Organ Transplant Flashcards by Ruby Trella

allograft

tissue that is transplanted between members of the same species

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autograft

transplantation of tissue from one part of a person’s body to another

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heterograft

transplantation of tissue between two different species

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isograft

transplantation of tissues between identical twins

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brain death definition

when respiration and circulation are artificially maintained and there is total and irreversible cessation of all brain function including the brain stem

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clinical determinants of brain death

EEG
cerebral blood flow/perfusion scan
physical exam (by 2 non-transplant MDs)
GCS of 3
no reflexes with fixed pupils, negative dolls eyes, negative ice water calorics, no corneal reflex, no gag reflex, no cough, positive apnea test

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apnea test

normal temp, no sedatives/paralytics, normal PCO2, pre-oxygenated, SBP >90
CPAP with 100% FiO2
observe for spontaneous respirations/chest excursions
after 5, 8, & 10 min draw ABG and reconnect

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positive apnea test findings

PCO2 >/= 60 with no respirations AND
pH < 7.3

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donor evaluation criteria

age
blood typing - ABO compatibility
serological testing for diseases so NONE
HLA antigen matching
tests done on the specific organ
no active systemic cancers
no high risk behaviors
absence of hyper/hypotension

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5 major goals for physiologic management of the donor

maintain hemodynamic stability
maintain optimal oxygenation
maintain normothermia
maintain fluid & electrolyte balance
prevent infections

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physiologic management rule of 100s

SBP > 100
PO2 > 100
PEEP of 5
lowest FiO2
temp 96-100*F
urine output 50-100cc/hr

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asystolic or non-heart beating donor

surgical recovery of organs of CV death
severe neurological injury but doesn’t meet brain death criteria
withdraw from support in PACU with family
have 1 hr to procure organs

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evaluation for all transplant recipients

end stage organ failure (6-12 months with severe functional disability)
clinical status: tests specific to organ, blood test
nutritional status
social services: family support, spiritual
psychological readiness: psych history, response to stress, compliance
financial: insurance

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ways to increase kidney transplants

living related donors
non-living related donors
paired kidney transplant
re-transplant of decreased transplant recipients (death not transplant related)

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conditions that indicate heart transplant

cardiomyopathy, aneurysms, malformations, ASHD, refractory dysrhythmias/angina
NYHA class III or IV (marked limitation of activities, mostly stay at rest or complete rest)

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heart cold time

4-6 hrs

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heart orthotopic transplant

receives donor heart in place of own heart

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physiology of denervated heart

donor heart completely denervated at time of transplant
2 p-waves b/c donor heart retains own sinus node
only donor sinus nodes conducts to ventricles

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effects of denervated heart

no SNS or PNS innervation
rapid resting heart rate
orthostatic hypotension
doesn’t respond to valsalva or carotid massage
atropine doesn’t work (isuprel should)
may not feel angina

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s/s of heart transplant rejection

fatigue/weakness, flu-like aches and pain
fever of 100.5 or higher
just not feeling right
shortness of breath
tachycardia or dysrhythmia
swelling of the hands or feet
sudden weight gain
hypotension

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dysrhythmias in transplant heart

usually indicates rejection (so biopsy)
can be due to prolonged ischemia or pre-op meds
sinus bradycardia (pacer or isuprel)
PVCs (K and Mg)
atrial dysrhythmias

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lung transplant clinical indications

irreversible end stage lung disease, expected to die in 1-2 years
single lung: COPD, alpha 1 antitrypsin deficiency
double lung: CF, bronchiectasis
heart-lung: pulmonary HTN, eisenmenger’s

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lung cold time

4-6 hrs

how often are patients on lung transplant list seen and assessed?

seen every 2-3 months
diagnostic tests updated every 6 months

s/s of lung transplant rejection

fever/malaise dyspnea non-productive cough decreased oxygen saturation abnormal pulmonary function tests

indications for liver transplant

primary biliary cirrhosis non-alcoholic cirrhosis: post-necrotic, cryptogenic, TPN induced, laennec's alcoholic liver disease chronic active hepatitis hepatocellular cancer biliary atresia

liver cold time

less than 12 hrs

s/s of liver transplant rejection

fever/flu like symptoms deterioration of mental, hemodynamic, renal, & respiratory function jaundice and itching abdominal pain: RUQ and back pain increase in liver enzymes (AST, ALT, LDH, bilirubin) increase in PT/PTT decrease in platelets and fibrinogen decrease in bile output or change in color

indications for kidney transplant

ERSD caused by HTN, DM, polycystic and glomerulonephritis

kidney cold time

< 30 hrs

s/s of kidney transplant rejection

fever greater than 100f general malaise pain or tenderness over grafted kidney sudden weight gain edema HTN elevated serum creatinine and BUN decreased creatinine clearance

how to test for rejection

ultrasound biopsy

kidney pancreas transplant indication

for type 1 diabetes

kidney pancreas transplant cold time

less than 24 hrs

surgical transplant compllications

bleeding vascular thrombosis anastomosis leakage

types of graft rejection

hyperactute acute chronic

medication related transplant complications

HTN nephrotoxicity hepatotoxicity osteoporosis diabetes weight gain bone marrow suppression

transplant complications

surgical graft rejection infection organ dysfunction malignancy med related

post-op nursing considerations

recover in ICU (kidneys medsurg) hemodynamic stability: pressure, drips, CVP monitoring, hypothermia, bleeding, EKG, drains, strict I&O monitor for s/s of infection meticulous hand washing remove tubes/drains asap start immunosuppressive meds pt and family teaching of meds/care

hyperacute rejection

immediate post-op period immediate graft failure re-transplant or life-sustaining treatment caused by preformed reactive antibodies from exposure to antigens

acute rejection

occurs 1st 3-6 months caused by cell mediated response activated by T-lymphocytes biopsy

chronic rejection

after 6months both humoral and cellular mediated immune response chronic inflammation = diffuse scarring and stenosis of vasculature of organ lack of blood supply = ischemia to organ

common infections

leading cause of death Lund and blood borne infections: bacterial, disruption in skin integrity CMV: viral, from recipient or reactive disease, mild or severe fungal: yeast in mouth and vagina, nystatin tx

transplant associated malignancies d/t immunosuppression

NHL Laposi'a sarcoma hepatobiliary and renal malignancies skin tumors gout

goals of immunosuppressive therapy

suppress activity of helper and cytotoxic T cells

types of calcineurin inhibitors

cyclosporin tacrolimus sirolimus (rapamune)

action of cyclosporin

suppresses T cells without affecting B cells

tacrolimus action

inhibits interleukin release and attacks t-lymphocytes

sirolimus (rapamune) action

inhibits T cell and antibody formation 3rd choice med

which corticosteroids are prescribed

solumedrol initially prednisone for life

why corticosteroids

anti-inflammatory actions protect against transplanted organ and impair sensitivity of T cells to antigen

imuran (azathioprine) action

inhibits DNA/RNA synthesis causing suppression of T-cell and some B-cells

cellcept(mycophenolate mofetil) action

affects T and B cells (so monitor WBCs) excreted into bile

lifelong triple therapy

1. CSA, tacrolimus, or rapamune 2. prednisone 3. imuran or cellcept work towards dual theray and eliminate prednisone

additional transplant meds: prophylaxis and treatment

antibiotics antivirals for CMV antifungals for valley fever, aspergillus, yeast

recipient self care for life

strict med regimen routine visits with MD and compliance with testing close contract with transplant coordinator support group strict infection control NOT A CURE