An Introduction to Transplantation

Lauren Walker, RN, BSN, CCRN

Other Contributors:

Lisa Dreyfuss, RN, BSNHilary Poan, RN, BSN

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

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

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

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.

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

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%

Liver Transplant

Common indications for liver transplant seen on our unit include: Biliary Atresia Alagille’s Syndrome Hepatitis B Hepatoblastoma Hemochromatosis

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

Liver Transplant

A liver transplant can be done in 3 ways:

1) Cadaver

2) Living-Related Donor

(generally left lobe)

3) Cadaver Split Liver

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

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)

Diagnosis leading to a SB Transplant

Structural: NEC, Gastroschisis, malformation/volvulus, trauma, atresia, tumor

Functional: Pseudo-obstruction, Megacystis, Microcolon, Intestinal Hypoperistalsis, Hirschsrpung’s disease

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%

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

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

Criteria for transplantation

Can only be listed for Intestinal transplant with: Loss of access Irretractable dehydration Multiple septic infections Liver failure r/t TPN

Types of Intestinal Transplant

Isolated Intestine Liver/Bowel Multivisceral

Liver, intestine, pancreas, stomach

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)

Pre Transplant Care Issues

TPN Dependent Infection Dehydration Malnutrition GI bleed r/t portal hypertension Waiting Time Socialization

Pre-transplant Medications

Vitamins (ADEK) Calcitriol Nystatin Iron

Post-Transplant Medications

Immune Suppression: Prograf, Prednisolone, Rapamune, Cellcept, Baxiliximab

Other Common Meds: Prevacid, Imodium, Lomotil, Reglan, Norvasc, Propranolol

Post Transplant Issues

Immunosuppression Rejection Infection Education Adherence Support

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.

Early signs and Symptoms of rejection

General Fever greater than 38°C Tachycardia High or low immunosuppressant levels Lethargy/irritability Abdominal pain or distention

Liver Rejection

Liver Increased liver function tests Nausea and/or vomiting Dark urine Jaundice Itchy skin

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

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

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

Lifetime Management Issues

Quality of Life Lifetime medication regime Lifetime laboratory surveillance of

immunosuppression levels Lifetime surveillance for rejection Annual visits to transplant center

Resources

Unos: http://unos.org/ Georgetown University Hospital

Transplant Center for Children http://www.georgetownuniversityhospital.org/body.cfm?id=555650