Transplant- final Flashcards
what can be donated
- specific organs or tissue type (skin, hair, heart valve, bone)
- whole body
- living or cadaver
rule about living donors
-cannot sacrifice their life for donation
highest demand organs
- kidneys
- heart
- liver
how to become a living donor
- extensive workup
- meets with coordinator for patient and family education of long term issues
- if anonymous: phsych eval
what does insurance pay for in terms of donors
- donor evaluation, testing, surgery, and some follow up care
HIV or Hep C
- they can donate and receive but they are considered high risk transplantations
what if i donate a kidney and end up needing one later?
-you are bumped up the list
how can I get on the list
- referral from transplant center
- verification of need: organ specific criteria like for the kidneys < 20 % function
- blood and tissue typing to determine a perfect match
what does tissue typing encompass?
- blood compatibility
- HLA typing- three different groups of antigens (A,B,DR)
- panel of reactive antibodies
- crossmatching
what is panel of reactive antibodies (PRA)
- determines recipients sensitivity to HLAS
- sensitivity to HLAS recipient serum mixed with randomly selected panel of donor lymphocytes to determine reactivity
high percentage on PRA
- person has a large number of cytotoxic antibodies and is highly sensitized
- you need to give plasmaphorisis or IVIG to lower the number of performed HLA antibodies
positive PRA
-transplantation is contraindicated d/t hyper acute rejection
what is crossmatch
serum from the recipient is mixed with donor lymphocytes to test for anti-HLA antibodies to a potential organ
what is needed for compatibility
-ABO compatibility is needed between the donor and recipient but they do not need to share the same Rhfactor
why do kidneys need a close HLA matching
-due to the high vasculature nature and the high risk of graft rejection
high panel of reactive antibodies means
indicates that a person has a large number of cytotoxic antibodies and highly sensitive which means there is a poor chance of finding a crossmatch or a negative donor.
Crossmatch that is negative
negative indicates a person has no preformed antibodies present and it is safe to proceed with transplantation.
waiting for a transplant
- monthly verification of labs
- criteria is constantly reevaluated (if get better move down, if get sicker move up)
- some people may need dialysis as a bridge awaiting a kidney
Kidney allocation system (KAS)
- waiting time starts at the listing or start of dialysis (whichever is first)
- donors are scored with a kidney profile index (KDPI)
- recipients are scored with estimated post transplant survival (EPTS)
- what the healthcare team will use to determine the score if someone is eligible to donate a kidney/ receive a kidney without having issues of rejection.
Kidney profile index
- age
- ht/wt
- ethnicity
- cause of death
- BP
- DM
- Hep C
- creatinine
- all looked at to summarize the likelihood of graft failure after deceased donor kidney transplant
Estimated post transplant survival is dependent on
- age
- time on dialysis
- previous solid organ transplant
- current diabetes status
why was the kidney allocation system made
in response to higher than necessary discard rates of kidneys, variability in access to transplants for candidates who are harder to match due to biologic reasons, inequities resulting from the way waiting time was calculated, and a matching system that results in unrealized life years and high re-transplant rates.
maximum organ transplant time for Heart and lungs
4-6 hours
maximum organ transplant time for liver
8-12 hours
maximum organ transplant time for pancreas
12-18 hours
maximum organ transplant time for kidney
24-36 hours
recipient contraindications
- disseminated malignancies or active malignancy
- cirrhosis ( unless on liver list)
- refractory or untreated cardiac disease
- chronic respiratory failure
- extensive vascular disease
- chronic infection
- unresolved psychosocial disorders
- obesity (BMI >35)
- current alcohol use
examples of unresolved psychosocial disorders that disqualifies someone for recipients
non-adherence to medical regimens, alcoholism, or current substance use disorder
how long does someone need to be free of substances to be a recipient
-6 months
who needs treatment prior to transplant
- active infection (Hepatitis, DM skin or foot infection, TB)
- CV disease- must have angioplasty and possible CADG at least 6 months prior
- ulcers healed x6 months
- CVA post 6 months
- substance abuse: 6 months of clean screens
- smoking/drinking: resolved for 6 months
living donor process- tests to make sure can live without a kidney
- relatives, altruistic, paired organ donation
- crossmatch
- nephrologist
- 24 hour urine
- viral status screening (CMV, HBV, HCV, EBV, VZV, HIV)
- ECG, chest x ray
- renal ultrasound
- transplant psychologist- emotionally stable
live vs dead donor?
Live donors are preferred because the patient and graft survival rates are increase
- With live donors the benefit is that the recipient is in the best health so their body can be prepared for the surgery and there is immediate organ availability instead of waiting for one
Cold time or cold ischemic time
refers to the amount of time that an organ is chilled or cold and not receiving a blood supply.
*none for kidney
Kidney donation
-greatest demand
-1 kidney is transplanted so one deceased donor can actually help 2 people
pt may or may not be on dialysis at time of transplant
where is the new kidney added to
The transplanted kidney is added to the retroperitoneal space in the iliac fossa.
where is the ureter connected to after kidney transplant
bladder
where is the vessels connected to after kidney transplant
-iliacs
how long can kidney be on ice before transplant
36 hours
how many patients experience rejection episode in the 1st year
- 15 %
- 90-95% survival
what is important to graft survival post kidney transplant
-lifestyle
graft life for kidney
-1-25 + years
is transplant better than dialysis
- In the long run it is cheaper than dialysis after the first year of transplant .
- Transplant is better than dialysis especially for a type 2 diabetic patient
rapid revascularization after kidney transplant
-critical to prevent ischemic injury to the kidney
ICU care after kidney transplant
- 12-24 hours
- monitor UO: hourly urine output replacement (1:1)- within the first day could be 1 l/hr
- ability to filter bun
- fluids during operation
- renal tubular dysfunction so kidney cannot concentrate urine normally
what to monitor for post of
- central venous pressure
- electrolytes (k+ and bicarb)
surgical complications
- bleeding
- wound infection
- clotting
- twisting (torsion of kidney)
- urine leak
observe for ATN
- may need dialysis temporarily because the body can excrete fluids but not metabolic wastes or electrolytes
- can happen with increased cold times
urine output catheter in place
- for 3-5 days
- may need catheter irrigation
- A common cause is obstruction of a urinary catheter by a blood clot
-after discharge from kidney transplant
-will have frequent blood tests and follow ups
what causes the large urine output after kidney transplant in first 24 hours
- The diuresis is due to the kidneys ability to filter BUN and fluids during the operation but there is initial renal tubular dysfunction so the kidney is not concentrating urine normally
- Output can be as high as 1L/hr and should gradually decrease but fluids are replaced on a 1:1 basis the first 24 hours to prevent damage.
why may need dialysis after transplant
required to maintain fluid and electrolyte balance
hyperacute transplant rejection
- Minutes to hours after transplantation: d/t preexisting antibodies against the transplanted tissue organ
- No treatment
- Transplanted organ removed
- Rare
Acute transplant rejection
- First 6 months d/t recipients lymphocytes active against donated tissue (cell-mediated rejection)
- Not uncommon to have at least 1 rejection when from a deceased donor
- Reversible with additional immunosuppressive therapy,increase corticosteroid or polyclonal or monoclonal antibodies
- Put on long term immunosuppressants to prevent this
chronic transplant rejection
- Months to years d/t unknown reasons ore repeated acute rejections
- Get fibrosis and scaring on organ
- T and B cells have a low grade immune mediated injury which leads to fibrosis and scarring of organ.
- Irreversible
- Treatment is supportive
how to prevent or lessen rejection
rejection immunosuppressive therapy, performing ABO and HLA matching and ensuring crossmatch is negative are important
*but perfect match is not possible unless from identical twin
polyclonal antibodies
derived from a rabbit or horse with human lymphoid cells that help to “purify” the resultant antibody
monoclonal antibodies
interferes with the function of T cells
pain management post op
- Remember, these patients are post op
- Address pain management needs
- Consider organ function related to drug elimination
- Pain management is essential for effective patient mobility
complications after traNSPLANT
- Infection: significant cause of morbidity and increased due to the immunodepressed state
- Increased incidence of atherosclerotic vascular disease-Teach to control risk factors
- Malignancies due to immunosupressive state: higher rate than general population-Regular screening
- Recurrence of original kidney disease
- Corticosteroid-related complications: hard on the body and because of it centers may institute “corticosteroid free drug regimens”
- CV disease: need to encourage adherence to prescribed antihypertensives to not damage the new kidney.
post op care for donor- surgical approach
- Monitor renal function
- Donors can have more pain then recipient
- Discharge 4-5 days
- return to work 6-8 weeks
post op care for donor- laprascopic approach
- Monitor renal function
- Pain (less pain than surgical more than recipient)
- Discharge 2-4 days
- Return to work 4-6 weeks
