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  • Advancements in immunosuppression, transplant techniques, antimicrobials, postoperative management, and bridging techniques have had an enormous impact on morbidity and mortality of transplant recipients.

  • Although some generalizations can be made regarding the management of transplant patients, organ-specific considerations based on the particular allograft transplanted are critically important.

  • 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.

  • Risks and benefits of sustained immunosuppressive therapy must be balanced in transplant recipients.

  • Immunosuppressive drugs have significant side effects and many have important drug−drug interactions that must be recognized by the intensivist.


Advances in transplant immunology, organ preservation, and expansion in the number of donors have allowed organ transplantation to become a feasible management strategy for more patients with end-stage organ dysfunction. The adoption of expanded donor selection criteria and innovations in extracorporeal organ support has increased the number of available organs for transplantation, while innovations in transplant technique and perioperative management have improved eligibility and outcomes in sicker patients. Advances in surgical technique have also allowed for “fast-tracking” organ recipients into stepdown units bypassing the intensive care unit (ICU), with the objective of avoiding complications and facilitating early mobilization and rehabilitation. However, the majority of lung, heart, and a minor proportion of liver recipients will still require ICU admission for postoperative management.

The role of the critical care physician in the management of the transplant patient extends beyond the perioperative period to managing transplant recipients with critical illness due to chronic graft dysfunction. In addition to organ-specific complications, critical care physicians will encounter the full spectrum of complications and consequences related to immunosuppression, including standard and opportunistic infections, organ failures from drug toxicity or comorbid conditions, metabolic complications, and significant drug interactions. Early recognition of typical or atypical clinical syndromes is imperative for timely initiation of appropriate therapy and avoiding consequences including death and graft failure.

The spectrum of this chapter includes indications; postoperative management; complications; and outcomes of lung, liver, and heart transplant. Whether a transplant intensivist or not, understanding the basics of immunosuppression, perioperative organ optimization, and identification of potential early and delayed complications is essential to enhance outcomes of transplant recipients.


Immunosuppression is essential to avoid rejection of the allograft. Advances in immunology have led to the creation a variety of immunosuppressive agents targeting different effector pathways. The standard immunosuppressive regimen typically includes steroids, calcineurin inhibitors, and antiproliferative agents. Newer immunosuppressive agents are typically reserved for episodes of rejection or as alternative agents in the event of drug-induced toxicity. However, it is essential to remember that regardless the mechanism of action, all immunosuppressive agents will result in downregulation ...

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