Transcript Transplant 101 - UK HealthCare

Transplant 101
Transplant Nurse Coordinators
 Carol
Broughton, RN, CCTC
 Nancy Dawson, RN
 Rhonda Jairam, RN, CCTC
 Isaac Payne, RN
 Lori Tummonds, RN, CCTC
Transplant Team







Transplant Surgeons - Thomas Johnston, Dinesh
Ranjan, Hoonbae Jeon, Roberto Gedaly
Transplant Nephrologists - Wade McKeown and
Thomas Waid
Transplant Pharmacist - Tim Clifford
Social Workers - Mindy Murphy and Molly Patchell
Financial Counselors - Marybeth Henry and Angela
Hernandez
Clinic Staff - Erica Lynch, Lisa Collett, Aimee Bishop,
Marva Paris, and Amy Wright
Scheduling Coordinator - Mike Pelfrey
Acronyms and Abbreviations







AST = American Society of Transplantation
BMI = body mass index
CBC = complete blood count
CKD = chronic kidney disease
CMS = Centers for Medicare and Medicaid
Services
CMV = cytomegalovirus
EBV = Epsein-Barr virus
Transplant 101: Overview



Transplant as treatment for ESRD
The pretransplant evaluation
Deciding on a donor



Deceased
Living
The referring nephrologist can be responsible
for coordinating some of the pretransplant
care

Point person in coordinating care with
transplant center, specialists (eg, cardiology)
Recipient Evaluation
Process
Kidney Transplant Evaluation Process
Referred for transplant
Initial information session
Still a
candidate?
No
Potential
barrier?
Yes
Evaluate
No
Proceed with evaluation
Yes
Barrier
removed?
Adapted with permission from Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-95.
No
Dialysis when
indicated
Contraindications to Transplantation

Active malignancy or metastatic cancer

Immunosuppression can enable tumor growth

Cirrhosis
 Severe myocardial dysfunction or peripheral
vascular disease



Unless due to potentially reversible ischemia,
which should be corrected prior to transplant
Other severe, irreversible extrarenal disease
Active mental illness

If patient cannot give informed consent or comply
with drug regimens
Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-15.
Contraindications to Transplantation




Chronic infection or untreated current infection
Irreversible limited rehabilitative potential
Persistent nonadherence to treatment
Active substance abuse


Must be treated prior to transplant; drug screening may be
required as proof of drug-free status
Primary oxalosis

Unless combined liver/kidney transplant is an option
Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-15.
Suggested malignancy wait time
Prostate – 2 years
 Liver – Transplant not
recommended with liver
transplant
 Multiple myeloma –
Transplant not
recommended
 Lymphoma – 2 to 5 years
 Leukemia – 2 years






Malignant melanoma – 5
years
In situ or superficial
melanoma – 2 years
Squamous cell carcinoma
– Surveillance
Basal cell carcinoma –
None
Cervical/uterine – 2 to 5
years
Suggested malignancy wait time
Testicular – 2 years
 Kaposi’s sarcoma – 2
years; second transplant
contra-indicated
 Breast cancer – 2 to 5
years
 Lung cancer – 2 years
 Bladder cancer – 2 years,
In situ – None





Renal cell carcinoma
small low-grade tumor –
2 years
Renal cell carcinoma
large high-grade tumor –
5 years
Colon cancer stage 1 – 2
years
Colon cancer stage 2 or
higher – 5 years
Pretransplant Recipient Evaluation
Routine tests

Full medical history and
physical exam
 CBC and chemistry panel
 PT and PTT
 Blood type
 HBV and HBC serology
 HIV screen
 EBV
 VZV








CMV test
Pelvic exam and Pap
smear
Chest X-ray
ECG
HLA tissue typing and
cytotoxic antibodies
VDRL screen
Lipid profile
Abdominal U/S
Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-95.
Pretransplant Recipient Evaluation
Elective tests



Voiding
cystourethrogram
Pharmacologic or
exercise stress test
Noninvasive
vascular study






Barium enema and
lower endoscopy
PSA test
Pap smear
Mammogram
Coronary angiogram
ECG
Siddqi N, et al. In: Danovitch GM, ed. Handbook of Kidney Transplantation.
2005:169-192.
Waiting List for a Deceased-Donor Kidney

When a living donor cannot be identified
 Wait can exceed 2 years for blood types O
and B
 Administered by UNOS



Patient can be listed when GFR <20 mL/min
Transplant center will list the patient after
evaluation
Patients should ask the transplant center if
their names are on the list
Accruing Points on the UNOS List
Points are awarded in accordance with this formula:






Time on waiting list
Quality of antigen mismatch—HLA-DR antigens only (no
points for HLA-A or HLA-B matches)
PRA—points are assigned if PRA level is >80% with a
negative preliminary donor/patient crossmatch
Pediatric patients (age <18) awarded additional points
Donation status—individuals who have donated a vital organ
in the US receive preference
Medical urgency NOT a factor in points system except by
local agreement
United Network for Organ Sharing. Available at: http://www.unos.org.
Interim Medical Examinations

During wait for a deceased-donor, routine medical
evaluations should be conducted




Social worker
Surgeon
Vascular studies
Cancer screening
• Pap smears and mammograms for women
• Digital rectal exam or PSA test for men


Cardiovascular examination as indicated
The community nephrologist should advise the transplant
center of changes in health that preclude transplantation
 Patients who require medical intervention may remain on the
UNOS list, but do not accrue “time of waiting” points
Living Donor Kidney
Transplant Evaluation
Living and Deceased Kidney Donors,
1993-2002
Deceased donor
Living donor
Transplants, No.
6000

Trend is toward
living donation
 Driven by longer
waiting times
 Can use donor
that is not a close
blood relative
5000
4000
3000
2000
1000
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
2003 Annual Report of the United States OPTN/SRTR: Transplant Data 1993-2002.
Advantages and Disadvantages of LivingDonor Transplantation
Advantages
Disadvantages









Preemptive transplant option
Can select donor for haplotype
match, age
Better outcomes
Minimal delayed graft function
No wait for deceased-donor
kidney
Can time transplant for
convenience
Immunosuppressive regimen
may be less aggressive
Emotional gain to donor







Psychological stress to donor
Complete donor evaluation
process
Operative donor mortality (~1/3000
patients)
Major complications (0.2%-2%)
Minor complications
Potential donor hypertension,
proteinuria
Risk of trauma to remaining kidney
Risk of unrecognized covert renal
disease
Kendrick E, et al. In: Danovitch GM, ed. Handbook of Kidney Transplantation. 2005:135-168.
Living Donor Evaluation




Donor’s risk must be considered separately from
recipient’s need for transplant
Donor must be informed of the risks
ABO blood-type compatibility, tissue type, and
crossmatch are initial screening steps
With multiple suitable donors, the transplant
center will help determine the best donor


Family to be included in this decision
For a younger recipient who may require a second
transplant, a parent may be selected over a sibling, whose
kidney may be needed in the future
Living Donor Evaluation


Medical history and physical exam
Comprehensive lab screening




Urinalysis


Spot urine for protein and creatinine ratio
Cardiovascular workup





Blood count/chemistry panel
HBV, HCV, HIV, and CMV tests
Fasting glucose
Chest X-ray
ECG
Helical CT urogram
Psychosocial evaluation
Repeat crossmatch before transplant
Contraindications to Kidney Donation

Age


Hypertension





>140/90 mm Hg or need for
medication
May need 24-hour blood
pressure monitor
Diabetes
Proteinuria


<18 years or >60-65 years
>250 mg/24 hours
GFR <80 mL/min by MDRD
Microscopic hematuria






Multiple renal vessels
Significant medical illness
History of thrombosis or
thromboembolism
Strong family history of renal
disease, diabetes, or
hypertension
Psychiatric conditions or
substance abuse
Pregnancy
Kasiske BL, et al. J Am Soc Nephrol. 1996;7:2288-2313.
Donor/Recipient Matching
 Three
factors are involved in tissue
matching and antibody production



Human leukocyte antigen (HLA)
antibodies
Crossmatch
Panel-reactive antibody (PRA)
HLA Matching

Three groups of HLA proteins:




HLA-A
HLA-B
HLA-DR
One HLA in each group (haplotype) is inherited from
each parent
Example:
Mother = A1, A2, B8, B44, DR3,4
Father = A3, A10, B7, B55, DR11,15
Child = A2, A10, B7, B44, DR4,15
Crossmatch
 Crossmatch
tests whether the recipient
has antibodies to the potential donor



Negative crossmatch is desired
Positive crossmatch increases risk of
rejection
Antibodies can develop, so repeat
crossmatch testing is required immediately
before transplant
Panel-Reactive Antibody (PRA)

PRA is the amount of HLA antibody present
in the recipient’s serum (expressed as a
percentage)



Determined by testing the recipient’s serum
against a panel of cells from 60 people with
different HLA proteins
HLA antibodies can change, especially in
response to blood transfusion, prior transplant, or
pregnancy
Higher % PRA makes finding a donor more
difficult
Laparoscopic Nephrectomy

Advantages





Less postoperative pain
Minimal surgical scarring
Rapid return to work
(~4 weeks)
Shorter hospital stay
Magnified view of renal
vessels

Disadvantages




Impaired early graft
function
Pneumoperitoneum may
compromise renal blood
flow
Longer operative time
Tendency to have shorter
renal vessels and multiple
arteries
Kendrick E, et al. In: Danovitch GM, ed. Handbook of Kidney Transplantation.
2005:135-168.
Discharge
Post-Operative Care




After surgery, return to
Transplant wing (8 East)
Incision will be closed with
staples
May have small drain placed in
the incision called a “JacksonPratt” drain
Will have catheter in bladder a
few days
Post-Operative Care




(continued)
Will be out of bed walking in room and hallway in first
24 hours
Discharge information will be reviewed with you
frequently by your floor nurse and Transplant nurse
coordinator
Written discharge information and instructions will be
provided to take home with you
Much emphasis will be placed on teaching you your
medications, their doses, and their purpose. A
medicine list will be provided.
Post-Operative Care




(continued)
Discharge topics that will be discussed include signs
and symptoms of rejection, dietary and activity
guidelines, and clinic routine.
Average length of stay is 4-10 days
May return home at discharge
Clinic appointments are twice a week for 4-6 weeks
Once a week for 4-6 weeks
Every other week for 4-6 weeks
Post-Operative Care

(continued)
Approximately 3 months after discharge, you will be
referred to primary care doctor or nephrologist. Will
alternate visits a few times between local doctor and
us, and then most of follow-up will be with referring
or primary care physician.
Pharmacist






Home Medication Review
Inpatient medication recommendations
Coordinate with nurses and social
worker for discharge medications
Availability in hospital and clinic
Involved pre- and post-transplant
Facilitate education
Pharmacist
 Medications

After Transplant
Anti-rejection drugs
• Prograf (tacrolimus)
• Cellcept (mycophenolate mofetil)
• Prednisone


Anti-infective drugs
Take all medications as prescribed
Financial Counselor
1.
2.
3.
4.
5.
Call with any insurance changes.
Call with any changes in employment of you or your
spouse if it will affect your insurance coverage.
If you are in the process of obtaining Medicaid please
notify us for further assistance.
Insurance benefits are monitored every month by our
office.
Approval for transplant will be obtained through our
office.
Social Worker

Support System / Caregiver
 Substance Abuse Policy
 Insurance / Medication Coverage PostTransplant
 Transportation
For More Information

UK Transplant Center
(859) 323-6544 http://www.mc.uky.edu/transplant

Kentucky Organ Donor Affiliates (KODA)
(800) 525-3456 http://www.kyorgandonor.org

National Kidney Foundation
(800) 622-9010 http://www.kidney.org
For More Information

Transplant Patient Partnering Program
(800) 893-1995 http://www.tppp.net

National Foundation for Transplants
(800) 489-3863 http://www.transplants.org

United Network for Organ Sharing (UNOS)
(888) 894-6361 http://www.unos.org
Transplant-Related Quality-of-Life Benefits





Relatively unrestricted diet
Freedom to travel
Ability to become pregnant and bear children
Can engage in training for athletic
competition
Lifestyle free of dialysis constraints
Questions?