Transplant Surgery

complications of immunosuppression

- cardio (HTN, CVD) -infx (opportunistic) - metabolic (HLD, DM, obesity, bone dz) - nephrotoxic -malignancy (cutaneous, de novo, PTLD) - lymphoproliferative -heme -drug interactions -hepatotoxic - neurotoxic PRES***

two weeks post op liver dysfunction

-Acute cellular rejection -Bacterial and fungal infection -Biliary complications -Cytomegalovirus infection

intestinal transplant procedure

-At least 100-150cm needed for adequate absorptive surface -Bowel anastomosed at both ends or one side brought out as ileostomy -Vascular anastomoses via vena cava or portal vein and aorta

lung transplant procedure

-Donor pulmonary veins sewn to recipient atrial cuff AFTER bronchial anastomosis is made

domino procedure

-Heart/lung transplanted into CF patient; CF patient's heart transplanted into other recipient

two month post op dysfunction

-Hypertension -Hyperlipidemia -Diabetes -Obesity -Cardiac disease -Renal dysfunction -Chronic rejection -Fungal infection (Cryptococcus, Aspergillus) -Cytomegalovirus -Post-transplant lymphoproliferative disorder -Malignancy -Recurrence of primary disease

How is a heart transplant performed?

-Left/right atria of donor sewn into left/right atria of recipient -Pulmonary and aortic anastomoses made -Heart resuscitated

two day post op liver dysfunction

-Primary non-function -Early graft dysfunction -Hepatic artery thrombosis -Hepatic and portal vein thrombosis -Preservation injury

indications for heart-lung transplant and 1 yr survival

-Severe pulmonary hypertension -Eisenmenger's syndrome (occurs when the pressure in the pulmonary arteries becomes so high that it causes oxygen-poor (blue) blood to flow from the right to left ventricle and then to the body, causing cyanosis. The high pressure also causes the wall of your heart's right ventricle to thicken (hypertrophy) 1 yr survival = 63%

indications for intestinal transplant

-Short-gut syndrome: due to many causes •Bowel infarction •Bowel strangulation •Bowel obstruction •Volvulus •Hernias •Trauma •vascular accidents -TPN dependent

Benefits of living donor

-less immunosuppression -reduced risk of rejection -minimize wait time - preemptive transplantation -usually no delayedgraft function

less than 9 meld score

1.9% mortality

class c

10-15 points (most severe)

one haplotype living related donor

12-14 years

living unrelated donor half life (MC)

12-15 years

preservation time of lung heart liver kidney pancreas

2-4 hours 4-6 hours 12-18 hours 24-48 hours 12-18

identical LRD half life

24 years

class A child turcotte-pugh

5-6 points (least severe liver disease)

donor to recipient for heart surgery mst be within ___ hours

6

acute rejection

7-10 days activation of T LYMPHOCYTES by the host

class B

7-9 points (moderately severe liver dz)

3 month mortality risk 40 or more meld score

81.3%

half life for deceased donor

9 years

leading cause of death after kidney transplant

CAD

RENAL DYSFUNCT > YEARS

CHR. ALLOGRAFT NEPHROPATHY CI NEPHROTOXICITY HYPERTENSIVE NEPHROSCLEROSIS VIRAL INFECTIONS VOLUME DEPLETION RECURRENT / DE NOVO RENAL DISEASE

RENAL DYSFUNCT 1-12 WKS

CI TOXICITY ACUTE ALLOGRAFT REJECT URINARY OBSTRUCT INFECTION HYPOVOLEMIA RECURRENT DISEASE

MC indication for lung transplant

COPD

BK virus

DNA virus causing severe UTI and kidney disease in immunocompromised patients effects kidneys

absolute CI to live donor (renal)

GFR under 80**** urologic abnormalities dz infx DM substance abuse

mycophenolate

GI intolerance neutropenia

indications for kidney transplant

Glomerular disease Diabetes Mellitus Polycystic kidney Hypertensive nephrosclerosis Congenital diseases neoplasm

Tacrolimus (Prograf)

Immunosuppressant used for heart, liver and kidney transplant

two virus we are concerned with post kidney transplant

JC and BK

how do t cells recognize antigens

MHC(HLA) recognize through t cell receptor on cell surface

how is pancreas and islet cell transplant performed

Pancreas and C-loop of duodenum are brought together to recipient pelvis -C-loop anastomosed to jejunum (usually) -Vascular anastomoses to Iliac artery and vein -simultaneous kidney-pancreas transplant

PRES Syndrome

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological syndrome characterized by a headache, seizures, altered mental status and visual loss and characterized by white matter vasogenic edema affecting the posterior occipital and parietal lobes of the brain predominantly.

complications of heart transplant

•Rejection, infection, respiratory/pulmonary/cerebrovascular issues •Immunosuppression issues (nephropathy) •Skin and lung cancer •Prognosis: •1yr graft-patient survival rate 80% •Median survival 9.3yrs

how do you determine child turcotte pugh class

adding MELD score of each parameter

polyclonal antilymphocyte SE

anaphylaxis fever leukopenia thrombocytopenia lymphoproliferative disorders cytokine 20 release syndrome

Azathioprine SE

bone marroe suppression veno occlussive hepatic dz arthralgias pancreatitis red cell aplasia

chronic rejection

cellular and humoral (T and B) anti donor antibodies develop after transplantation takes years

corticosteroid SE

cushings dyspepsia HTN osteonecrosis DM

double lung or single have higher success rate?

double 77% survival at 1 year and 25% at 10 years

two causes of PRES

drugs and HTN

corticosteroids azathiprine cyclosporine tacrolimus mycophenolate mofetil sirolimus OKT3 polyclonal antilymphocyte Daclizumab, Basilixumab

drugs for immunosuppression

clinical and lab criteria for MELD score

encephalopathy ascites bilirubin albumin prothrombin time (seconds or internalized normalized ratio)

OKT3 SE

fever chills pulm edema lymphoproliferative disorders

_______ ________ is not equal in living donors

functional longevity

inflammation is what kind of response

innate

Daclizumab, basiliximab SE

minimal

tacrolimus SE

nephrotixicity glucose intolerance neurotoxic

cyclosporine SE

nephrotoxicity HTN hyperkalemia hepatotoxicity hirsutism gingival hyperplasia tremors

sirolimus

neutropenia dyslipidemia impaired wound healing

Heterotopic graft

placement of organ in different site than normal (kidney)

Orthotopic graft

placement of organ in normal anatomical position (heart)

type of incision for single lung transplant

posterolateral thoracotomy incision

JC virus

progressive multifocal leukoencephalopathy (PML) effects brain

hyperacute rejection

recipient has preexisting ANTIBODIES AGAINST THE GRAFT immediate reaction

rejection is organized by what type of cell s

t lymphocytes of the recipient against the MHC molecules of the donor

isograft

transplant between identical twins

xenograft

transplantation (dermis only) from a foreign donor (usually a pig) and transferred to a human; also called heterograft

allograft

transplantation of healthy tissue from one person to another person; also called homograft

autograft

transplantation of healthy tissue from one site to another site in the same individual

type of incision for double

transverse thoractomy incision

indication for pancreas and islet cell transplant

type 1 diabetes -Insulin independence-> normoglycemia -Improves peripheral neuropathy -Improvement of retinopathy

MELD score

used to prioritize pts on liver transplant list - 3 month mortality scoring system higher number = increased chance of mortality

what parts of the liver are donated in a complete transplant

vena cava, bile duct, hepatic artery, liver, portal vein they are attached to recipients hepatic artery

indications for liver transplant

•ALF OR ESLD W/ IRREVERSIBLE DECOMPENSATION •NAFLD •ENCEPHALOPATHY )Grades 2 or3) •COAGULOPATHY •HEPATORENAL SYNDROME •GASTROINTESTINAL BLEEDING •DRUGS/TOXINS (Acetaminophen, etc.) •VIRAL INFECTIONS (HCV) •GENETIC DISORDERS /HEPATIC INVOLVEMENT •UNRESECTABLE HEPATOCELLULAR CARCINOMA SINGLE LESION < 5 CM IN DIAMETER NO MORE THAN 3 LESIONS, ALL < 3 CM IN DIAMETER NO VASCULAR INVASION, NO EXTRAHEPATIC METS