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Progressive experience and success in application of blood and marrow transplantation has heightened attention to clinical management of the complications and long-term outcomes of such procedures. More than 20,000 patients yearly undergo transplant therapy and more than 25,000 patients survive beyond 5 years after transplantation. The recognition, prophylaxis, management, and screening for early complications and for late effects following successful transplant have developed by extrapolation of procedures for intensive therapy of hematologic malignancy (e.g., acute leukemia) and by recognition of specific toxicities, immunodeficiencies and problems encountered uniquely by the transplant recipient.1 Similar to other hematology/oncology procedures, most management strategies are supported principally by empirically derived and some experience-supported evidence. Overall, less than one-quarter of transplant decision making is supported by Level 1 evidence. We review the approach to transplant complications through the phases of therapy emphasizing the available evidence, the frequently held consensus opinions, and areas for future study.

Survival after cardiac transplantation continues to improve, and many transplant recipients are able to re-enter the workforce. The 2010 ISHLT report identifies the median survival among heart transplant recipients as 13 years for those patients living beyond the first year of transplant and 10

Orthotopic heart transplantation (OHT) is currently the most effective long-term therapy for patients with end-stage cardiac disease, even as left ventricular devices show markedly improved outcomes. As surgical techniques and immunosuppressive regimens have been refined, short-term mortality caused by sepsis has decreased, while morbidity caused by repeated rejection episodes and vasculopathy has increased, and is often manifested by arrhythmias. These chronic transplant complications require early and aggressive multidisciplinary treatment. Understanding the relationship between arrhythmias and these complications in the acute and chronic stages following OHT is critical in improving patient prognosis, as arrhythmias may be the earliest or sole presentation. Finally, decentralised/denervated hearts represent a unique opportunity to investigate the underlying mechanisms of arrhythmias.

Nuclear medicine provides a great clinical impact in the assessment and follow-up of kidney transplantation. In addition to the direct evaluation of transplant perfusion and function, indirect scintigraphic features may enhance the detection of potential transplant complications. The authors present a renal scintigraphy showing a large parenchymal perfusion compromise based on transplant caliceal reflux.

The incidence of urologic complications is approximately 10% of all renal transplant patients. These complications may have conseqences such as graft loss and even death and the surgical correction is required. The surgical complications can be divided into: A) Urologic B) Vascular C) Lymphatic and D) extrarenal. More than 90% of urological complications are due to urinary fistulae and ureteric obstruction.

From January 1985 to October 1990, 487 adult renal transplantations were performed at our institution. Of 16 ureteral complications noted 15 were initially managed with percutaneous nephrostomy. Of the 8 complications that occurred during the last 2 years 5 resolved on percutaneous nephrostomy and stenting, or stenting with dilation alone. We conclude that percutaneous nephrostomy is indicated as an initial step in the diagnosis and treatment of urological transplant complications, and that it allows for nonoperative resolution of many of these complications.

Based on a preclinical canine model of low-dose TBI (200 cGy) given in combination with postgrafting mycophenolate mofetil (MMF) and cyclosporine (CSP), the feasibility of performing allogeneic hematopoietic stem cell transplants in older or debilitated patients (pts) was established. In this report we provide an update on 56 pts treated for malignancies with the diagnoses of AML (n=12), CML (n=10), CLL (n=10), multiple myeloma (n=9), Hodgkin disease (n=4), NHL (n=3), MDS (n=4), and others (n=4). The follow-up was a median of 332 days (range 100–723). The median age was 56 years (range 31–71). All pts were conditioned with 200 cGy TBI and 6 received, in addition, fludarabine 30 mg/m 2 /day × 3. Short-term (35 or 56 days) MMF/CSP was given after transplant to prevent GVHD and graft rejection, and donor lymphocyte infusions were given in pts with persistent disease and/or mixed chimerism. Overall, transplants were well tolerated. The median number of days of hospitalization in the first 60 days for eligible pts was 0. All pts had initial engraftment with median donor T-cell chimerisms of 60% and 70% on days 28 and 56, respectively. Nonfatal graft rejection occurred in 16% of pts. Grade II–III acute GVHD occurred in 26 of 45 pts with sustained engraftment. Eight pts (14.3%) died of transplant complications between days 54 and 361, and 7 pts (12.5%) died of disease progression between days 38 and 408. Twenty-six pts (46.4%) were in CR, and an additional 9 (14.3%) were in PR at the point of last contact. In summary, successful allografts in pts otherwise ineligible for conventional allografting can be done with minimal regimen-related toxicities. Remissions of the underlying diseases, including molecular remissions, have been seen in almost 50% of pts.

The use of percutaneous endourological techniques is demonstrated in recipients of renal allografts. Transplant complications that previously had required prompt surgical intervention may be approached safely by the judicious use of percutaneous manipulations. While examples of perirenal hematoma, renal abscess, urinary fistula and renal pelvic stone extraction are presented, close patient observation and a low threshold for surgical intervention are recommended to permit the continued, safe evaluation of this approach.

Four of 602 renal and hepatic transplant recipients had porokeratosis of Mibelli develop in the posttransplant period. Porokeratosis is an uncommon, autosomally dominant inherited disorder that presents in adolescence as a proliferation of an abnormal clone of epidermal cells. Clinically, it is characterized by non-healing plaques that develop most commonly on the limbs. Porokeratosis, a premalignant condition, must be added to the list of potential cutaneous complications seen in immunosuppressed organ transplant recipients.