Transplant

Pathophysiology

Organ transplant is the primary treatment for

end stage organ failure

first successful transplant was 1954, and the organ was a

kidney

about __% of US adults are listed donors

54

Tissue and organs that can be donated:

•Heart

•Lungs

•Liver

•Pancreas

•Kidneys

•Intestine

•Skin

•Bone/bone marrow

•Heart valves

Eyes and corneas

Homograft

transplant between members of same species

Allograft

cadaveric/living source

Autologous

•same individual (skin graft, bone marrow)

Isograft

•between identical siblings

Most often xenografts are

pigs and cows

Xenograft

•transplant between members of different species

Orthotopic

•Diseased organ is excised, and donor organ is installed in its normal anatomic location

Heterotopic

•Diseased organ left intact, and the donor organ is placed in a parallel arrangement.

Not in normal anatomical location

Regulations Governing Transplant

•National Organ Transplant Act 1984

•2004: Organ Donation and Recovery Improvement Act

•2006: Uniform Anatomical Gift Act

•United Network for Organ Sharing (UNOS)

2006: Uniform Anatomical Gift Act

•increased donations 24%

•Prevents others from overriding donors wishes

2004: Organ Donation and Recovery Improvement Act

•Grant: living donor travel coverage, education to increase donation rates

National Organ Transplant Act 1984

•National Registry: track processes and outcomes

United Network for Organ Sharing (UNOS)

•Established regional Organ Procurement Organizations (OPOs)

•National and regional waiting lists

•Centralized computer database of all potential donors, recipients, their characteristics and match criteria

•Allocation Policy

Allocation Policy

•Prioritizes potential recipients based on objective ranking

•Those who have most imminent need and greatest risk of death get the organ

Medical

•Matched blood type

•Bodyweight 70-120% of ideal BW

•Absent the following diseases:

•Other end-stage organ disease

•Acute sepsis

•HIV

•Malignancy with metastases

•High cardiac risk

•Must have rehab potential!

Contraindications that rule out candidacy:

•Poor medical compliance

•Ongoing ethanol or illicit drug use

•Ongoing/recent tobacco abuse

•Psychological instability

•Absence of financial, familial and community support

Post-Operative Complications

1)  Complications with procurement and surgical procedure

2)  Complications of the transplantation itself

3)  Complications as a result of the immunosuppressive agents used to prevent rejection

complication with procurement/surgical procedure

•Possible transmission of disease from donor to recipient

•Ischemic-reperfusion injury

Possible transmission of disease from donor to recipient examples

CMV, Hepatitis C, herpes zoster

Ischemia

•prior to implantation

Reperfusion

Based on rate of return of blood flow once transplanted

graft rejection

hyperacute: immediate

acute:initial day to months

late/chronic

Immunosuppression goal:

•Stop the immune system from attacking the donor organ, while still allowing other immune functions to take place

common agents in immunosuppression:

Prednisone

Cyclosporine

Azathioprine

Prednisone

•corticosteroid, strong anti-inflammatory properties

•Suppresses cell-mediated immunity

Cyclosporine

lowers T cell activity and response to antigens

Azathioprine

suppresses bone marrow

Long term immunosuppression side effects":

•Diabetes mellitus

•Neurotoxic effects

•Accelerated hyperlipidemia

•Atherosclerosis (cardiac, cerebral, other areas)

•Increased incidence of cancers

•Osteopenia/osteoporosis

post transplant complication: GI issues include

Diverticulitis, GI perforation, malignancy, malabsorption

post transplant complication: Wound Healing

•Immunosuppression:  compromises the inflammatory responseà delay healing

•Higher incidence of wound infection

Post-transplantation Pain Syndromes

link between organ rejection and pain, worsened by depression

PT Implications: Pre-transplant

•Pre-transplant PT is important to ameliorate those declines

•General exercise prescription, tailored to the person’s individual needs

•Address energy conservation, fall risk, ambulation needs

•Patient/Family education

•The stronger and more functional they are going into surgery, the stronger they will be when they come out of surgery

organ dysfunction

cause overall decline in metabolic function, fitness, functional mobility and ADL performance

Many transplanted organs are denervated

lack sympathetic NS connection

•May result in decreased HR response, TV, and insulin production (organ dependent)

•Need longer warm up and cool down period to allow circulation of catecholamines (slower process)

Renal Transplant

most common solid organ transplant

diabetes is the most common cause of

end stage renal disease

Renal transplant has HTN develops in 80% of reciepents

renal transplant prognosis

5 yr survival 92-93%, 10 yr 87%

liver transplant prognosis

70-85% 10 yr survival, >50% 20 yr survival

liver transplant complications

hemorrhage

liver transplant indications

Primary biliary cirrhosis (PBC), acute liver failure, alcoholic cirrhosis with evidence of recovery

Heart transplant are almost all

orthotopic

heart transplant individuals have

higher resting HR, blunted HR response, altered fight or flight.

Heart transplant complicaiton

•Acute rejection: 24% of recipients in 1^st yr

Chronic rejection: immune mediated, 43% of recipients in 8 yrs

heart transplant prognosis

75% 5yr survival, 56% 10 yr survival

Ventricular Assist Device (VAD):

bridge to transplant OR destination therapy

Lung transplant contraindications

other organ damage, HIV, untreatable psych disorder

lung transplant indications

COPD, pulmonary fibrosis, cystic fibrosis, idiopathic pulm HTN

Lung transplant is

most difficult to preserve duing procurement and implication

double lung transplant

most common now, slight survival benefits

Lung Allocation System (LAS)

Estimates risk of death and stratifies priority accordingly

lung transplant complications

•Primary graft dysfunction: up to 25% of all recipients, 50% of which die due to ischemic-reperfusion injury

•Leading cause of death in 1^st yr: infection, followed by graft failure

•Acute rejection: T cell mediated

•Chronic rejection: Bronchiolitis Obliterans Syndrome-fibrosis of small airways

lung transplant prognosis

•5-yr survival rate 47.5%-54%

•Lower for retransplantation

pancreatic transplant indication

DM Type 1

pancreatic transplant is in conjunction with

renal transplant

pancreatic transplant complications

•Graft thrombosis, hemorrhage, failure, ischemia-reperfusion injury

pancreatic transplant prognosis

92% 3yr survival

•What is the most common solid organ transplanted and what is its greatest complication?

kidney, hypertension

What structures are cut to access the heart? 

•Biatrial: suture new heart to old L/R atrial wall-inc arrhythmia risk, no longer common

•**Bicaval: anastomosis of superior and inferior vena cava + L atrium, most common

•Total: bicaval + separate anastomosis of pulmonary veins, less common

•Involve median sternotomy

Results of loss of ANS (denervated) with lung transplant results in

•Loss of cough reflex

•Delayed bronchial dilation during exercise

•Impaired ciliary function

What is its surgical approach of a double lung transplant?

•B anterior thoracotomies (Clamshell incision)

•“Lifting the hood of a car”

True or false: primary graft dysfunction has a high rate of occurrence.

true

•Why would pancreas and renal transplants be performed together?

to combat diabetic issues