Organ TransplantationProfessor Richard Frank, MSN, RN

A Few Key Historical Facts:

• 1954: First successful kidney transplant performed

• 1968: Uniform Anatomical Gift act signed

• 1968: First organ procurement organization (OPO) established, New England Organ Bank (based in Boston)

• 1983: FDA approved cyclosporine anti-rejection medication

• 1984: National Organ Transplant Act operated by UNOS

• 1998: Plasmapheresis introduced; enabled kidney transplants in patients whose blood group/antibodies incompatible with donor

• 1998: First successful hand transplant performed in France

• 2011: First successful full face transplant performed in the US (Boston, MA)

1968: Uniform Anatomical Gift • Establishes uniform organ donor card as a legal document.

• Next of kin can donate without the presence of a donor card.

• Website

1984: National Organ Transplant Act • National Organ Transplant Act (NOTA) maintained by the United

Network for Organ Sharing (UNOS)

• Authorizes financial support for Organ Procurement Organizations (OPOs); prohibits buying or selling of organs in the United States.

• Website

1986: Required Request Law

• Requires hospitals to develop policies to identify patients as potential donors

• Requires hospitals to approach families regarding organ donation

1998: National Conditions of Participation Legislation• Requires hospitals to refer all deaths and imminent deaths to the

local procurement organization.

LET’S REVIEW …

Uniform Anatomical Gift: __________________________________________________________________________________________________________________

National Organ Transplant Act: ________________________________________________________

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Required Request Law: ________________________________________________________

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National Conditions of Participation Legislation: ________________________________________________________

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Organ & Tissue Transplantation

• Cornea

• Kidneys

• Skin

• Bone marrow

• Heart and heart valves

• Intestine

• Bone

• Lung

• Liver

• Pancreas

Who Can Donate?• Direct Donation

• Non-Direct Donation

• Living Donor

• Cadaver Donor

Determining Brain Death & the Uniform Brain Death Act• Irreversible coma

• Unresponsive to all stimuli

• Absence of spontaneous muscle activity

• Irreversible cessation of circulatory and respiratory function

• Isoelectric electroencephalogram (EEG) for 30 minutes

The Different Types of Organ Donors:

• Types of Living Donor Transplants• Kidney (entire organ)• Liver (segment)• Lung (lobe)• Intestine (portion)• Pancreas (portion)• After brain death

• Kidney• Heart• Liver • Lungs• Pancreas• Intestine• Heart valves• Connective tissue

• Cadaver• After natural death

• Cornea• Bone• Skin • Blood vessels

Living-Relative-Stranger

Cadaver

Types of Transplants

• Autograft

• Allograft

• Isograft

• Xenograft

LET’S REVIEW …Who Can Donate? _______________________________________________________

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How is Brain Death Determined? ________________________________________________________

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Uniform Determination of Death Act:

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What are the Different Type of Organ Donors? ________________________________________________________

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What are the Different Types of Transplants? ________________________________________________________

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Liver Transplant• End-stage liver disease

• Chronic viral hepatitis

• Live and cadaver donors

• Post-op complications• Rejection

• Infection

• Nursing Care• Neuro assessment

• Hemorrhage

• Respiratory assessment

• Urinary output

• Labs

• Vital signs

• Assess for s/s of infection and rejection

Heart Transplant

•End-stage heart failure• Patient dependant on

inotropes• Refractory cardiogenic

shock

•Cardiomyopathy

• Inoperable CAD

Lung Transplant • End-stage lung disease

• 4 types of surgery• Single lung• Bilateral lung• Heart-lung• Lobe transplant

• Post-op care • Ventillatory support• Hemodynamic monitoring• Immunosuppressive therapy• Monitor for s/s of infection

and rejection

• Website

LET’S REVIEW …LIVER Transplant:

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LUNG Transplant:

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HEART Transplant: ________________________________________________________

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How are organs allocated?

•ABO blood type

•Medical urgency

•Time on the waiting list

•Geographic location

United Network for Organ Sharing (UNOS)• Coordinates the organ transplant system in the United States

• Increases public awareness of the critical need for donated organs and tissues

• Maintains the national organ transplant waiting list• Coordinates the matching and distribution of donated

organs

• Collects and reports data on transplant recipients, donors and outcomes

Organ Procurement Organizations (OPOs)•Responsible for recovering the organ and keeping it

viable until it is transplanted, and transporting the organ to the recipient

•New England Organ Bank: oldest OPO in the US• Covers the 6 New England states and Bermuda• OPO procurement coordinator will take over the care of

the donor until surgery

Organ Donor Waiting list:

Data source: http://optn.transplant.hrsa.gov/

Prioritizing Patients for Transplantation• Each organ type has its own individual distribution policy

• Patients who are close biological matches with a particular donor offer are given priority

• Patients whose medical status is most urgent receive priority

• Organs are offered locally first

• Children are often offered priority

• Wait time is used to break ties between patients who are similar

UNOS Regional Map Region 1 - Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island

Region 2 - Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania, Northern Virginia,

West Virginia

Region 3 - Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Puerto Rico

Region 4 - Oklahoma, Texas

Region 5 - Arizona, California, Nevada, New Mexico, Utah

Region 6 - Alaska, Hawaii, Idaho, Montana, Oregon, Washington

Region 7 - Illinois, Minnesota, North Dakota, South Dakota, Wisconsin

Region 8 - Colorado, Iowa, Kansas, Missouri, Nebraska, Wyoming

Region 9 - New York, Vermont

Region 10 - Indiana, Michigan, Ohio

Region 11 - Kentucky, North Carolina, South Carolina, Tennessee, Virginia

LET’S REVIEW …ORGAN ALLOCATION: ________________________________________________________

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ONUS:

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ORGAN PRIORITIZATION FOR TRANSPLANTATION: ________________________________________________________

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UNOS REGIONS: ________________________________________________________

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Organ offer process

•Deceased organ donor is identified

•UNOS notifies transplant team of the first person on the match list•Potential recipient must be available 24 hours a

day •Given one hour to accept or turn down the organ

• Evaluated for presence of infection

• Admit to hospital for pre-op

Blood type matching

Human leukocyte antigen typing (HLA)• HLA antigens are detected on the surface of White Blood Cells.

• Regulates how the body recognizes and rejects foreign tissue.

• There are 5 loci with 2 antigens at each locus (total of 6 antigens)• A, B, C, D and DR

• The goal is to match as many antigens as possible

• Certain organs and tissue transplants require a closer match than other organs

Human leukocyte antigen (HLA) type

LET’S REVIEW …ORGAN OFFERING:________________________________________

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UNOS & OPOs: ___________________________________________

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PRIORITIZATION: _________________________________________

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Transplant RejectionTransplant rejection

• Hyperacute• Occurs minutes to hours after

transplantation

• No treatment (organ must be removed)

• Acute• Occurs days (one week) to

months after transplantation

• T- cytotoxic lymphocytes attack the transplanted organ

• Chronic• Occurs over months to years

• Most common in lung transplants

Some Common Signs & Symptoms

• Pain at the site of the transplant

• Feeling ill

• Flu-like symptoms

• Fever

• Weight change

• Swelling

• Decreased urine output

Immunosuppressive Therapy•Triple therapy (all PO/IV)

• Cyclosporine• Prevent a cell-mediated attack (helper T-cells) against the organ

• Corticosteriod: prednisone-methylprednisolone (Solu-Medrol)• Suppress inflammatory response

• Cytotoxic drug: mycophenolate mefetil (CellCept) or cyclophosphamide (Cytoxan)• Suppress immune response by inhibiting proliferation of T and B cells

•Monoclonal Antibodies: muromonab-CD3• Used for preventing and treating acute rejection episodes

•Polyclonal Antibodies: Atgam• Used as induction therapy or to treat acute rejection

Calcineurin inhibitor: Cyclosporine•Most effective immunosuppressant available

•Prevents cell mediated attack against the new organ

•Potentially nephrotoxic

•Avoid grapefruit juice

•Side effects• Nephrotoxicity• Increased risk of infection• Neurotoxicity (seizure activity, tremor)• Hepatotoxicity• Lymphoma• Hypertension• Gingiveal hyperplasia

Corticosteroids: Prednisone, Methylprednisolone, Solu-Medrol

•Very effective in suppressing the inflammatory response but large doses are associated with adverse effects• Altered wound healing• Altered metabolism of fats, proteins, and carbohydrates• Increased blood glucose levels• Emotional disturbance• Osteoparosis• Change in fat distribution: cushingoid appearance

• Moon face

• Increased truncal fat

• Buffalo hump

Cytotoxic Drug: mycophenolate(CellCept)•Suppresses T and B lymphocytes

•Decreases the incidence of graft loss

•Side effects•GI toxicity n/v/d•Neutropenia•Thrombocytopenia• Increased risk of infection• Increased risk of malignancy

Monoclonal Antibodies: muromonab-CD3, orthoclone OKT-3

•Used in preventing and treating acute rejection episodes

•The antiantigen receptor antibody interferes with the function of the T-lymphocytes

•Given IV push 7-14 days

•All T-cells are affected with in minutes of administering the drug and the number of circulating T-cells decrease rapidly

•Associated with terrible side effects

Polyclonal Antibody: Atgam•Used to as induction therapy

•Side effects• Fever• Chills• Muscle and joint pain• Increased heart rate• Back pain• Shortness of breath• Hypotension• Rash• Increased risk of infection

Immunosuppressive Therapy: Side Effects

•Nephrotoxicity

• Increased risk of infection

• Lymphoma

•Hepatotoxicity

•Neutropenia

•Thrombocytopenia

•Diarrhea/nausea/vomiting

LET’S REVIEW …

REJECTION: ______________________________________________

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IMMUNOSUPPRESSIVE THERAPIES: ___________________________

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IST SIDE EFFECTS: _________________________________________

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Nursing Care of the Transplant Recipient•THE PATIENT

•THE HOME

•THE TRANSPLANT

•INFECTION & REJECTION

Nursing Care of the Transplant Recipient•THE PATIENT:•Hand washing•Assess for infection•Restrict visitors who have minor upper respiratory infections

Nursing Care of the Transplant Recipient•THE HOME•Assess for graft vs host disease•Monitor labs•Reverse or protective isolation

Nursing Care of the Transplant DONOR•THE TRANSPLANT•Adequate nutrition•IV bags and tubing •Invasive lines and catheters

Nursing Care of the Transplant Recipient

•INFECTION & REJECTION•Strict personal hygiene and mouth care•Assess for evidence of rejection•Strict medication regime

LET’S REVIEW …THE PATIENT: _____________________________________________

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THE HOME:_______________________________________________

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THE TRANSPLANT: _________________________________________

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INFECTION & REJECTION: ___________________________________

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