transplant

Question 1

What immune cells are typically involved in organ rejection?

Answer 1

T Lymphocytes (acquired, cell-mediated immunity)
there is an antibody-antigen interaction

Question 2

How does transplantation impact VO2 Max?

Answer 2

decrease to 50-60% of typical due to deconditioning/myopathy and changes in cellular respiration that may be caused by cyclosporine

Question 3

What medical issues are common following transplant?

Answer 3

anemia, hypertension, electrolyte abnormalities, excessive weight gain, myopathies, glucose intolerance, osteoporosis and AVN

infections, malignancies, renal failure risk increased with cyclosporine

Question 4

What is the 50% survival time following heart transplant?

Answer 4

10 years

Question 5

Indications for heart transplant

Answer 5

Chronic disease, single organ failure

NYHA class III or IV with VO2 20%; no infection or malignancy; no pulmonary infarction; some pulmonary resistance and perfusion requirements; no renal or hepatic failure; no diabetic organ failure; FVC>50% and FEV1 >1L; no evidence of current substance abuse; able to comply with medical advice; adequate financial resources

Donor match criteria: ABO blood type; within +/-20% of recipient mass; negative prospective cytotoxic T-cell crossmatch (not usually checked prospectively); allograft ischemic time <4-5 hours

Question 6

NYHA Class 1

Answer 6

No limitation in normal physical activity

Can complete any activity requiring ≤ 7 mets:
Carry 11 kg up 8 steps
Carry objects weighing 36 kg
Shovel snow
Spade soil
Ski ; Play squash, handball or basketball
Jog/walk 8 km/h

Question 7

NYHA Class 2

Answer 7

Ordinary physical activity can cause fatigue, dyspnea, palpitation, angina

Can complete any activity requiring ≤ 5 mets:
Typically ind. With ADL/ IADL but may have sypmtoms
Sexual intercourse without stopping
Garden
Roller skate
Walk 7 km/h on level ground

Question 8

NYHA class 3

Answer 8

less than ordinary physical activity can cause fatigue, dyspnea, palpitation, angina

Can complete any activity requiring ≤ 2 - 3 mets: 
Shower or dress without stopping
Strip and make bed
Clean windows
Play golf
Walk 4 km/h

Question 9

NYHA Class 4

Answer 9

has symptoms at rest

Cannot do or cannot complete any activity requiring ≥ 2 mets; cannot do any of the above activities with prolonged rest and/ or assistance

Question 10

What are the different heart transplant surgeries?

Answer 10

Heterotopic–recipient heart remains in place and is connected to donor heart–used only when donor heart too small or weak to function alone, but allows donor heart to be removed if rejected

Orthotopic–recipient heart is removed by cutting great vessels and left atrium (pulmonary veins preserved)–>anastamoses at pulmonary artery and aorta, left atrium, IVC and SVC (or some of right atrium can be preserved)

Both are done using median sternotomy

Question 11

How does body compensate for loss of innervation to heart after transplantation?

Answer 11

Loss of vagal nerve stimulation=no suppression of HR at AV and SA nodes
Loss of sympathetic (????)=no reflex tachycardia in response to hypovolumia/hypotension

body increases circulating catecholamines to increase cardiac output via starling mechanism (SV)–patient may need longer warm up and cool down for appropriate cardiac response

Question 12

What ECG changes may be present after heart transplant?

Answer 12

2 p-waves (2 SA nodes, but recipient SA signals not transmitted past suture/anastamosis)

Question 13

time frames for rejection of heart transplant

Answer 13

hyperacute: within minutes to hours due to antibodies already present in blood stream interacting with donor organ
acute: within 6-12 months, t-lymphocyte mediated
chronic: longer-term due to antibodies, lymphocytes, etc–variety of mechs/less well defined

Question 14

what are signs and symptoms of rejection in heart transplant?

Answer 14

fever, increased dyspnea, decreased exercise tolerance, dysrhythmia, decreased contractility

Question 15

What does chronic rejection in heart transplant cause?

Answer 15

Post-transplant vasculopathy (concentric wall thickening of coronary arteries)

Question 16

What are indications for lung transplant?

Answer 16

Advanced lung disease (50% mortality 24-36 months???)
Progressive dyspnea
Decreasing Function
High Lung Allocation Score
Good Match available (Blood type, Body type,CMV)

contraindications: Smoking – usually must prove abstinence; Extremes of weight (cachexia  obesity);Profound debility; Symptomatic osteoporosis leading to disability; Other chronic medical conditions poorly controlled or associated with end-organ damage
E.g.: CAD/ MI; DM; renal disease; hepatic disease
Psychosocial issues (substance abuse, medical noncompliance, severe psychiatric illness)

Question 17

When are double lung transplants indicated

Answer 17

• Cystic fibrosis–can move between lungs

- better survival, esp under 60

Question 18

Mean 50% survival after lung transplant

Answer 18

7-8 years

Question 19

What is the Lung Allocation Score (LAS)?

Answer 19

Score 0-100, higher=higher priority for transplant

Question 20

What goes in to determining LAS?

Answer 20

Forced vital capacity
Pulmonary artery systolic pressure
Supplemental O2 required at rest
Age
Body mass index
Presence/absence of insulin-dependent diabetes
Functional status  I-IV (NYHA Class)
Six-minute walk distance
Ventilator use
Pulmonary capillary wedge pressure
Serum creatinine
Diagnosis (cystic fibrosis and IPF favored over emphysema)

Question 21

Lung concerns immediately after transplantation

Answer 21

edema/secretions (increased hydrostatic pressure and capillary permeability)

hypoxemia (diffusion of O2 impaired)

loss of lymphatics increases interstitial fluid

loss of innervation decreases mucocilliary clearance and cough

Question 22

What are possible surgical approaches for lung transplantation?

Answer 22

median sternotomy,bilateral transverse thoracosternotomy (“clam shell”), thoracotomy

Question 23

Systemic concerns following lung transplant

Answer 23

Hemodynamic instability: hypovolemia
myocardial irritability
depressed myocardial contractility
supraventricular dysrhythmias

Question 24

What activities should be the focus of inpatient rehab following lung transplant?

Answer 24

Deep breathing, airway clearance, pain control, prevent deconditioning

Question 25

What activities should be the focus of outpatient rehab following lung transplant?

Answer 25

Increasing fitness (DOE will be early limiter) and pain control

watch for signs of rejection or infection

Question 26

What are signs of infection following lung transplant?

Answer 26

SUBTLE fever/ malaise/ cough
reduced airflow
FEV1 & FVC
oxygen desaturation
reduced exercise capacity

Question 27

What are signs of acute rejection following lung transplant?

Answer 27

Biopsy
Histological diagnosis
0-no symptoms, no evidence; no treatment
1-mild
2-moderate
3-severe-rare 
4-severe-rare
Rx:  ↑ immunosuppression

Question 28

What are signs of chronic rejection following lung transplant?

Answer 28

Bronchiolitis Obliterans Syndrome (BOS)
Diagnosis of exclusion
Worsening Pulmonary Function Testing

Rx: ↑ immunosuppression
retransplant

Question 29

What is the result of chronic rejection following lung transplant?

Answer 29

Bronchiolitis Obliterans Syndrome (BOS) (fixed obstruction of airway due to inflammation and scarring. Symptoms include dry cough, shortness of breath, wheezing)

Question 30

What is VO2 max following lung transplant

Answer 30

about 40-60% expected max, if patient completes aerobic training–can be worse