ^1.18 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2021.
↑ ^2.0 ^2.1 Engels EA et al. Spectrum of cancer risk among US solid organ transplant recipients. JAMA 2011 Nov 2; 306:1891. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22045767
↑ Tullius SG, Milford E. Kidney allocation and the aging immune response. N Engl J Med 2011; 364:1369-1370. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21410395
↑ ^4.0 ^4.1 ARUP Consult: Immunosuppressive Drug Optimization and Monitoring - Organ Transplantation Drugs The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/organ-transplantation
↑ Eid AJ, Razonable RR. New developments in the management of cytomegalovirus infection after solid organ transplantation. Drugs. 2010 May 28;70(8):965-81 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20481654
↑ Nishi SP, Valentine VG, Duncan S. Emerging bacterial, fungal, and viral respiratory infections in transplantation. Infect Dis Clin North Am. 2010 Sep;24(3):541-55 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20674791
↑ Lemonovich TL, Watkins RR. Update on cytomegalovirus infections of the gastrointestinal system in solid organ transplant recipients. Curr Infect Dis Rep. 2012 Feb;14(1):33-40. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22125047
↑ Cervera C, Fernandez-Ruiz M, Valledor A Epidemiology and risk factors for late infection in solid organ transplant recipients. Transpl Infect Dis. 2011 Dec;13(6):598-607. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21535336
↑ Danziger-Isakov L, Kumar D; AST Infectious Diseases Community of Practice. Vaccination in solid organ transplantation. Am J Transplant. 2013 Mar;13 Suppl 4:311-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23465023 Free Article
↑ Fishman JA. Infections in immunocompromised hosts and organ transplant recipients: essentials. Liver Transpl. 2011 Nov;17 Suppl 3:S34-7. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21748845 Free Article
↑ Grim SA, Clark NM. Management of infectious complications in solid-organ transplant recipients. Clin Pharmacol Ther. 2011 Aug;90(2):333-42. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21716270
↑ Hodson EM, Ladhani M, Webster AC, Strippoli GF, Craig JC. Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev. 2013 Feb 28;2:CD003774. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23450543
↑ Weigt SS, Gregson AL, Deng JC, Lynch JP 3rd, Belperio JA. Respiratory viral infections in hematopoietic stem cell and solid organ transplant recipients. Semin Respir Crit Care Med. 2011 Aug;32(4):471-93. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21858751 Free PMC Article
↑ Trofe-Clark J, Lemonovich TL; AST Infectious Diseases Community of Practice. Interactions between anti-infective agents and immunosuppressants in solid organ transplantation. Am J Transplant. 2013 Mar;13 Suppl 4:318-26. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23465024 Free Article
↑ ^15.0 ^15.1 Lanz J, Bouwes Bavinck JN, Westhuis M et al Aggressive Squamous Cell Carcinoma in Organ Transplant Recipients. JAMA Dermatol. Published online December 5, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30516812 https://jamanetwork.com/journals/jamadermatology/fullarticle/2717171
↑ Angarone M, Ison MG. Diarrhea in solid organ transplant recipients. Curr Opin Infect Dis. 2015 Aug;28(4):308-16. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26098506
↑ Petrara MR, Giunco S, Serraino D, Dolcetti R, De Rossi A. Post-transplant lymphoproliferative disorders: from epidemiology to pathogenesis-driven treatment. Cancer Lett. 2015 Dec 1;369(1):37-44. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26279520 Free Article

[ref1-1] 1.00 ^1.01 ^1.02 ^1.03 ^1.04 ^1.05 ^1.06 ^1.07 ^1.08 ^1.09 ^1.10 ^1.11 ^1.12 ^1.13 ^1.14 ^1.15 ^1.16 ^1.17 ^1.18 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2021.

[ref2-2] 2.0 ^2.1 Engels EA et al. Spectrum of cancer risk among US solid organ transplant recipients. JAMA 2011 Nov 2; 306:1891. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22045767

[ref3-3] Tullius SG, Milford E. Kidney allocation and the aging immune response. N Engl J Med 2011; 364:1369-1370. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21410395

[ref4-4] 4.0 ^4.1 ARUP Consult: Immunosuppressive Drug Optimization and Monitoring - Organ Transplantation Drugs The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/organ-transplantation

[ref5-5] Eid AJ, Razonable RR. New developments in the management of cytomegalovirus infection after solid organ transplantation. Drugs. 2010 May 28;70(8):965-81 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20481654

[ref6-6] Nishi SP, Valentine VG, Duncan S. Emerging bacterial, fungal, and viral respiratory infections in transplantation. Infect Dis Clin North Am. 2010 Sep;24(3):541-55 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20674791

[ref7-7] Lemonovich TL, Watkins RR. Update on cytomegalovirus infections of the gastrointestinal system in solid organ transplant recipients. Curr Infect Dis Rep. 2012 Feb;14(1):33-40. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22125047

[ref8-8] Cervera C, Fernandez-Ruiz M, Valledor A Epidemiology and risk factors for late infection in solid organ transplant recipients. Transpl Infect Dis. 2011 Dec;13(6):598-607. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21535336

[ref9-9] Danziger-Isakov L, Kumar D; AST Infectious Diseases Community of Practice. Vaccination in solid organ transplantation. Am J Transplant. 2013 Mar;13 Suppl 4:311-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23465023 Free Article

[ref10-10] Fishman JA. Infections in immunocompromised hosts and organ transplant recipients: essentials. Liver Transpl. 2011 Nov;17 Suppl 3:S34-7. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21748845 Free Article

[ref11-11] Grim SA, Clark NM. Management of infectious complications in solid-organ transplant recipients. Clin Pharmacol Ther. 2011 Aug;90(2):333-42. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21716270

[ref12-12] Hodson EM, Ladhani M, Webster AC, Strippoli GF, Craig JC. Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev. 2013 Feb 28;2:CD003774. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23450543

[ref13-13] Weigt SS, Gregson AL, Deng JC, Lynch JP 3rd, Belperio JA. Respiratory viral infections in hematopoietic stem cell and solid organ transplant recipients. Semin Respir Crit Care Med. 2011 Aug;32(4):471-93. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21858751 Free PMC Article

[ref14-14] Trofe-Clark J, Lemonovich TL; AST Infectious Diseases Community of Practice. Interactions between anti-infective agents and immunosuppressants in solid organ transplantation. Am J Transplant. 2013 Mar;13 Suppl 4:318-26. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23465024 Free Article

[ref15-15] 15.0 ^15.1 Lanz J, Bouwes Bavinck JN, Westhuis M et al Aggressive Squamous Cell Carcinoma in Organ Transplant Recipients. JAMA Dermatol. Published online December 5, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30516812 https://jamanetwork.com/journals/jamadermatology/fullarticle/2717171

[ref16-16] Angarone M, Ison MG. Diarrhea in solid organ transplant recipients. Curr Opin Infect Dis. 2015 Aug;28(4):308-16. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26098506

[ref17-17] Petrara MR, Giunco S, Serraino D, Dolcetti R, De Rossi A. Post-transplant lymphoproliferative disorders: from epidemiology to pathogenesis-driven treatment. Cancer Lett. 2015 Dec 1;369(1):37-44. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26279520 Free Article

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organ transplantation

Contents

Pathology

Laboratory

Radiology

Complications

Management

More general terms

More specific terms

Additional terms

References

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organ transplantation

Pathology

Laboratory

Radiology

Complications

Management

More general terms

More specific terms

Additional terms

References

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