As of the end of 2006, there were 173,339 patients in the U.S.
living with solid-organ transplants, and an additional 27,578 U.S.
transplants in 2007.1 The kidney is the most commonly
transplanted organ (58%), followed by liver (21%),
heart (8%), lung (5%), pancreas (5%),
and, less commonly, combined organ transplants and intestine transplants.
In 2008, there were 4300 hematopoietic stem cell transplants (HSCTs) (bone
marrow transplants) in the U.S.2
Most transplant patients require lifelong immunosuppression.
Transplant patients present to the EDs with a number of acute to
life-threatening emergencies, including (1) transplant-related infection,
(2) medication side effects, (3) rejection, (4) graft-versus-host
disease, and (5) postoperative complications and complications of
altered physiology secondary to the transplanted organ. Frequently,
transplant patients present with common medical problems that require
unique management due to their immunosuppression or altered physiology.
Finally, transplant patients are at risk for presenting with symptoms
of a new malignancy due to their extended immunosuppression.
The largest study of transplant patients presenting to the ED
was published in 2009 (1251 visits),3 adding to
previously published studies of liver transplant patients (290 ED
visits),4 heart transplant patients (131 ED visits),5 and
renal transplant patients (78 ED visits).6 With
multiple diagnoses possible per patient, the most common diagnosis
in all studies was infection (39%) followed by noninfectious
GI/GU pathology (15%), dehydration (15%),
electrolyte disturbances (10%), cardiopulmonary pathology
(10%) or injury (8%), and rejection in 6%.
Acute graft-versus-host disease occurs in 20% to 80% of
patients post-HSCT, depending on the degree of major histocompatability
complex mismatch, and rarely occurs post–solid-organ mismatch,
depending on the amount of lymphoid tissue transplanted.7
The initial history may reveal other immediate patient concerns
Table 295-1 Key Historical
Elements Specific to Transplant Patients |Favorite Table|Download (.pdf)
Table 295-1 Key Historical
Elements Specific to Transplant Patients
|Recent temperature increase or decrease from baseline||Potential clue to onset of infection or, rarely, rejection.|
|Changes from baseline function||Decreased urine may signify rejection in renal transplant patients.|
|Decreased exercise tolerance may signify rejection in heart transplant
|Change in skin color (jaundice specifically) may signify
rejection in liver transplant patients or graft-versus-host disease.|
|Date of transplant surgery||The date from transplant helps to predict typical infections
and types of post-transplant complications (i.e., graft-versus-host disease
|Graft source for solid-organ transplant special features
of graft if any, prior infections; donor living related vs. cadaveric||These details predict the potential for certain infections
|Graft source for hematopoietic stem cell transplant: autologous, degree
of match, related donor||These details predict the potential graft-versus-host disease.|
|Rejection history||May predict current rejection if similar presentation and
difficulty in controlling a current episode of rejection.|
|Recent changes in dosages ...|