Objectives Organ Transplant Pathology

Current challenges in transplantation

donor shortages, use of expanded criteria donor grafts, disparities (⅔ of candidates are from racial and ethnic backgrounds)

Typical transplant process

Referral, Evaluation, Placement on the wait list, Matching for blood type, body size, severity of your condition, geographical location, tissue type, and how long you have been waiting. Then Transplant

Criteria for an organ transplant

End stage disease in a transplantable organ, Failure of conventional therapies, Life expectancy of < 1-3 years, Absence of an untreatable CA, irreversible infection, or disease that would attack the transplanted organ

Types of donors

Cadaveric and living

Living donors

Often for kidney, stem cells, Sometimes liver, lung, pancreas, Genetically or non genetically related

Donor matching

ABO blood typing

Tissue typing

will their tissue be attacked by the recipient’s immune system

Course once you are matched

Living donors and recipients are matched with outpatient testing, Living donors are out of the hospital 1 to 8 days unless there are complications, and they go on their merry way, Recipients depend on how the body reacts to the new organ, usually moved to specialized floors

Renal/Kidney Transplant

Most common organ transplanted

Procedure for kidney transplant

Typically, oblique lower abdomen incision, Native kidney not always removed, instead donor is placed extra peritoneally in the iliac fossa

Indications of post op success for a kidney transplant

Return of urine production and diuresis, Decreased BUN and creatinine, Increased creatinine clearance, Delayed graft function

Pancreas Transplant

May be done alone, or simultaneous with kidney

Procedure of pancreas transplant

Usually, cadaveric, Pancreas + small part of the duodenum, Placed intraperitoneally (R iliac fossa)

Pancreas only transplant

small lower abdomen incision

Kidney and pancreas transplant

larger midline incision

Indications of post op success for pancreas transplant

Glucose levels generally norm 2 3 days after, Wean from insulin 7 to 10 days, Amylase used to monitor rejection

Liver Transplant

2nd most common

Main types of liver transplant

Cadaveric (orthotopic and split), living adult liver donor

Orthotopic transplant

normal anatomic position

Split transplant

smaller L lobe for a child and larger R lobe for an adult

Living adult liver donor

single lobe to recipient bc of regeneration

Liver transplant Procedure

Large “+” incision on the abdomen, Bile bag “T tube” showing thick dark green = good function

Indications of post op success for liver transplant

Bile production, Clotting times, Albumin and glucose levels, Renal labs also paint a good picture

Cardiac Transplant Indication

Irreversible end end-stage cardiac disease, No other options, Poor prognosis

Pre cardiac care involves

Usually, hospitalized and have bridge devices like LVAD, VAD, etc.May be asked to do “prehab” to help condition and QOL while waiting

Cardiac Transplant Procedure

mostly orthotopic, heterotopic

Orthotopic procedure

median sternotomy with removal of native heart

Heterotopic procedure

rare and you retain the failing heart for any residual function

Indications of post op success for cardiac transplant

Pressures return, CO, ejection fraction, and O2 return, Other tests like ECG, biopsy, May take days to achieve stable intrinsic rhythm

Post Cardiac Typical Course

Promotion of mediastinum drainage, Pacing wires removed after 1 week if stable, Increased risk of post op bleeding

Mediastinum drainage

Head of bed elevated to 30°, turning every 1-2 hours, “dangle” at end of the bed, progressive mobility, chest tubes

Post Op Complications Surgical

vascular compromise

Post Op Complications Medical

fluid/electrolyte imbalances

Post Op Complications Rejection

while normal, remains one of the leading problems post transplant, Requires the use of long-term immunosuppressants

Induction

high dose medications to prevent acute rejection within the first 30 days

Anti rejection

given for a specific acute rejection episode

Common side effects of immunosuppressants

HTN, Bone marrow suppression, Decreased bone density, Risk of metabolic syndrome, Muscle loss and weakness

Types of rejection for transplants

hyperacute, acute, chronic

Hyperacute rejection is

rare, first 48 hours, generally requires removal and re transplantation

Acute rejection

common, first 3 to 12 months, treatable and reversible

Chronic rejection

gradual deterioration over time, will eventually require re transplantation

S/S of rejection transplant

Variable based on organ, Chronic rejection you will typically see a more gradual rise in lab values compared to acute rejection

Prophylaxis

antivirals, antibiotics, and antifungals

Active Infections

decrease immunosuppressants and give meds targeting the pathogen

S/S of infection

fever, fatigue, shaking, chills, body aches, etc.

PT implication for Mobilization

Once medically stable, PT will be able to mobilize the patient

PT implication for Rejection

Monitor for S/S, watch lab values

PT implication for Infection

Monitor for S/S, Handwashing, DO NOT TREAT if you are ill, Clean all equipment, Wear a mask if the site or patient requires

Pre cardiac Care is

Advanced training required to work with those who have “bridge” devices, Precautions depend on device and placement

PT implications for Post op Cardiac Care

Initial target HR of 90

What is the Target RPE for post op cardiac care

11 to 13 based on tolerance (fairly light to somewhat hard)