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Transplant
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An Introduction to Transplantation
Lauren Walker, RN, BSN, CCRN
Other Contributors:
Lisa Dreyfuss, RN, BSNHilary Poan, RN, BSN
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Goals and Objectives:*By the end of the lecture, students will have an understanding of:
-The history of pediatric GI transplant
-The qualification of being listed for transplant
-Common diagnosis indicating a need for a liver or small bowel transplant
-Signs and symptoms of liver and small bowel failure
-Common preop/postop medications
-Signs and symptoms of organ rejection
-Lifetime management concerns after transplant
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History
Transplants have been performed for over 50 years in United States: 1950s
First Successful Kidney 1954
1960s First Successful Liver 1967 First Successful Heart 1968 First Successful Pancreas 1968
--UNOS http://www.unos.org/whoWeAre/history.asp
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Transplant History
Then nothing until…. 1980s
Why? CYCLOSPORIN (early generation Prograf) introduced 1983
First Successful Single Lung 1983 First Successful Double lung 1986 First Successful Intestine 1987 First Living donor liver 1989
--UNOS www.unos.org/whoWeAre/history.asp
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Organ Allocation: Getting Listed
United Network for Organ Sharing
(UNOS) maintains the transplant list.
Transplant centers do a thorough evaluation of a candidate
When a person is accepted for transplant by a transplant center, the center contacts UNOS and they are added to the list.
Once listed, the transplant center contacts the candidate to let them know they are listed.
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Organ Allocation: Allocation
When an organ is available, UNOS tracks and allocates the organ
Organs are allocated by status. For Georgetown criteria is based on the Pediatric End Stage Liver Disease (PELD) Scoring System
Status 1A – fulminant liver failure (no previous liver failure)
Status 1B – liver failure necessitating the need for a blood transfusion within a 24 hour period for liver candidates
Score from 1-40 based on labs including bilirubin, albumin, INR, age, growth failure. Pt. in need of SB get an automatic 23 points.
Priority is as follows: Local Regional (DC is in region 2 , which also includes - Delaware, Maryland, New
Jersey, Pennsylvania, West Virginia) National
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Who needs a Transplant?
As of 06/6/11 111,502 people are waiting for transplants
16,487 waiting for a liverMean waiting time kids < 1 yr 223 daysMean waiting time kids 1-5 yrs 262 days
221 waiting for an intestineMean waiting time kids < 1 yr 358 daysMean waiting time kids 1-5 yrs 425 days
National pediatric (up to 17yrs) survival from 1 to 5 years: over 83%
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Liver Transplant
Common indications for liver transplant seen on our unit include: Biliary Atresia Alagille’s Syndrome Hepatitis B Hepatoblastoma Hemochromatosis
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Signs of Liver Failure
Increased Liver Function Tests (ALT, AST, Alk phos, bilirubin (direct and indirect)
Jaundice Bleeding Ascites Spleno/Hepatomegaly Glucose Intolerance Increased Infection Malnutrition (Vit. A, D, E, K) Dark Urine Puritis Osteoporosis/Fractures
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Liver Transplant
A liver transplant can be done in 3 ways:
1) Cadaver
2) Living-Related Donor
(generally left lobe)
3) Cadaver Split Liver
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Intestinal Failure: Definition
The inability of the gastrointestinal
system to maintain fluid, electrolyte, and nutritional balance of the body
Condition requires supplementation from sources outside of the GI tract
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History of Intestinal Transplant
1988 1st successful transplant. Why so late? Large organ Lots of lymphoid tissue in intestinal system = immunity Bacterial flora
Outcomes have improved with new medications (Prograf)
Currently 23 centers have patients listed for intestinal transplant. Pittsburgh and GUH are the largest.
National pediatric (up to 17yrs) survival rate from 1 to 5 yrs: over 71.5% (63.8% for kids under a yr)
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Diagnosis leading to a SB Transplant
Structural: NEC, Gastroschisis, malformation/volvulus, trauma, atresia, tumor
Functional: Pseudo-obstruction, Megacystis, Microcolon, Intestinal Hypoperistalsis, Hirschsrpung’s disease
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Indications in Children for Small Bowel Transplant
Other2%
Microvillus Inclusion
6%
Re-Tx7%
Pseudo-Obstruction
9%
Malabsorption Other
4%
Tumor1%
Motility - Other
2%Aganglionosis/Hirshsprung's
7%
Volvulus18%
Gastroschisis21%
Necrotizing Enterocolitis
12%
Intestinal Atresia7%
Short Gut Other
4%
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Management of Intestinal Failure
Gut Rehabilitation STEP procedure Intestinal stretching Time (as patient grows, gut grows and
absorbs more) Lifetime TPN – Will lead to liver failure Intestinal Transplant
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Diarrhea Constipation Emesis Fluid Imbalance and signs and symptoms of fluid
imbalance Electrolyte Imbalance and signs and symptoms of
electrolyte imbalance Malnutrition and signs and symptoms of malnutrition Failure to Thrive (FTT) Skin breakdown r/t diarrhea Liver failure and its signs and symptoms if TPN
cholestatis occurs
Signs of Intestinal Failure
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Criteria for transplantation
Can only be listed for Intestinal transplant with: Loss of access Irretractable dehydration Multiple septic infections Liver failure r/t TPN
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Types of Intestinal Transplant
Isolated Intestine Liver/Bowel Multivisceral
Liver, intestine, pancreas, stomach
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The transplanted organ
Must be at least 70% size of recipient Minimal downtime/ischemic time
(intestine 10 hours or less, liver 24 hours)
minimal pressor support before harvest ABO compatibility Negative crossmatch (PRA)
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Pre Transplant Care Issues
TPN Dependent Infection Dehydration Malnutrition GI bleed r/t portal hypertension Waiting Time Socialization
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Pre-transplant Medications
Vitamins (ADEK) Calcitriol Nystatin Iron
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Post-Transplant Medications
Immune Suppression: Prograf, Prednisolone, Rapamune, Cellcept, Baxiliximab
Other Common Meds: Prevacid, Imodium, Lomotil, Reglan, Norvasc, Propranolol
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Post Transplant Issues
Immunosuppression Rejection Infection Education Adherence Support
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Rejection
The immune system protects the body from anything that is not self.
Because a transplant is foreign to the body, without intervention, the immune system will attempt to destroy it.
Goal of immunosuppressants is to inhibit immunological response and therefore prevent rejection.
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Early signs and Symptoms of rejection
General Fever greater than 38°C Tachycardia High or low immunosuppressant levels Lethargy/irritability Abdominal pain or distention
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Liver Rejection
Liver Increased liver function tests Nausea and/or vomiting Dark urine Jaundice Itchy skin
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Intestine Rejection
Intestine Increased stools and/or ostomy output Dehydration Increasing WBC Falling hemoglobin, albumin, or iron saturation Weight loss Bloody stools/ostomy output Pale, black, or bleeding stoma Output with clots or chunks of tissue Sepsis
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Rejection Monitoring
LFTs for Liver Output and stoma for SB, appearance
during scopes ONLY SURE WAY TO KNOW is
through a biopsy
Rejection is treated with high dose Steroids and Thymoglobulin
Major Complication: Infection
Most common complication because of immunosuppression
HAND WASHING Avoid sick contacts No raw foods, no live vaccines, no cleaning
up after pets Prophylactic Meds Surveillance labs for EBV, CMV, Adenovirus
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Life after Transplant
Scope twice a week for the first month Once a week for the next two months Annual scope Blood draws twice a week for the first 3 months Labs once a week until labs are stable Labs at least once every three months Lifetime of immunosuppressants Rejection can happen at any time
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Lifetime Management Issues
Quality of Life Lifetime medication regime Lifetime laboratory surveillance of
immunosuppression levels Lifetime surveillance for rejection Annual visits to transplant center
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Resources
Unos: http://unos.org/ Georgetown University Hospital
Transplant Center for Children http://www.georgetownuniversityhospital.org/body.cfm?id=555650
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