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Transplant 101

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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


1
Transplant 101
2
Transplant Nurse Coordinators
  • Carol Broughton, RN, CCTC
  • Nancy Dawson, RN
  • Rhonda Jairam, RN, CCTC
  • Isaac Payne, RN
  • Lori Tummonds, RN, CCTC

3
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

4
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

5
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)

6
Recipient Evaluation Process
7
Kidney Transplant Evaluation Process
Referred for transplant
Initial information session
Still a candidate?
No
Yes
Potential barrier?
Evaluate
No
Yes
No
Barrier removed?
Dialysis when indicated
Proceed with evaluation
Adapted with permission from Kasiske BL, et al.
Am J Transplant. 20011 (suppl 2)1-95.
8
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
2)1-15.
9
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. 20011 (suppl
2)1-15.
10
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

11
Suggested malignancy wait time
  • Testicular 2 years
  • Kaposis 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

12
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
2)1-95.
13
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.
14
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
    evaluation
  • Patients should ask the transplant center if
    their names are on the list

15
Accruing Points on the UNOS List
  • Points are awarded in accordance with this
    formula
  • 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
    points
  • 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
http//www.unos.org.
16
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

17
Living Donor Kidney Transplant Evaluation
18
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.
19
Advantages and Disadvantages of Living-Donor
Transplantation
Kendrick E, et al. In Danovitch GM, ed. Handbook
of Kidney Transplantation. 2005135-168.
20
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

21
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

22
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.
199672288-2313.
23
Donor/Recipient Matching
  • Three factors are involved in tissue matching and
    antibody production
  • Human leukocyte antigen (HLA) antibodies
  • Crossmatch
  • Panel-reactive antibody (PRA)

24
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

25
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

26
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
    pregnancy
  • Higher PRA makes finding a donor more difficult

27
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.
28
Discharge
29
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

30
(continued)
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.

31
(continued)
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
    weeks
  • Once a week for 4-6 weeks
  • Every other week for 4-6 weeks

32
(continued)
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
    physician.

33
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

34
Pharmacist
  • Medications After Transplant
  • Anti-rejection drugs
  • Prograf (tacrolimus)
  • Cellcept (mycophenolate mofetil)
  • Prednisone
  • Anti-infective drugs
  • Take all medications as prescribed

35
Financial Counselor
  • 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.

36
Social Worker
  • Support System / Caregiver
  • Substance Abuse Policy
  • Insurance / Medication Coverage Post-Transplant
  • Transportation

37
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

38
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

39
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

40
Questions?
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