Transplant Flashcards
most common transplant?
kidney
what can be transplanted?
-organs
-tissues
-corneas
-stem cells
-bone marrow
xenotransplant
-donor is an animal, recipient is human
allotransplant
donor and recipient are same species
isotransplant
donor and recipient are identical twins
autotransplant
-donor and recipient are self
-bone, skin, ligaments, blood vessels, stem cells
living donor
-patient survival rate and graft survival is better with the donor living
-surgery happens at the same time and organ is transplanted sooner
-wait time is 2-4 months
-lower rate of delayed graft function
deceased donor
-wait time is 1-3 years
-increased rate of delayed graft function
-standard brain dead donor
-donation after circulatory death
-if organ becomes available from a donor with high risk criteria, recipient is notified and can decline transplant
Human Leukocyte Antigens (HLA)
-gene clusters that mostly exist on the surface of our cells
-use uniqueness to distinguish self from non-self
-responsible for the presentation of “forge in” peptides (antigens) to the immune competent cells
-T lymphocytes recognize foreign antigens when it combines with HLA molecules
-a close match between donor’s and patient’s HLA markers is essential for successful transplant outcome
-HLA matching promotes the growth and development of new healthy blood cells and reduce CVHD disease
Graft-versus-host disease (GVHD)
-a major cause of morbidity and mortality in 30-50% of allogenic transplant population
-occurs when the donor lymphocytes initiate an immune response against the recipient’s tissues during the beginning of engraftment
when does acute GVHD occur?
within first 100 days after transplant
when does chronic GCHD occur?
after the first 100 days post transplant
clinical manifestations of acute GVHD
-diffuse rash that progresses to blisters and desquamation (like 2nd degree burn)
-mucosal inflammation of eyes and GI tract with severe diarrhea
-biliary stasis (bile slows down), abdominal pain, hepatomegaly, elevated liver enzymes
treatment of GVHD
immunosuppressant drugs
-cyclosporine
-methotrexate
-tacrolimus
-mycophenolate mofetil
what does the success of a transplant depend on?
-general health of recipient (renal diet, mask, exercise)
-degree of histocompatibility with donor (HLSA, ABO, & Rh)
-degree of the recipient’s end organ disease
-how well immunologic response is managed
contraindications for recipient
-recent malignancy
-active or chronic infection
-severe irreversible other disease
-class II obesity
-current substance use disorder
-inability to give informed consent
-active psychiatric disease
-history of nonadherence with treatment regimens
contraindications of donor
- same as any condition that is determined to have an impact on the remaining organ
-example: kidney transplant with hypertension & diabetes
transplant criteria
-ABO, Rh, HLA compatibility
-body sizes of donor and potential recipient
-age, severity of illness, and length of time on waiting list
-geographic location (some organs need to be implanted within certain time frames)
Hematopoietic Stem Cell Transplant (HSCT)
-used to treat severe malignant and nonmalignant diseases
-most transplants obtained from peripheral blood cell collection through aphaeresis
-also can come from umbilical cord blood from newborn placenta at birth
apheresis
-cells are specially processed and reinfused into the patient
Syngeneic
from an identical twin
myeloablative
patient is given high dose of chemo and sometimes total-body irradiation
nonmyeloablative
(mini-transplants) bone arrow not completely destroyed
candidates for heart transplant
patients who have severe uncontrolled by medical therapy, no other surgical options and a prognosis of less than 1-2 years
most common procedure for cardiac transplantation
orthotropic transplantation with implantation of the donor heart with intact atria at the vena cava and pulmonary veins
liver transplants
-have good patient outcomes
-candidates with cancer must net strict selection criteria
diseases liver removed and replaced with a healthy liver - 4 years survival rates 85%
kidney transplants
-become the treatment choice for most ESRD patients
-should be evaluated early-before starting dialysis
-GFR <20mL to be on the list
when do kidney transplants have the best outcomes?
before dialysis or minimal dialysis time
preoperative care for transplant
-proper diet
-dialysis within 24 hours of surgery
-complete physical exam on recipient and donor
-blood from living kidney donor often transfused into recipient
-psychological eval for recipient and donor
pre-op teaching
-pain
-dietary restrictions
-IV
-foley catheter
-early ambulation
-pulmonary care
-anxiety
-possible rejection
-treatment adherence
pre-op labs
-BMP
-CMP
-CBC
-coags
-urine culture
-blood type and crossmatch
pre-op medications
antibiotics & immunosuppressive therapy
caring for deceased donor
-an intensive care setting
-goal is to preserve function of the organs through maintaining hemodynamic stability, decreasing risk of infection, and monitoring lab values
-once pronounces brain dead the patient may need additional; tests and procedures to check for organ function and quality
-provide dignified care to donor and family
surgery for kidney transplant
-2-3 hour surgery
-places in the patient’s iliac fossa anterior to the iliac crest
-allows easier access to the blood supply
-ureter is sutured to the bladder
-3-4 day hospital stay
post op kidney transplant care
-goal is to maintain homeostasis until the kidney is transplanted is functioning
-more favorable prognosis when kidney functions immediately
-donor usually has more pain & requires more medication
-monitor fluid, electrolyte, & hemodynamic closely in both donor and recipient
hyper acute transplant rejection
-within 3 days of transplant
-causes immediate destruction and necrosis of organ
-requires immediate removal of organ
-s/s - fever, hypertension, pain at transplant site
acute transplant rejection
-occurs within 3-14 days or suddenly later
-requires early detection and increased immunosuppression treatment to prevent further damage
-s/sx- oliguria, anuria, fever, graft site tenderness, lethargy, fluid retention, azotemia (BUN & creatinine)
-treatment - increase immunosuppressive meds
chronic transplant rejection
occurs gradually over months to years
-often result of immune-mediated ischemic damage over time
-s/sx - progressing organ failure, fluid retention, electrolyte imbalance, azotemia returns
-treatment - monitor and continue meds until dialysis is needed
assessing for kidney rejection
-oliguria
-edema
-fever
-hypertension
-increased BUN & creatinine
-weight gain
-swelling or tenderness over transplant site
complications of kidney rejection
-bleeding, hypovolemic shock
-presence of uremia
-GI ulceration
-interventions – platelets, blood, Epogen & IV fluids
-fluid & electrolyte imbalances
-infection
patient teaching
-coping
-lifelong proces
-monitor for complications and signs of rejection
-diet (low fat, high fiber, increased protein, low sodium, avoid sugary foods & carbs, adequate electrolytes)
-avoid contact sports
-medication adherence
-avoid infection
-cancer screenings
immunosuppressive medications
-goal: to suppress the immune system enough to prevent rejection but not too much to allow infections or cancers
-start immediately after transplant to get to therapeutic level asap
-combination of corticosteroids and medications
-avoid grapefruit juice with most meds
risk associated with immunosuppressive meds
-nephrotoxicity
-hypertension
-hyperlipidemia
-hirsutism
-tremors
-blood dyscrasias
-cataracts
-gingival hyperplasia
-several types of cancer
what do calcineurin inhibitors do?
bind to & inhibit calcineurin and decrease T-cell activation and proliferation
Tacrolimus
-given oral or IV
-adverse effects: nephrotoxic, hypertension, insomnia, asthenia, photosensitivity, GI upset, electrolyte imbalances
-monitor trough levels
-best taken on empty stomach at same time of day
-avoid grape fruit juice
mycophenolate mofetil
pregnancy category D
do not crush
Sirolimus
-do not chew or crush tablets
-avoid grapefruit juice
-limit exposure to light
adverse effects of glucocorticosteroids
-peptic ulcers
-increased appetite
-fluid restriction
-weight gain
-hyperglycemia
-impaired wound healing
-muscle weakness
-osteoporosis
-irregular menses
-insominia
-pyschosis
