Organ Transplantation
Hemodynamic status is a major factor in determining suitability as a donor. Why?
Rule of 100's: SBP > 100 PO2 > 100 -PEEP of 5 -Lowest FiO2 Temp: 96 - 100° Urine output 50- 100cc/hr
Physiologic Management: Rule of 100's
SBP > 100 PO2 > 100 -PEEP of 5 -Lowest FiO2 Temp: 96 - 100° Urine output 50 - 100cc/hr
Side effects of Cyclosporine
SE: acute & chronic nephrotoxicity, *hypertension*, *dyslipidemia*, *hirsutism*, *GI upset*, *edema*, *gingival hyperplasia* Taken for life
Kidney-Pancreas Transplant
Same type of criteria for kidney transplant Will test Hemoglobin A1C prior and after If kidney working and blood sugars decreased then pancreas should be working Very good success rate
Lung Allocation Scoring
Score is between 0-100 for 12 or older (0 is worse, higher the score the more they would benefit from transplant) Children under 12 go by time on waiting list to determine priority Cold Time: 4 - 6 hours
HLA testing
Siblings 1 and 3 are more close in HLA antigens Identical twins have same antigens More close in antigens --> better chance for accepting organ
Inborn errors of Metabolism for liver transplants
-Wilson's disease -Maple Syrup -Hemochromatosis -Alpha-1-antitrypsin deficiency
One organ donor can save
1 organ donor can save 8 lives and 1 organ and tissue donor can save and heal up to 50 lives
Brain Death: Three factors must be known
1. Determine cause of unresponsiveness: -Make sure it is not reversible 2. Absence of metabolic central nervous system depression - must fix first -Hypotensive (SBP < 90) -Hypothermic (< 90*F) -Severe acid-base imbalance 3. Absence of toxic CNS depression -Sedatives -Alcohol -Neuromuscular blockades
Anatomy Overview for liver
2 lobes, each with own vasculature & biliary systems, working together as 1 unit
*Cold Time*
4-6 hours Needs to be transplanted within this time
1A
< 7 days to live, vent, cont. inotrope, intra-aortic balloon pump (IABP), a ventricular assist device (VAD)
Paired Kidney Transplant
A kidney paired exchange consists of two or more donor/recipient pairs who are not compatible with each other They provide a way for recipients and their incompatible donor to be paired with another incompatible recipient and donor.
Negative dolls eye
A negative response is said to occur if the eyes move in the direction of the head movement.
NYHA class III or IV
Actively waiting for donor 4 is more critical than 3
Donor Evaluation Criteria - How do we know if one can be a donor?
Age criteria (depends on health & organ...typically 65 and younger) Blood typing - ABO compatibility Serological testing for diseases -HIV, Hep B & C, CMV, STD's HLA Antigen matching (kidney/ pancreas) Heart, Lung, Liver and Pancreas & Kidney: -Different tests on each individual organ prior to procurement
Corticosteroids mechanism of action
Anti-inflammatory actions protect transplanted organ & impair sensitivity of T cells to antigen. Titrated down to lowest dose.
Why higher chance of malignancy?
Anti-rejection medications
Specifics of HLA testing
Antigens Mother- 1,2,3,4,5,6 Father- 7,8,9,10,11,12 Sibling 1- 1,2,3,7,8,9 Sibling 2- 4,5,6,10,11,12 Sibling 3- 1,2,4,7,8,12
Most common viral infection
CMV (Cytomegalovirus) Normal immune systems can fight it, but immunosuppressed cannot
Indications for Lung Transplant
COPD Alpha 1 Antityrpsin Deficiency
Heart Transplantation: major conditions
Cardiomyopathy, aneurysms, malformations, ASHD, refractory dysrhythmias/ angina NYHA class III or IV Listed as status 1A, 1B, 2, or 7
Hyperacute Rejection is caused by?
Caused by the presence of preformed reactive antibodies from exposure to antigens -Blood transfusions, pregnancies, previous organ transplants, wrong blood type
Imuran
Causes thrombocytopenia, leukopenia
Cold time for kidneys
Cold Time: < 30 hours
Cold time for liver
Cold time: less than 12 hours
Consider weaning for who?
Consider weaning prednisone for children, brittle diabetics, severe osteoporosis
Indications for Double Lung Transplant
Cystic Fibrosis - bronchietasis
Prograf / Tacrolimus admin
DO NOT administer at the same time with Cyclosporine Best taken on an empty stomach Trough levels monitored frequently until dose stabilized Taken for life
Treatment for acute rejection
Depending on organ and patient condition -High dose IV Solumedrol -OKT3 (a monoclonal antibody) may be started -Antithymocyte globulin (attack T cells) -Plasmapheresis: process that filters the blood and removes harmful antibodies
The Denervated Heart does not respond to or experience
Does not respond to Valsalva or Carotid massage to lower HR Atropine does not work! May not experience angina In future, may have silent MI's r/t arteriosclerotic heart disease (ASHD) from meds
Physiology of the Denervated Heart
Donor Heart: Completely *denervated* at the time of transplant. Donor heart retains it's own sinus node, thus 2 P-waves. Only the *Donor Sinus Node* will conduct through to the ventricles and stimulate synchronized atrioventricular contraction.
What can indicate rejection for heart transplant?
Dysrhythmias Biopsy to be performed to confirm rejection
How to Clinically Determination of Brain Death
EEG (not determinate) Cerebral Blood Flow/ Perfusion Scan -nuclear medicine - measure blood flow in brain Physical exams -by 2 separate non-transplant MD's if donating Clinical Exam: GCS 3
Kidney Transplantation indications
ESRD caused from primarily HTN, DM, Polycystic & glomerulonephritis
Common Signs and Symptoms of Heart Transplant Rejections
Fatigue/weakness - flu-like aches and pains Fever of 100.5F or higher "Just not feeling right" Shortness of breath Tachycardia or dysrhythmia Swelling of the hands or feet Sudden weight gain Hypotension
Common Signs and Symptoms of Renal Transplant Rejection
Fever greater than 100 F/general malaise Pain or tenderness over grafted kidney Sudden weight gain (2-3 lbs in 24hr) Edema Hypertension - occurs in 70% of pts and complicated by medications Elevated serum creatinine and BUN Decreased creatinine clearance
Common Signs and Symptoms for Liver Transplant Rejection
Fever/Flu like symptoms Deterioration of mental/hemodynamic/renal/respiratory function Jaundice Itching Abdominal pain - mostly RUQ and back pain *The difference between rejection & infection is pain in the RUQ* ↑ Liver enzymes - LFT's (AST, ALT, LDH, bilirubin) ↑ PT/PTT and ↓ platelets and fibrinogen ↓ in bile output or change in color of bile if T-tube present Liver less susceptible to acute rejection than kidneys Test for rejection: liver biopsy
Common Signs and Symptoms of Lung Transplant Rejection
Fever/Malaise Dyspnea Nonproductive Cough Decreased Oxygen Saturation Abnormal Pulmonary Function Tests Test for rejection: biopsy via bronchoscopy
Clinical Exam: GCS 3....No reflexes with
Fixed pupils Negative doll's eyes Negative ice water calorics No corneal, no gag, no cough Positive apnea test
Lung Transplantation: when performed
For irreversible end-stage lung disease expected to result in death within 1-2 years
Fungal-yeast infections
Fungal -Yeast infections common - mouth/vaginal area. Treat with Nystatin swish & swallow or powder
Immunosuppression: Calcineurin Inhibitors - Cyclosporine
Generic formulas now available, but not interchangeable. Take same meds consistently Suppresses T cells without affecting B cells Allows immune system to maintain some degree of protection from bacterial infection. Based on blood work and CsA levels, immunosuppressive meds will only be adjusted by the Attending Dr. or Transplant coordinator
Sirolimus (Rapamune) admin
Helpful to those patients with renal insufficiency Patient will be switched to this if Prograf causes Creatinine to ↑ or if patient develops hyperglycemia Also used for post transplant patients that develop graft vasculopathy May be used alone, or in combination with other immunosuppressants
Circulation to liver consists of
Hepatic Artery Portal Vein
Types of Heart Transplant
Heterotopic transplant (Piggyback): patient receives donor organ *In Addition* to his own heart Orthotopic transplant (Most Common): patient receives donor organ *In Place Of* his own heart
HLA Testing
Human leukocyte antigens HLA - can elicit the immune response. Found on Chromosome 6. Come in pairs called haplotypes - help distinguish self from non-self
Sirolimus (Rapamune) side effects
Hyperlipidemia, infection, leukopenia, acne, hypertension and poor wound healing (so typically not administered in the immediate post-op period)
Medication related Transplantation Complications
Hypertension Nephrotoxicity Hepatotoxicity Osteoporosis Diabetes Weight gain Bone Marrow Suppression
Positive apnea test
If PCO2 is greater than 60 w/ no RR & pH < 7.30 = + apnea
What is the law on donors?
If person is 16 yrs. or year old and driver's license indicates donor --> legal binding contract This applies to brain death, not cardiac events
Kidney Transplantation
If successful, costs significantly less than long term dialysis therapy Transplant only one kidney Can be living related or non-living related Dialysis done prior to tx
Hyperacute Rejection
Immediate postoperative period Results in immediate graft failure Rare, but necessitates re-transplantation or life sustaining treatment Results from activation of humoral-mediated rejection (B lymphocytes)
Immunosuppressive Therapy goal is to?
Immunocompromise the patient enough so that they do not reject the transplanted organ, but not so much that they develop infection or neoplasm.
Malignancies
Immunosuppression places a patient at increase risk for malignancy Non-Hodgkin Lymphoma, Kaposis sarcoma, hepatobiliary and renal malignancies, & skin tumors 5% renal tx pts develop malignant disease - 100% higher than general population Higher rates of Gout noted
7
Inactive Not on list
Side effects of corticosteriods
Increased blood sugar, weight gain, bone disorders (soft), moon face, vision changes, etc.
Kidney-Pancreas Transplant indication
Indicated for Type 1 Diabetes Try to do both at same time, but can do isolated organs
*Leading cause of death in 1st year after transplant?*
Infection !!!
Immunosuppression: Antiproliferative Agent - Imuran
Inhibits DNA/RNA synthesis causing suppression of T-cell and some B-cells
Immunosuppression: Sirolimus (Rapamune)
Inhibits T-cell and antibody formation
Kidney-Pancreas Transplant cold time
Less than 12 hours
What electrolytes cause PVCs?
Low potassium and magnesium
Physiologic Management of the Donor: 5 Major Goals
Maintain Hemodynamic Stability Maintain Optimal Oxygenation Maintain Normothermia Maintain Fluid & Electrolyte Balance Prevent Infections
Dysrhythmias in the Transplanted Heart
May be due to prolonged ischemic time or pre-op meds Sinus Bradycardia -Treat with Pacing and/ or Isuprel PVC's -Check electrolytes Atrial dysrhythmias -Can be caused from heart biopsies - done 1 wk post op and periodically to check graft status
M.E.L.D. Scoring System
Model End Stage Liver disease (M.E.L.D.) Based on the probability of death within 3 months Calculates "risk of mortality" using: -Bilirubin -INR -Creatinine -Cancer
Post-op Nursing Considerations
Most recover in ICU Kidneys - med surg floors Hemodynamic Stability -Pressure, Drips, CVP monitoring, hypothermia, bleeding, EKG readings, drains, strict I & O Monitor for signs and symptoms of infection -Meticulous hand washing! (scrub) -Look to remove tubes and drains as soon as possible Monitor for signs & symptoms of rejection Start immunosuppressive meds Start patient and family teaching
Evaluation Process for All Transplants Recipients
Must have End Stage Organ Failure - Short life expectancy 6- 12 mo., severe functional disability Clinical Status - Specific tests related to each organ, blood tests, diagnostics Nutritional Status - if malnourished susceptible to post-op complications Social Services - family support, spiritual Psychological readiness - psych history, response to stress, compliance Financial - insurance, overall costs not covered by insurance
Can a person with HIV donate organs?
NO!
Prograf / Tacrolimus side effects
Nephrotoxicity but less than CSA, hyperkalemia, *hypergylcemia - leading to diabetes*, increases bioavailability of Cellcept
Who obtains consent? Order of consent?
Never the nurse who is caring for the patient A donor team will obtain consent Spouse, parents, siblings
Donor Evaluation Ideal Criteria (cont.)
Next of Kin consent - who obtains it? -What is the law on donors? No active bacterial, viral (HIV, Hep B), or severe fungal infections No active *systemic* cancers Assessment of high risk behaviors (prison, IV drug use, multiple sexual partners) Absence of hyper/ hypotension (dependent upon length & severity) Diabetes may or may not be an issue Corneas less stringent (avascular)
40 y/o male, cirrhosis secondary to Hepatitis C with no tumors Source of infection is from IV drug use Failed Hepatitis C treatment due to severe anemia Upon evaluation for transplant he indicated he used methamphetamine 1 week prior Would you transplant? If so, what would be the some of the criteria he would need to meet?
No Needs to be 6 months- 1 year sober He is not compliant
ABO - same as for transfusion! Universal donor and recipient?
O is universal transplant donor type. AB is the universal transplant recipient
Chronic Rejection
Occurs at various times and progresses for years Result of both humoral and cellular-mediated immune response Chronic inflammation = diffuse scarring & stenosis of the vasculature of the organ Lack of blood supply = ischemia to organ
Acute Rejection
Occurs in the first 3-6 months 40-50% experience Caused by cell-mediated response activated by T lymphocytes Determined by biopsy of the organ
Scoring M.E.L.D
Patient scoring system to list for transplant The higher the score the greater the need for transplant -The range is from 6-40 This is frequently updated by the transplant team *This score is not used for anything else*
While Waiting for Transplant
Patients are seen in clinic every 2-3 months while waiting for transplantation. Patients must be in pulmonary rehab at least 2 weeks prior to listing. Diagnostic testing to be updated every 6 months to maintain an allocation score.
Preventing Infections
Predisposed - Immunosuppressive drugs Lung & blood-borne infections account for 50% of serious incidences - mostly bacterial Skin integrity disrupted - surgery/lines Good hand washing/mask as needed
Indications for Liver Transplant
Primary Biliary Cirrhosis (most common) Other Cirrhosis (non-alcoholic) -Post necrotic, Crytogenic, TPN induced, Laennec's Alcoholic Liver Disease Chronic Active Hepatitis Budd Chiari Syndrome Biliary Atresia Hepatocellular Cancer (from most common to least)
Indications for heart-lung transplants
Pulmonary Hypertension Eisenmengers (long-standing left-to-right cardiac shunt caused by a congenital heart defect)
The Denervated Heart: heart rate
Rapid resting heart rate (100) May have orthostatic hypotension if can't increase HR Warm up prior to exercise to compensate
Immunosuppression: Corticosteroids
Solumedrol initially & Prednisone for life
Clinical Determination of Brain Death
Start with normal temp, no sedatives or paralytics, normal PCO2, pre-oxygenated, SBP >90mmHg CPAP with 100% FiO2 Observe for spontaneous respirations/chest excursion After 5, 8, & 10 minutes, draw ABG and reconnect (dependent on period of apnea) Reconnect sooner if decrease BP or arrhythmias
Immunosuppressive Therapy primary goal
Suppress activity of helper and cytotoxic T cells
Immunosuppression: Prednisone
Suppresses immune response Patient more susceptible to infection Increases appetite Causes stomach irritation, softening of bones, emotional changes, sodium retention, wt. gain, increase blood sugar at high doses
Transplantation Complications
Surgical (bleeding, vascular thrombosis, anastomosis leakage) Graft Rejection -Hyperacute -Acute -Chronic Infection Organ Dysfunction Malignancy
Asystolic or Non-Heart Beating Donor
Surgical recovery of organs after CV death Severe neurological injury -does not meet brain death criteria Patient withdrawn from support in OR and organs procured only if dies within 1 hour -Withdrawal occurs in PACU with family Must be in OR minutes after death Organs procured within 1 hour (Golden hour)
The Denervated Heart: SNS and PNS
Sympathetic & Parasympathetic innervation is severed Not able to respond to SNS impulses to increased HR
Immunosuppression: Prograf
Tacrolimus Inhibits interleukin release & attacks T - lymphocytes DOES NOT CAUSE hyperlipidemia, hirsutism, gingival hyperplasia, or increased appetite (^ which cyclosporine does!)
Liver facts
The LARGEST solid organ in the body Only need 10-20% functioning liver tissue to sustain life Regeneration occurs of healthy liver and can transplant small portion of liver
Why would a person who dies from cardiac standstill death be considered an unsuitable organ donor?
The heart tissues might already be dead If golden hour is over --> unsuitable
Brain Death
The initial step in obtaining an organ Often a difficult concept for families Definition: *When respiration & circulation are artificially maintained and there is total and irreversible cessation of all brain function including the brain stem*
Active systemic cancers
Throughout the body and currently treating
*Allograft*
Tissue that is transplanted between members of the same species
What is the purpose of doing an apnea test?
To determine brain death
Heterograft
Transplantation of tissue between two different species Ex. heart valve from pig or cow
Autograft
Transplantation of tissue from one part of a person's body to another
Isograft
Transplantation of tissues between identical twins
Test for kidney transplant rejection
Ultrasound or biopsy
