Transplantation replaces a failing organ or tissue with one from a donor. The kidney is the most commonly transplanted solid organ, followed by liver, heart, and lung; pancreas, intestine, cornea, and hematopoietic stem cells are also transplanted.
Donor sources
- Living donors — kidney, part of the liver
- Deceased donors — after death by neurologic criteria (brain death) or after circulatory death
Why rejection happens. The recipient's immune system recognizes donor human leukocyte antigens (HLA) as foreign. T cells and antibodies attack the graft unless immunity is suppressed. Matching reduces the risk:
- ABO blood group compatibility
- HLA tissue typing
- Crossmatch — tests whether the recipient already has antibodies against the donor; a positive crossmatch predicts hyperacute rejection
Types of rejection
| Type | Timing | Mechanism | Outcome |
|---|
| Hyperacute | Minutes to hours | Preformed antibodies (ABO or HLA) cause clotting in graft vessels | Graft is lost and removed; now rare because of crossmatching |
| Acute | Days to months (most often in the first 6 months) | T-cell–mediated or antibody-mediated | Usually reversible with prompt treatment |
| Chronic | Months to years | Gradual fibrosis and narrowing of graft vessels | Slow, progressive loss of function; not reversible |
Graft-versus-host disease (GVHD) is the reverse process, seen mainly after allogeneic stem cell transplant: donor T cells attack the recipient's skin (rash, often palms and soles), liver (jaundice), and GI tract (diarrhea).
Signs of rejection by organ
| Organ | Findings |
|---|
| Kidney | Rising creatinine, decreasing urine output, weight gain and edema, hypertension, fever, tenderness over the graft (iliac fossa) |
| Liver | Rising liver enzymes and bilirubin — often the first sign, before symptoms; then jaundice, fever, dark urine, pale stools; if a biliary drain is present, less bile or a change in its color |
| Heart | Often no symptoms early; fatigue, dyspnea, dysrhythmias, hypotension, signs of heart failure — detected by surveillance biopsy |
| Lung | Dyspnea, cough, fever, falling oxygen saturation, drop in home spirometry (FEV₁) |
Many clients with early rejection feel well, so laboratory surveillance is essential. Immunosuppression also blunts fever and inflammation, so small changes matter.
The transplanted heart is denervated
- Resting heart rate is higher than normal (often around 90–110/min)
- Heart rate rises slowly with exercise and relies on circulating catecholamines — teach longer warm-up and cool-down periods
- Atropine does not increase the rate; pacing or other drugs are used for bradycardia
- Myocardial ischemia may occur without chest pain (cardiac allograft vasculopathy)
| Test | Purpose |
|---|
| ABO, HLA typing, crossmatch, antibody screen | Pretransplant compatibility |
| Creatinine, BUN, urine output | Kidney graft function |
| AST, ALT, bilirubin, INR | Liver graft function |
| Immunosuppressant trough levels (tacrolimus, cyclosporine, sirolimus) | Drawn just before the next dose; keep within range to avoid rejection or toxicity |
| CBC, potassium, magnesium, glucose, lipids | Drug adverse effects |
| Biopsy of the graft | Definitive diagnosis of rejection |
| Doppler ultrasound | Blood flow in the graft (thrombosis), fluid collections |
| Echocardiogram, spirometry | Heart and lung graft function |
| Cytomegalovirus and Epstein-Barr virus PCR | Viral infection monitoring |
Immunosuppression
- Induction (at transplant): basiliximab or antithymocyte globulin — premedicate as ordered; watch for fever, chills, hypotension, and anaphylaxis during infusion; leukopenia and thrombocytopenia
- Maintenance (usually triple therapy) and treatment of acute rejection (high-dose IV corticosteroids, antithymocyte globulin, or antibody-directed therapy)
| Drug | Key adverse effects and monitoring |
|---|
| Tacrolimus (calcineurin inhibitor) | Nephrotoxicity, tremor, headache, seizures, hyperglycemia (new-onset diabetes), hyperkalemia (avoid potassium-sparing diuretics and potassium supplements unless prescribed), hypomagnesemia, hypertension; trough levels; take the same way each day relative to food |
| Cyclosporine (calcineurin inhibitor) | Nephrotoxicity, hypertension, gum overgrowth, excess hair growth, hyperkalemia; trough levels |
| Mycophenolate | Diarrhea, nausea, leukopenia; pregnancy loss and birth defects — pregnancy testing and effective contraception required |
| Azathioprine | Marrow suppression, liver toxicity; interaction with allopurinol |
| Corticosteroids | Hyperglycemia, infection, osteoporosis, weight gain, mood change, cataracts, GI bleeding; never stop abruptly |
| Sirolimus, everolimus (mTOR inhibitors) | Impaired wound healing (often avoided early after surgery), hyperlipidemia, mouth ulcers, proteinuria |
Drug interactions — calcineurin and mTOR inhibitors are metabolized by CYP3A4:
- Raise levels (toxicity): grapefruit and grapefruit juice, azole antifungals, macrolide antibiotics (clarithromycin), diltiazem, verapamil
- Lower levels (rejection): St. John's wort, rifampin, some antiseizure drugs
- NSAIDs add to kidney toxicity
Infection prophylaxis — trimethoprim-sulfamethoxazole (Pneumocystis), valganciclovir for cytomegalovirus (marrow suppression; teratogenic and a hazardous drug — do not crush or split tablets; wear gloves), antifungals as indicated. Vaccines are completed before transplant when possible; live vaccines are avoided afterward; inactivated vaccines such as yearly influenza are recommended.
Long-term risks: infection, skin cancer and post-transplant lymphoproliferative disorder, cardiovascular disease, diabetes, chronic kidney disease, bone loss.
Surgery-specific care
- Kidney: the graft is placed in the iliac fossa. Monitor hourly urine output and replace fluid as ordered (a living-donor kidney often produces large volumes at once; a deceased-donor kidney may have delayed function and need temporary dialysis). Sudden drop in urine output → check the catheter for clots or kinks, then report at once (possible thrombosis, obstruction, or rejection)
- Heart: bleeding and cardiac tamponade (hypotension, rising central venous pressure, muffled heart sounds, sudden drop in chest tube drainage), right ventricular failure, dysrhythmias
- Liver: bleeding and coagulopathy, hepatic artery thrombosis (rising enzymes), bile leak. If a biliary T-tube is present: keep the bag below the insertion site, record volume and color (normally golden to greenish-brown), keep the skin clean and dry, and report sudden changes in amount or appearance; only the provider removes it
Organ donation
- Brain death is determined by qualified clinicians using a standardized protocol (2023 AAN/AAP/CNS/SCCM guideline). Prerequisites: a known irreversible cause, core temperature at least 36 °C (96.8 °F), adequate blood pressure, and no sedating drugs or metabolic confounders. Adults need one full examination; children need two. The apnea test requires PaCO₂ of at least 60 mmHg and at least 20 mmHg above baseline with no breathing effort. Ancillary tests are used only when the examination or apnea test cannot be completed. The client is legally dead; ventilation and circulation are maintained only to preserve organs
- Hospitals must refer imminent and actual deaths promptly to the organ procurement organization; the donation request is made by trained requesters, separate from the news of death
- Donor care maintains blood pressure, oxygenation, temperature, and fluid balance (diabetes insipidus is common — polyuria treated with fluids and desmopressin)
- Living donors must donate voluntarily, may withdraw at any time, and receive an independent evaluation. Teach surgical risks, long-term risks (a small increase in kidney failure and hypertension risk), recovery time, pain management, and the need for lifelong follow-up
Kidney transplant listing (US): candidates can be registered at any level of kidney function, but waiting time starts at dialysis or when eGFR is 20 mL/min or less — dialysis is not a prerequisite, and preemptive transplant has the best outcomes.
Listed in priority order.
- Airway, breathing, circulation — early postoperative monitoring for bleeding, hypovolemia, tamponade (heart), and respiratory compromise (lung, heart)
- Graft function — hourly urine output and daily weight (kidney); liver enzymes and coagulation (liver); rhythm and hemodynamics (heart); SpO₂ and spirometry (lung)
- Infection prevention — strict hand hygiene; aseptic care of lines, drains, and wounds; screen visitors for illness; report even a low-grade fever
- Medication safety — give immunosuppressants on time; time trough draws before the dose; review every new drug for interactions; monitor glucose, potassium, magnesium, and blood pressure
- Detect rejection early — compare trends, not single values; report rising creatinine or liver enzymes
- Psychosocial support — fear of rejection, body image, guilt toward donors, financial strain; include family in teaching
- Take immunosuppressants exactly as prescribed, at the same times every day — never skip, stop, or change the dose, even when feeling well; missed doses are a leading cause of rejection and graft loss
- On lab days, delay the morning dose until after the trough blood draw
- Avoid grapefruit and St. John's wort; ask before taking any new prescription, over-the-counter, or herbal product
- Fever of 38.0 °C (100.4 °F) or higher, cough, or other infection signs: contact the transplant team and come in for evaluation promptly — do not treat at home and wait
- Know rejection signs: decreased urine, weight gain, swelling, graft tenderness, jaundice, shortness of breath, fatigue
- Infection prevention: hand hygiene, avoid sick contacts and crowds early after transplant, safe food handling, avoid cleaning litter boxes or bird cages
- No live vaccines; household members should be vaccinated
- Sun protection and yearly skin checks; routine cancer screening; dental care
- Mycophenolate: effective contraception; plan pregnancy with the team
- Heart recipients: longer warm-up and cool-down with exercise
| Complication | Red flags |
|---|
| Acute rejection | Rising creatinine or liver enzymes, falling urine output, fever, graft tenderness, dyspnea |
| Serious infection | Fever (may be low-grade), cough, diarrhea, confusion |
| Bleeding / tamponade | Hypotension, tachycardia, muffled heart sounds, sudden drop in chest tube output |
| Graft vessel thrombosis | Sudden anuria (kidney); sharp rise in liver enzymes (liver) |
| Calcineurin inhibitor toxicity | Tremor, headache, seizures, rising creatinine, hyperkalemia |
| Post-transplant diabetes | Rising glucose, polyuria |
| Malignancy | New skin lesions, lymph node enlargement |
| Graft-versus-host disease (stem cell transplant) | Rash, diarrhea, jaundice |
- Purpose of immunosuppressants: prevent rejection — the trade-off is infection and cancer risk
- Hyperacute (minutes–hours, preformed antibodies, prevented by crossmatch); acute (days–months, treatable); chronic (months–years, irreversible)
- Kidney rejection: rising creatinine, falling urine output, weight gain, fever, graft tenderness
- Liver rejection: rising liver enzymes and bilirubin first
- Immunosuppressed client with fever or cough → prompt in-person evaluation
- Never skip or stop immunosuppressants; trough drawn before the dose
- Tacrolimus → nephrotoxicity, tremor, hyperglycemia, hyperkalemia; cyclosporine → gum overgrowth, hypertension
- Grapefruit raises tacrolimus and cyclosporine levels; St. John's wort lowers them
- No live vaccines after transplant
- Early post–heart transplant: watch for cardiac tamponade; denervated heart does not respond to atropine
- Brain death is legal death; the donation request is made by trained requesters
Country Notes
United States
- Organ allocation is managed through the national Organ Procurement and Transplantation Network; hospitals must notify their organ procurement organization of imminent and actual deaths.
- Kidney waiting time begins at the start of dialysis or at eGFR 20 mL/min or less.
Philippines
- The Organ Donation Act of 1991 (Republic Act 7170) allows any person aged 18 or older and of sound mind to donate all or part of the body after death, and requires hospitals to train staff for organ donation programs.
- The National Kidney and Transplant Institute is the main national referral center for kidney transplantation. PhilHealth has a Z Benefit package for kidney transplantation and, since 2025, a separate Z Benefit for post-kidney transplantation services (immunosuppressants, drug-level monitoring, laboratory tests, graft biopsy, and living-donor follow-up) at accredited facilities.