Pediatric emergency medicine trisk 1033

The decision to send a patient home or to admit the patient should rely on the
usual metrics: appearance on arrival, test results, response to therapy, parental
comfort, and availability of follow-up. Patients with high persistent fever, need
for continuous intravenous hydration, or an evolving process should remain in
hospital until their condition stabilizes. Here again, transplant team input is
essential to a successful outcome.

GRAFT REJECTION
CLINICAL PEARLS AND PITFALLS
Clinical signs and symptoms of rejection may be nonspecific and can
mimic an infectious illness. They include fever, abdominal pain,
vomiting, tachypnea, malaise, and pallor.
Specific signs and symptoms of rejection for each solid organ
transplant are listed in Table 125.2 .
If rejection is suspected based on clinical appearance, the transplant
team must be notified immediately. Do not wait for laboratory results.
In cardiac patients, when rejection is suspected and dehydration is
present, consult with the transplant team prior to fluid resuscitation.
Early recognition and treatment of acute rejection results in improved
outcomes.


TABLE 125.1
INTERACTIONS BETWEEN TRANSPLANT
IMMUNOSUPPRESSANTS AND OTHER COMMONLY USED
MEDICATIONS



Current Evidence
Cardiac Transplantation

Acute cellular rejection (T cell mediated) most commonly occurs in the first 6
months after heart transplant. Twenty to forty percent of heart transplant
recipients experience at least one episode of acute cellular rejection in the first
postoperative year. Acute antibody-mediated rejection is less common than
cellular rejection, and occurs in about 10% of patients in conjunction with
hemodynamic instability. Most patients are asymptomatic during the early phases
of rejection. Surveillance, with serial echocardiography or right heart cardiac
catheterization and endomyocardial biopsy, is required to identify early rejection
and initiate treatment. Clinical evidence of rejection signals a more advanced
process, and may be identified by tachycardia and S3 gallop on examination.
Contributory symptoms may include malaise, pallor, fatigue, anorexia, nausea, or
respiratory complaints. More advanced rejections may be evidenced by
hemodynamic instability, and on examination, hepatomegaly, pulmonary
congestion, and JVD.
Liver Transplantation
Acute cellular rejection occurs in up to two-thirds of patients following liver
transplantation and is suspected when there is an increase in liver enzymes
including bilirubin, GGT, and transaminases. Rejection should also be suspected
if immunosuppression levels are low. Acute rejection is primarily diagnosed
histologically because elevated LFTs can also be seen in other settings such as
infection. The histologic triad of bile duct injury, endothelialitis, and lymphocytic