Transplants / organ donation

29. Hyperacute transplant rejection

29. *Humoral immunity* /*antibody-mediated immune system* 1. a rejection that usually develops immediately after the implantation of a vascular graft; may be caused by preformed, cytotoxic antibodies to the graft; 2. a form of antibody-mediated, usually irreversible damage to a transplanted organ, particularly the kidney, manifested predominantly by diffuse thrombotic lesions, usually confined to the organ itself and only rarely disseminated

18. The most common cause of secondary immunodeficiency disorders is:

18. drug induced immunosuppression with antineoplastic agents and corticosteroids.

20. A transplant rejection which most commonly occurs with kidney transplant.

20. Hyperacute

21.Organ must be removed when "this" transplant rejection occurs.

21. Hyperacute

22. A transplant rejection which Infiltration of the organ with B and T lymphocytes occur.

22. Chronic

23. Treatment is supportive with this transplant rejection.

23. Chronic

24. In this type of transplant rejection the recipient's T-cytotoxic lymphocytes attack the foreign organ.

24. Acute

25. A transplant rejection which usually reversible with additional or increased immunosuppressant therapy.

25. Acute

26. A transplant rejection which occurs when recipient has antibodies against donor's histocompatibility Leukocyte antigens (HLA's)

26. Hyperacute

27. Transplant rejection which requires long-term use of immunosuppressant necessary to combat the rejection

27. Acute

28. Irreversible, transplant rejection, immune-mediated injury to transplanted organ

28. Chronic

30. Acute transplant rejection

30. Developing with formation of *cellular immunity*, acute rejection occurs to some degree in all transplants, except between identical twins, unless immunosuppression is achieved (usually through drugs). Acute rejection begins as early as one week after transplant, the risk being highest in the first three months, though it can occur months to years later. Highly vascular tissues such as kidney or liver often host the earliest signs—particularly at endothelial cells lining blood vessels—though it eventually occurs in roughly 10 to 30% of liver transplants, and 50 to 60% of kidney transplants. A single episode of acute rejection can be recognized and promptly treated, usually preventing organ failure, but recurrent episodes lead to chronic rejection. It is believed that the process of acute rejection is mediated by the cell mediated pathway, specifically by mononuclear macrophages and T-lymphocytes.

31. Chronic transplant rejection

31. Chronic rejection explains *long-term morbidity* in most lung-transplant recipients, the median survival roughly 4.7 years, about half the span versus other major organ transplants. In histopathology the condition is bronchiolitis obliterans, which clinically presents as progressive airflow obstruction, often involving dyspnea and coughing, and the patient eventually succumbs to pulmonary insufficiency or secondary acute infection.

12. The decision to donate one's organs or tissues can be made by person __________ death or by a person's ____________after death.

before death, a person's family after death

14. A patient with cirrhosis asks the nurse about the possibility of a liver transplant. The best response by the nurse is: a. "liver transplants are only indicated in children with irreversible liver disease" b. "If you are interested in a transplant, you really should talk to your doctor about it. " c. "rejection is such a problem in liver transplants that it is seldom attempted in patients with cirrhosis. " d. "Cirrhosis is an indication for transplantation in some cases. Have you talked to your doctor about this? "

d. "Cirrhosis is an indication for transplantation in some cases. Have you talked to your doctor about this? " Liver transplantation is indicated for patients with cirrhosis as well as for many adults and children with other irreversible liver diseases. Although health care providers make the decisions regarding the patient's qualifications for transplant, nurses should be knowledgeable about the indications for transplantation and be able to discuss the patient's questions and concerns related to transplantation. Rejection is less of a problem in liver transplants than in kidney or heart transplantation.

10. Which of the following accurately describes rejection following transplantation? a. Hyperacute rejection can be treated with OKT3 b.Acute rejection can be treated with *sirolimus* or tacrolimus. c.Chronic rejection can be treated with tacrolimus or cyclosporine. d. Hyper-acute reaction can usually be avoided is crossmatching is done before the transplantation.

d. Hyper-acute reaction can usually be avoided is crossmatching is done before the transplantation. Correct answer: d Rationale: A positive crossmatch indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation. If transplanted, the organ would undergo hyperacute rejection.

13. Patients with a heart transplantation are at rick for which of the following complication in the first year after transplantation? (select all that apply) a. Cancer b. Infection c. Rejection d. Vasculopathy e. Sudden Cardiac Death

Correct answers: b, c, e b. Infection c. Rejection e. Sudden Cardiac Death Rationale: A variety of complications can occur after heart transplantation. In the first year after transplantation, the major causes of death are acute rejection and infection. Heart transplant recipients also are at risk for sudden cardiac death. Later, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated coronary artery disease) are major causes of death.

6. A patient is admitted to the hospital with acute rejection of a kidney transplant. The nurse will anticipate a. administration of immunosuppressant medications. b. insertion of an arteriovenous graft for hemodialysis. c. placement of the patient on the transplant waiting list. d. drawing blood for human leukocyte antigen (HLA) and ABO compatibility matching.

a. administration of immunosuppressant medications ANS: A Acute rejection is treated with the administration of additional immunosuppressant drugs such as corticosteroids. Because acute rejection is reversible, there is no indication that the patient will require another transplant, hemodialysis, or HLA/ABO testing. DIF: Cognitive Level: Application REF: 229-230

4. A patient who received a bone marrow transplant for treatment of leukemia develops a skin rash 10 days after the transplant. The nurse recognizes this reaction as an indication that the: a.donor T cells are attacking the patient's skin cells. b. patient's antibodies are rejecting the donor bone marrow. c. patient is experiencing a delayed hypersensitivity reaction. d. patient will need treatment to prevent hyperacute rejection.

a. donor T cells are attacking the patient's skin cells. The patient's history and symptoms indicate that the patient is experiencing graft-versus-host disease, in which the donated T cells attack the patient's tissues. The history and symptoms are not consistent with rejection or delayed hypersensitivity. DIF: Cognitive Level: Comprehension REF: 232

16. The nurse plans long-term goals for the patient who has had a heart transplant with the knowledge that a common cause of death in heart transplant patients during the first year is: a. infection b. heart failure. c. embolization d. malignant conditions

a. infection Because of the need for long-term immunosuppressant therapy to prevent rejection, the patient with a transplant is at high risk for infection, a leading cause of death in transplant patients. Acute rejection episodes may also cause death in patients with transplants, but can be successfully treated with augmented immunosuppressive therapy. Malignancies occur in patients with organ transplants after taking immunosuppressants for a number of years.

11. In a person having an acute rejection of a transplanted kidney, which of the following would help the nurse understand the course of events? (Select all that apply) a. A new transplant should be considered b. Acute rejection can be treated with OKT3 c. Acute rejection usually leads to chronic rejection d. Corticosteroids are the most successful drugs used to treat acute rejection. e. Acute rejection is common after a transplant and can be treated with drug therapy.

b,e B. Acute rejection can be treated with OKT3 E. Acute rejection is common after a transplant and can be treated with drug therapy. Rationale: Acute rejection is treatable and does not usually require a new transplant. Monoclonal antibodies such as Muromonab-CD3 (Orthoclone OKT3) are used for preventing and treating acute rejection episodes. Calcineurin inhibitors are the most effective immunosuppressants available to treat organ rejection. It is not uncommon to have at least one acute rejection episode, especially with organs from deceased donors. These episodes are usually reversible with additional immunosuppressive therapy that may include increased corticosteroid doses or polyclonal or monoclonal antibodies.

8. A 55-year-old with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is appropriate? a. "Since you are diabetic, you would not be a candidate for a heart transplant." b. "The choice of a patient for a heart transplant depends on many different factors." c. "Your heart failure has not reached the stage in which heart transplants are considered." d. "People who have heart transplants are at risk for multiple complications after surgery."

b. "The choice of a patient for a heart transplant depends on many different factors." ANS: B Indications for a heart transplant include end-stage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered. Diabetic patients who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, this response does not address the patient's question. DIF: Cognitive Level: Application REF: 814

17. Currently, histocompatibility leukocyte antigen (HLA) typing can be used to : a. determine paternity and predict risk for certain diseases. b. match tissue types for transplantation and determine paternity. c. establish racial background and predict risk for certain diseases. d. predict risk for certain diseases and match tissue types for transplantation.

b. match tissue types for transplantation and determine paternity. At the current time, HLA typing is used to determine paternity and to match tissue for transplantation. As more knowledge is gain, there is a strong possibility that HLA associations with certain diseases can be specified and an individual's risk for disease identified.

3. After teaching a patient on immunosuppressant therapy after a kidney transplant about the posttransplant drug regimen, the nurse determines that *additional teaching* is needed when the patient says, a. "If I develop an acute rejection episode, I will need to have other types of drugs given IV." b. "I need to be monitored closely because I have a greater chance of developing malignant tumors." c. "After a couple of years, it is likely that I will be able to stop taking the calcineurin inhibitor." d. "The drugs are given in combination because they inhibit different aspects of transplant rejection."

c. "After a couple of years, it is likely that I will be able to stop taking the calcineurin inhibitor." The calcineurin inhibitor will need to be continued for life. The other patient statements are accurate and indicate that no further teaching is necessary about those topics. DIF: Cognitive Level: Application REF: 230-232

2. When the nurse is admitting a patient who has acute rejection of an organ transplant, which of these already admitted patients will be the most appropriate roommate? a. A patient who has viral pneumonia b. A patient with second degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant

c. A patient who is recovering from an anaphylactic reaction to a bee sting ANS: C Treatment for a patient with acute rejection includes administration of additional immunosuppressants, and the patient should not be exposed to increased risk for infection as would occur from patients with viral pneumonia, graft-versus-host disease, and burns. There is no increased exposure to infection from a patient with anaphylaxis. DIF: Cognitive Level: Application REF: 230

7. Which information about patient and donor tissue typing results for a patient who needs a kidney transplant is most important for the nurse to communicate to the health care provider? a. Patient is Rh positive and donor is Rh negative. b. Six antigen matches are present in HLA typing. c. Results of patient-donor cross matching are positive. d. Panel of reactive antibodies (PRA) percentage is low.

c. Results of patient-donor cross matching are positive. ANS: C Positive crossmatching is an absolute contraindication to kidney transplantation, since hyperacute rejection will occur after the transplant. The other information indicates that the tissue match between the patient and potential donor is acceptable. DIF: Cognitive Level: Application REF: 229

9. When assessing a patient who had a liver transplant a week previously, the nurse obtains the following data. Which finding is most important to communicate to the health care provider? a. Dry lips and oral mucous b. Crackles at both lung bases c. Temperature 100.8° F (38.2° C) d. No bowel movement for 4 days

c. Temperature 100.8° F (38.2° C) ANS: C Infection risk is high in the first few months after liver transplant and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions, but do not indicate a need for urgent action. DIF: Cognitive Level: Application REF: 1088

19. A common combination of immunosuppressive agents used to prevent rejection of transplanted organs is: a. cyclosporine, sirolimus, and muromonab-CD3 b. everolimus, mycophenolate mefetil, an sirolimus c. tacrolimus, prednisone, and mycophenolate mofetil d. prednisone, polyclonal antibodies, and cyclosporine

c. tacrolimus, prednisone, and mycophenolate mofetil Standard immunotherapy involves the use of 3 different immunosuppressants that act in different ways: a calcineurin inhibitor (cyelosporin, tacrolimus), a corticosteroid, and the antimetabolite mycophenolate mofetil. Although cyclosporin is still used, tacroliums is the most frequently percribed calcineurin inhibitor.

1. A 21-year-old is dying after an automobile accident. The family members want to donate the patient's organs and ask the nurse how the decision about brain death is made. The nurse explains that the patient will be considered brain dead when a. the patient is flaccid and unresponsive. b. CPR is ineffective in restoring heartbeat. c. the patient is apneic and without brainstem reflexes. d. respiratory efforts cease and no apical pulse is audible.

c. the patient is apneic and without brainstem reflexes. The diagnosis of brain death is based on irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient brain dead. DIF: Cognitive Level: Comprehension REF: 155

5. A patient has a new prescription for *cyclosporine* after having a kidney transplant. Which information in the patient's health history has the most implications for planning patient teaching about the medication at this time? a. The patient restricts salt to treat prehypertension. b. The patient drinks 3 to 4 quarts of fluids every day. c. The patient has many concerns about the effects of cyclosporine. d. The patient has a glass of grapefruit juice every day for breakfast.

d. The patient has a glass of grapefruit juice every day for breakfast. ANS: D Grapefruit juice can increase the cyclosporine to toxic levels. The patient should be taught to avoid grapefruit juice. High fluid intake will not impact cyclosporine levels or renal function. Cyclosporine may cause hypertension, and the patient's many concerns should be addressed, but these are not potentially life-threatening problems. DIF: Cognitive Level: Application REF: 230

15. The evaluation team for cardiac transplantation determines that the patient who would most benefit from a new heart is: a. a 24-year-old man with Down Syndrome who has received excellent care from parents in their 60's b. a 46-year-old single woman with a limited support system who has alcohol-induced cardiomyopathy. c. a 60-year-old man with inoperable coronary artery disease who has not been compliant with lifestyle changes and rehabilitation programs. d. a 52 -year-old woman with end-stage coronary artery disease who has limited financial resources but is emotionally stable and has strong social support.

d. a 52 -year-old woman with end-stage coronary artery disease who has limited financial resources but is emotionally stable and has strong social support. The 52 year old woman does not have any contraindications for cardiac transplantation, even though she lacks the indication of adequate financial resources. The postoperative transplant regimen is complex and rigorous , and patients who have not been compliant with other treatments or who might not have the means to understand the care would NOT be good candidates. A history of drug or alcohol abuse is usually a contraindication to the heart transplantation. (This would add rationale for why "a" is not the answer.)