organ transplant

allograft

tissue that is transplanted between members of the same species

autograft

transplantation of tissue from one part of a person's body to another

heterograft

transplantation of tissue between two different species

isograft

transplantation of tissues between identical twins

organ transplant milestones: 1984

national organ transplant act- prohibits selling of organs

established network- fair and equitable allocation of donated organs

organ transplant milestones: 1987

first intestinal treatment, medicare pays for heart tx at approved hospitals

organ transplant milestones: 1999

first secure internet based database system for organ tx

organ transplant milestones: 2003

april is national donate life month

organ transplant milestones: 2014

vascular composite allographs

brain death definition

when respiration and circulation are artificially maintained and there is total and irreversible cessation of all brain function including the brain stem, this is the initial step in obtain an organ and it is a difficult concept for families to understand

brain death criteria

determine cause of unresponsiveness and ensure it is not reversible, absence of metabolic central nervous system depression (must fix first) hypotensive, hypothermic, severe acid-base imbalance, absence of toxic cns depression with sedatives, alcohol, neuromuscular blockades

clinical determination of brain death

EEG not determinate, cerebral blood flow/perfusion scan (nuclear medicine to measure blood flow in brain), physical exam done by two separate MDs, clinical exam GCS of 3, fixed pupils, negative dolls eyes, negative ice water calories, no corneal, gag, or cough reflex, positive apnea test

apnea test

normal temp, no sedatives/paralytics, normal PCO2, pre-oxygenated, SBP >90, CPAP with 100% FiO2, observe for spontaneous respirations/chest excursions, after 5, 8, 10 mins draw ABG and reconnect, reconnect sooner if decrease in BP or arrhythmias, if PCo2 is >60 with no respirations and pH <7.3 it is positive

donor evaluation criteria

age criteria, blood typing ABO compatibility, serological testing for diseases (HIV, HEP B/C, CMV, STDs), HLA antigen matching, different tests on heart, lung, liver, pancreas, and kidney prior to procurement, next of kin consent, no active severe infection, no active systemic cancer, assessment of high risk behaviors, absence of hyper/hypotension, diabetes may or may not be an issue, corneas less stringent

5 major goals of physiologic management of the donor

maintain hemodynamic stability, maintain optimal oxygenation, maintain normothermia, maintain fluid and electrolyte balance, prevent infections

physiologic management rule of 100s

SBP >100, PO2>100, Peep of 5, lowest FiO2, temp 96-100, urine output 50-100cc/hr

asystolic or non-heart beating donor

surgical recovery of organs of CV death, severe neurological injury, patient withdrawn from support in OR and organs procured only if dies within. hour, must be in OR minutes after death, organs procured within 1 hr

evaluation for all transplant recipients

ESOF (short lift expectancy 6-12 mo, severe functional disability), clinical status (specific tests related to each organ, blood test, diagnositcs), nutritonal status (if malnourished susceptible to post op complications), social services (family support and spiritual), psychological readiness (psych history, response to stress, compliance), finance (insurance, overall costs not covered by insurance)

waiting for donation of organs

over 100,000, but only 75000 are active, every 10 mins another name is added to the waiting list, each day 20 people die waiting for an organ, 1 organ can save up 8 lives and eye and tissue donors can heal up to 50,

centers in az performing organ transplant

banner UMC tucson, mayo clinic scottsdale, st josephs hospital phx, az gs banner umc

ways to increase kidney transplants

living related donors and non-living related donors, able to donate 1 kidney, paired kidney transplant consists of two or more donor recipient pairs who are not compatible with each other, recipients and incompatible donor are paired with another incompatible recipient and donor, retransplant of deceased transplant recipients, patient must have died from something non transplant related

heart transplant

major conditions include cardiomyopathy, aneurysms, malformations, ashd, refractory dysrhythmias/angina, NYHA class III IV (marked limitation of activities, mostly stay at rest to complete rest), listed as status 1A (<7 days to live), 1B, 2, or 7, cold time 4-6 hours out of body on ice

orthotopic transplant

receives donor heart in place of own

physiology of the denervated heart

donor heart completely denverated at the time of transplant, donor heart retains its own sinus node, thus 2 p waves, only the donor sinus node will conduct through to the ventricles and stimulates synchronized av contraction

the denervated heart

sympathetic and parasympathetic innervation is severed, it is not able to respond to SNS impulses to increase HR, rapid resting rate is 100, may have orthostatic hypotension if cant increase HR, warm up prior to exercise, does not respond to valsalva or corotid massage to decrease HR, atropine does not work, may not experience angina and can't feel pain, could have silent MIs

common s/sx of heart transplant rejection

fatigue/weakness, flu like aches and pains, fever of 100.5 or higher, just not feeling right, shortness of breath, tachycardia or dysrhythmia, swelling of hands or feet, sudden weight gain, hypotension

dysrhythmias in the transplant heart

usually indicates rejection, biopsy is to be performed, may be due to prolonged ischemic time or pre-op meds, sinus bradycardia (treat with pacing), PVCs (check electrolytes), atrial dysrhythias (can be caused by biopsies)

lung transplant indications

irreversible end stage lung disease, expected to die in 1-2 yrs, single lung for COPD, alpha 1 antitrypsin deficiency, double lung for cystic fibrosis, bronchiectasis, heart lung for pulmonary hypertension and elsenmengers

lung allocation scoring

score is between 0-100 for 12 and older, the higher the score the higher the need, children under 12 go by on time on waiting list, cold time 4-6 hrs, once listed patients are seen every 2-3 months and diagnostic tests need to be updated every 6 months

common s/sx of lung rejection

fever/malaise, dyspnea, non-productive cough, decreased O2 sats, abnormal pulmonary function tests

liver transplant

2 lobes, each has its own vasculature and biliary systems, works together as one unit, circulation to liver consists of hepatic artery and portal vein, the largest solid organ in the body, only need 10-20% to sustain life, regeneration occurs of healthy liver, can transplant small portion of liver

indications for liver transplant

primary biliary cirrhosis, other cirrhosis (post necrotic, cryptogenic, tpn induced, laennecs), alcoholic liver disease, chronic active hepatitis, hepatocellular cancer, biliary atresia

liver transplant scoring

model end stage liver disease scoring used for listing, based on the probability of death within 3 months, calculates risk of mortality using bilirubin, inr, creatinine, cancer, range is 6-40, the higher the score the greater the need for transplant, cold time is less than 12 hrs

s/sx of liver rejection

fever/flu like symptosm, deterioration of mental, hemodynamic, renal, and respiratory function, jaundice and itching, abdominal pain mostly RUQ and back, increase in liver enzyme LFTs, increase in PT/PTT and decrease in platelets and fibringen, decrease in bile output or change in color if t-tube present, liver less susceptible to acute rejection than kidneys, liver biopsy done to test for rejection

kidney transplant indications

esrd caused by HTN, DM, polycystic and glomerulonephritis, if successful cost signficantly less than long term dialysis, transplant only 1 kidney, can be LRD or NLRD, dialysis needs to be done prior, cold time less than 30 hours

s/sx kidney rejection

fever > 100, general malaise, pain or tenderness over grafted kidney, sudden weight gain of 2-3 lbs in 24 hrs, edema, htn, elevated serum creatinine and BUN, decreased creatinine clearance, test for rejection with ultrasound or biopsy

kidney pancreas transplant

indicated for T1DM, do both at same time but can do isolated organs, cold time less than 24 hrs, same type of criteria for kidney transplant, will test for HGB A1C prior and after, if kidney working and blood sugars decreased, than pancreas should be working, very good success rate

transplant complications

surgical (bleeding, vascular trhombosis, anastomosis leakage), graft rejection (hyperacute, acute, chronic), infection, organ dysfunction, malignancy, medication related (HTN, nephrotoxicity, hepatotoxicity, osteoporosis, diabetes, weight gain, bone marrow suppression)

post op nursing considerations

most recover in ICU, kidney can go to med surg floor, hemodynamic stability (pressure, drips, cvp monitoring, hypothermia, bleeding, ekg changes, drains, strict I/O), monitor for s/sx infection (hand washing, look to remove tubes and drains ASAP), start immunosuppressive meds, start patient and family teaching of meds/care

hyperacute rejection

rare, immediate post op period, immediate graft failure, retransplant or life sustaining treatment, caused by preformed reactive antibodies from exposure to antigens i.e. blood transfusions, pregnancies, previous organ transplant, wrong blood type

acute rejection

most common 50%, occurs first 3-6 months, caused by cell mediated response activated by T lymphocytes, biopsy of organ to determine

chronic rejection

after 6 months, both humoral and cellular mediated immune response, chronic inflammation equals diffuse scarring and stenosis of vasculature of organ, lack of blood supply= ischemia to organ

preventing infections

major cause of morbidity and mortality, leading cause of death in first year, immunosuppressed by medications, lung and blood borne infections (mostly bacterial, disruption in skin integrity), CMV most common viral infection (may have come from recipient and reactive disease, may be mild or severe, can cause organ dysfunction), fungal infections (yeast most common in mouth and vagina, treat with nystatin switsh and swallow or powder), good hand washing and masks if needed

malignancies

immunosuppression place a patient at increased risk for malignancy, non hodgkin lymphoma, kaposi sarcoma, hepatobiliary and renal malignancies and skin tumors, 5% of renal transplant pts develop malignant disease, higher rates of gout noted

immunosuppressive therapy

primary goal is to suppress activity of helper and cytotoxic t cells, goal of immunocompromise the patient enough to not reject the transplanted organ but not so much that they develop an infection or neoplasm

calcineurin inhibits (take for life)

cyclosporin (CSA), tacrolimus (Fk506/progaf), sirolimus (rapamune)

cyclosporin (CSA)

suppresses t cells without affecting b cells, side effects of acute and chronic nephrotoxicity, HTN, dyslipidemia, hirsutism, GI upset, edema, gingival hyperplasia

tacrolimus (Fk506/progaf)

inhibits interleukin release and attacks T lymphocytes, does not cause hyperlipidemia, hirsutism, gingival hyperplasia or increased appetite, side effects of nephrotoxicity but less than CSA, hyperkalemia, hyperglycemia

sirolimus (rapamune)

inhibits T cell and antibody, side effects of hyperlipidemia, infection, leukopenia, HTN, poor wound healing, given if do not tolerate the other meds

corticosteroids

solumedrol initially and prednisone for life, antiinflammatory actions protect transplanted organ and impair sensitivity of T cells to antigen, titrated to lowest dose (susceptible to infection), side effects of increase in blood sugar, weight gain (increase appetite), bone disorders, moon face, vision changes, stomach irritation, etc

imuran (azathioprine)

inhibits DNA/RNA synthesis causing suppression of T cell and some B cells, side effects of thrombocytopenia and leukopenia, GI upset, suppress bone marrow

cellcept (mycophenolate mofeti)

affects T and B cells, monitor WBCs, excreted into bile (caution with other drugs that interfere with enterohepatic circulation), renal patients avoid doses >1 gm BID

long life triple therapy

1) CSA, tacrolimus or rapamune

2) prednisone

3) imuran or cellcept

working towards duel therapy to eliminate prednisone, if patient rejects organ despite medications, use stronger anti-rejections medications, patient hospitalized and given IV

additional transplant meds

prophylactic and treatment, antibiotics (MWF), antivirals (CMV), antifungals (valley fever, aspergillus, yeast)

self care for life

strict medication regimen, routine visits with md and compliance with testing, close contact with transplant coordinator, support group, strict infection control, not a cure- transplant replaces one disease for another