5-Minute Emergency Consult
Transplant Rejection
Transplant Rejection is a topic covered in the 5-Minute Emergency Consult.
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Basics
Description
Immune response to a graft's genetically dissimilar antigens resulting in rejection of the transplanted organ:Description
- HLA incompatibility:
- Most common cause of rejection
- Rejection of solid organ transplants
- Blood group incompatibility:
- Much less of a risk to graft survival than HLA incompatibility
- May result in hyperacute rejection of primarily vascularized grafts (kidney and heart)
- 3 phases of rejection:
- Hyperacute:
- Immediate postoperative period
- Antibody reaction to red cells or HLA antigens
- Endothelial damage
- Platelets accumulate, thrombi develop, and tissue necrosis occurs
- Rare with careful donor–recipient matching
- Hyperacute:
- Acute:
- Within the first 3 mo postop
- At any time if immunosuppressant (IS) medication is stopped
- T-cell–dependent process. Inflammatory cells infiltrate allograft, release cellular and humoral factors, destroys graft
- Presents with constitutional symptoms and signs of transplant organ insufficiency
- Chronic:
- Occurs over years
- Results in gradual organ failure
Epidemiology
Incidence and Prevalence EstimatesEpidemiology
- Solid organ transplants:
- Over 30,000 organs transplanted yearly
- Most transplanted organs: Kidney, liver, heart, lung, intestine, pancreas
- Most common diagnosis from visit to ED: Infection, GI/GU pathology, dehydration, electrolyte, CV and pulmonary pathology, injury, rejection
- Up to 75% require hospitalization
Etiology
Etiology
- Reduction or noncompliance with medication:
- Multiple medication interactions with cyclosporine, tacrolimus, or sirolimus including:
- Phenobarbital, phenytoin, carbamazepine, rifampin, isoniazid
- Multiple medication interactions with cyclosporine, tacrolimus, or sirolimus including:
- Kidney transplant rejection:
- Early rejection caused by T- and B-lymphocytes, which attack microvasculature and impair graft perfusion; volume depletion, hypotension, infection
- Chronic rejection caused by progressive nephrosclerosis of renal vessels, infection
- Liver transplant rejection:
- Acute: 48% by 6 wk, 65% by 1 yr
- Commonly follows reduction in the IS regimen
- Chronic: <5%
- 1 wk–6 mo MC range to experience
- Acute: 48% by 6 wk, 65% by 1 yr
- Cardiac transplant rejection:
- Acute rejection:
- 75–85% of patients within the first 3–6 mo due to T-cell–mediated response
- Chronic rejection:
- Accelerated atherosclerosis is the hallmark
- Associated with change in IS therapy
- Acute rejection:
- Lung transplant rejection:
- Acute rejection develops early:
- Can occur up to 6 times in the first year
- Chronic rejection:
- 25–40% of patients postop
- MCC of death in second postop year
- Rejection caused by endothelial, vascular, and lymphocyte inflammation, recurrent acute rejection
- Acute rejection develops early:
- Bone marrow transplant rejection:
- Acute graft vs. host disease:
- Immune attack of donor marrow on lung tissue
- Chronic graft vs. host disease:
- 25–50% of patients
- Marrow rejection:
- MC in patients with plastic anemia who do not receive total body radiotherapy or in patients receiving mismatched or unrelated transplants
- Acute graft vs. host disease:
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Basics
Description
Immune response to a graft's genetically dissimilar antigens resulting in rejection of the transplanted organ:Description
- HLA incompatibility:
- Most common cause of rejection
- Rejection of solid organ transplants
- Blood group incompatibility:
- Much less of a risk to graft survival than HLA incompatibility
- May result in hyperacute rejection of primarily vascularized grafts (kidney and heart)
- 3 phases of rejection:
- Hyperacute:
- Immediate postoperative period
- Antibody reaction to red cells or HLA antigens
- Endothelial damage
- Platelets accumulate, thrombi develop, and tissue necrosis occurs
- Rare with careful donor–recipient matching
- Hyperacute:
- Acute:
- Within the first 3 mo postop
- At any time if immunosuppressant (IS) medication is stopped
- T-cell–dependent process. Inflammatory cells infiltrate allograft, release cellular and humoral factors, destroys graft
- Presents with constitutional symptoms and signs of transplant organ insufficiency
- Chronic:
- Occurs over years
- Results in gradual organ failure
Epidemiology
Incidence and Prevalence EstimatesEpidemiology
- Solid organ transplants:
- Over 30,000 organs transplanted yearly
- Most transplanted organs: Kidney, liver, heart, lung, intestine, pancreas
- Most common diagnosis from visit to ED: Infection, GI/GU pathology, dehydration, electrolyte, CV and pulmonary pathology, injury, rejection
- Up to 75% require hospitalization
Etiology
Etiology
- Reduction or noncompliance with medication:
- Multiple medication interactions with cyclosporine, tacrolimus, or sirolimus including:
- Phenobarbital, phenytoin, carbamazepine, rifampin, isoniazid
- Multiple medication interactions with cyclosporine, tacrolimus, or sirolimus including:
- Kidney transplant rejection:
- Early rejection caused by T- and B-lymphocytes, which attack microvasculature and impair graft perfusion; volume depletion, hypotension, infection
- Chronic rejection caused by progressive nephrosclerosis of renal vessels, infection
- Liver transplant rejection:
- Acute: 48% by 6 wk, 65% by 1 yr
- Commonly follows reduction in the IS regimen
- Chronic: <5%
- 1 wk–6 mo MC range to experience
- Acute: 48% by 6 wk, 65% by 1 yr
- Cardiac transplant rejection:
- Acute rejection:
- 75–85% of patients within the first 3–6 mo due to T-cell–mediated response
- Chronic rejection:
- Accelerated atherosclerosis is the hallmark
- Associated with change in IS therapy
- Acute rejection:
- Lung transplant rejection:
- Acute rejection develops early:
- Can occur up to 6 times in the first year
- Chronic rejection:
- 25–40% of patients postop
- MCC of death in second postop year
- Rejection caused by endothelial, vascular, and lymphocyte inflammation, recurrent acute rejection
- Acute rejection develops early:
- Bone marrow transplant rejection:
- Acute graft vs. host disease:
- Immune attack of donor marrow on lung tissue
- Chronic graft vs. host disease:
- 25–50% of patients
- Marrow rejection:
- MC in patients with plastic anemia who do not receive total body radiotherapy or in patients receiving mismatched or unrelated transplants
- Acute graft vs. host disease:
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Citation
Schaider, Jeffrey J., et al., editors. "Transplant Rejection." 5-Minute Emergency Consult, 5th ed., Lippincott Williams & Wilkins, 2016. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307116/2.2/Transplant_Rejection.
Transplant Rejection. In: Schaider JJJ, Barkin RMR, Hayden SRS, et al, eds. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2016. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307116/2.2/Transplant_Rejection. Accessed February 6, 2023.
Transplant Rejection. (2016). In Schaider, J. J., Barkin, R. M., Hayden, S. R., Wolfe, R. E., Barkin, A. Z., Shayne, P., & Rosen, P. (Eds.), 5-Minute Emergency Consult (5th ed.). Lippincott Williams & Wilkins. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307116/2.2/Transplant_Rejection
Transplant Rejection [Internet]. In: Schaider JJJ, Barkin RMR, Hayden SRS, Wolfe RER, Barkin AZA, Shayne PP, Rosen PP, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2016. [cited 2023 February 06]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307116/2.2/Transplant_Rejection.
* Article titles in AMA citation format should be in sentence-case
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ED - Wolfe,Richard E,
BT - 5-Minute Emergency Consult
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PB - Lippincott Williams & Wilkins
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DB - Emergency Central
DP - Unbound Medicine
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