transplant 101.  carol broughton, rn, cctc  nancy dawson, rn  rhonda jairam, rn, cctc ...

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  • Slide 1
  • Transplant 101
  • Slide 2
  • Carol Broughton, RN, CCTC Nancy Dawson, RN Rhonda Jairam, RN, CCTC Isaac Payne, RN Lori Tummonds, RN, CCTC Transplant Nurse Coordinators
  • Slide 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
  • Slide 4
  • 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 Acronyms and Abbreviations
  • Slide 5
  • Transplant as treatment for ESRD The pretransplant evaluation Deciding on a donor Deceased Deceased Living 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) Point person in coordinating care with transplant center, specialists (eg, cardiology) Transplant 101: Overview
  • Slide 6
  • Recipient Evaluation Process
  • Slide 7
  • Adapted with permission from Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-95. Referred for transplant Initial information session Still a candidate? Potential barrier? Proceed with evaluation Evaluate Barrier removed? Dialysis when indicated No Yes No YesNo Kidney Transplant Evaluation Process
  • Slide 8
  • Active malignancy or metastatic cancer Immunosuppression can enable tumor growth 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 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 If patient cannot give informed consent or comply with drug regimens Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-15. Contraindications to Transplantation
  • Slide 9
  • 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 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 Unless combined liver/kidney transplant is an option Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-15. Contraindications to Transplantation
  • Slide 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
  • Slide 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
  • Slide 12
  • Pretransplant Recipient Evaluation 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 Routine tests Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-95.
  • Slide 13
  • Pretransplant Recipient Evaluation Voiding cystourethrogram Pharmacologic or exercise stress test Noninvasive vascular study Barium enema and lower endoscopy PSA test Pap smear Mammogram Coronary angiogram ECG Elective tests Siddqi N, et al. In: Danovitch GM, ed. Handbook of Kidney Transplantation. 2005:169-192.
  • Slide 14
  • 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
  • Slide 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 >80% with a negative preliminary donor/patient crossmatch Pediatric patients (age
  • Contraindications to Kidney Donation Age 60-65 years 60-65 years Hypertension >140/90 mm Hg or need for medication >140/90 mm Hg or need for medication May need 24-hour blood pressure monitor May need 24-hour blood pressure monitor Diabetes Proteinuria >250 mg/24 hours >250 mg/24 hours GFR
  • Slide 23
  • Donor/Recipient Matching Three factors are involved in tissue matching and antibody production Human leukocyte antigen (HLA) antibodies Human leukocyte antigen (HLA) antibodies Crossmatch Crossmatch Panel-reactive antibody (PRA) Panel-reactive antibody (PRA)
  • Slide 24
  • HLA Matching Three groups of HLA proteins: HLA-A HLA-A HLA-B HLA-B HLA-DR 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
  • Slide 25
  • Crossmatch Crossmatch tests whether the recipient has antibodies to the potential donor Negative crossmatch is desired Negative crossmatch is desired Positive crossmatch increases risk of rejection Positive crossmatch increases risk of rejection Antibodies can develop, so repeat crossmatch testing is required immediately before transplant Antibodies can develop, so repeat crossmatch testing is required immediately before transplant
  • Slide 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 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 HLA antibodies can change, especially in response to blood transfusion, prior transplant, or pregnancy Higher % PRA makes finding a donor more difficult Higher % PRA makes finding a donor more difficult
  • Slide 27
  • Laparoscopic Nephrectomy Advantages Less postoperative pain Less postoperative pain Minimal surgical scarring Minimal surgical scarring Rapid return to work (~4 weeks) Rapid return to work (~4 weeks) Shorter hospital stay Shorter hospital stay Magnified view of renal vessels 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. 2005:135-168.
  • Slide 28
  • Discharge
  • Slide 29
  • After surgery, return to Transplant wing (8 East) After surgery, return to Transplant wing (8 East) Incision will be closed with staples Incision will be closed with staples May have small drain placed in the incision called a Jackson- Pratt drain May have small drain placed in the incision called a Jackson- Pratt drain Will have catheter in bladder a few days Will have catheter in bladder a few days Post-Operative Care
  • Slide 30
  • (continued) Will be out of bed walking in room and hallway in first 24 hours 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 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 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. Much emphasis will be placed on teaching you your medications, their doses, and their purpose. A medicine list will be provided. Post-Operative Care
  • Slide 31
  • (continued) Discharge topics that will be discussed include signs and symptoms of rejection, dietary and activity guidelines, and clinic routine. 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 Average length of stay is 4-10 days May return home at discharge May return home at discharge Clinic appointments are t

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