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MED CON III > Transplantation > Flashcards

Transplantation Flashcards

1
Q

What are the goals of transplant?

A

-decrease disabling symptoms
-improve functional capacity
-improve health related QOL
-increase life expectancy

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2
Q

What organ has the greatest wait time for transplant?

A

kidney- 5 years (due to number of people on the transplant list)

-there is much greater need for organs compared to the numbers that are available

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3
Q

Thorough evaluation for a transplant candidate (common outcome measures:

A
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4
Q

Continuous distribution composite allocation score (CAS)

A

A tool that uses statistical modeling that is used to
estimate each candidate’s organ specific CAS range
using various patient factors.

FACTORS:
-med urgency
-likelihood of recipient survival over next 5 years post-transplant
-biological factors (blood type, height, immune sensitivity)
-age when listed
-prior living donor status
-donor and recipient hospital regions

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5
Q

What is the most common age range on the waiting list for an organ transplant?

A

50-64

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6
Q

Infection versus rejection and immunosuppression:

A

-use of immunosuppressive drugs:
–> needed because the body will automatically have a negative reaction to the new organ
(need to dampen down the effect of the immune system)

-too much immunosuppression could lead to infection, malignancy, toxicity (lack of oncogenic regulation–> malignancy)

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7
Q

What is organ transplant rejection?

A

Failure of immunosuppression medications to prevent activation of immune effector cells

-primarily mediated by T lymphocytes
–> involves both cellular (macrophages; cytotoxic T cells) and humoral immune responses (antigen-antibodies)

-white blood cells try to attack invading tissues–> leading to rejection

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8
Q

Common Post HEART Transplant Operative Issues

A

PSYCHIATRIC:
-unfulfilled expectations –> expects to return to pre-disease level
-complex medical regimen
-moodiness/agitation
-post-op complications
-unaccustomed lifestyle

MEDICAL:
-anemia
-hypertension
-electrolyte abnormalities
-weight gain
-glucose intolerance/DM
-myopathy
-osteoporosis (avascular necrosis)

EXERCISE LIMITATIONS:
-VO2max at 50-60% of normal
– myopathy, DEconditioning
– altered cellular respiration at level of mitochondria
—> related to immunosuppressive medications (affect function of mitochondria)

LONG TERM MEDICAL CONCERNS:
-injection/rejection: acute and long term
-malignancies
-renal failure

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9
Q

What is the common reason for a heart transplant?

A

-heart failure

** usually pre-renal syndrome is corrected with a heart transplant

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10
Q

Is the prevalence of heart failure in America increasing or decreasing?

A

increasing

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11
Q

Heart Transplant Indications:

A

-chronic, irreversible disease

-usually only single organ dysfunction

-correction of primary dysfunction could lead to improvement in secondary problems

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12
Q

What classes on the NYHA Classification Scale are most common for heart failure transplant patients?

A

NYHA CLASS III

NYHA CLASS IV

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13
Q

NYHA CLASS I

A

no symptoms with normal phys activity

normal functional status

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14
Q

NYHA CLASS II

A

mild symptoms with normal physical activity

comfortable at rest

slight limitation of functional status

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15
Q

NYHA CLASS III

A

-moderate symptoms with less than normal physical activity

-comfortable only at rest

-marked limitation of functional status

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16
Q

NYHA CLASS IV

A

-severe symptoms with features of heart failure with minimal physical activity and even at rest

** symptomatic at rest

-severe limitation of functional status

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17
Q

What is the most common decade of age that ppl get heart transplants?

A

5th-6th

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18
Q

What is the median survival (in years) for a heart transplant patient?

A

12 years

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19
Q

Is pediatric heart transplant survival better or worse than adult?

A

better

20
Q

If a person survives 1 year after heart transplant surgery than the likelihood of them surviving longer _____

A

increases

21
Q

In the bicaval technique of a heart transplant, does the donated or original organ drive the heart beat?

A

the heart beat and rhythm is driven by the donated organ

22
Q

Orthotopic versus heterotopic heart transplant:

A

ORTHOTOPIC:
-remove the native heart and fully implant the damaged heart

HETEROTOPIC:
-Heterotopic heart transplant in which the recipient’s heart is not excised and the donor’s heart is implanted into the recipient’s chest (rare)

23
Q

Information about the Denervated Heart:

A

-electrical activity cannot cross suture line
–> recipient atrial activity present but not conducted (2 P waves); native SA node still fires and native RA may still contract
–> donor atrium denervated but source of electrophysiologic response

-loss of SNS, PNS, innervation to donor heart
–> vagal stimulation has not effect on sinus and AV nodes
–> no reflex tachycardia in response to hypovolemia, hypotension (lack of reflex tachycardia)

-rely on increases in SV via Frank-Starling mechanism and circulating catecholamine to increase CO with activity
–> warm up and cool down are critical
** hormonal response from adrenal medulla is key

24
Q

Signs of acute heart transplant rejection:

A

-fever
-dysrhythmias
-reduced contractility
-increased dyspnea
-decreased exercise tolerance

25
Q

Signs of chronic heart transplant rejection:

A

-post transplant vasculopathy–> similar to CAD

-concentric wall thickening

26
Q

What is a similar physiological effect of both acute heart transplant rejection and chronic heart transplant rejection?

A

immune injury to myocardial cell wall and intima of coronary arteries

27
Q

Even though VO2max is typically 50-60% lower compared to baseline after a heart transplant, what is true about exercise after heart transplant?

A

Exercise can still improve outcomes after heart transplant

28
Q

Who are candidates for lung transplant?

A

-advanced lung disease
-50% mortality in 24-36 months
-progressive dyspnea (MRC 4/5)
-decreasing function
-high Lung Allocation Score: The lung allocation score estimates the severity of each candidates’ illness and his or her chance of success following a lung transplant.

-Good Match Based on:
–> blood type
–> body type
–> Cytomegalovirus (decreases match possibility)

** consider benefits of transplant versus risk of waiting**

29
Q

MRC dyspnea scale

A

1- I only get breathless with strenuous exercise.

2- I get short of breath when hurrying on the level ground or walking up a slight hill.

3- I walk slower than ppl of the same age on the level bc of breathlessness, or I have to stop for breath when walking on my own pace on the level.

4- I stop for breath after walking about 100 m or after a few minutes on the level.

5- I am too breathless to leave the house or I am breathless when dressing or undressing.

30
Q

CIs to transplant

A

-smoking- must prove abstinence
-extremes of weight (cachexia–> obesity)
-profound debility
-symptomatic OP leading to disability
-chronic med conditions that are poorly controlled or associated with end-organ damage
–> CAD, MI, DM, renal disease, hepatic disease

-psychosocial issues (substance abuse, etc)

31
Q

Is BL or unilateral lung transplant more common for an individual with CF?

A

-bilateral due to risk of infection

32
Q

Are outcomes better for BL or unilateral lung transplants?

A

-bilateral

(usually one lung transplant is performed after the other rather than both at the same time)

33
Q

What is the most common age for lung transplant?

A

-50-59

-then 60-65

-the percentage of pediatric lung transplants is going down as time goes on whereas the percentage of older adults transplants is going up as time goes on

34
Q

Survival in years for heart versus lung transplant?

A

HEART: 12 years

LUNG: a little over 6 years (a bit greater for adults compared to children)

35
Q

Difference in pediatric and adult lung transplant survival conditional on survival to 1 Year:

A

Pediatric survival is better than adults
**OVERALL SURVIVAL RATE IS HIGHER FOR BOTH

PEDIATRIC: 9.1

ADULT: 8.3

36
Q

Is the survival rate better for single lung or double lung transplants?

A

double

37
Q

Survival rates for pediatric lung transplant patients are greater than adult lung transplant patients at what year following tx?

A

about 7.5-8 years is when pediatric survival rates begin to be greater than adult

38
Q

Most common reason for pediatric lung transplant:

A

cystic fibrosis

39
Q

Most common dx for adult lung transplant:

A

COPD

IIP - Idiopathic interstitial pneumonias (IIPs)

40
Q

Considerations following lung transplant:

A

Pulmonary issues:
-loss of pulmonary lymphatics
-denervated lung
–> impaired cough reflex (reduced)
-pulmonary edema
-increased secretions

41
Q

3 types of surgical approaches for lung transplant:

A

1) Bilateral transverse thoracosternotomy (open up rib case/sternum anteriorly)

2) Thoracotomy

3) Median Sternotomy

42
Q

Ex training after lung transplant:

A

Outcomes associated with PT and ex training after transplant:

INTENSITY: 3x/week, 3 months; ex training included symptom-limited cycling, walking, stair climbing and resistance exercise

OUTCOMES:
-improved ex capacity –> aerobic capacity increases compared to pre-transplant levels but it is at 50-60% predicted levels
-improves “myopathy”
-improved bone health (BMD)
-improved health related QOL

43
Q

Various causes of exercise limitation post-transplant (oxygen transport system)

A

SKELETAL MUSCLE
-deconditioning
-dec oxidative enzymes
-dec type I fibers
-impaired mitochondrial oxygen extraction
-dec. ATP and IMP
-corticosteroid-induced myopathy

LUNG
-oxyhemoglobin desaturation
-abnormal lung mechanics
-prior to transplant, ppl are deconditioned

VASCULATURE
-impaired vasodilation (due to immunosuppressant drug)

BLOOD
-medication-induced anemia

HEART
-deconditioning
-cardiac denervation in recipients of heart-lung transplants

44
Q

Why does the transplant recipient have long-term issues with infection?

A

Transplant recipients are at risk for long-term infections because they take immunosuppressive medications to prevent transplant rejection. These medications reduce the immune system’s ability to fight infections, and a suppressed immune system has fewer white blood cells, which raises the risk of infection.

45
Q

Exercise following heart transplant:

A

-delayed HR acceleration at the start of exercise in heart transplant patients

-loss of SNS, PNS, innervation to donor heart
–> vagal stimulation has not effect on sinus and AV nodes
–> no reflex tachycardia in response to hypovolemia, hypotension (lack of reflex tachycardia)

-rely on increases in SV via Frank-Starling mechanism and circulating catecholamine to increase CO with activity
–> warm up and cool down are critical
** hormonal response from adrenal medulla is key

**MAKE SURE TO FACTOR IN WARM UP AND COOL DOWN PERIODS

46
Q
A

MED CON III (14 decks)

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