Practical Approach to Emergencies in Lung Transplant Recipients: How We Do It

Abstract

Lung transplant recipients (LTRs) are prone to medical complications and emergencies due to the transplanted organ being in constant direct contact with the environment and the need for life-long profound immunosuppression (IS). As a result of these specific circumstances, the medical and surgical management of LTRs frequently differs from usual standard care. Therefore, we outline here some of the principles we take into account when dealing with the most frequent medical emergencies encountered in our lung transplant cohort in Zurich. The main topics dealt with are: diagnostics and treatment of infections, gastrointestinal emergencies, IS and other medication issues as well as work-up of unclear inflammatory signs and peri-operative precautions in LTRs. Early post-operative transplant complications, rare medical emergencies and surgical problems are not covered. Our report is intended to help internists and pulmonologists new to the field to obtain a better understanding of the peculiarities of LTRs and their management.

Patient- and physician-related risk factors for hyperkalaemia in potassium-increasing drug–drug interactions

“…2); (ii) diabetes mellitus [6,31]; (iii) the highest risk concerned pulmonary allograft, mainly due to PID combinations of immunosuppressive agents, trimethoprim, and ACE inhibitor [32,33]; (iv) female gender, confirming another analysis of gender as a predictor in drug-induced hyperkalaemia [34]; (v) elevated serum potassium (> 4.5 mEq/l) at onset of the DDI. 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 In contrast to other studies, we couldn't establish an association between hyperkalaemia during potassium-increasing DDIs and age or hospitalisation in surgical versus non-surgical specialties [12].…”

Earlier switching from intravenous to oral antibiotics owing to electronic reminders

“…However, some patients require aggressive IV antimicrobial treatments (9), e.g. patients with cystic fibrosis, and particularly lung transplant recipients often present with complex infections (30). Yet, the potential of CDS in such specific clinical settings is unknown.…”

Managing Viral Respiratory Tract Infections in Lung Transplant Recipients

“…IgG<7.0 g/L as the lower limit of normal) appears not to influence the incidence of CARVs (16). It is suggested that the administration of IVIG for CARV infection results in the transfer of specific antibodies directed against viruses and thus helps accelerate the resolution of the infection.…”

“…In case of strong lymphopenia (<500 cells/uL) or leukopenia (<3000 cells/uL), we reduce the dose of immunosuppressants, commonly by reducing the antimetabolite. The reduction of mycophenolate mofetil is usually by one-third to one-half of the maintenance dose and is performed already when the respiratory tract infection is suspected (16). In case of progressive loss of lung function despite established antiviral and antibacterial therapy, we consider increasing the prednisone dose to counteract a possible inflammatory response.…”