Author: Catherine Buckley MD
Working in the ED of a hospital that performs transplants means that you see a lot of people that are pre-, post-, post-and-pre-again-transplant. We are very very lucky that the transplant teams at Rush are very involved and involved early. In fact we are so lucky that transplant surgeon Dr. Edie Chan, came and give us a talk. This post is in summary of some of the wisdom she imparted on us: focusing specifically on liver and kidney transplants.
First
Call their transplant team. These patient’s are complicated with specialists who are heavily involved in their care. Take advantage.
Infection
Remember these patients are on a ton of immunosuppressants to keep their body from fighting off their new beautiful organ. So the chance for infection is high. Although fever may be the most directing symptom, it is only present in about half of infected post-transplant patients. (Savitsky et al.) So keep those infection searching eyes open.
Timing post transplant should be the most guiding fact for your course. Infections within the first month are frequently nosocomial, or related to the surgical site (think wound, fluid collection, etc.) Infections between 1 – 6 months are occurring when the patient is at their max immunosuppression – so think opportunistic infections. All those things that you get scared of but rarely see: CMV, EBV, VZV, aspergillus, toxoplasmosis, PJP, Listeria, the list goes on. 6 months post transplants these patients are more likely to just be infected with the typical community acquired bugs like the rest of us. (Fishman 2007.)
Rejection
Rejection is going to rear its ugly head in a myriad of ways. Signs will be specific based on organ. Liver patients in rejection will have elevated AST, ALT with normalish Alk phos and GGT. (If all the LFTs are elevated be more concerned about stricture… see below.) They may have low grade fevers, and low levels of their immunosuppression drugs.
Now in kidneys, 10-20% of patient will experience acute rejection and it may be even more indolent. Patients may have no symptoms at all. We are always taught to look for rapidly elevating Cr levels- but this is a late sign- so also consider if patient has worsening hypertension, or new proteinuria. (Brennan et al.)
You will likely be handing rejection patients some IV steroids and an admission card, don’t pass go.
Medications
While you are remembering to be concerned for infections and rejections don’t forget that their symptoms may just be caused by their hodge podge of medications.
Tacrolimus- the standard of care for all transplants- can basically cause adverse reactions on any organ system. Patients may experience neurologic complaints rainging from tremors to PRES. About 50% will develop DMII in 2 years of Tacro treatment. They may get hypertension, kidney failure (increasing Cr levels,) gout, alopecia. Now this is quite opposite to Cyclosporine that can cause hirsutism (as well as nephrotoxicity and neurotoxicity.) Meanwhile Sirolimus may cause hyperlipidemia, leukopenia, ulcers. Side note, sirolimus significantly inhibits wound healing.
Why does all this matter to us ER docs? We may be able to attribute some complaints to these medications, and we may need to stop these medications depending on the severity of the symptoms. Again though, you should talk to their transplant team first.
Further Transplant Complications
Liver
Dr. Chan talked us through several acute/ intermediate complications that may bring a Liver patient to the ED. To make things straight forward she suggested that any Liver patient presenting with elevated LFTs, Jaundice etc first undergo liver Ultrasound. Concerning findings would include vascular complications (hepatic vein occlusion, portal vein thrombosis, hepatic artery stenosis,) fluid collections (Biloma, hematoma), Biliary strictures. If you see any of these- update the specialists who may request further imaging or may begin prepping the OR.
Other complications may include recurrent pleural effusions from the take down of the liver off the diaphragm requiring pigtail placement. Acute Heart failure may also occur s/p liver transplant. This is because their heart has been used to working against a super low afterload (always hypotensive, marked vasodilation) and now that the patient has a functioning liver- the patient’s blood pressure has normalized. Suddenly the heart can’t push against this new afterload. Go ahead, diurese, and lower their blood pressure.
Kidney
Again fluid collections hit top of the list, as well as ureteral structure, vascular issues- go ahead and get that ultrasound and call the team with findings. Now if that ultrasound is normal but the patient’s Cr is bumping- besides rejection, your differential should include dehydration/ATN. These patients have been on HD for years, have been told for years to limit their fluid intake, they may be struggling with the sudden ability to take in water. So go ahead and hydrate them based on exam/labs.
Not so Fun Facts
- NO NSAIDS. Not only in kidney transplants! As you see above transplant patients are already on some kidney killer meds. Don’t add to the mess. On this same line- try to check with the transplant team before giving contrast.
- No Benzos in liver patients.
- Limit Tylenol to 2 g per day.
- Graft v. Host Disease is extremely rare in solid transplants (~1%) however is extremely concerning (75-100% mortality.) GVHD would present with diarrhea, rash, high fevers, leukopenia.
- Post- Transplant Lymphoproliferative Disorder (PTLD) is the most common post-transplant cancers, a type of lymphoma associated with EBV. It presents as a painless lump ANYWHERE. Lung mass? Be concerned for PTLD. Neck mass? Be concerned for PTLD. Scrotal mass? Be concerned for PTLD. Patient will need to be admitted to oncology where they will likely perform a biopsy and be started on Rituximab. Meanwhile in the ED you can stop their immunosuppression and send an EBV PCR.
- Hyperkalemia is common in these patients, even with functioning kidneys. This is because they are on Tacrolimus that impairs K excretion with it’s nephrotoxic effects AND often on Bactrim (PJP Prophylaxis) which blocks Na-K exchange in the kidney. Give those lovely medical hyper-k management meds.
Special thanks to Edie Y Chan, MD for giving such a thorough lesson to the ED residency
References
- Brennan, D. Alhamad, T. Malone,A. Clinical features and diagnosis of acute renal allograft rejection. Up to date. Published Nov 29, 2018. Accessed 11.18.2019. Available at <https://www-uptodate-com.ezproxy.rush.edu/contents/clinical-features-and-diagnosis-of-acute-renal-allograft-rejection?search=transplant%20rejection&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1>
- Fishman JA. Infection in Solid-Organ Transplant Recipients. N Engl J Med 2007;357:2601-14.
- Savitsky, F. Votey, S. Mebust, D. Schwartz, E. Uner, A. McCain, S. A descriptive analysis of 290 liver transplant patient visits to an emergency department. Emerg Med. 2000 Aug;7(8):898-905