N470: Organ transplant

Tissue that is transplanted between members of the same species

allograft

Transplantation of tissue from one part of a person's body to another; example- skin graft

Autograft

Transplantation of tissue between two different species

Heterograft

Transplantation of tissues between identical twins

Isograft

The initial step in obtain an organ

brain death

brain death definition

- respiration and circulation artificially maintained

- total and irreversible cessation of all brain function including the brain stem

law that makes donating organs legal

Uniform Anatomical Gift Act

Brain death criteria (3)

- Determine cause of unresponsiveness (reversible?)

- Absence of metabolic CNS depression (must fix first):

• Hypotensive (SBP <90), Hypothermic (<90*F), Severe acid-base imbalance

- Absence of toxic CNS depression

• sedatives, alcohol, neuromuscular blockades

Clinical Determination of Brain Death (5)

1) EEG (not determinate)

2) Cerebral Blood Flow/Perfusion Scan: Nuclear Medicine - measure blood flow in brain

3) Physical Exam Done by 2 separate non-tx MD's

4) Clinical Exam: GCS of 3

5) No reflexes

what does a negative dolls eye look like?

when you turn the head, eyes stay fixed (instead of moving in opposite reaction)

reflex results that indicate brain death (5)

1) Fixed pupils

2) Negative dolls eyes

3) Negative ice water calorics

4) No corneal, no gag, no cough

5) Positive apnea test

preparation for an apnea test

1) pt must have normal temp

2) no sedatives/paralytics

3) normal PCO2

4) pre-oxygenated

5) SBP >90

How is an apnea test conducted? (5)

1) preoxygenate patient

2) CPAP w 100% FiO2

3) Observe for spontaneous respirations/chest excursions

4) After 5, 8 & 10 min, draw ABG and reconnect (dependent on period of apnea)

5) Reconnect sooner if decrease in BP or arrhythmias

interpret apnea tests results

If PCo2 is > 60 with no resp. & pH <7.3 = positive apnea

Universal donor

O negative

universal recipient

ABO positive

Donor Evaluation Criteria (11)

1) Age Criteria - dependent on health of donor

2) Blood typing - ABO compatibility

3) Serological Testing for Diseases- HIV, HEP B & C, CMV, STD's

4) HLA antigen matching (kidney/pancreas)

5) Heart, Lung, Liver and Pancreas & Kidney- Different tests on each individual organ prior to procurement

6) No active bacterial, viral (HIV, Hep B) or severe fungal infections

7) No active systemic cancers

8) No high-risk behaviors ( IV drug use, etc.) (clean for 6 mo)

9) Absence of hyper/hypotension (dependent upon length and severity)

10) Diabetes may or may not be an issue

11) Next of Kin consent by donor network

5 major goals for managing a donor

•Maintain Hemodynamic Stability

•Maintain Optimal Oxygenation

•Maintain Normothermia

•Maintain Fluid & Electrolyte Balance

•Prevent Infections

rule of 100's* (4)

1) SBP > 100

2) PO2 > 100

-PEEP of 5

-Lowest FiO2

3) Temp 96 - 100*F

4) Urine output 50 - 100 cc/hr

Asystolic or Non-Heart Beating Donor

Surgical recovery of organs of CV death with Severe neurological injury (not necessarily brain death)

Procurement of a heart from an asystolic donor

- Patient withdrawn from support in OR and organs procured only if dies within 1 hr.

- Must be in OR minutes after death

- Organs procured within 1 hr. (Golden hour)

Evaluation for all transplant recipients (6)*

1) End Stage Organ Failure – Short life expectancy 6 – 12 mo., severe functional disability

2) Clinical Status – Specific tests related to each organ, blood test, diagnostics

3) Nutritional Status – if malnourished susceptible to post–op complications

4) Social Services – family support, spiritual

5) Psychological readiness – psych history, response to stress, compliance

6) Financial – insurance, overall costs not covered by insurance

Consists of 2 or more donor recipient pairs who are not compatible with each other- Recipients and incompatible donor are paired with another incompatible recipient and donor

paired kidney transplant

Why would a person who dies from cardiac standstill death be considered an unsuitable organ donor?

the golden hour has passed

What is the purpose of doing an apnea test?

to test for brain death- should be positive

Hemodynamic status is a major factor in determining suitability as a donor. Why?

ensures perfusion to organs- follow rule of 100s

major conditions for heart transplant

1) Cardiomyopathy

2) aneurysms

3) malformations

4) ASHD

5) refractory dysrhythmias/angina

A functional and therapeutic classification for prescription of physical activity for cardiac patients.

NYHA class for heart transplant

heart transplant cold time

4 - 6 hours (out of body on ice)

receives donor heart in place of own heart

Orthotopic Transplant

Physio of the denervated heart

1. Donor heart: completely denervated at the time of transplant

2. Donor heart retains its own sinus node, thus 2 P-waves

3. Only the Donor Sinus Node will conduct through to the ventricles and stimulates synchronized atrioventricular contraction

The denervated heart (transplant heart) (6)

1) Sympathetic and parasympathetic innervation is severed- not able to respond to SNS impulses to increase in HR

2) Rapid resting heart rate (100)- possible orthostatic hypotension

3) Warm up prior to exercise to compensate

4) Does not respond to Valsalva or carotid massage to decrease HR- Atropine does not work, but Isuprel should

5) May not experience angina

6) Can't feel pain, may have silent MI's r/t ASHD from medications

Common signs and symptoms of heart tx rejection (8)

1) Fatigue/weakness - flu like aches and pain

2) Fever of 100.5 or higher

3) Just not feeling right

4) SOB

5) tachycardia or dysrhythmia

6) Swelling of the hands or feet

7) Sudden weight gain

8) hypotension

Dysrhythmias in the transplant heart

- usually indicates rejection

- may be d/t prolonged ischemic time or pre-op meds

Nursing actions for different types of dysrhythmias in the heart transplant patient

1) sinus brady- treat with pacing and Isuprel

2) PVCs- check electrolytes

3) atrial dysrhythmias- Can be caused from heart biopsies done 1 week post op and periodically to check on transplant

Indications fort a lung transplant (4) (2 each: single lung, double lung, heart-lung)

1) Irreversible end stage lung disease, expected to die in 1- 2 yrs

2) single lung- COPD, Alpha1 Antitrypsin Deficiency

3) double lung- CF, bronchiectasis

4) Heart-lung- Pulmonary Hypertension, Eisenmenger's

Lung allocation score system

- score between 0-100

- higher score=higher need

cold time for lung transplant

4 - 6 hours

Common signs and symptoms of lung tx rejection (5)

1) Fever/Malaise

2) Dyspnea

3) Non-productive cough

4) Decreased oxygen saturation

5) Abnormal pulmonary function tests

what is done for a suspected lung transplant rejection?

biopsy done via bronchoscopy

anatomy of liver

1) 2 lobes- each has own vasculature & biliary systems, works together as 1 unit

2) Circulation to liver consists of Hepatic artery and Portal vein

cold time for liver

<12 hrs

Indications for Liver transplant (6)

1) Primary Biliary Cirrhosis

2) Other Cirrhosis (non-alcoholic)- post necrotic, Cryptogenic, TPN induced, Laennec's

3) Alcoholic Liver Disease

4) Chronic Active Hepatitis

5) Hepatocellular Cancer

6) Biliary Atresia

Liver Transplant MELD scoring (2)

- based on probability of death within 3 months (using bilirubin, INR, creat)

- range 6-40: the higher the score, the greater the need for transplant

Signs & symptoms of liver tx rejection (8)

1) Fever/Flu Like symptoms

2) Deterioration of mental, hemodynamic, renal, & respiratory function

3) Jaundice & Itching

4) Abdominal pain – mostly RUQ and back pain

5) Increase in liver enzymes LFT’s, (AST, ALT, LDH, bilirubin)

8) Increase in PT/PTT and decrease in platelets & fibrinogen

9) Decrease in bile output or change in color if T-tube present

how to test for liver tx rejection

liver biopsy

Indications for kidney transplant (4)

ESRD caused by

1) HTN

2) DM

3) Polycystic

4) Glomerulonephritis

Dialysis needs to be done prior to which transplant?

kidney

kidney cold time

<30 hrs

Signs and Symptoms of kidney tx rejection

1) Fever greater than 100* F/general malaise

2) Pain or tenderness over grafted kidney

3) Sudden weight gain (2-3 lbs in 24 hr)

4) Edema

5) HTN - occurs in 70% of pts and complicated by medications

6) Elevated serum creatinine and BUN

7) Decreased creatinine clearance

How to test for kidney tx rejection

Ultrasound or biopsy

indication for a Kidney Pancreas Transplant

Type 1 Diabetes

Kidney Pancreas Transplant cold time

<24 hrs

What is tested before and after a kidney pancreas transplant?

HGB A1C

Which assessments after a kidney-pancreas transplant indicate that the organs are functional? (3)

- test HGB A1C prior and after

- blood sugars decreased?

- if blood sugar decreased and kidney is working, pancreas should also be working

General transplant complications (6)

1) surgical- bleeding, thrombosis, anastomosis leakage

2) graft rejection- hyperacute, acute, chronic

3) infection

4) organ dysfunction

5) malignancy

6) medication related- HTN, nephrotoxicity, hepatotoxicity, osteoporosis, DM, weight gain, BMS

transplant post-op nursing considerations (5)

1) recover in ICU (except kidneys)

2) Hemodynamic Stability

3) infection precaution- meticulous hand washing, remove tubes/drains asap

4) start immunosuppressive medications

5) start patient and family teaching of meds/care

three types of rejection

Hyperacute

Acute

Chronic

describe hyperacute rejection (4)

1) Immediate post-op period

2) Immediate graft failure

3) Re-transplant or life sustaining treatment

4) Caused by preformed reactive antibodies from exposure to antigen- Blood transfusions, pregnancies, previous organ tx, wrong blood type

describe acute rejection (3)

1) Occurs 1st 3- 6 months

2) Caused by cell mediated response activated by T - Lymphocytes

3) of organ to determine

Describe chronic rejection

1) after 6 months

2) Both humoral and cellular mediated immune response

3) Chronic inflammation = diffuse scarring & stenosis of vasculature of organ

4) Lack of blood supply = ischemia to organ

leading cause of death (in first year) in transplant patients

infection

goal of immunosuppressive therapy

Suppress activity of helper & cytotoxic T cells

Calcineurin inhibitors (3)

- Cyclosporine (CSA)

- Tacrolimus (Fk506/Prograf)

- Sirolimus (Rapamune)

life long triple therapy

1. CSA, Tracrolimus or Rapamune

2.Prednisone

3.Imuran or Cellcept

Additional prophylactic transplant meds

1) Antibiotics- MWF

2) Antivirals- For CMV

3) Antifungals- Valley Fever, aspergillus, & yeast

self care for life (6)

1) Strict medication regimen

2) Routine visits with MD and compliance with testing

3) Close contact with transplant coordinator

4) Support group

5) Strict infection control

6) Not a cure - transplant replaces one disease process for another

Sensitivity tests (2)

- PRA (panel of reactive antibodies)

- CPRA (calculated panel of reactive antibodies)

What does a high PRA (panel of reactive antibodies) number indicate?

high chance of rejection by organ recipient

How can one become sensitized to HLA antigens? (4)

1) pregnancy

2) blood transfusion

3) previous transplant

4) bacterial or viral illness

Common infections in transplant patients (3)

1) lung and blood born infections- bacterial, disrupted skin integrity

2) CMV (most common viral)

3) fungal infections (yeast most common)- Nystatin*

what is the link between transplants and malignancies?

immunosuppression increases risk for malignancy

- NHL, Kaposi sarcoma, renal malignancies

Which calcineurin inhibitor is this?

Suppresses T cells w/o affecting B cells

cyclosporin (CSA)

Which calcineurin inhibitor is this?

Inhibits interleukin release and attacks T lymphocytes; does not cause hyperlipidemia, hirsutism, gingival hyperplasia, or increased appetite

Tacrolimus

Which calcineurin inhibitor is this?

inhibits T cell and antibody formation. Can be used by itself or with CSA or Tacrolimus

Sirolimus

ADEs of cyclosporin (7)

1) nephrotoxicity

2) HTN

3) dyslipidemia

4) hirsutism

5) GI upset

6) edema

7) gingival hyperplasia

ADEs of Tacrolimus (3)*

1) hyperglycemia and diabetes

2) hyperkalemia

3) nephrotoxicity

ADEs of Sirolimus (5)

1) hyperlipidemia

2) infection

3) leukopenia

4) HTN

5) poor wound healing

corticosteroids used for transplant patients (2)

1) solumedrol initially

2) prednisone for life

ADEs of corticosteroid therapy (6)

1) hyperglycemia

2) weight gain

3) bone softening

4) moon face

5) vision changes

6) stomach irritation

MOA of Imuran

inhibits DNA/RNA synthesis causing suppression of T cell and some B cells

ADEs of Imuran (3)

1) thrombocytopenia and leukopenia

2) GI upset

3) BMS

MOA and considerations for Cellcept

- affects T and B cells (monitor WBCs)

- excreted into bile

- avoid doses >1gm BID in renal patients