Goals of Treatment The goals of emergency department (ED) management of acute rejection include identifying that rejection is the most likely diagnosis, hemodynamic stabilization of the child’s condition, and potential initiation of rejection therapy When there is a concern for rejection, transplant recipients should be promptly evaluated in a transplant center where they may have screening labs, immunosuppressive drug levels, and graft-specific imaging studies performed ( Table 125.2 ) Clinical Considerations Clinical Recognition Cardiac Transplantation Cardiac transplant patients may present to the ED with early or fulminant signs and symptoms of rejection Mild, or early, clinical signs and symptoms of rejection are often nonspecific One presentation may include fever, abdominal pain, nausea, and vomiting, mimicking a gastrointestinal infection Another typical, nonspecific presentation may include respiratory symptoms such as tachypnea, pulmonary congestion, and cough In moderate to severe graft rejection, the clinical signs and symptoms mimic heart failure The decisive findings that lead to a rejection diagnosis are tachycardia out of proportion to fever or hydration status and an S3 gallop rhythm Hepatomegaly, ascites, facial and peripheral edema, jugular venous distention, and inability to lie flat may all be seen on examination of a child in moderate to severe rejection These findings are usually sufficient to initiate therapy Liver Transplantation Rejection of the hepatic allograft should be considered in the setting of elevated liver enzymes (ALT, AST, bilirubin, GGT) with or without fever Other subtle symptoms such as increased fatigue, pruritus, jaundice, or low-grade fevers also warrant screening laboratory studies to evaluate for rejection One challenge is that many of these symptoms can also be seen with infectious etiologies Elevation of these liver enzymes should prompt the clinician to ensure that the patient is receiving therapeutic immunosuppression as well as to consider rejection Triage Considerations Triage of transplant patients at risk of rejection requires knowledge of the solid organ involved as well as the risk of impending cardiovascular collapse For cardiac transplant patients, the presence of tachycardia, gallop rhythm, and low blood pressure should be recognized as potential signs of rejection requiring