Transplant 101

1. Transplant101

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

3. 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 Transplant Team

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. 2001;1 (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. 2001;1 (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. 2001;1 (suppl 2):1-15.

10. 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

11. 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 Suggested malignancy wait time

12. 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 Pretransplant Recipient Evaluation Routine tests Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-95.

13. Voiding cystourethrogram Pharmacologic or exercise stress test Noninvasive vascular study Barium enema and lower endoscopy PSA test Pap smear Mammogram Coronary angiogram ECG Pretransplant Recipient Evaluation Elective tests Siddqi N, et al. In: Danovitch GM, ed. Handbook of Kidney Transplantation. 2005:169-192.

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 <20 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 waitinglist • 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.

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. 2005:135-168.

20. 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

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. Age <18 years or >60-65 years Hypertension >140/90 mm Hg or need for medication May need 24-hour blood pressure monitor Diabetes Proteinuria >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 Contraindications to Kidney Donation Kasiske BL, et al. J Am Soc Nephrol. 1996;7:2288-2313.

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 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

27. 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 Laparoscopic Nephrectomy Kendrick E, et al.In:Danovitch GM, ed. Handbook of Kidney Transplantation. 2005:135-168.

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) 622-9010http://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?