07 Living Donation and Transplantation Flashcards
1
Q
The principle of living donation requires the person giving consent to be…
A
- competent
- willing to donate
- free from coercion medically and psychosocially
suitable - fully informed of the risks and benefits as a donor
- fully informed of the risks, benefits, and alternative treatment available to the recipient
2
Q
The ethical principles that apply to living donation include…
A
- Autonomy
- Beneficence
- Non-maleficence
- Justice
3
Q
The regulatory agencies that have an impact on living donation include…
A
- CMS: Conditions of Participation
- OPTN
- JCAHO: The Joint Commission on Accreditation of Healthcare Organizations
- State Regulatory Agencies
4
Q
CMS requires that living donor selection…
A
- living donor receives a medical and psychosocial eval prior to donation
- Document in the living donor’s medical record that the living donor is suitable for donation
- Document that the living donor has given informed consent as required.
5
Q
Per CMS requirements, ABO verification for living donor transplant must be done…
A
- immediately before removal of the donor organ
- Prior to implantation in recipient on day of transplant
6
Q
Per CMS requirements, the transplant center must have written policies for…
A
the informed consent process.
7
Q
Per CMS requirements, each living donor must be informed of the following:
A
- that communication between the donor & the transplant center will remain confidential
- Evaluation process
- Surgical procedure, including post op treatment
- The availability of alternative treatments for the transplant recipient
- Potential medical or psychosocial risks to donor
- National and center-specific outcomes for recipients & living donors as data are available.
- The possibility that future health problems related to the donation may not be covered by the donor’s insurance, and the ability to obtain health disability, or life insurance may be affected
- The donor’s right to opt out of donation at any time during the donation process
- The fact, if applicable, that his or her transplant is not provided in a Medicare approved transplant center and it could affect the transplant recipient’s ability to have his or her immunosuppressive drugs paid under Medicare Part B
8
Q
Per OPTN requirements, transplant centers must follow the following policies:
A
- Psychosocial Evaluation
- Independent Living Donor Advocate (ILDA)
- Informed Consent
- Medical Evaluation
- Registration and Blood Type Verification prior to Donation
- Placement of Living Donor Organs
- Packaging, Labeling, and Transporting of Living Donor Organs
- Reporting Requirements: Follow-up required post donation, for 2 years
9
Q
Transplant centers must document the following medical expertise:
A
- Surgical Expertise
- Medical Expertise
- Psychological services
- Coordinator staff
- Anesthesia Radiology expertise
- Blood donor center
- Social services
- Nutritional services
10
Q
Principles of Donor Evaluation include…
A
- Never Solicit a donor:
- Potential donor should call themselves for initial appointment and subsequent follow-up
- Have separate donor and recipient teams
- Assign an “Independent Donor Advocate/ Advocate Team”
- Emphasis is on the health, safety and confidentiality of the donor
11
Q
Responsibilities of the Independent Living Donor Advocate include…
A
- Ensures protection of the rights and prospective of living donors
- Functions independently of the candidate’s team and must not be involved in the transplant activities on a routine basis
- Must demonstrate knowledge of living organ donation, transplant, medical ethics, informed consent, impact of family and external pressures on living donor decisions to donate
- May be a nurse, social worker, MD, clergy, ethicist, or psychologist
- Must follow programs written protocols and grievance process to protect the rights and best interest of donor
- Must determine that the living donor has received information on all or the following areas and assess donor in obtaining additional information on: informed consent, evaluation process, surgical procedure, medical risks, psychological risk, and follow-up care.
12
Q
With respect to informed consent, the capacity to make medical decisions includes…
A
- Communication of choice
- Understanding of information provided
- Appreciation of options available
- Rational decision making
13
Q
The psychosocial evaluation of a potential living donor includes…
A
- Thorough psychosocial history
- Presence of psychological disorders
- Coping skills during time of stress
- Substance abuse history
- Assess for competency
- Evidence of coercion Is part of the care team for donor
- May provide patient education
- Assesses understanding of education
- Emotional support pre and post donation
14
Q
Living Donor education should include…
A
- Donor evaluation procedure
- Surgical procedure
- Recuperation period
- Short and long-term follow-up care
- Alternatives to live donation
- Potential psychiatric benefits/risks
- Potential medical and financial risks
15
Q
Potential living donors include…
A
- Donors must be 18 years of age or older
- Blood relative: siblings, parents, adult children
- Other blood relatives (cousins, aunts, uncles, grandparents, etc)
- Non-blood related family member (spouse, in-law, adopted or step-child)
- Close friend or acquaintance; someone known to family of recipient; church members, co-workers
- Altruistic , web-based matching, paired donation
- However, it is not advisable for the donor to be employed by the recipient or the recipient’s family
- Payment for organs is prohibited in the United States
16
Q
A medical history of the living donor should include…
A
- General health
- Psych history
- Potential co-morbidities:
- Obesity
- Diabetes
- Smoking
- hypertension
17
Q
Medical examinations of the living donor include…
A
- General
- Cardiovascular
- Respiratory
- Abdominal
18
Q
Immunological and hematologic screenings of living donors include…
A
- Blood group
- HLA typing
- Lymphocytoxic XM
- Blood count
- Coagulation studies
19
Q
Biochemistry screenings of the living donor include…
A
- Urea and electrolytes
- Creatinine clearance
- Liver function tests
- Blood glucose
20
Q
Screenings of the living donor, designed to uncover conditions that would increase the risk of surgery include…
A
- Urinalysis
- Cardiovascular
- Radiology
- Microbiological (infectious disease)
- Age-appropriate Cancer screenings
21
Q
The role of the transplant coordinator in living donation includes…
A
- Identify multi-disciplinary recommendations: (psychosocial, dietary, social work, nutrition, pharmacology, financial)
- Assess donor suitability and adherence
- Present findings and make recommendations to the transplant team regarding donor suitability:
- Additional procedures and tests based on the team’s recommendations (CT scan, cholecystectomy, arteriogram)
- Scheduling of a potential candidate for protocols as indicated (desensitization, incompatible ABO)
- Recommended health maintenance (colonoscopy, dental, PSA, pap smear, mammogram)
22
Q
Absolute Contraindications to living kidney donation include…
A
- evidence of kidney disease
- diabetes
- heart disease
- cancer
- Hepatitis B or C
- HIV
- uncontrolled hypertension
23
Q
Relative Contraindications to living kidney donation include…
A
- obesity, hyperlipidemia, history of kidney stones, controlled hypertension, and substance abuse
- Intellectual impairment with inability to give informed consent
- Evidence of coercion or financial reward
24
Q
Living Donor Kidney Assessment includes…
A
- Family history of Renal Disease
- Past or current renal infections, hematuria, renal calculi
- Attention to urinalysis: proteinuria, hematuria, glycosuria, creatinine clearance
- Attention to blood pressure
- Additional radiology studies
- Isotope GFR
- Renal Ultrasound
- CT Angiogram
- Intravenous pyelogram
25
The types of surgical options available for a living kidney donor include…
* Laparoscopic donor nephrectomy or laparoscopic hand-assisted nephrectomy, robotic laparoscopic nephrectomy
* Open nephrectomy
26
Complications of an open nephrectomy include…
* Very low morbidity
* Atelectasis and pneumonia
* DVT and pulmonary emboli
* UTI
* Bowel ileus
* Rhabdomyolysis- serious syndrome due to a direct or indirect muscle injury. Death of muscle fibers and release of their contents into the bloodstream. Leads to serious complications such as renal (kidney) failure.
27
Post operative care for kidney surgery may include…
* Pain medication as needed
* Incisional pain
* Back and shoulder pain (due to use of CO2 in laparoscopic surgery)
* Meticulous attention to intake and output
* IV fluids to prevent dehydration until diet resumed
* Increase diet as tolerated
* Labs drawn to assess for stabilization of kidney function
* Early and frequent ambulation
* Average LOS 2-3 days
28
Discharge education for living donor kidney patients includes…
* Recovery at home: lift nothing greater than 10-12 pounds for 4 to 6 weeks to avoid incisional hernias.
* Avoid dehydration
* Avoid nephrotoxic medications unless under carefully medical supervision, including NSAIDS.
* Patients return to clinic 2 weeks post-op, and may be released to return to work at 6 to 8 weeks depending on nature of employment.
29
Long term concerns for living kidney donors includes…
* incidence of renal failure in donors less than the general public
* Donor priority points on UNOS Wait List
* Women can carry pregnancy without additional risk following donor nephrectomy
30
Living donor Liver Assessment includes…
* History of liver disease
* Alcohol intake (highly recommended)
* abstinence for 1 month prior to surgery
* Abstinence for 6 months post surgery
* Additional Radiology studies
* Liver ultrasound
* Magnetic Resonance Cholangiopancreatography (MRCP): magnetic resonance imaging to visualize the biliary and pancreatic ducts, also ducts surrounding the gallbladder.
* Abdominal CT angiogram / MRA (magnetic resonance angiogram): uses a magnetic field and pulses of radio wave energy to provide pictures of blood vessels inside the body.
31
Exclusion criteria for Living Liver donors includes…
* Age \<18 or \>60
* BMI \>35
* Significant CV, pulmonary, renal disease
* Diabetes
* Ongoing malignancy
* Severe local or systemic infection
* Severe neurologic deficits
* Active substance abuse
* Untreatable/unstable psychiatric illness
* HIV, HCV, HBsAg positive
32
General Inclusion criteria for living liver donors includes…
* Age
33
Risks to Living Liver Donors include…
* Interrupted surgery
* Death: 1.7/1,000 or about 0.2%
* Acute liver failure
* Reversible liver dysfunction
* Bile leak (10%)
* Bile duct stricture
* Need for blood
* General risks of surgery- infection, anesthesia, etc.
* Psychosocial risks
* Organ failure in the recipient
34
In an adult donating to a child what segment of the adult liver is usually donated?
Left Lateral Segment
35
In an adult donating to an adult, what segment of the donor liver is usually donated?
Right Lobe
36
Complications of liver donor surgery include…
* Complications of general anesthesia, intubation, line placement, DVT, pulmonary emboli, pleural effusions, pneumonia.
* Wound infection, wound dehiscence, intestinal obstruction, adhesions, ileus, severe pain.
* Acute liver failure, bleeding, biliary leaks, bilomas, incisional hernia
37
Post operative care for liver surgery may include…
* Monitor hepatic and renal function
* Monitor mental status
* Observe for bleeding and Bile leak
* Pain management
* Epidural anesthesia
* PCA for initial post operative period
* Oral agents: percocet 2tabs Q4h
* NSAIDS: toradol 60mg IM q6h for 48Hrs
* Chronic Pain concerns
* Uncomplicated LOS is 5-7 days
38
Long term concerns for living liver donors include…
* Liver regenerates within 6 weeks (full size within 12 months)
* LFT’s are monitored at 1, 3, 6, 12 months after donation
* No heavy lifting for 3 months
* Return to “normal “ 3-4 months
39
Medication restrictions for living liver donors include…
* No tylenol until LFTs have returned to normal
* No alcohol until off narcotics and LFTs have normalized.
* No other restrictions because the liver regenerates
