Transplantation Flashcards
major histocompatibility complex (MHC) what is it
a set of molecules on cell surfaces that are responsible for lymphocyte recognition - these set of molecules uniquely identify us as us
also known as HLA - human leukocyte antigen - set of molecules responsible for recognizing foreign antigens that come into contact with me as a person
self cells recognize self cells, any protein that enters my organism of self gets recognized as a foreign antigen, the recognition of foreign antigen illicit’s an immune response which response
an inflammatory response which potentiates the risk for SIRS
what is an antigen
foreign substance/protein that illicit’s immune response (antibodies)
its what keeps us healthy
identical twins have the same
HLA - human leukocyte antigen
a transplant pt is at HIGH RISK for
organ REJECTION and INFECTION secondary to suppression of immune response
in 1968 the UAGA (uniform anatomical gift act) stated
increased donation - framework when we donated an organ it was a gift - given upon death - donate tissue, skin, eyes - the 1st legal process
NOTA (national organ transplant act) stated
1984 - resulted in formation of an organ procurement organization network that provided professional education for a need for national coordinated organization for transplantation - beginnings of network - hospitals in charge of procurement of organ
phila gift of life 1 of the 1st organ procurement transplant centers
UNOS - United Network for Organ Sharing
1986 - US government created this for organ procurement of organs - management of organ donation - national network - all regions in US required to have an organ procurement center by law - hospitals no longer in charge of managing organ procurement - outside source builds trust
difference between donation and transplantation
Donation - OPO (organ procurement organizations) “gift of life” is the one responsible for coordinating and managing donation process. OPO provides support to families prior to, during and after donation
Transplant - OPO will help coordinate with hospitals transplant coordinators - interdisciplinary approach
what is a nurses responsibility when a family shows interest in organ donation of a loved one
notify charge nurse - contact OPO invite them to talk to family - we don’t directly discuss donation with patients
**what is best practice in organ donation process
the earlier we identify potential donors the better - OPO gets involved early on and builds relationships
strategies to increase organ donation
All hospitals must have an agreement with an OPO
The hospital must notify the OPO in a timely manner
The OPO determines medical suitability for donation
The hospital and the OPO must collaborate in family notification and education services
The hospital and the OPO must collaborate in educating hospital staff
Hospitals must review death records analysis of identification of potential donors and maintain fxn of donors
Responsible for recovery of organ from deceased
box 21-1
categories of organ donor/sources
- **living relatives or unrelated (kidneys,liver) - must meet certain criteria - HLA most closely matches relatives (except liver)
- **deceased donor (meets brain death criteria) best transplant donor - still perfusing
- **deceased after cardiac/circulatory death (DCD) - heart has stopped beating and pt stopped breathing
living donor is at risk for this post-op/assess for
LIVER (infection - decreased immune response
bleeding problems)
KIDNEYS (urine output)
what criteria must be met to become a donor
overall good health
free from: diabetes, cancer, heart disease, kidney disease
compatible blood type (HLA testing)
***in liver transplant what is different for appropriate donation
don’t need to match HLA
ONLY BLOOD TYPE and BODY SIZE
brain death is determined by
complete cessation of brain function that is irreversible
2 physicians determinant (neurologist and intensivist)
3 elements of cessation of brain functioning
pt is in a coma
pt is apnic
absence of brain-stem reflexes
***criteria for the physician exam to determine brain death
complete entire physical exam
pt must be normothermic (can’t be hypothermic)
pt must be oxygenated (can’t be hypoxemic) as e/b ABG
pt cannot be on medications that suppress the CNS (no sedation)
federal and state laws require physician notification of the OPO following determination of brain death, t or f
true
clinical criteria for brain death determination
pt will have absent corneal reflexes
pt will have absent light reflexes - pupils unresponsive pt must be w/o sedation
pt will have absent dolls eyes - eyes turn opposite direction of the turned eyes
pt does not have a gag reflex (when suctioned no gag reflex)
apnea testing - PaC02 >60
**what is apnea testing when determining brain death
pg 661 chart 21-3
pt on ventilator - Take baseline ABG - take pt off vent for 8 min draw ABG
pre apnea ABG PaC02 is normal (35-45)
post apnea ABG Pa02 decreases - PaC02 is increased; greater than 60 indicates brain death - not exhaling C02,
can a DCD pt still be a donor
yes - (kidneys within 8hrs)
hypo-perfusion/re-perfusion injury is at increased risk for
SIRS
how do we obtain consent for donors
informed consent
family consent for donation - (donor designation - drivers license is the consent)
presumed consent - if i don’t mark on license everyone is considered as a donor - must identify NOT wanting to donate
**what are some myths and fears assoc w/consent to donate
think they might not be dead yet
inferior care - personnel will not care as much
disfiguring - cant do open casket funeral
religious beliefs
costs - fear of fees for those uninsured
***once pt is identified as brain dead the focus of care shifts to
promoting optimal physiologic status to preserve organ fxn (maint norm ABG’s, glucose reg, hemodynamic stability, electrolytes, clotting fxrs)
*nursing mgmt goals for donor care - 4
oxygenate the organs - ABG
maintain hemodynamic stability - determined by BP
maintain fluid/electrolyte balance (K, Na)
maintain temp regulation
recovery of organs - role of the critical care nurses
emotional support for family - OPO
physiological support for pt
communication/collaboration
transplant rejection - we expect every pt to have some type of rejection, t or f
true - assess for rejection and complications r/t infection because we expect an immune response, mostly cell-mediated rejection response
which immunity would come from an antibody response
humoral immunity
transplanted organ will have different antigens (proteins) than the recipient, t or f
true - we anticipate an antigen mediated immune response that is cell-mediated
a cell-mediated antigen response occurs because
cytotoxic T cells are capable of killing foreign cells from foreign organ
what do helper T Cells do
help regulate the immune response and send proliferative cells to destroy the foreign invader
what do suppressor T cells
helps down regulate up-regulators
normal immune response wants to get rid of the foreign organ, t or f
true
trt for patients receiving an organ is about
regulating the cell mediated immune response - we want to suppress cytotoxic T cells, stop helper T cells to up-regulate an immune response
what drugs do we give to try and regulate the immune response
immuno-suppressants, steroids, anti-inflammatory
suppression of the immune response
** 3 types of rejection **
hyper-acute
acute
chronic
what is hyper-acute rejection
antibody (humoral) mediated response - the person who received the organ had already had a memory of that antigen (blood transfusion w/bld type, mother with incompatibility RH pregnancy)
what is acute rejection
cell-mediated immune response - happens to everybody
what is chronic rejection
a combination of cell mediated and antibody mediated long term rejection response
a hyper-acute rejection happens when
as soon as the organ is reperfused, in the OR or ICU
how do we trt acute rejection
anticipate it give immune-suppression meds in OR to help decrease effects after surgery
when does a chronic rejection occur
years after transplant - long term antibody development/chronic which induces organ to be rejected after a long period of time
when does acute rejection occur
weeks to months after transplant - we balance and coordinate immune-suppressant therapies
treatment after chronic rejection
pt would need another transplant
which renal transplant pt being cared for in the ICU is showing s/s of acute rejection
pt with tenderness over the graft site and a 15lb 3-day weight gain
tenderness over a graft site is indicative of
rejection
***what is the purpose of induction therapy
to induce tolerance of transplanted graft - can be given
pre, intra or post-op
goal of immunosuppression
decrease activity of the helper T cells
immunosuppression therapy is given 2 ways
induction therapy - pre-inta-post operatively
maintenance therapy - long-term combination therapy
immunosuppressant meds cause increased risk for
infection, malignancies, glucose intolerance, rejection - down-regulating immune response
most definitively determine rejection by doing this
biopsy the organ - EXCEPT THE LIVER
why not do liver biopsy to determine rejection
bleeding and infection
pt with end stage liver disease and are in need of a transplant are at high risk for
bleeding, infection, hepatic encephalopathy
contraindications for receiving a liver transplant
metastatic cancer, alcohol cirrhosis, AIDS, advanced cardiovascular disease
donor criteria for a liver transplant
blood type and body size - NO HLA required
good for non-relative donor
MELD (model end-stage liver disease) criteria formula that calculates
risk for mortality - used to classify severity of liver disease
the sicker pt is w/liver disease the less likely to survive transplation
MELD score parameters
assess for increased serum creat levels INR Bilirubin if increased, increased risk for death
mgmt of pre-transplantation phase
q 1hr neuro assessments HOB elevated 30-40 degrees (avoid aspiration w/declining mental status and oxygen) 1:1 bed in low position do paracentesis for ascites
post-op mgmt for liver transplant pt
maintain BP, electrolyte status
watch for coagulopathy problems
carefully measure t-tube drainage (biliary drainage)
monitor liver fxn tests - elevated = possible rejection
monitor PT and INR times
monitor temp - chg with tachycardia be suspicious of infection - call the DR!
any decrease in t-tube drainage would indicate
the liver is starting to not work
pain and tenderness at the site, other than post-op would warrant suspicion of
rejection
the most common complication of liver transplant is
hepatic artery thrombosis or HAT
HAT (hepatic artery thrombosis) happens because of and includes these s/s
a graft dysfunction - causing increased bleeding, infection, decreased drainage from t-tube and increased liver enzymes
dx of HAT (hepatic artery thrombosis)
Doppler ultrasound
family education upon discharge of liver transplant
continued surveillance of infection and rejection
weekly visits to PCP
