Transplantation Flashcards
With transplant what 2 opposing factors are docs trying to balance?
Oversuppression, drug toxicity and Infection VS Undersuppression & Organ/cellular rejection.
What mediates the main antigenic response to the transplanted organ?
T lymphocytes
What are common psychological issues post transplant?
Unfulfilled expectations - patient anticipates return to pre-disease level.
- Doesn’t understand transplant process: “chronic transplant disease”.
- Complex medical regimen
- Moodiness/ agitation
- Post-operative complications
- Unaccustomed lifestyle
What are common medical issues post transplant?
anemia hypertension electrolyte abnormalities: excessive weight gain glucose intolerance/ DM Myopathy*** Osteoporosis*** (avascular necrosis)
What are common exercise limitations post transplant?
VO2 max ~ 50- 60% of normal
Myopathy/ deconditioning
change in cellular respiration –> cyclosporine
Long term “Medical” concerns post transplant?
Infection/ Rejection
Malignancies
Renal failure
What factors have caused the # of heart transplants per year to level off?
donor shortages, but also mechanical hearts are being used.
What is survival rate after heart transplant at 10 years? at 25 years?
50%, and ~15%
What are the top 2 medical conditions which prompt heart transplant?
Cardiac myopathy and Coronary artery disease.
How many levels are there for the New York Heart Association Classification of heart failure
4
What is definition of NYHA Classification of heart failure level I?
Ordinary physical activity does not cause undue fatigue, dyspnea, palpitation
Can complete any activity requiring ≤ 7 mets
What is definition of NYHA Classification of heart failure level II?
Ordinary physical activity causes fatigue, dyspnea, palpitation, or angina.
Can complete any activity requiring ≤ 5 mets
What is definition of NYHA Classification of heart failure level III?
Comfortable at rest; less than ordinary physical activity causes fatigue, dyspnea, palpitation, or angina.
moderate limitations.
Can complete any activity requiring ≤ 2 - 3 mets
What is definition of NYHA Classification of heart failure level IV?
Cannot do or cannot complete any activity requiring ≥ 2 mets .
severe limitations.
What are some features of the denervated heart?
Electrical activity cannot cross suture line
Recipient atrial activity present but not conducted
Donor atrium denervated but source of electrophysiologic response
Loss of SNS, PNS innervation to donor heart
Vagal stimulation has no effect on sinus and AV nodes
No reflex tachycardia in response to hypovolemia, hypotension
ECG has 2 P waves
rely on increases in SV via Frank-Starling Mechanism and circulating catecholamine to increase CO (CO = SV x HR) with activity
“warm up” & “cool down” are critical
What are some sign/symptoms of acute or chronic heart transplant rejection?
fever , increased dyspnea, dysrhythmias, decreased exercise tolerance, reduced contractility. chronic rejection/ CAD: “Post transplant vasculopathy .
When vasculopathy develops from chronic heart transplant rejection, what is the treatment?
another transplant
Who Are the Candidates for Lung Transplant?
Advanced lung disease 50% mortality 24-36 months Progressive dyspnea Decreasing Function High Lung Allocation Score Good Match Blood type Body type CMV **Benefits of transplant versus risk of waiting**
Contraindications to Transplant
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)
Which age group has the highest percentage of lung transplants?
50-59 years old
What are the top two reasons to have a lung transplant?
COPD and IPF (idiopathic pulmonary fibrosis)
The 50% survival rate for lung transplant is about how many years?
5 years
What are the factors that go into making the Lung Allocation Score (0-100 where higher # has higher priority)
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
New transplant guidelines are based on a lung allocation score (LAS)
How sick is the patient?
LAS (0 - 100) prioritizes lung allocation
Lung donation not based on waiting list time
Get fully evaluated for future lung transplant
IPF & Cystic Fibrosis favored over Emphysema
What are issues after lung transplant?
Pulmonary Issues: -pulmonary capillary changes -loss of pulmonary lymphatics -denervation leads to Pulmonary Edema leads to Secretions
What are the issues related to loss of lung lymphatics following transplant?
increased extravascular fluid –>
increased pulmonary edema leads to high arterial-alveolar gradient causing hypoxemia
What are the issues related to denervation following lung transplant?
impaired ciliary function/ decreased mucociliary clearance, decreased sensation in transplanted airway/ decreased cough reflex –>
impaired mucociliary clearance
Surgical approaches to lung transplant:
bilateral transverse thoracosternotomy
“clam shell”
median sternotomy
thoracotomy
Musculoskeletal Issues from lung transplant:
chest wall hurts like a bastard.
limited inspiratory/ expiratory volumes and flows
↑ risk of Post op Pulm Complications
Post transplant inpatient management, extra pulmonary:
Hemodynamic instability:
-hypovolemia, -myocardial irritability, -depressed myocardial contractility, -supraventricular dysrhythmias
mechanical ventilation/ chest tubes/ lines/ physiologic monitors
Pulmonary Surgical Considerations:
- denervation
- pulmonary capillary & lymphatic changes’s
Extra-pulmonary Surgical Considerations:
HR/ CO/ BP changes’s lines/ tubes/ monitors Poor cough Impaired mucociliary clearance increased retained secretions Pulmonary edema Pain ↑ infection risk/ Immobility & deconditioning
Post Transplant - Inpatient Management
Airway Clearance:
deep breathing/ incentive spirometry CPT as needed directed cough “Brace” incision Early & frequent mobilization Pain control
Post Transplant - Inpatient Management
mobilization:
upright/ OOB
assisted ambulation
progression to treadmill/ bicycle ergometer
physiologic responses
HR/ BP/ SaO2/ RR/ RPE
Pulmonary Rehabilitation OR Phase I Cardiac Rehab
Transplantation: Outpatient Management
Exercise prescription initial:
symptom limitation: DOE/ pain
Cardiac (Phase II through III)
Pulmonary Rehab
Transplantation: Outpatient Management
Exercise prescription later (maintenance):
Fitness/ Wellness Program
Signs/ symptoms of rejection &/ or infection
Lung Transplantation: Infection and Rejection
Signs/ symptoms & treatments
fever/ malaise/ cough
decreased airflow (FEV1 & FVC)
oxygen desaturation
decreased exercise capacity
Tx:
activity/ exercise modifications
“collaborative self management”
Acute lung rejection (First 3 months) scale:
Biopsy Histological diagnosis 0-no symptoms, no evidence; no treatment 1-mild 2-moderate 3-severe-rare 4-severe-rare (likely fatal) Rx: ↑ immunosuppression (e.g.: corticosteroids)
Chronic lung rejection (> 1 year)
Bronchiolitis Obliterans Syndrome (BOS)
Diagnosis of exclusion
Worsening Pulmonary Function Testing
Rx: ↑ immunosuppression
retransplantOutcomes Associated with Physical Therapy in lung Transplant
Improved exercise capacity VO2 / work capacity: significantly , but remains sub-normal (~ 40 – 60% max. predicted) Improves “myopathy” Improved “bone health” ↑ BMD Improved heath related quality of life (HRQOL) \+/- changes in post-op” complications HTN Hyperlipidemia Hyperglycemia/ DM Increased body weight
