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