Post-Transplant Care and Complications
What the exam tests
This domain covers the timeline of post-transplant complications, recognition of rejection, infection syndromes, surgical complications, and long-term surveillance. Know the classic windows: hyperacute (minutes), acute (days to months), and chronic (months to years).
Traps
- Hyperacute rejection is antibody-mediated and occurs in the operating room or immediately after; treatment is graft removal, not immunosuppression escalation.
- Infection timing mirrors immunosuppression intensity. Early: surgical site, urinary, and wound infections. Intermediate (1–6 months): CMV, Pneumocystis, BK virus. Late: community-acquired infections and opportunistic disease in poorly suppressed patients.
- BK virus nephropathy presents with rising creatinine and high BK viral load-reducing immunosuppression is the mainstay, not increasing it.
- CMV disease often presents with fever, leukopenia, and GI or pulmonary symptoms; distinguish infection (asymptomatic viral replication) from disease (symptoms plus tissue invasion).
- Post-transplant lymphoproliferative disorder is associated with Epstein-Barr virus and intensified immunosuppression; reduced immunosuppression is part of management.
- Surgical complications-vascular thrombosis, ureteral leak or stricture, lymphocele-present with pain, oliguria, or fluid collections and are diagnosed by imaging.
Rule of thumb
Match the time since transplant to the likely complication before choosing a test. A new fever at 3 weeks is a surgical/infectious problem; at 3 months, think CMV or Pneumocystis.
Worked example
A kidney recipient 4 months out has creatinine rising from 1.3 to 2.0 mg/dL, BK viral load of 10,000 copies/mL, and no donor-specific antibodies. The diagnosis is BK virus nephropathy, and the correct action is reduction of immunosuppression with serial viral load monitoring.