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Primary Care
oftheSolid Organ
Transplant Recipient
SecondEdition
ChristopherJ. Wong
Editor
Primary Care of the Solid Organ Transplant
Recipient
Christopher J. Wong
Editor
Primary Care of the Solid
Organ Transplant Recipient
Second Edition
ISBN 978-3-031-98075-6 ISBN 978-3-031-98076-3 (eBook)
https://doi.org/10.1007/978-3-031-98076-3
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland
AG 2020, 2025
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microlms or in any other physical way, and
transmission or information storage and retrieval, electronic adaptation, computer software, or by similar
or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specic statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
If disposing of this product, please recycle the paper.
Editor
Christopher J. Wong
Division of General Internal Medicine
Department of Medicine
University of Washington
Seattle, WA, USA
v
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Christopher J. Wong
2 Overview of Solid Organ Transplantation for Primary
Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Diana Zhong and Christopher J. Wong
3 Anti-Rejection Medication Therapy in the Adult Solid
Organ Transplant Recipient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Lydia Sun, Tyra Fainstad, and Christopher Knight
4 Primary Care of the Adult Kidney Transplant
and Kidney-Pancreas Transplant Recipient . . . . . . . . . . . . . . . . . . . . . 55
Boonphiphop Boonpheng and Iris C. De Castro
5 Primary Care of the Adult Liver Transplant Recipient . . . . . . . . . . . 111
Courtney L. Tuegel, Lauren A. Beste, and Anne M. Larson
6 Primary Care of the Adult Heart Transplant Recipient . . . . . . . . . . . 133
Vidang P. Nguyen, Andy Y. Lee, Aris Karatasakis,
and Richard K. Cheng
7 Primary Care of the Adult Lung Transplant Recipient . . . . . . . . . . . 173
Erika D. Lease
8 Infections in the Adult Solid Organ Transplant Recipient . . . . . . . . . 193
Jennifer Hu, Mackenzie H. Holmberg, Rachel A. Bender Ignacio,
and Ralph Tayyar
9 Common Syndromes in the Adult Solid Organ
Transplant Recipient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Kim O’Connor and Christopher J. Wong
10 Cancer Risk in the Adult Solid Organ Transplant Recipient . . . . . . . 299
Christopher J. Wong and Christopher D. Blosser
Contents
vi
11 Metabolic Complications in the Adult Solid Organ
Transplant Recipient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Anna L. Golob, Jennifer Wright, and Kim O’Connor
12 Mental Health in the Adult Solid Organ Transplant Recipient . . . . . 355
Gena Lenti, Ashwin Karnik, and Thomas Soeprono
13 Gynecologic and Reproductive Health Considerations
in the Adult Solid Organ Transplant Recipient . . . . . . . . . . . . . . . . . . 381
Nina Tan and Adelaide H. McClintock
14 Preventive Health in the Adult Solid Organ Transplant Recipient . . 397
Rebecca S. Gold and Leah Marcotte
15 Care of the Pediatric Solid Organ Transplant Recipient . . . . . . . . . . 431
Katelyn M. Saarela and Evelyn K. Hsu
16 Palliative Care in the Adult Solid Organ Transplant Recipient . . . . . 447
Katherine G. Hicks, Eleanor Curtis, and Melissa A. Bender
17 Gender-Affirming Care of the Adult Solid Organ
Transplant Recipient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Julia Becke, Lydia Sun, and Christopher J. Wong
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
Contents
1© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
C. J. Wong (ed.), Primary Care of the Solid Organ Transplant Recipient,
https://doi.org/10.1007/978-3-031-98076-3_1
Chapter 1
Introduction
ChristopherJ.Wong
1.1 Why Primary Care?
Solid organ transplantation is a miracle of modern medicine. Transplant medicine
has dramatically altered the natural history of end-organ failure: instead of death,
there is life. While there are many potential complications, often solid organ trans-
plant (SOT) recipients have excellent quality of life for their remaining years.
But the work is not done after transplantation. There is a wide range of behav-
iors, monitoring, and treatment necessary to maximize health and function of the
transplanted organ and the well-being of the patient. Primary care can—and in
many cases must—play a vital role in a solid organ transplant recipient’s health.
First, patients may live far from their transplant center and may need a local primary
care provider for both urgent and chronic medical conditions. Second, patients often
have a pre-existing relationship with their primary care provider prior to solid organ
transplantation. Third, the number of surviving solid organ transplant recipients is
increasing—it is unlikely that transplant centers will have the resources to provide
all care for this population.
The balance of what aspects of care are performed by which provider should be
a continued conversation between the transplant specialist and primary care pro-
vider. The transplant specialist typically will maintain immunosuppression and con-
tinue to assess function of the transplanted organ. Some transplant centers will
follow patients closely even if they are doing well, while others may see patients
yearly with the bulk of the patients’ care returned to primary care and local special-
ists as needed. For example, a liver transplant recipient may return yearly to the liver
transplant clinic, and be followed by a primary care provider and a local
C. J. Wong (*)
Division of General Internal Medicine, Department of Medicine, University of Washington,
Seattle, WA, USA
e-mail: cjwong@uw.edu
2
gastroenterologist in between those yearly visits, unless there are complications that
would require a return evaluation sooner. Sometimes the transition back to primary
care is colloquially called “graduating.” In contrast, a lung transplant recipient may
be followed more closely by their transplant team indenitely.
1.2 Primary Care Roles intheCare ofSolid Organ
Transplant Recipients
While there will always be a vital role for the transplant specialist, primary care
providers nevertheless are front-line in managing other illnesses that may arise.
Primary care providers who care for solid organ transplant recipients must be vigi-
lant in identifying and treating the patient’s complications and comorbidities. For
example:
• Is the patient’s diarrhea due to mycophenolate or is there a new cause of diarrhea,
either infectious or non-infectious?
• Is the cough and shortness of breath a sign of organ failure or an opportunistic
infection, or a viral upper respiratory infection? If it is a viral infection, is there
concern for SARS-CoV-2?
• What medications should a solid organ transplant recipient be taking, and what
side effects are likely?
• Will treatment of other conditions with medications interfere with the patient’s
transplant medications?
• When should the transplant specialist be consulted?
These questions can pose clinical challenges but are both important to the patient
as well as rewarding to the provider. Caring for solid organ transplant recipients
requires all the tools of a clinician to synthesize the presentation and determine the
best evaluation and treatment.
In addition to new symptoms, primary care providers are front-line for delivering
preventive health and care of chronic conditions to their patients. The primary care
provider has an important role in making sure recommended screenings take place,
modify screening as indicated, and be alert for metabolic complications and manage
them appropriately. Questions might include:
• Should the vaccination schedule be altered?
• How is cancer screening different in a solid organ transplant recipient?
• What metabolic problems, such as diabetes and osteoporosis, are more common
in solid organ transplant recipients?
• How should common conditions be managed differently in a solid organ trans-
plant recipient?
C. J. Wong
3
1.3 How toUse this Book
This book is written with primary care providers in mind, as they try to sort out
whether new symptoms and syndromes might represent a transplant-related compli-
cation, or, instead, fall into the category of routine primary care; as they navigate
recommended preventive health and metabolic complications; and as they learn
about complications specic to the transplanted organ.
New to this edition are Chaps. 12, 13, 15, and 17; other chapters are updated to
reect changes in practice as well as changes since the COVID-19 pandemic.
In this book, we hope to provide guidance for primary care providers in the rich
and rewarding care of solid organ transplant recipients.
Chapter 2 covers a general overview of solid organ transplantation, including
review of the pre-transplant course and taking a basic medical history of the patient
after transplantation.
Chapter 3 addresses the basics of common anti-rejection medications used in
solid organ transplantation, including their common side effects. The authors dis-
cuss drug interactions for medications commonly used in the primary care setting.
Chapters 4–7 provide overviews of the care of kidney and kidney-pancreas, liver,
heart, and lung transplant recipients. (Note that this book does not address com-
bined heart-lung, or small intestine transplantation.)
Chapter 8 is a review of infections in the solid organ transplant recipient. It
includes discussion of select respiratory, gastrointestinal, urinary tract, central ner-
vous system, and skin and soft tissue infections.
Chapter 9 provides a general approach to a set of common syndromes, including
shortness of breath and cough, diarrhea, urinary tract symptoms, musculoskeletal
symptoms, and skin lesions.
Chapter 10 addresses the important topic of cancer, a life-limiting complication
in the immunosuppressed population.
Chapter 11 is an overview of metabolic complications including diabetes, hyper-
tension, hyperlipidemia, gout, and osteoporosis, all of which are common in the
solid organ transplant population.
Chapter 12 reviews mental health in solid organ transplant recipients, including
screening and treatment of common mental health disorders.
Chapter 13 reviews gynecologic considerations in solid organ transplant recipi-
ents, including contraception, preconception planning, and menopause.
Chapter 14 provides an overview of preventive health, highlighting similarities
and differences between recommendations for solid organ transplant recipients
compared to the general population.
Chapter 15 addresses concerns specic to pediatric solid organ transplantation
that a general pediatrician will nd useful.
Chapter 16 addresses palliative care, as solid organ transplant recipients may
have important symptoms that impact quality of life, and discusses end-of-life issues.
Chapter 17 reviews gender-afrming care for solid organ transplant recipients.
1 Introduction
4
This book does not need to be read cover-to-cover. The chapters specic to a
transplanted organ will provide useful knowledge for primary care providers should
they be involved in the care of patients with these transplanted organs. All providers
may nd useful the general overview chapter and the chapters on medications and
complications. Those who see patients for urgent symptoms may nd the chapter
discussing common syndromes to be helpful, as well as the individual organ chap-
ters as needed. When applicable, chapters are cross-referenced to each other.
This goal of this book is to provide a framework and a starting point—a solid
organ transplant recipient’s care must still be individualized based on their unique
circumstances and one must consult with the patient’s specialty providers when the
need arises.
C. J. Wong