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CHAPTER 125 ■ TRANSPLANTATION
EMERGENCIES
HEIDI C. WERNER, KARAN MC BRIDE EMERICK, MARYANNE CHRISANT

GOALS OF EMERGENCY CARE
Solid organ transplantation is an effective and acceptable form of therapy that
results in pediatric patients living healthy lives in an immunocompromised state.
These children are active and social, and as a result experience the usual range of
pediatric ailments and conditions. They are also, however, subject to ailments
unique to transplant patients because of their recipient status and need for daily
immunosuppression. The survival and longevity of these patients improves with
increased understanding of immune function, rejection, and medically induced
tolerance. In emergent situations, the morbidity and mortality of these patients is
directly related to prompt diagnosis and treatment.
KEY POINTS
In transplant patients, fever may be sign of infection or acute rejection.
Immunosuppressive medications put transplant patients at risk of
adverse effects or altered metabolism of common therapies used in the
emergency department (ED).
Decisions about initiation of new therapies should be made in
consultation with the transplant team.
RELATED CHAPTERS


Signs and Symptoms

Abdominal Distension: Chapter 12
Diarrhea: Chapter 23
Gastrointestinal Bleeding: Chapter 33
Pain: Abdomen: Chapter 53
Medical, Surgical, and Trauma Emergencies
Cardiac Emergencies: Chapter 86
Renal and Electrolyte Emergencies: Chapter 100

POSTTRANSPLANT INFECTIOUS COMPLICATIONS
CLINICAL PEARLS AND PITFALLS
Presentation of infectious conditions in a transplant recipient may range
from benign to uncharacteristically severe.
Early identification of infectious etiologies allows for directed treatment.
Patients on immunosuppression may not mount fever or elevated white
blood cell count.
Significant infections, such as bacterial sepsis or varicella, may
progress rapidly.
Unusual infections should be considered in immunocompromised
patients with clinical signs or symptoms.
Avoid NSAIDs for antipyresis in patients taking calcineurin inhibitors
(CNIs) (e.g., cyclosporine, tacrolimus). In combination, these drugs can
cause acute renal insufficiency.
Fever and elevated aminotransferases may be a sign of infection,
rejection, or venous thrombosis in the pediatric liver transplant patient.

Current Evidence
In the immediate posttransplant period, the transplant patient is at risk for
bacterial, viral, and fungal infections. Etiologies of the increased infectious
susceptibility include high-dose immunosuppression and indwelling central
venous access. Bacterial sources of infection include wound infection, urinary

tract infection, and central-line infections. Both gram-positive organisms, such as
staphylococcal or streptococcal species, and gram-negative organisms, especially


enteric species, may be the etiologic agents of these infections. The risk of fungal
sepsis is highest in children who have received numerous courses of antibiotics or
require multiple operative procedures. Viral infections in the posttransplant period
are typically caused by members of the herpes virus family. Epstein–Barr virus
(EBV) and cytomegalovirus (CMV) serologies are routinely screened in both
donor and recipient with prophylaxis typically required for CMV naïve recipients.
Following the immediate posttransplant period, there remains an increased
incidence of opportunistic infections and increased severity of common childhood
infections. Yet, most children post solid organ transplant retain enough immune
function so that they are able to fight and recover from typical infections.

Goals of Treatment
Infectious complications represent a common cause of posttransplant morbidity
and mortality with fever being a primary presenting sign. However, a fever in a
transplant patient may be a manifestation of infection, rejection, or anatomic
complication. As such, the goal of treatment is to identify the etiology of fever
and direct treatment appropriately. The most common etiologies are typical
childhood infections such as otitis media, sinusitis, viral respiratory illnesses,
pharyngitis, and gastroenteritis. For the majority of patients, the care is supportive
and not substantially different than for nontransplant recipients. Careful attention
must be paid, however, to hydration status, drug interactions with
immunosuppressive medications, and establishing appropriate follow-up with the
transplant team and the primary healthcare provider ( Fig. 125.1 ).