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Transplant 101


Transplant 101 * PRA is expressed as a percentage and represents the amount of HLA antibody present in the recipient s serum. To determine a recipient s PRA, a ... – PowerPoint PPT presentation

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Title: Transplant 101

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
  • 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?
Potential barrier?
Barrier removed?
Dialysis when indicated
Proceed with evaluation
Adapted with permission from Kasiske BL, et al.
Am J Transplant. 20011 (suppl 2)1-95.
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. 20011 (suppl
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
  • Primary oxalosis
  • Unless combined liver/kidney transplant is an

Kasiske BL, et al. Am J Transplant. 20011 (suppl
Suggested malignancy wait time
  • Prostate 2 years
  • Liver Transplant not recommended with liver
  • 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
  • Kaposis sarcoma 2 years second transplant
  • 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
  • Renal cell carcinoma large high-grade tumor 5
  • Colon cancer stage 1 2 years
  • Colon cancer stage 2 or higher 5 years

Pretransplant Recipient Evaluation
Routine tests
  • CMV test
  • Pelvic exam and Pap smear
  • Chest X-ray
  • ECG
  • HLA tissue typing and cytotoxic antibodies
  • VDRL screen
  • Lipid profile
  • Abdominal U/S
  • Full medical history and physical exam
  • CBC and chemistry panel
  • PT and PTT
  • Blood type
  • HBV and HBC serology
  • HIV screen
  • EBV
  • VZV

Kasiske BL, et al. Am J Transplant. 20011 (suppl
Pretransplant Recipient Evaluation
Elective tests
  • Barium enema and lower endoscopy
  • PSA test
  • Pap smear
  • Mammogram
  • Coronary angiogram
  • ECG
  • Voiding cystourethrogram
  • Pharmacologic or exercise stress test
  • Noninvasive vascular study

Siddqi N, et al. In Danovitch GM, ed. Handbook
of Kidney Transplantation. 2005169-192.
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 lt20 mL/min
  • Transplant center will list the patient after
  • 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
  • Time on waiting list
  • Quality of antigen mismatchHLA-DR antigens only
    (no points for HLA-A or HLA-B matches)
  • PRApoints are assigned if PRA level is gt80 with
    a negative preliminary donor/patient crossmatch
  • Pediatric patients (age lt18) awarded additional
  • Donation statusindividuals 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
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
  • Trend is toward living donation
  • Driven by longer waiting times
  • Can use donor that is not a close blood relative

2003 Annual Report of the United States
OPTN/SRTR Transplant Data 1993-2002.
Advantages and Disadvantages of Living-Donor
Kendrick E, et al. In Danovitch GM, ed. Handbook
of Kidney Transplantation. 2005135-168.
Living Donor Evaluation
  • Donors risk must be considered separately from
    recipients 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
  • Blood count/chemistry panel
  • HBV, HCV, HIV, and CMV tests
  • Fasting glucose
  • Urinalysis
  • Spot urine for protein and creatinine ratio
  • Cardiovascular workup
  • Chest X-ray
  • ECG
  • Helical CT urogram
  • Psychosocial evaluation
  • Repeat crossmatch before transplant

Contraindications to Kidney Donation
  • Age
  • lt18 years or gt60-65 years
  • Hypertension
  • gt140/90 mm Hg or need for medication
  • May need 24-hour blood pressure monitor
  • Diabetes
  • Proteinuria
  • gt250 mg/24 hours
  • GFR lt80 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.
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 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
    recipients serum (expressed as a percentage)
  • Determined by testing the recipients 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
  • 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. 2005135-168.
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 Jackson-Pratt drain
  • Will have catheter in bladder a few days

Post-Operative Care
  • 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
  • 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
  • Once a week for 4-6 weeks
  • Every other week for 4-6 weeks

Post-Operative Care
  • 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

  • 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

  • Medications After Transplant
  • Anti-rejection drugs
  • Prograf (tacrolimus)
  • Cellcept (mycophenolate mofetil)
  • Prednisone
  • Anti-infective drugs
  • Take all medications as prescribed

Financial Counselor
  • Call with any insurance changes.
  • Call with any changes in employment of you or
    your spouse if it will affect your insurance
  • 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 Post-Transplant
  • Transportation

For More Information
  • UK Transplant Center
  • (859) 323-6544 http//
  • Kentucky Organ Donor Affiliates (KODA)
  • (800) 525-3456 http//
  • National Kidney Foundation
  • (800) 622-9010 http//

For More Information
  • Transplant Patient Partnering Program
  • (800) 893-1995 http//
  • National Foundation for Transplants
  • (800) 489-3863 http//
  • United Network for Organ Sharing (UNOS)
  • (888) 894-6361 http//

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