HARD DECISIONS IN INTENSIVE CARE UNIT

Intensivecareunitkapak

DIFFICULT CASES IN TRANSPLANTED PATIENTS

Muhammed Halit Satıcı

Konya City Hospital, Department of Anesthesiology and Reanimation, Konya, Türkiye

Satıcı MH. Difficult Cases in Transplanted Patients. In: Turan S, editor. Hard Decisions in Intensive Care Unit. 1st ed. Ankara: Türkiye Klinikleri; 2025. p.505-516.

ABSTRACT

Postoperative management following solid organ transplantation is complex and requires specialized approaches tailored to the specific organ transplanted. Liver transplantation involves deceased donor, split, or living donor methods, with postoperative care focused on intensive monitoring for complications such as graft dysfunction, infection, and thrombosis. Key complications include hyperdynamic circulation, acute kidney injury, and sepsis. Doppler ultrasonography (DUS) is essential for evaluating vascular patency and detecting biliary or vascular complications. Kidney transplantation rarely requires intensive care unit (ICU) monitoring unless hemodynamic instability arises. Postoperative indicators like urine output and creatinine levels guide graft function evaluation. Complications such as graft thrombosis, renal artery stenosis, and urological issues are identified using DUS and managed with surgical or interventional techniques. While standard, delayed graft function often resolves without dialysis unless severe complications occur. Lung transplantation presents unique challenges, with primary graft dysfunction (PGD) being a leading early complication. PGD is characterized by alveolar infiltrates, hypoxemia, and poor shortand long-term outcomes. Infectious complications, including bacterial pneumonia, cytomegalovirus, and invasive fungal infections, are significant, especially in the first year. Atrial arrhythmias, neurological issues such as hyperammonemia, and pulmonary edema are also common post-lung transplantation challenges. Heart transplantation requires meticulous ICU care, focusing on hemodynamic stability, fluid management, and preventing complications like hyperacute rejection, primary graft dysfunction, and arrhythmias. Early recognition and management of cardiac tamponade, bleeding, and right ventricular failure are critical for successful outcomes. Immunosuppression, including induction, maintenance, and rejection management phases, remains central to transplantation success. Calcineurin inhibitors like cyclosporine and tacrolimus are pivotal but carry risks of nephrotoxicity and neurotoxicity. Alternatives like mycophenolate mofetil, sirolimus, and monoclonal antibodies benefit patients with calcineurin inhibitor intolerance or renal dysfunction. Infection prophylaxis, including trimethoprim-sulfamethoxazole, antifungals, and antivirals, is critical in mitigating the heightened infection risks of immunosuppression. This comprehensive approach is vital for improving graft survival and patient outcomes across all organ types.

Keywords: Donor; Immunosuppressive therapy; Intensive care; Organ transplantation; Difficult cases

Referanslar

  1. Amaral B, Vicente M, Pereira CSM, Araújo T, Ribeiro A, Pereira R, et al. Approach to the liver transplant early postoperative period: an institutional standpoint. Revista Brasileira de Terapia Intensiva. 2019;31(4):561-70. [Crossref]  [PubMed]  [PMC]
  2. Pollok JM, Tinguely P, Berenguer M, Niemann CU, Raptis DA, Spiro M, et al. Enhanced recovery for liver transplantation: recommendations from the 2022 International Liver Transplantation Society consensus conference. Lancet Gastroenterol Hepatol. 2023;8(1):81-94. [Crossref]  [PubMed]
  3. Tinguely P, Morare N, Ramirez-Del Val A, Berenguer M, Niemann CU, Pollok JM, et al. Enhanced recovery after surgery programs improve short-term outcomes after liver transplantation-A systematic review and meta-analysis. Clin Transplant. 2021;35(11):e14453. [Crossref]  [PubMed]
  4. Rodríguez-Laiz GP, Melgar-Requena P, Alcázar-López CF, Franco-Campello M, Villodre-Tudela C, Pascual-Bartolomé S, et al. Fast-Track Liver Transplantation: Six-year Prospective Cohort Study with an Enhanced Recovery After Surgery (ERAS) Protocol. World J Surg. 2021;45(5):1262-71. [Crossref]  [PubMed]  [PMC]
  5. Agopian VG, Harlander-Locke MP, Markovic D, Dumronggittigule W, Xia V, Kaldas FM, et al. Evaluation of early allograft function using the liver graft assessment following transplantation risk score model. JAMA Surg. 2018;153(5):436-44. [Crossref]  [PubMed]  [PMC]
  6. Lin Y, Huang H, Chen L, Chen R, Liu J, Zheng S, et al. Assessing donor liver quality and restoring graft function in the era of extended criteria donors. J Clin Transl Hepatol. 2023;11(1):219-30. [Crossref]  [PubMed]  [PMC]
  7. Hernandez MDP, Martin P, Simkins J. Infectious complications after liver transplantation. Gastroenterol Hepatol (N Y). 2015;11(11):741-53. [PubMed]
  8. Moreno R, Berenguer M. Post-liver transplantation medical complications. Ann Hepatol. 2006;5(2):77-85. [Crossref]  [PubMed]
  9. Gheorghe G, Diaconu CC, Bungau S, Bacalbasa N, Motas N, Ionescu VA. Biliary and Vascular Complications after Liver Transplantation-From Diagnosis to Treatment. Medicina. 2023;59(5):850. [Crossref]  [PubMed]  [PMC]
  10. Agostini C, Buccianti S, Risaliti M, Fortuna L, Tirloni L, Tucci R, et al. Complications in Post-Liver Transplant Patients. J Clin Med. 2023;12(19):6173. [Crossref]  [PubMed]  [PMC]
  11. Dec GW, Kondo N, Farrell ML, Dienstag J, Cosimi AB, Semigran MJ. Cardiovascular complications following liver transplantation. Clin Transplant. 1995;9(6):463-71. [Crossref]  [PubMed]
  12. Bahirwani R, Reddy, KR. Outcomes after liver transplantation: chronic kidney disease. Liver Transpl. 2009;15 Suppl 2:S70-4. [Crossref]  [PubMed]
  13. Yalavarthy R, Edelstein CL, Teitelbaum I. Acute renal failure and chronic kidney disease following liver transplantation. Hemodial Int. 2007;11 Suppl 3:S7-12. [Crossref]  [PubMed]
  14. Živković SA. Neurologic complications after liver transplantation. World J Hepatol. 2013;5(8):409-16. [Crossref]  [PubMed]  [PMC]
  15. Baker RJ, Mark PB, Patel RK, Stevens KK, Palmer N. Renal association clinical practice guideline in post-operative care in the kidney transplant recipient. BMC Nephrol. 2017;18(1):174. [Crossref]  [PubMed]  [PMC]
  16. Kruszyna T, Niekowal B, Kraśnicka M, Sadowski J. Enhanced recovery after kidney transplantation surgery. Transplant Proc. 2016;48(5):1461-5. [Crossref]  [PubMed]
  17. Wu WK, Famure O, Li Y, Kim SJ. Delayed graft function and the risk of acute rejection in the modern era of kidney transplantation. Kidney Int. 2015;88(4):851-8. [Crossref]  [PubMed]
  18. Lee SY, Chung BH, Piao SG, Kang SH, Hyoung BJ, Jeon YJ, et al. Clinical significance of slow recovery of graft function in living donor kidney transplantation. Transplantation. 2010;90(1):38-43. [Crossref]  [PubMed]
  19. Schrezenmeier E, Müller M, Friedersdorff F, Khadzhynov D, Halleck F, Staeck O, et al. Evaluation of severity of delayed graft function in kidney transplant recipients. Nephrol Dial Transplant. 2022;37(5):973-981. [Crossref]  [PubMed]
  20. Mannon RB. Delayed graft function: the AKI of kidney transplantation. Nephron. 2018;140(2):94-98. Epub 2018 Jul 13. [Crossref]  [PubMed]  [PMC]
  21. Humar A, Matas AJ. Surgical complications after kidney transplantation. Semin Dial. 2005;18(6):505-10. [Crossref]  [PubMed]
  22. Shaw TM, Lonze BE, Feyssa EL, Segev DL, May N, Parsikia A, et al. Operative start times and complications after kidney transplantation. Clin Transplant. 2012;26(3):E177-83. [Crossref]  [PubMed]
  23. Chambers DC, Yusen RD, Cherikh WS, Goldfarb SB, Kucheryavaya AY, Khusch K, et al. The Registry of the International Society for Heart and Lung Transplantation: Thirty-fourth Adult Lung And Heart-Lung Transplantation Report-2017; Focus Theme: Allograft ischemic time. J Heart Lung Transplant. 2017;36(10):1047-59. [Crossref]  [PubMed]
  24. Snell GI, Yusen RD, Weill D, Strueber M, Garrity E, Reed A, et al. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction, part I: Definition and grading-A 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2017;36(10):1097-03. [Crossref]  [PubMed]
  25. Kreisel D, Krupnick AS, Puri V, Puri V, Guthrie TJ, Trulock EP, et al. Short- and long-term outcomes of 1000 adult lung transplant recipients at a single center. J Thorac Cardiovasc Surg. 2011;141(1):215-22. [Crossref]  [PubMed]
  26. Diamond JM, Lee JC, Kawut SM, Shah RJ, Localio AR, Bellamy SL, et al. Clinical risk factors for primary graft dysfunction after lung transplantation. Am J Respir Crit Care Med. 2013;187(5):527-34. [Crossref]  [PubMed]  [PMC]
  27. Siegleman SS, Sinha SB, Veith FJ. Pulmonary reimplantation response. Ann Surg. 1973;177(1):30-6. [Crossref]  [PubMed]  [PMC]
  28. Zamora MR, Nicolls MR, Hodges TN, Marquesen J, Astor T, Grazia T, et al. Following universal prophylaxis with intravenous ganciclovir and cytomegalovirus immune globulin, valganciclovir is safe and effective for prevention of CMV infection following lung transplantation. Am J Transplant. 2004;4(10):1635-42. [Crossref]  [PubMed]
  29. Roukoz H, Benditt DG. Atrial arrhythmias after lung transplantation. Trends Cardiovasc Med. 2018;28(1):53-61. [Crossref]  [PubMed]
  30. Waldron NH, Klinger RY, Hartwig MG, Snyder LD, Daubert JP, Mathew JP. Adverse outcomes associated with postoperative atrial arrhythmias after lung transplantation: A meta-analysis and systematic review of the literature. Clin Transplant. 2017;31(4). [Crossref]  [PubMed]
  31. Chen C, Bain KB, Iuppa JA, Yusen RD, Byers DE, Patterson GA, et al. Hyperammonemia Syndrome After Lung Transplantation: A Single Center Experience. Transplantation. 2016;100(3):678-84. [Crossref]  [PubMed]
  32. Colvin-Adams M, Smith JM, Heubner BM, Skeans MA, Edwards LB, Waller CD, et al. OPTN/SRTR 2013 annual data report: heart. Am J Transplant. 2015;15 Suppl 2:1- 28. [Crossref]  [PubMed]
  33. Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S, et al. The International society of heart and lung transplantation guidelines for the care of heart transplant recipients. J Heart Lung Transplant. 2010;29(8):914-56. [Crossref]  [PubMed]
  34. Chandraratna PA, Mohar DS, Sidarous PF. Role of echocardiography in the treatment of cardiac tamponade. Echocardiography. 2014;31(7):899-910. [Crossref]  [PubMed]
  35. Segovia J, Cosio MD, Barcelo JM, Bueno MG, Pavía PG, Burgos R, et al. RADIAL: a novel primary graft failure risk score in heart transplantation. J Heart Lung Transplant. 2011;30(6):644-51. [Crossref]  [PubMed]
  36. Quintana-Quezada RA, Rajapreyar I, Postalian-Yrausquin A, Yeh YC, Choi S, Akkanti B, et al. Clinical factors implicated in primary graft dysfunction after heart transplantation: a single-center experience. Transplant Proc. 2016;48(6):2168-71. [Crossref]  [PubMed]
  37. Haddad F, Couture P, Tousignant C, Denault AY, et al. The right ventricle in cardiac surgery, a perioperative perspective: I. Anatomy, physiology, and assessment. Anesth Analg. 2009;108(2):407-21. [Crossref]  [PubMed]
  38. Awad M, Czer LS, Hou M, Golshani SS, Goltche M, Robertis MD, et al. Early denervation and later reinnervation of the heart following cardiac transplantation: A Review. J Am Heart Assoc. 2016;5(11):e004070. [Crossref]  [PubMed]  [PMC]
  39. Singh N, Limaye AP. Infections in solid-organ transplant recipients. Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 2014:3440-52. [Crossref]  [PMC]
  40. Fishman JA. Infection in solid-organ transplant recipients. N Engl J Med. 2007;357(25):2601-14. [Crossref]  [PubMed]
  41. Sole A, Morant P, Salavert M. Aspergillus in lung transplant recipients: risk factors and outcome. Clin Microbiol Infect. 2005;11(5):359-65. [Crossref]  [PubMed]
  42. San Juan R, Aguado JM, Lumbreras C. Incidence, clinical characteristics and risk factors of late infection in solid organ transplant recipients: data from the RESITRA study group. Am J Transplant. 2007;7(4):964-71. [Crossref]  [PubMed]
  43. Stewart S, Winters GL, Fishbein MC, Tazelaar HD, Kobashigawa J, Abrams J, et al. Revision of the 1990 working formulation for the standardization of nomenclature in the diagnosis of heart rejection. J Heart Lung Transplant. 2005;24(11):1710-20. [Crossref]  [PubMed]
  44. Penninga L, Moller CH, Gustafsson F, Gluud C, Steinbrüchel DA. Immunosuppressive T-cell antibody induction for heart transplant recipients. Cochrane Database Syst Rev. 2013;2013(12):CD008842. [Crossref]
  45. Lindenfeld J, Miller GG, Shakar SF, Zolty R, Lowes BD, Wolfel EE, et al. Drug therapy in the heart transplant recipient: part II: immunosuppressive drugs. Circulation. 2004;110(25):3858-65. [Crossref]  [PubMed]
  46. Guethoff S, Meiser BM, Groetzner J, Eifert S, Grinninger C, Ueberfuhr P, et al. Ten-year results of a randomized trial comparing tacrolimus versus cyclosporine a in combination with mycophenolate mofetil after heart transplantation. Transplantation. 2013;95(4):629-34. [Crossref]  [PubMed]
  47. Dandel M, Jasaityte R, Lehmkuhl H, Knosalla C, Hetzer R, et al. Maintenance immunosuppression with mycophenolate mofetil: long-term efficacy and safety after heart transplantation. Transplant Proc. 2009;41(6):2585-88. [Crossref]  [PubMed]
  48. Emin A, Rogers CA, Thekkudan J, Bonser RS, Banner NR, Group S, et al. Antithymocyte globulin induction therapy for adult heart transplantation: a UK National study. J Heart Lung Transplant. 2011;30(7):770-77. [Crossref]  [PubMed]