Transcript Infections in Patients with Diabetes Mellitus

Getting on the Waitlist
August 29, 2014
Rhonda Duggan, BSN, RN, CCTC
Living Donor Coordinator
Carolinas Medical Center
Why Choose Transplant?
•It’s expensive
•There’s not enough donors
•Quality of life issues
•Patient Survival
Advantages of Successful
Transplantation
 Increased strength & ability to engage in a more
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physically active lifestyle
Fewer dietary restrictions
Improved blood counts & improvement of symptoms of
specific disease
Improved life satisfaction, physical & emotional well
being
Potential to return to work or school without disability
Disadvantages of transplantation
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Unfortunately, there are no guarantees in transplantation.
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Need to take anti-rejection medications as long as transplanted is functioning.
These medications have potential for significant adverse effects.
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Anti-rejection medications are very expensive.
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If disability is dependent upon end stage organ disease, it will be discontinued
after a successful transplant.
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Frequent & chronic follow-up with Transplant Physician, as often as
2-3 times a week following discharge from hospital.
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Worsening of current medical problems
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Organ may not work
The BIG Questions????
Who can be evaluated?
When to begin the evaluation?
When is Liver Transplant Evaluation Initiated?
•Patients with a Model of End-stage Liver Disease score (MELD) of greater than 10.
•Patients who have developed end-stage liver disease of all types and have had
evidence of life-threatening complications such as:
ascites/fluid retention, variceal hemorrhage, encephalopathy requiring
medication, spontaneous bacterial peritonitis, worsening renal
•Patients with hepatic decompensation
•Patients with Hepatocellular carcinoma (HCC)
Early referral is essential, allowing for pre-transplant problems to be addressed and
resolved while the liver disease is relatively well-compensated. There is no
advantage, however, of early referral in terms of waiting time.
Children with liver disease should be referred for liver transplant evaluation when
they fall off their growth curve, or when their liver decompensates.
Referrals sources:
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Primary Care Physicians
Hepatologist/Gastroenterologist
 Insurance Companies
When is Cardiac Transplant
Evaluation Initiated?
 NYHA Class III-IV heart failure symptoms on maximal heart
failure medications
 Maximal Oxygen Consumption (MVO2) <14
 Severe, limiting ischemia, not amenable to surgical or catheter
intervention
 Recurrent VT
Referral sources:
• CMC’s Heart Failure Service (in and outpatient referrals)
• Outlying cardiology practices with or without heart failure
programs
• Patients in outlying hospitals in cardiogenic shock
When is Kidney Transplant Evaluation Initiated?
Once a patient has lost nearly 90% of their kidney function, the only treatment
options are dialysis or a kidney transplant. While dialysis replaces failed renal
function, a transplant replaces a diseased kidney.
Referral Sources:
 Dialysis units are regulated/mandated by CMS to address transplant as a
treatment option for every patient
 CMC has contracts with most major insurance companies
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Inhibiting Factors to
Transplantation
 Nearly 135,000 people
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are waiting for an organ
transplant
Lack of supportive care
for patients
Lack of knowledge of
the transplant process
Religious beliefs
Cost of healthcare
continues to rise and
more patients have
limited financial
resources
Contraindications to
Transplantation
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Active malignancy
Severe myocardial dysfunction
Active mental illness/Dementia
Severe Pulmonary Hypertension
Active substance abuse
Extreme obesity
Non-adherence
No support/ financial or social
Core Evaluation Appointments
 RN/NP – Transplant Coordinator
 Social Worker
 Financial Coordinator
 Dietician
 Nephrologist/Hepatologist/Cardiologist
 Surgeon
 Consults as indicated (Pulmonary, Urology, Endocrine, ID, Psychiatry)
Evaluation Tests
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Labs (organ specific)
EKG
Chest X-Ray
Other tests as indicated
Patient responsible to complete
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Yearly Dental if indicated
Yearly Pap (Females)
Yearly Mammogram (Females > age 40)
Colonoscopy (> age 50)
Yearly TB skin test (PPD)
Cardiac Evaluation Tests
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Right and left heart catheterization
MVO2
Pulmonary function tests
Abdominal ultrasound
Ankle/arm indices*
Carotid ultrasound*
*(age >50 or ischemic heart disease)
Liver Evaluation Test
Renal & Carotid Ultrasound
 Abdominal & Chest CT Scan
MRI of liver/MRA of arteries, veins & mesenteric vessels
EGD/Colonoscopy
Echo and/or Adenosine Myoview and/or Cardiac Cath
PFT with ABG
APPROVAL/LISTING
 Present to Selection Committee
 Final Insurance Approval
 UNOS Wait Listing
 Phone notification & Letter to the patient and their referring MD
Monthly blood work is required by UNOS to update MELD/PELD score,
update listing status, and assess immunologic status
And now the waiting begins……