ORGAN AND BMT

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CHAPTER 21

CHAPTER 21Organ and Bone Marrow Transplantation

ComplicationsComplications associated with organ transplantation generally consist of :

technical problems involving the surgical procedure problems related to immunosuppression special problems specic to the organ transplanted

ImmunosuppressionExcessive immunosuppression increases the risk for infection and must be avoided.signs :Infectionsdelayed healingHypertensionDiabetes Addisons disease-type reactions cushingoid features (e.g., edema, ascites, buffalo hump, moonfacies) increased susceptibility to infectionWeaknessfatigue

RejectionRejection --- signs and symptoms of organ failure. Organ biopsy is used to conrm the rejection reaction (Figure 21-9). evidence of acute rejection ----- increase dosage of the immunosuppressive agents.Chronic rejection occurs insidiously and is progressive.It cannot be reversed with intensied therapy.Chronic rejection ---- organ failure. Classic evidence of chronic rejection is found by biopsy.

Drug Side EffectsA major side effect of azathioprine is bone marrow suppression with resulting leukopenia, thrombocytopenia, and anemia. These changes greater risk for infection and excessive bleeding. Cyclosporine has replaced azathioprine.Cyclosporine side effects : severe kidney and liver changes hypertension- bleeding anemia potentiate renal injury caused by other agents. gingival hyperplasia hirsutismGynecomastiacancers of the skin and cervix

Antithymocyte globulin (ATG) and ALG both act as lymphocyte-selective immunosuppressants.side effects : feverHemolysisLeukopeniaThrombocytopeniatumor developmentincreased risk for infection

Prednisone side effects :hypertensiondiabetes mellitusOsteoporosisimpaired healingmental depressionPsychosesincreased risk for infection adrenal gland suppression.

cancersImmunosuppressed patients exhibit an increased incidence of certain cancers.6% various forms of cancer.Cancers commonly seen in the general population (carcinomas of lung, breast, prostate, and colon) show no change in occurrence in immunosuppressed patients.two types of cancer found commonly increased frequency :squamous cell carcinoma of the skincarcinomas of the uterine cervix

Cancers that are uncommon in the general population but that occur with increased frequency in immunosuppressed patients are Lymphomaslip carcinomasKaposi sarcomacarcinomas of the kidney carcinomas of the vulva and perineum

Special Organ Complications involve: heart bone marrowGVHD is an important and often lethal complication of allogenic BMT Acute GVHD : rst 3 months after transplantation mucosal, skin, liver, gastrointestinal tract involvementIntraorally there are nonspecic mucosal ulcers and palatal mucoceles. (Figures 21-10 to 21-12).

Chronic GVHD :occurs later (often after day 100) characterized by skin changes similar to those in scleroderma, sicca syndrome, malabsorption, and features of autoimmunity.

DENTAL MANAGEMENT Pretransplant Medical Considerations :

Posttransplantation Medical Considerations:

(1) immediate posttransplantation period:rst 3 months afterimmunosuppressive therapy(2) stable posttransplantation period (3) chronic rejection period.

(2) stable posttransplantation period

TREATMENT PLANNING CONSIDERATIONSPre transplantation Patients

Post transplant Patients

Immediate Post transplantation Period.Stable Post transplantation Period .Risk of Infection.Viral Infections.Excessive Bleeding.Adverse Reaction to Stress.Hypertension.Chronic Rejection Period.

Oral Complications and ManifestationsOral ndings that may indicate over immunosuppression include :Mucositisherpes simplex infectionsherpes zosterCMV infectionCandidiasislarge and slow-to- heal aphthous ulcers and other ulcerationsunusual alveolar bone loss on occasionLymphomaKaposi sarcomasquamous cell carcinoma of the liphairy leukoplakia.