Altered Immune Response and Transplantation

What are the most common organs transplanted?

Most common are the kidneys, the heart, and the liver.

The nurse is assessing a patient who underwent a transplant 3 weeks ago who reports having multiple diarrheal stools per day and abdominal pain. On examination, the nurse notes icteric sclera. Which other finding would be consistent with graft-versus-host disease (GVHD)? Redness and peeling of the skin Evening temperatures greater than 100.0° F Anemia and thrombocytopenia Decreased level of consciousness

Redness and peeling of the skin GVHD involves the integumentary system and is manifested by a maculopapular rash or formation of bullae with redness and skin peeling.

methylprednisolone

Route: IV Mechanism of action: Suppress inflammatory response; inhibit cytokine production and T-cell activation Side effects: Hyperglycemia, water retention, irritability, osteoporosis, delayed healing, stomach upset, increased appetite

Prednisone

Route: Oral (PO) Mechanism of action: Suppress inflammatory response; inhibit cytokine production and T-cell activation Side Effects: Hyperglycemia, water retention, irritability, osteoporosis, delayed healing, stomach upset, increased appetite

Cyclosporine, tacrolimus

Route: PO and IV Mechanism of action: Act on T-helper cells to prevent production of interleukins and interferon Side effects: Nephrotoxicity, hepatotoxicity, risk for infection, hirsutism, hypertension, gingival hyperplasia

When does acute rejection occur?

Usually takes place within the first 6 months after transplantation.

What does a negative crossmatch indicate?

indicates no antibodies are present and the transplantation can be done.

What does a positive crossmatch indicate?

indicates the recipient has antibodies to the donor's blood and tissue, and if the transplant were to take place, hyperacute rejection would occur.

What all is involved in organ transplantation?

involves major surgery, the use of medications to suppress the immune system (immunosuppressants), and the possibility of transplant rejection and fatal complications.

The nurse is caring for a patient who received an organ transplant 3 days ago. Which nursing assessments and interventions will decrease the risk for infection? Select all that apply. Refrain from allowing any visitors Administer prophylactic antibiotics Auscultate the patient's lung sounds Measure and record intake and output Give immunosuppressant medications

Administer prophylactic antibiotics Prophylactic antibiotic administration helps prevent infection. Auscultate the patient's lung sounds The nurse would auscultate the patient's lung sounds to determine fluid overload and pneumonia. This intervention will help prevent infection.

The nurse is caring for a patient who had a liver transplant 3 months ago. Which nursing intervention can prevent acute rejection in this patient? Select all that apply. Administering the immunosuppressant medications as prescribed Instructing the patient to avoid crowds and sick people Monitoring the patient's blood pressure on a daily basis Assisting the patient to find support groups for resources

Administering the immunosuppressant medications as prescribed

HLA typing

Both the donor and recipient undergo HLA testing. This procedure is important to prevent rejection of the transplanted organ. In HLA typing, six antigens in donor and recipient are tested to determine tissue compatibility, and it is preferable to have at least five or six antigens match to prevent rejection.

The nurse would anticipate a patient being evaluated for cadaveric organ transplantation to undergo which diagnostic tests? Select all that apply. Biopsy Ultrasound examination Crossmatching Human leukocyte antigen (HLA) typing Panel of reactive antibodies (PRA) testing

Crossmatching Human leukocyte antigen (HLA) typing Panel of reactive antibodies (PRA) testing

A patient who underwent organ transplantation 2 months ago is admitted to the hospital with acute rejection. Which order would the nurse anticipate from the health care provider? A decrease in the daily dose of corticosteroids Administration of intravenous antibiotics Increased doses of monoclonal antibodies Surgery to remove the transplanted organ

Increased doses of monoclonal antibodies

The nurse is reviewing the laboratory results for a patient who underwent kidney transplantation. Which finding warrants immediate health care provider notification? Temperature of 98.9° F at bedtime Patient-reported increase in appetite Abdominal incision that is approximated Intake of 2000 mL and output of 800 mL in 24 hours

Intake of 2000 mL and output of 800 mL in 24 hours

Is it (common or uncommon) for each patient to experience one episode of rejection after transplantation?

It is common for each patient to experience one episode of __________ after transplantation.

Just read it..

Mechanism of action of T cytotoxic lymphocyte activation and attack of transplanted tissue. The transplanted organ (e.g., kidney) is recognized as foreign and activates the immune system. T helper cells are activated to produce interleukin-2 (IL-2), and T cytotoxic lymphocytes are sensitized. After the T cytotoxic cells proliferate, they attack the transplanted organ.

A family member of a patient who underwent organ transplantation asks the nurse why so much blood is being drawn for testing. Which statement made by the nurse is most appropriate? "We are checking the transplanted organ for rejection." "It is needed to monitor immunosuppressant drug levels." "The blood work is done to detect antigens for human leukocyte antigen (HLA) typing." "You seem concerned about the amount of blood being drawn."

"It is needed to monitor immunosuppressant drug levels." Many immunosuppressant drugs require serum blood levels to be determined on a regular basis to help prevent toxic levels.

A female transplant recipient asks the nurse to explain why she is receiving a cytotoxic drug even though she does not have cancer. What is the nurse's best response? "I will recheck the health care provider's prescription to determine whether this is a mistake." "The use of chemotherapy medications can play an important role in preventing organ rejection." "Immunosuppressant medications can place you at risk for cancer, and this drug will prevent it." "Have you been diagnosed with cancer in the past? This may be why this medication has been prescribed."

"The use of chemotherapy medications can play an important role in preventing organ rejection."

What will the nurse include in the discharge teaching for a patient who has received a prescription for prednisone after liver transplantation? Select all that apply. "Weigh yourself daily." "Drink 2000 to 3000 mL of water every day." "Take daily calcium supplements." "Do not suddenly stop taking the drug." "Take prednisone on an empty stomach."

"Weigh yourself daily." "Take daily calcium supplements." "Do not suddenly stop taking the drug."

A nurse is caring for a patient who underwent organ transplantation 2 days ago. Which nursing intervention is a priority to prevent rejection? Monitor the incisional site for redness and drainage Administer immunosuppressant medications on time Assign the patient to a private room and limit visitors Obtain vital signs and temperature every 4 hours

Administer immunosuppressant medications on time The nurse should administer the immunosuppressant medications at the regularly scheduled times to prevent rejection.

Tissue transplantation

Examples of successful tissue transplantation and their purposes include: Cornea transplantation is used in prevention or correction of blindness Skin grafts are used in the management of burn injuries Bone marrow transplantation is often used as a treatment of leukemias and other malignancies

Which assessment component will the nurse check when administering a dose of lymphocyte immune globulin to a patient with acute rejection? Heart rate Bowel sounds Blood urine nitrogen (BUN) and creatinine levels Oral cavity and mucosa

Heart rate The nurse will assess the patient's heart rate because tachycardia is a side effect of lymphocyte immune globulin.

The nurse is caring for a patient who underwent kidney transplantation 8 hours ago. Which finding would indicate that the patient is developing hyperacute rejection? Decreased to no urine output Pale and yellow urine Increased white blood cell count Maculopapular palmar skin lesions

Decreased to no urine output Hyperacute rejection usually occurs within the first 24 hours after transplantation. The first sign is that the transplanted organ stops working. Because this patient received a kidney, this would be evidenced by a decrease in or absence of urinary output.

what is essential to maintain organ and tissue viability?

Early diagnosis and treatment of rejection are essential for this

Which interventions are appropriate for the nurse to include in the plan of care for a patient who underwent organ transplantation 2 days ago? Select all that apply. Give immunosuppressant drugs Assist the patient with ambulation Administer intravenous (IV) fluids Have patient wear a mask in the room Change the surgical site dressing as prescribed

Give immunosuppressant drugs The nurse will administer immunosuppressant drugs to prevent rejection. Assist the patient with ambulation The patient will be unsteady on his or her feet and weak, so the nurse will assist the patient with ambulation to regain muscle strength. Administer intravenous (IV) fluids The patient will be receiving IV fluids postoperatively to maintain hydration status. Change the surgical site dressing as prescribed The surgical dressing should be changed as ordered for assessment of the incision and prevention of infection.

Chronic rejection

Happens over years and cannot be reversed. May occur as a result of repeated episodes of acute rejection or may have no known cause. The transplanted organ becomes filled with T cells and B cells, consistent with a low-grade immune-mediated injury. Causes fibrosis and scarring of the transplanted organ. Damage that takes place is specific to the organ that was transplanted. No specific treatment exists other than provision of supportive care to the patient.

What will the nurse include in the discharge instructions for a patient who underwent cadaveric organ transplantation? Select all that apply. Notify the transplant team of increased pain. Take your medications on time as scheduled. Ambulate regularly at the gym to get exercise. Take your temperature daily when you wake up. Wash your hands before changing your dressing.

Notify the transplant team of increased pain. The nurse should instruct the patient to notify the transplant team if pain increased. Because the patient is being discharged, pain should be decreased, not increased. Take your medications on time as scheduled. The patient should be taught to take immunosuppressant medications at the regularly scheduled times to prevent complications Wash your hands before changing your dressing. The nurse should teach the patient to wash his or her hands before changing the dressing over the incision to prevent infection.

what are the two types of Acute rejection?

One type is based on a cell-mediated immunity response by the recipient's lymphocytes to the foreign donated organ or tissue. Another type is humoral based and happens when the recipient develops antibodies against the donated organ or tissue.

Pain Management

Pain management is important because the patient underwent a major surgical procedure. The nurse will need to perform a complete pain assessment and administer pain medications as needed or prescribed. When a patient has better pain control, the patient will ambulate, which is essential to promote healing and prevent pneumonia. The nurse will also inform the patient that as the time passes, the need for pain medication will decrease.

Which patient would the nurse expect to be at highest risk for developing graft-versus-host disease (GVHD)? Patient who had a lung transplant 4 years ago Patient who is taking immunosuppressant drugs Patient who had a recent bone marrow transplant Patient who had a negative result for crossmatching

Patient who had a recent bone marrow transplant

what two things can help lower the PRA level and result in positive outcomes?

Plasmapheresis and intravenous (IV) administration of immune globulin are used for this

What laboratory report will the nurse review before administering cyclosporine to a patient? Human leukocyte antigen (HLA) typing Platelet count Serum drug level White blood cell (WBC) count

Serum drug level It is important to assess the serum drug level of calcineurin inhibitors, such as cyclosporine, before administration because these drugs have toxic side effects.

Partial organ transplantations

Some organs can be transplanted in parts or segments. This technique allows living donors to donate part of an organ or one of their organs in the case of kidneys. Liver and lung lobes may be transplanted instead of the whole organ. An intestine may be used in segments, allowing for one donor organ to benefit many recipients.

Medication compliance

The patient who undergoes organ or tissue transplantation requires lifelong immunosuppressant therapy. The nurse will educate the patient about: Medication including information on administration, scheduling, and side effects Laboratory testing related to drug levels Signs and symptoms to report The need to report any difficulty paying for the medications

fluid and electrolyte balance

The patient will receive IV fluids during surgery and the immediate postoperative period. The nurse will need to monitor: Fluid volume Edema Lung sounds Electrolytes Renal function

The nurse is caring for a patient who received a heart transplant, and the patient reports gum discomfort. Which medication does the nurse suspect is the cause of the patient's concern? Tacrolimus Daclizumab Cyclophosphamide Methylprednisolone

Tacrolimus Gingival hyperplasia is a side effect of tacrolimus and other calcineurin inhibitors.

Tissue typing

The donor must have the same ABO blood type as the recipient; however, the Rh factor does not need to match.

A patient is undergoing panel of reactive antibodies (PRA) testing to determine whether transplantation will be successful. The PRA results come back at 80%. What will the nurse infer from this finding? The patient will be at an increased risk for developing graft-versus-host disease (GVHD). The patient will undergo successful transplantation with few complications. The patient is at a higher risk for developing organ rejection after transplantation. The patient is a poor candidate for transplantation and should consider hospice services.

The patient is at a higher risk for developing organ rejection after transplantation. The patient undergoes PRA testing immediately before transplantation. The higher the result, the more likely the patient will have organ rejection.

Is there any treatment for Hyperacute rejection?

There is no treatment or cure for this and the newly transplanted organ must be removed.

When does Hyperacute rejection occur?

This Happens within 24 hours of transplantation; blood vessels are destroyed, and the transplanted organ stops working.

What has reduced the number of incidences of Hyperacute rejection?

This has been greatly decreased as a result of HLA typing and PRA testing immediately before transplantation.

Crossmatching

This is performed by mixing the donor's blood with the recipient's blood to determine whether the recipient has any preformed antibodies. This is helpful as a screening test for potential living donors or when a cadaver becomes available.

PRA testing

This is used to determine a patient's sensitivity to HLAs before transplantation. The result is measured as a percentage.

Why does Hyperacute rejection occur?

This occurs because the recipient had preexisting antibodies to the transplanted organ or tissue.

What tests must a patient undergo before transplantation?

Tissue typing, HLA typing, panel of reactive antibodies (PRA) testing, and crossmatching must be done.

The nurse is preparing to administer lymphocyte immune globulin intravenously to a patient who underwent kidney transplantation. What is the rationale for giving this drug in this situation? To prevent anaphylaxis To prevent hyperacute rejection To prevent graft-versus-host disease (GVHD) To decrease pain after transplantation

To prevent hyperacute rejection Lymphocyte immune globulin is administered intravenously to prevent hyperacute rejection in a patient undergoing transplantation.

Rejection prevention

Transplantation places the patient at risk for the immune system to reject the organ or tissue. Interventions include: Administering immunosuppressant medications at scheduled times without skipping doses. Assessing the patient for signs of rejection including transplanted organ dysfunction. For example, a patient who received a kidney will show signs of renal failure such as a decrease in urinary output, fluid volume overload, and an increase in serum creatinine. Assisting with patient preparation for a biopsy if one is scheduled.

Organ Transplantations

Transplanted organs currently originate from many different body systems. These organs include the heart, lungs, liver, kidneys, pancreas, and intestines. More than one organ can be transplanted together, such as kidney and pancreas, kidney and liver, kidney and heart, or the complete intestinal tract. Most patients with diabetes who receive a pancreas transplant also receive a kidney transplant because the diabetes has led to renal failure.

What are the two possible sources of organs that are donated?

Two possible sources of organs, are deceased (cadaver) and living donors.

What are the tree categories of rejection?

hyperacute, acute, and chronic (depending on when it occurs) are the three categories of this.

what is the last treatment option when a persons vital organs have failed?

organ transplantation may be the last treatment option to prolong life.

how can the incidence of rejection be reduced?

reduced by HLA typing, PRA testing, crossmatching, and use of immunosuppressive drugs.

How can Acute rejection be reversed?

reversed by increasing the doses of immunosuppressive agents with monoclonal antibodies and steroids.

can rejection always be prevented?

sometimes this cannot be prevented.

The higher the PRA percentage results are the ____________ the recipients risk of organ rejection.

the __________ the PRA percentage results are, the higher is the recipient's risk of organ rejection.

What are the common tissues that are transplanted?

these include corneas, skin, bone marrow, heart valves, bone, and connective tissue.

Define transplantation

this is a surgical procedure that involves transfer of tissues, whole organs, or parts of an organ from one site to another.

How are patients matched to available donors?

this is based on several factors: ABO blood and human leukocyte antigen (HLA) typing, medical urgency, length of time on the waiting list, and geographic location.

When can rejection occur?

within the first few minutes of transplantation or several years afterward.