surgery- solid organ transplants

MCC of ESRD in adults

diabetes

indications for kidney transplant in ESKD

GFR

indications for early evaluation for kidney transplantation

-all CKD stage 4-5

-GFR

kidney transplantation absolute contraindications

-active malignancy

-severe cardio/renal/pulm/hepatic disease

-progressive neurodegenerative disorder

-infection

-demonstrated nonadherance

types of pancreas transplants

-simultaneous pancreas-kidney transplant (SPK)

-pancreas after kidney transplant (PAK)

-pancreas transplant alone (PTA)

indications for simultaneous pancreas-kidney transplant (SPK)

-type 1 DM and ESRD

-better outcome than kidney transplant alone

indications for pancreas after kidney transplant (PAK)

type 1 DM with prior kidney transplant

indications for pancreas transplant alone (PTA)

type 1 DM with preserved renal function

indications for liver transplant

-acute liver failure(fulminant hepatic failure)

-decompensated cirrhosis

-unresectable hepatocellular carcinoma (HCC)

causes of acute liver failure(fulminant hepatic failure)

acetaminophen toxicity, acute viral hepatitis

criteria used for transplant in acute liver failure

either king's college or MELD

additional s/s seen in someone with decompensated cirrhosis being considered for transplant

-refractory ascites

-hepatic encephaopathy

-variceal bleeding

-coagulopathy

-hypoalbuminemia

indications for transplant in HCC

no vascular invasion or metastasis

MELD score to be considered for transplantation

>15

child-pugh score to be considered for transplantation

>9

a patients MELD score is reevaluated every______ days

7-30

primary indication for heart transplant

advance stage D heart failure refractory to traditional therapies

other indications for heart transplant

-end-stage HF from cardiomyopathy, congenital heart disease

-NYHA class 3-4 sx

-refractory angina

-failure of LVAD

-refractory arrhythmias

-peak VO2

disease indications for lung transplant

-interstitial lung disease/idiopathic pulmonary fibrosis

-COPD

-cystic fibrosis

-pulmonary arterial hypertension

-sarcoidosos, pneumonitis

general indications for lung transplant

-end stage lung disease with life expectancy

COPD guidelines for transsplant

FEv

CF guidelines for transplant

-FEV

common causes of small bowel organ failure

-short bowel syndrome due to chron's, mesenteric vascular accidents, trauma

-congenital/surgical causes of intestinal failure

indications for small bowel transplant

basically when they can't tolerate TPN anymore

-liver failure due to long term TPN

-loss of central venous access

-recurrent catheter related infx

-severe dehydration

pre transplant radiology tests

-ultrasound to assess blood flow

-MRI for surgical planning

-CXR to detect pulmonary disease

pre transplant lab tests

-ABO/Rh/HLA typing

-viral screening

-autoimmune/cancer markers

-general bloodwork

pre transplant procedures + screenings

-endoscopy/colonoscopy >50y/o

-full cardiac eval

-cancer screenings

-TB testing

-dental exams (identify infection sources)

-social, psych, and nutritional evals

pre transplant vaccinations

make sure theyre up to date on all vaccines

what is human leukocyte antigen (HLA)

cell surface proteins that act as your body's ID markers, helping the immune system tell self from foreign.

how to detect HLA antigen vs HLA allele mismatch

antigen- serology

allele- molecular (DNA) methods

the more HLA _________, the higher risk of rejection and shorter graft survival

mismatches

crossmatch testing

detects antibodies in recipient serum and identifies if any would be directed against the potential donor

flow cytometry crossmatch

detects IgG donor specific antibodies that may not have an active complement

which is more sensitive, crossmatch or flow cytometry

flow cytometry

why would a patient have HLA antibodies already?

-pregnancy

-previous blood transfusions

-previous transplants

**about 30% of waitlisted patients

what HLA status is an absolute contraindication to transplantation

-donor-specific antibodies

-recipient antibodies directed against the donor's HLA antigens.

only ______% of potential donors actually become donors

30-40%

a patient must be declared __________ before donating organs

brain dead

define warm ischemic time

amount of time organ remains at body temp after removal of blood supply

define cold ischemic time

amount of time that an organ is left chilled "on ice" and not recieving blood after removal

organ specific cold ischemic times (heart, lungs, liver, pancreas, intestines, kidney)

heart- 4hr

lungs- 4-6hr

liver- 6-10hr

pancreas- 12-18hr

intestiens- 6-12 hr

-kidneys- up to 24hr

during a kidney transplant, the original kidney is removed (T/F)

False- the OG kidney is left in

the kidney graft is placed inside or outside of the peritoneum?

extraperitoneally in illiac fossa

what type of vein anastomoses is present in kidney transplant

-donor renal vein

-recipient external iliac vein

what type of artery anastomoses is present in kidney transplant

-donor renal artery

-recipient internal/external iliac vein

during a pancreas transplant, the original pancreas is removed (T/F)

false- OG pancreas left in

mc complication of pancreas transplant

hyperinsulinemia

why does hyperglycemia occur after pancreas transplant

reconstruction causes insulin to bypass hepatic first pass metabolism

the donor pancreas is attached to the ____________

small bowel

Immunosuppression is initiated in the ______

OR

Immunosuppression induction therapy goals

-T cell depletion or

-IL-2 receptor blocking

immunosuppresion induction therapy med

antithymocyte globulins (IgG from horses or rabits)

maintenance immunosuppression meds

-tacrolimus

-cyclosporine

-mycophenolate

-azathioprine

-sirolimus

-prednisone taper

transplant ABX? how long are they given?

-valgancyclovir or bactrim

-given for 3-6mo post transplant

the first __________ after transplant are most vulnerable to rejection

3 months

3 types of rejections and their timelines

hyperacute- right away

acute- weeks to months

chronic- years later