An Introduction to Transplantation

1. An Introduction to Transplantation Lauren Walker, RN, BSN, CCRN Other Contributors: Lisa Dreyfuss, RN, BSN Hilary Poan, RN, BSN

2. 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

3. 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

4. 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

5. 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.

6. 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

7. Who needs a Transplant? • As of 06/6/11 111,502 people are waiting for transplants 16,487 waiting for a liver Mean waiting time kids < 1 yr 223 days Mean waiting time kids 1-5 yrs 262 days 221 waiting for an intestine Mean waiting time kids < 1 yr 358 days Mean waiting time kids 1-5 yrs 425 days • National pediatric (up to 17yrs) survival from 1 to 5 years: over 83%

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

9. 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

10. Liver Transplant A liver transplant can be done in 3 ways: 1) Cadaver 2) Living-Related Donor (generally left lobe) 3) Cadaver Split Liver

11. IntestinalFailure: 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

12. Historyof 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)

13. Diagnosis leading to a SB Transplant • Structural: NEC, Gastroschisis, malformation/volvulus, trauma, atresia, tumor • Functional: Pseudo-obstruction, Megacystis, Microcolon, Intestinal Hypoperistalsis, Hirschsrpung’s disease

14. Indications in Children for Small Bowel Transplant

15. Managementof 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

16. Signs of Intestinal Failure • 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

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

18. Typesof Intestinal Transplant • Isolated Intestine • Liver/Bowel • Multivisceral • Liver, intestine, pancreas, stomach

19. 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)

20. PreTransplantCare Issues • TPN Dependent • Infection • Dehydration • Malnutrition • GI bleed r/t portal hypertension • Waiting Time • Socialization

21. Pre-transplant Medications • Vitamins (ADEK) • Calcitriol • Nystatin • Iron

22. Post-Transplant Medications • Immune Suppression: Prograf, Prednisolone, Rapamune, Cellcept, Baxiliximab • Other Common Meds: Prevacid, Imodium, Lomotil, Reglan, Norvasc, Propranolol

23. Post Transplant Issues • Immunosuppression • Rejection • Infection • Education • Adherence • Support

24. 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.

25. Early signs and Symptoms of rejection • General • Fever greater than 38°C • Tachycardia • High or low immunosuppressant levels • Lethargy/irritability • Abdominal pain or distention

26. Liver Rejection • Liver • Increased liver function tests • Nausea and/or vomiting • Dark urine • Jaundice • Itchy skin

27. 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

28. 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

29. 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

30. 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

31. Lifetime Management Issues • Quality of Life • Lifetime medication regime • Lifetime laboratory surveillance of immunosuppression levels • Lifetime surveillance for rejection • Annual visits to transplant center

32. Resources • Unos: http://unos.org/ • Georgetown University Hospital Transplant Center for Children http://www.georgetownuniversityhospital.org/body.cfm?id=555650