AUTOPSY OF TRANSPLANT RECIPIENT Barasima.pptx

Discuss the importance of autopies in the particular population that are recipents of organe

1. AUTOPSY OF TRANSPLANT RECIPIENT Dr. BARASIMA TSHILUNGU GUELORD, 2024-04-25683 Resident orthopedic surgery SUPERVISOR: Dr. SSENKUMBA BRIAN

2. OUTLINE INTRODUCTION PREPARATION FOR AUTOPSY OF A TRANSPLANT RECIPIENT GROSS EXAMINATION FINDINGS MICROSCOPIC EXAMINATION AND FINDINGS REFERENCES

3. INTRODUCTION Autopsy Also know as post mortem examination An examination and dissection of a dead body to determine cause of death or the changes produced by disease

4. INTRODUCTION Objectives of Autopsy : To find out cause of death To gain insight into the disease process To determine manner of death To establish the identity of the body To ascertain time passed since death

5. INTRODUCTION

6. INTRODUCTION Organ Allowable Time from Donor to Recipient (hours)

7. INTRODUCTION: WHY AUTOPSY IN TRANSPLANT RECEPIENT

8. PREPARATION FOR AUTOPSY OF A TRANSPLANT RECIPIENT In addition to all natural diseases, transplant recipients have; 1. T ransplantation surgical procedure complications risk 2. Rejection of the transplanted organ 3. Complications of post-transplant immunosuppression

9. An important part of doing a good autopsy is knowing what to pay most attention to. This requires a focused review of medical records before the autopsy A preparation checklist is recommended The more pertinent information an autopsy pathologist has before the autopsy, the easier it is to do a good autopsy PREPARATION FOR AUTOPSY OF A TRANSPLANT RECIPIENT

10. PREPARATION FOR AUTOPSY OF A TRANSPLANT RECIPIENT Review the deceased’s medical records for the following ; Type of transplant Type of disease for which transplant was performed Type of transplant anastomosis Type and level of immunosuppression History of rejection History of infections Contact the deceased’s clinician

11. PREPARATION FOR AUTOPSY OF A TRANSPLANT RECIPIENT The transplant surgeon can provide details regarding; Harvest Transportation Implantation Ischemic time

12. The photograph shows a fistula from the iliac artery to the jejunum at the site of a pancreas transplant. Knowing that the patient had presented with passing bright red blood per rectum allowed a focused dissection which revealed the fistula

13. GROSS EXAMINATION FINDINGS Disease categories that can be grossly visible at autopsy include; Infections Rejection Neoplasm ( esp post-transplant lymphoproliferative disorder) Reperfusion injury Graft versus host disease All other diseases any patient can have

14. GROSS EXAMINATION FINDINGS: Infections Infections Generally same gross pathology as inpatients without transplants Fungal and mycobacterial infections commonly produce nodular lesions most notably in the lungs

15. GROSS EXAMINATION FINDINGS Transplant rejection Hyperacute and acute rejection sufficiently severe to cause gross pathology have become rare Hyperacute rejection usually manifests with vascular thrombus Acute rejection if severe can be manifested by pallor, mottling or hemorrhage Most transplanted organs encountered autopsy have suffered rejection over years (chronic rejection) and generally manifest by scarring

16. GROSS EXAMINATION FINDINGS Post-transplant lymphoproliferative disorder Most common in the transplanted organ, but may also occur in lymph nodes or elsewhere in the body. Can present as a nodule or mass lesion If fully evolved to malignant lymphoma may produce discrete lesions with the color and consistency of fish flesh Can present without being grossly visible

17. GROSS EXAMINATION FINDINGS Reperfusion injury Gross pathology of reperfusion injury (harvest injury, preservation injury) is the same as ischemic reperfusion injury outside transplantation Transplanted organs with sufficient RI to cause primary graft failure may present as follows heart – hemorrhage visible from the reperfusion Lung – will be heavy,consolidated , congested and edematous. The color usually described as ‘beefy red’ and consistency as slippery Liver – softened and congested

18. GROSS EXAMINATION FINDINGS: Graft versus host disease Most common in stem cell transplant patients, but can occur in solid transplant recipients Due to passenger lymphocytes in the transplanted organ Can be acute or chronic, in both the skin is usually the first to be affected Acute GVHD – Starts 3-11 weeks post transplant, maculopaular rash Chronic GVHD – indurated erythematous or violaceous papules or plaques with squamous surface resembling lichen planus. Late chronic GVHD is associated with systemic sclerosis (scleroderma) Sometimes involves the liver( normal appearance or softened and discolored) and GIT (erythema or congestion,erosion or ulceration)

19. MICROSCOPIC EXAMINATION AND FINDINGS Several categories of diseases already discussed can be visible in microscopic sections from autopsies of transplant recipients The most unique is transplant rejection, especially cell mediated rejection Cell mediated rejection is characterized by an infiltrate of lymphocytes, and is frequently focused on blood vessels, airways, bile ducts or renal tubules For humoral rejection, immunostaining of C4d is helpful but has low sensitivity and specificity, usually has to be combined with other features of rejection

20. MICROSCOPIC EXAMINATION AND FINDINGS: Microscopic examination for infections Transplant recipients can die of all sorts of infections Immunostains are widely available for some of the common pathogens in transplant recipients including CMV, HSV, VZV, Adenovirus, Toxoplasma and pneumocystis Special stains like gram, grocott and acid fast remain helpful as well for identifying opportunistic infections

21. MICROSCOPIC EXAMINATION AND FINDINGS: Ancillary and adjunctive studies Microbiologic cultures More realiable if done less than 48 hours to avoid postmortem “contaminants” Samples usually taken from blood, a piece of lung tissue and a piece of spleen Nodular lesions in transplant recipients are more likely to be fungal or mycobacterial infections than in non transplant patients

22. References Mcmanus , B.M., Markin , R.S. (1994). The role of autopsy in transplantation. American society of clinical pathologists Cagaanan , A.P., Aesif , S.W. (2018). Pulmonary complications after solid organ transplantation: an autopsy perspective. Transplant proc, 50(10):3783-8 Ionescu, D.N., Hunt, J.L., Lomago , D., Yousem , S.A. (2005). Recurrent sarcoidosis in lung transplant allograft: granulomas are of recipient origin. Diagn mol pathol , 14(3):140-5 Sviland , L., Pearson, A.D.J., Hamilton, P.J. (1994). Diagnosis of acute graft versus host disease using skin and rectal biopsies. American society of clinical pathologists Lanuti , E.L., Keegan, B.R., Wolf, I.H., et al. (2009). Dermatological complications in transplant patients and composite tissue allotransplant pathology. Cambridge university press Caillard , S., Dharnidharka , V., Agodoa , L., Bohen , E., Abbott, K. (2005). Posttransplant lymphoproliferative disorders after renal transplantation in the united states in era of modern immunosuppression. Transplantation, 80 (9):1233-43

23. References Clarke, J. A., Wiemken, T. L., & Korenblat, K. M. (2022). Excess Mortality Among Solid Organ Transplant Recipients in the United States During the COVID-19 Pandemic. Transplantation, 106(12), 2399–2407. https://doi.org/10.1097/TP.0000000000004341 Suzuki, M., Kosugi, I., Terada, T., Shirakawa, K., Suzuki, H., Kono, S., et al. (2011). A case of epstein bar virus associated post transplant lymphoproliferative disorder with CNS involvement: pathological findings at both biopsy and autopsy. Neuropathology, 31(4):440-5 Nickeleit , V. (2009). The pathology of kidney transplant. Transplantation pathology Sun, H.Y., Singh, N. (2008). Emerging importance of infectionsdue to zygomycetes in organ transplant recipients. Int J Antimicrob Agents Ayva , E.S., Ozdemir , BH., Tepeoglu , M., Haberal , M. (2014). Pathological findings of liver allografts evaluated at autopsy. Exp Clin Transplant.