Chapter 90

• The critical care of the transplant recipient requires a multidisciplinary approach.
• Although some generalizations can be made regarding the management of all transplant patients, organ-specific considerations based on the particular allograft transplanted are often much more important.
• Risks and benefits of immunosuppressive therapy must be balanced in transplant recipients. Though immunosuppressive drugs are essential to prevent allograft rejection, they also increase the risk of infection and neoplasm.
• All immunosuppressive drugs have side effects and many have important drug-drug interactions that must be recognized by the intensivist.
• Rejection of the allograft can be divided into three broad categories: hyperacute, acute, and chronic rejection.
• Infections can reactivate in an immunocompromised recipient who has been previously exposed. Alternatively, a naïve recipient may acquire an infection following the transplant of an organ from a seropositive donor.
• Infections in transplant recipients can progress rapidly and hence must be promptly recognized and appropriately treated.
• Often immunosuppressive therapy must be adjusted or withdrawn in the presence of severe infection.

This chapter provides a practical approach to the critical care of patients following the most common solid-organ transplant procedures. Important scientific advances have greatly improved our understanding of transplant immunology. Therapies have been developed that markedly decrease the incidence and severity of allograft rejection, and this has resulted in dramatic improvements in the outcomes of transplant recipients (Table 90-1). The major causes of morbidity and death in these patients depend on the time since transplantation. Technical and bacterial infectious complications predominate in the early postoperative period. Chronic rejection remains the major cause of death overall in these patients, occurring months to years after transplantation (Fig. 90-1).

Table 90–1. One- and Five-Year Patient Survival by Organ
###### Figure 90–1.

Graphical presentation of the causes of death in the first 30 days of all patients having had either a heart, heart-lung, or lung transplant who were in the International Society for Heart and Lung Transplantation (ISHLT) registry from the period from January 1992 to June 2002. The graph serves to illustrate the high proportion of deaths from technical problems, infection, and rejection across all types of transplant patients.*Infection relates to non–cytomegalovirus-mediated disease; cardiac, allograft vasculopathy; multi-system organ failure. Developed using data taken from the ISHLT registry. (Reproduced with permission from Hertz MI, Mohacsi PJ, Taylor DO, et al:The registry of the International ...

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