Solid Organ Transplant

Aka: Solid Organ Transplant

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II. Definitions

  1. Solid Organ Transplant
    1. Transplant of heart, lung, liver, Pancreas, Kidney

III. Preparations: Immunosuppressants

  1. Corticosteroids (frequently used initially after transplant)
  2. Calcineurin Inhibitors
    1. Agents
      1. Cyclosporine (Sandimmune)
      2. Tacrolimus (Prograf)
    2. Adverse Effects
      1. Nephrotoxic Drugs (avoid all NSAIDs and other Nephrotoxins)
      2. Risk of Hypertensive Emergency including PRES
  3. Mammalian Target of Rapamycin Inhibitors
    1. Sirolimus
    2. Everolimus
  4. Purine Synthesis Inhibitors (Antimetabolites)
    1. Agents
      1. Azathioprine (Imuran)
      2. Mycophenolate (Cellcept)
      3. Mycophenolic acid (MyFortic)
    2. Adverse Effects
      1. Gastrointestinal side effects and cytopenias are common

IV. Labs: Transplant Rejection markers

  1. Heart Transplant
    1. Endomyocardial biopsy
  2. Kidney Transplant
    1. Protein to Creatinine ratio
    2. Serum Creatinine (and calculated GFR)
  3. Liver Transplant
    1. Serum transaminases (AST, ALT)
    2. Total Bilirubin
    3. Alkaline Phosphatase
  4. Lung transplant
    1. Transbronchial biopsy (via bronchoscopy)
    2. Pulmonary Function Testing

V. Complications

  1. Precautions
    1. Fever may be presentation for either Transplant Rejection or infection
    2. Typical markers (e.g. C-RP, Leukocytosis) of inflammation and infection are falsely normal on Immunosuppressants
  2. Transplant Rejection
  3. Infection
    1. Have a low threshold for initiating Sepsis working including Blood Cultures and initiating Antibiotics
    2. Infections follow a pattern based on time from transplant
      1. Month 1: Nosocomial infection (e.g. CAUTI, VAP, SSI)
      2. Month 1-6: Opportunistic infection (CMV, EBV, fungal and Parasitic Infections, Tuberculosis)
      3. Month 6+: Community acquired infection (e.g. Pneumonia) and opportunistic infections
  4. Post-Transplant Lymphoproliferative Disease
    1. Neoplastic complication most associated with EBV Infection
    2. Highest risk in first year after transplant
    3. May present with non-specific findings (fever, malaise)
    4. Obtain EBV Titers and consult transplant team

VI. Management: Opportunistic Infections

  1. Cytomegalovirus (CMV)
    1. Prophylaxis wtih Ganciclovir or Valganciclovir for 3 months post-transplant
    2. Treatment: Reduce Immunosuppressants if active CMV infection
  2. Epstein-Barr Virus (EBV)
    1. Treatment: Reduce Immunosuppressants if active EBV infection
  3. Fungal infection
    1. Candida prophylaxis with systemic Antifungal (e.g. Fluconazole) for 1-3 months post-transplant
    2. Treatment: Antifungals and reduce Immunosuppressants if active fungal infection
  4. Herpes Simplex Virus
    1. Treatment: IV Antivirals initially and reduce Immunosuppressants if active HSV infection
  5. Herpes Zoster Virus
    1. Prophylaxis after known exposure with VZV Ig or oral Antivirals
    2. Treatment: IV Antivirals initially and reduce Immunosuppressants if active VZV infection
  6. Pneumocystis jiroveci
    1. Prophylaxis with TMP-SMZ, Dapsone, or Atovaquone post-transplant (duration per organ transplanted)
    2. Treatment: High dose TMP-SMZ for 14 days and reduce Immunosuppressants if active VZV infection
  7. Tuberculosis
    1. Prophylaxis with Isoniazid in high risk patients (e.g. Latent Tb, DM, CMV, pneumocystis, Nocardia)
    2. Treatment per standard Tuberculosis management protocols (caution with Rifampin due to Drug Interactions)

VII. Management: Endocrine

  1. Chronic Kidney Disease
    1. Monitor Serum Creatinine (with GFR) and Serum Protein to Creatinine ratio yearly (more if GFR <60 ml/min)
  2. Diabetes Mellitus
    1. Screen for diabetes in Kidney and Liver Transplants every 3 months for year 1, then every year
    2. Goal Hemoglobin A1C <7% (Kidney and liver recipients)
  3. Hyperlipidemia
    1. Decrease Statin dose to 50% when used with Cyclosporine
  4. Hypertension
    1. Goal Blood Pressure <130/80 in liver and Kidney recipients
    2. Avoid nondihydropyridines (Diltiazem, Verapamil) especially in those on Calcineurin Inhibitors
  5. Osteoporosis
    1. Guidelines vary per organ transplanted (heart, liver, Kidney)
    2. Kidney recipients should have Serum Calcium, PTH, Phosphorus and Vitamin D
    3. Maintain Vitamin D >30 ng/ml in heart and liver recipients
  6. Contraception
    1. Preferred agents
      1. Intrauterine Device
      2. Medroxyprogesterone (Depo Provera) - risk of Osteoporosis
      3. Subcutaneous Progestin rod (e.g. Implanon)
    2. Other agents
      1. Estrogen-containing agents (e.g. Oral Contraceptives, Contraceptive Patch, Estrogen Ring)
        1. Estrogens raise drug levels of Cyclosporine, Tacrolimus, Sirolimus and Corticosteroids
    3. References
      1. Krajewski (2013) Transplantation 95(10): 1183-6 [PubMed]
      2. Patel (2013) Contraception 87(2): 138-42 [PubMed]

VIII. Prevention

  1. Tobacco Cessation
    1. All transplant patients (Tobacco increases transplant loss risk)
    2. Corbett (2012) Transplantation 94(10): 979-87 [PubMed]
  2. Foodbourne illness prevention
    1. Avoid unpasteurized cheese (e.g. soft cheese)
    2. Avoid undercooked deli meat
    3. Avoid unwashed fruits and vegetables
    4. Avoid raw honey
    5. http://www.fda.gov/Food/FoodborneIllnessContaminants/PeopleAtRisk/ucm352830.htm
  3. Immunizations
    1. Live Vaccines
      1. Allowed only up to 4 weeks pre-transplant
      2. Do not used Live Vaccine after transplant
    2. Inactivated Vaccines
      1. Allowed up to 2 weeks before transplant, and most are allowed after transplant
      2. Influenza Vaccine annually
      3. Age appropriate Vaccines
      4. Prevnar 13 followed >8 weeks later by Pneumovax
  4. Cancer Screening
    1. Highest risk for Nonmelanoma Skin Cancer (aggressive management including Actinic Keratoses)
      1. Annual exam with dermatology starting one year post-transplant
    2. Also high risk for Kaposi Sarcoma, Non-Hodgkin Lymphoma
    3. Increased risk of Colon Cancer, Lung Cancer, Breast Cancer, Prostate Cancer (double general population)
    4. Engels (2011) JAMA 306(17): 1891-1901 [PubMed]
  5. SBE Prophylaxis
    1. Heart Transplant patients should have SBE Prophylaxis before invasive dental procedures
    2. Other transplant patients need not undergo SBE Prophylaxis unless specific cardiac indication per guidelines
  6. Travel
    1. Avoid international travel for 6 months post-transplant
    2. Avoid travel to regions requiring live Vaccination
    3. Traveler's Diarrhea treatment (e.g. Cipro) should be brought by patient to regions at risk
    4. Malaria Prophylaxis
      1. Calcineurin Inhibitors are not affected by Malarone (but are affected by Mefloquine, Chloroquine, doxy)
      2. Other Immunosuppressants (Purine and mTOR Inhibitors) are not affected by Malaria Prophylaxis
    5. References
      1. Kotton (2005) Am J Transplant 5(1):8-14 [PubMed]

IX. Prognosis: Five year survival

  1. Heart Transplant >50%
  2. Lung transplant >50%
  3. Liver Transplant: 64%
  4. Kidney Transplant: 70%

X. References

  1. Cimino (2016) Am Fam Physician 93(3): 203-10 [PubMed]
  2. Costanzo (2010) J Heart Lung Transplant 29(8): 914-56 [PubMed]

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