TransplantTransplant 101101

Carol Broughton, RN, CCTC Carol Broughton, RN, CCTC Nancy Dawson, RNNancy Dawson, RN Rhonda Jairam, RN, CCTCRhonda Jairam, RN, CCTC Isaac Payne, RNIsaac Payne, RN Lori Tummonds, RN, CCTCLori Tummonds, RN, CCTC

Transplant Nurse CoordinatorsTransplant Nurse Coordinators

Transplant TeamTransplant Team Transplant SurgeonsTransplant Surgeons - - Thomas Johnston, Dinesh Thomas Johnston, Dinesh

Ranjan, Hoonbae Jeon, Roberto GedalyRanjan, Hoonbae Jeon, Roberto Gedaly Transplant NephrologistsTransplant Nephrologists - - Wade McKeown and Wade McKeown and

Thomas WaidThomas Waid Transplant PharmacistTransplant Pharmacist - - Tim CliffordTim Clifford Social WorkersSocial Workers - Mindy Murphy and Molly Patchell - Mindy Murphy and Molly Patchell Financial CounselorsFinancial Counselors - Marybeth Henry and Angela - Marybeth Henry and Angela

HernandezHernandez Clinic StaffClinic Staff - Erica Lynch, Lisa Collett, Aimee Bishop, - Erica Lynch, Lisa Collett, Aimee Bishop,

Marva Paris, and Amy WrightMarva Paris, and Amy Wright Scheduling CoordinatorScheduling Coordinator - Mike Pelfrey - Mike Pelfrey

AST = American Society of TransplantationAST = American Society of Transplantation BMI = body mass indexBMI = body mass index CBC = complete blood countCBC = complete blood count CKD = chronic kidney diseaseCKD = chronic kidney disease CMS = Centers for Medicare and Medicaid CMS = Centers for Medicare and Medicaid

ServicesServices CMV = cytomegalovirusCMV = cytomegalovirus EBV = Epsein-Barr virusEBV = Epsein-Barr virus

Acronyms and AbbreviationsAcronyms and Abbreviations

Transplant as treatment for ESRDTransplant as treatment for ESRD The pretransplant evaluationThe pretransplant evaluation Deciding on a donorDeciding on a donor

DeceasedDeceased LivingLiving

The referring nephrologist can be responsible The referring nephrologist can be responsible for coordinating some of the pretransplant for coordinating some of the pretransplant carecare Point person in coordinating care with Point person in coordinating care with

transplant center, specialists (eg, cardiology)transplant center, specialists (eg, cardiology)

Transplant 101: OverviewTransplant 101: Overview

Recipient Evaluation Recipient Evaluation ProcessProcess

Adapted with permission from Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-95.

Referred for transplantReferred for transplant

Initial information sessionInitial information session

Still a Still a candidate?candidate?

Potential Potential barrier?barrier?

Proceed with evaluationProceed with evaluation

EvaluateEvaluate

Barrier Barrier removed?removed?

Dialysis when Dialysis when indicatedindicated

NoNo

YesYes

NoNo

YesYes NoNo

Kidney Transplant Evaluation ProcessKidney Transplant Evaluation Process

Active malignancy or metastatic cancerActive malignancy or metastatic cancer Immunosuppression can enable tumor growthImmunosuppression can enable tumor growth

CirrhosisCirrhosis Severe myocardial dysfunction or peripheral Severe myocardial dysfunction or peripheral

vascular diseasevascular disease Unless due to potentially reversible ischemia, Unless due to potentially reversible ischemia,

which should be corrected prior to transplantwhich should be corrected prior to transplant Other severe, irreversible extrarenal diseaseOther severe, irreversible extrarenal disease Active mental illnessActive mental illness

If patient cannot give informed consent or comply If patient cannot give informed consent or comply with drug regimens with drug regimens

Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-15.

Contraindications to TransplantationContraindications to Transplantation

Chronic infection or untreated current infectionChronic infection or untreated current infection Irreversible limited rehabilitative potentialIrreversible limited rehabilitative potential Persistent nonadherence to treatmentPersistent nonadherence to treatment Active substance abuseActive substance abuse

Must be treated prior to transplant; drug screening may be Must be treated prior to transplant; drug screening may be required as proof of drug-free statusrequired as proof of drug-free status

Primary oxalosisPrimary oxalosis Unless combined liver/kidney transplant is an optionUnless combined liver/kidney transplant is an option

Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-15.

Contraindications to TransplantationContraindications to Transplantation

Suggested malignancy wait timeSuggested malignancy wait time Prostate – 2 yearsProstate – 2 years Liver – Transplant not Liver – Transplant not

recommended with liver recommended with liver transplanttransplant

Multiple myeloma – Multiple myeloma – Transplant not Transplant not recommendedrecommended

Lymphoma – 2 to 5 yearsLymphoma – 2 to 5 years Leukemia – 2 yearsLeukemia – 2 years

Malignant melanoma – 5 Malignant melanoma – 5 yearsyears

In situ or superficial In situ or superficial melanoma – 2 yearsmelanoma – 2 years

Squamous cell carcinoma Squamous cell carcinoma – Surveillance– Surveillance

Basal cell carcinoma – Basal cell carcinoma – NoneNone

Cervical/uterine – 2 to 5 Cervical/uterine – 2 to 5 yearsyears

Suggested malignancy wait timeSuggested malignancy wait time Testicular – 2 yearsTesticular – 2 years Kaposi’s sarcoma – 2 Kaposi’s sarcoma – 2

years; second transplant years; second transplant contra-indicatedcontra-indicated

Breast cancer – 2 to 5 Breast cancer – 2 to 5 yearsyears

Lung cancer – 2 yearsLung cancer – 2 years Bladder cancer – 2 years, Bladder cancer – 2 years,

In situ – NoneIn situ – None

Renal cell carcinoma small Renal cell carcinoma small low-grade tumor – 2 yearslow-grade tumor – 2 years

Renal cell carcinoma large Renal cell carcinoma large high-grade tumor – 5 high-grade tumor – 5 yearsyears

Colon cancer stage 1 – 2 Colon cancer stage 1 – 2 years years

Colon cancer stage 2 or Colon cancer stage 2 or higher – 5 yearshigher – 5 years

Pretransplant Recipient EvaluationPretransplant Recipient Evaluation

Full medical history and Full medical history and physical examphysical exam

CBC and chemistry panelCBC and chemistry panel PT and PTTPT and PTT Blood typeBlood type HBV and HBC serologyHBV and HBC serology HIV screen HIV screen EBVEBV VZVVZV

CMV testCMV test Pelvic exam and Pap Pelvic exam and Pap

smearsmear Chest X-rayChest X-ray ECGECG HLA tissue typing and HLA tissue typing and

cytotoxic antibodiescytotoxic antibodies VDRL VDRL screenscreen Lipid profileLipid profile Abdominal U/SAbdominal U/S

Routine tests

Kasiske BL, et al. Am J Transplant. 2001;1 (suppl 2):1-95.

Pretransplant Recipient EvaluationPretransplant Recipient Evaluation

Voiding Voiding cystourethrogramcystourethrogram

Pharmacologic or Pharmacologic or exercise stress testexercise stress test

Noninvasive Noninvasive vascular studyvascular study

Barium enema and Barium enema and lower endoscopy lower endoscopy

PSA testPSA test Pap smearPap smear MammogramMammogram Coronary angiogramCoronary angiogram ECGECG

Elective tests

Siddqi N, et al. In: Danovitch GM, ed. Handbook of Kidney Transplantation. 2005:169-192.

When a living donor cannot be identifiedWhen a living donor cannot be identified Wait can exceed 2 years for blood types O Wait can exceed 2 years for blood types O

and B and B Administered by UNOSAdministered by UNOS

Patient can be listed when GFR <20 mL/minPatient can be listed when GFR <20 mL/min Transplant center will list the patient after Transplant center will list the patient after

evaluationevaluation

Patients should ask the transplant center if Patients should ask the transplant center if their names are on the listtheir names are on the list

Waiting List for a Deceased-Donor KidneyWaiting List for a Deceased-Donor Kidney

Accruing Points on the UNOS ListAccruing Points on the UNOS List

Points are awarded in accordance with this formula:Points are awarded in accordance with this formula: Time on waitingTime on waiting listlist Quality of antigen mismatchQuality of antigen mismatch——HLA-DR antigens only (no HLA-DR antigens only (no

points for HLA-A or HLA-B matches)points for HLA-A or HLA-B matches) PRAPRA——points are assigned if PRA level is points are assigned if PRA level is >>80% with a 80% with a

negative preliminary donor/patient crossmatchnegative preliminary donor/patient crossmatch Pediatric patients (age <18) awarded additional pointsPediatric patients (age <18) awarded additional points Donation statusDonation status——individuals who have donated a vital organ individuals who have donated a vital organ

in the US receive preferencein the US receive preference Medical urgency NOT a factor in points system except by Medical urgency NOT a factor in points system except by

local agreementlocal agreement

United Network for Organ Sharing. Available at: http://www.unos.org.

During wait for a deceased-donor, routine medical During wait for a deceased-donor, routine medical evaluations should be conductedevaluations should be conducted

Social workerSocial worker SurgeonSurgeon Vascular studiesVascular studies Cancer screening Cancer screening

• Pap smears and mammograms for womenPap smears and mammograms for women• Digital rectal exam or PSA test for menDigital rectal exam or PSA test for men

Cardiovascular examination as indicatedCardiovascular examination as indicated The community nephrologist should advise the transplant The community nephrologist should advise the transplant

center of changes in health that preclude transplantationcenter of changes in health that preclude transplantation Patients who require medical intervention may remain on the Patients who require medical intervention may remain on the

UNOS list, but do not accrue “time of waiting” pointsUNOS list, but do not accrue “time of waiting” points

Interim Medical ExaminationsInterim Medical Examinations

Living Donor Kidney Living Donor Kidney Transplant EvaluationTransplant Evaluation

Living and Deceased Kidney Donors, Living and Deceased Kidney Donors, 1993-20021993-2002

0

1000

2000

3000

4000

5000

6000

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Tra

ns

pla

nts

, N

o.

Deceased donor Living donor

2003 Annual Report of the United States OPTN/SRTR: Transplant Data 1993-2002.

Trend is toward Trend is toward living donationliving donation

Driven by longer Driven by longer waiting timeswaiting times

Can use donor Can use donor that is not a close that is not a close blood relativeblood relative

Advantages and Disadvantages of Living-Advantages and Disadvantages of Living-Donor TransplantationDonor Transplantation

AdvantagesAdvantages DisadvantagesDisadvantages Preemptive transplant optionPreemptive transplant option Can select donor for haplotype Can select donor for haplotype

match, agematch, age Better outcomesBetter outcomes Minimal delayed graft functionMinimal delayed graft function No wait for deceased-donor No wait for deceased-donor

kidneykidney Can time transplant for Can time transplant for

convenienceconvenience Immunosuppressive regimen Immunosuppressive regimen

may be less aggressivemay be less aggressive Emotional gain to donorEmotional gain to donor

Psychological stress to donor Psychological stress to donor Complete donor evaluation Complete donor evaluation

processprocess Operative donor mortality (~1/3000 Operative donor mortality (~1/3000

patients)patients) Major complications (0.2%-2%)Major complications (0.2%-2%) Minor complicationsMinor complications Potential donor hypertension, Potential donor hypertension,

proteinuria proteinuria Risk of trauma to remaining kidneyRisk of trauma to remaining kidney Risk of unrecognized covert renal Risk of unrecognized covert renal

diseasedisease

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

Donor’s risk must be considered separately from Donor’s risk must be considered separately from recipient’s need for transplantrecipient’s need for transplant

Donor must be informed of the risks Donor must be informed of the risks ABO blood-type compatibility, tissue type, and ABO blood-type compatibility, tissue type, and

crossmatch are initial screening stepscrossmatch are initial screening steps With multiple suitable donors, the transplant With multiple suitable donors, the transplant

center will help determine the best donorcenter will help determine the best donor Family to be included in this decisionFamily to be included in this decision For a younger recipient who may require a second For a younger recipient who may require a second

transplant, a parent may be selected over a sibling, whose transplant, a parent may be selected over a sibling, whose kidney may be needed in the futurekidney may be needed in the future

Living Donor EvaluationLiving Donor Evaluation

Living Donor EvaluationLiving Donor Evaluation Medical history and physical examMedical history and physical exam Comprehensive lab screeningComprehensive lab screening

Blood count/chemistry panelBlood count/chemistry panel HBV, HCV, HIV, and CMV testsHBV, HCV, HIV, and CMV tests Fasting glucose Fasting glucose

Urinalysis Urinalysis Spot urine for protein and creatinine ratioSpot urine for protein and creatinine ratio

Cardiovascular workupCardiovascular workup Chest X-rayChest X-ray ECGECG

Helical CT urogramHelical CT urogram Psychosocial evaluationPsychosocial evaluation Repeat crossmatch before transplantRepeat crossmatch before transplant

Contraindications to Kidney DonationContraindications to Kidney Donation

Age Age <18 years or >60-65 years<18 years or >60-65 years

Hypertension Hypertension >140/90 mm Hg or need for >140/90 mm Hg or need for

medicationmedication May need 24-hour blood May need 24-hour blood

pressure monitorpressure monitor DiabetesDiabetes Proteinuria Proteinuria

>250 mg/24 hours>250 mg/24 hours GFR <80 mL/min by MDRDGFR <80 mL/min by MDRD Microscopic hematuriaMicroscopic hematuria

Multiple renal vessels Multiple renal vessels Significant medical illnessSignificant medical illness History of thrombosis or History of thrombosis or

thromboembolismthromboembolism Strong family history of renal Strong family history of renal

disease, diabetes, or disease, diabetes, or hypertensionhypertension

Psychiatric conditions or Psychiatric conditions or substance abusesubstance abuse

PregnancyPregnancy

Kasiske BL, et al. J Am Soc Nephrol. 1996;7:2288-2313.

Donor/Recipient MatchingDonor/Recipient Matching Three factors are involved in tissue Three factors are involved in tissue

matching and antibody productionmatching and antibody production Human leukocyte antigen (HLA) Human leukocyte antigen (HLA)

antibodiesantibodies CrossmatchCrossmatch Panel-reactive antibody (PRA)Panel-reactive antibody (PRA)

HLA MatchingHLA Matching Three groups of HLA proteins:Three groups of HLA proteins:

HLA-AHLA-A HLA-BHLA-B HLA-DRHLA-DR

One HLA in each group (haplotype) is inherited from One HLA in each group (haplotype) is inherited from each parenteach parent

Example:Example:Mother = A1, A2, B8, B44, DR3,4Mother = A1, A2, B8, B44, DR3,4Father = A3, A10, B7, B55, DR11,15Father = A3, A10, B7, B55, DR11,15Child = A2, A10, B7, B44, DR4,15Child = A2, A10, B7, B44, DR4,15

CrossmatchCrossmatch Crossmatch tests whether the recipient Crossmatch tests whether the recipient

has antibodies to the potential donorhas antibodies to the potential donor Negative crossmatch is desiredNegative crossmatch is desired Positive crossmatch increases risk of Positive crossmatch increases risk of

rejectionrejection Antibodies can develop, so repeat Antibodies can develop, so repeat

crossmatch testing is required immediately crossmatch testing is required immediately before transplantbefore transplant

Panel-Reactive Antibody (PRA)Panel-Reactive Antibody (PRA)

PRA is the amount of HLA antibody present in PRA is the amount of HLA antibody present in the recipient’s serum (expressed as a the recipient’s serum (expressed as a percentage)percentage) Determined by testing the recipient’s serum Determined by testing the recipient’s serum

against a panel of cells from 60 people with against a panel of cells from 60 people with different HLA proteinsdifferent HLA proteins

HLA antibodies can change, especially in response HLA antibodies can change, especially in response to blood transfusion, prior transplant, or pregnancyto blood transfusion, prior transplant, or pregnancy

Higher % PRA makes finding a donor more difficultHigher % PRA makes finding a donor more difficult

Laparoscopic NephrectomyLaparoscopic Nephrectomy AdvantagesAdvantages

Less postoperative painLess postoperative pain Minimal surgical scarringMinimal surgical scarring Rapid return to workRapid return to work

(~4 weeks)(~4 weeks) Shorter hospital stayShorter hospital stay Magnified view of renal Magnified view of renal

vesselsvessels

DisadvantagesDisadvantages Impaired early graft Impaired early graft

functionfunction Pneumoperitoneum may Pneumoperitoneum may

compromise renal blood compromise renal blood flowflow

Longer operative timeLonger operative time Tendency to have shorter Tendency to have shorter

renal vessels and multiple renal vessels and multiple arteriesarteries

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

DischargeDischarge

AfterAfter surgery, return to surgery, return to Transplant wing (8 East)Transplant wing (8 East)

Incision will be closed with Incision will be closed with staplesstaples

May have small drain placed in May have small drain placed in the incision called a “Jackson-the incision called a “Jackson-Pratt” drainPratt” drain

Will have catheter in bladder a Will have catheter in bladder a few daysfew days

Post-Operative CarePost-Operative Care

(continued)(continued) Will be out of bed walking in room and hallway in first Will be out of bed walking in room and hallway in first

24 hours24 hours Discharge information will be reviewed with you Discharge information will be reviewed with you

frequently by your floor nurse and Transplant nurse frequently by your floor nurse and Transplant nurse coordinatorcoordinator

Written discharge information and instructions will be Written discharge information and instructions will be provided to take home with youprovided to take home with you

Much emphasis will be placed on teaching you your Much emphasis will be placed on teaching you your medications, their doses, and their purpose. A medications, their doses, and their purpose. A medicine list will be provided.medicine list will be provided.

Post-Operative CarePost-Operative Care

(continued)(continued) Discharge topics that will be discussed include signs Discharge topics that will be discussed include signs

and symptoms of rejection, dietary and activity and symptoms of rejection, dietary and activity guidelines, and clinic routine.guidelines, and clinic routine.

Average length of stay is 4-10 daysAverage length of stay is 4-10 days May return home at dischargeMay return home at discharge Clinic appointments are twice a week for 4-6 weeksClinic appointments are twice a week for 4-6 weeks

Once a week for 4-6 weeksOnce a week for 4-6 weeks

Every other week for 4-6 weeksEvery other week for 4-6 weeks

Post-Operative CarePost-Operative Care

(continued)(continued) Approximately 3 months after discharge, you will be Approximately 3 months after discharge, you will be

referred to primary care doctor or nephrologist. Will referred to primary care doctor or nephrologist. Will alternate visits a few times between local doctor and alternate visits a few times between local doctor and us, and then most of follow-up will be with referring us, and then most of follow-up will be with referring or primary care physician.or primary care physician.

Post-Operative CarePost-Operative Care

Home Medication ReviewHome Medication Review Inpatient medication recommendationsInpatient medication recommendations Coordinate with nurses and social Coordinate with nurses and social

worker for discharge medicationsworker for discharge medications Availability in hospital and clinicAvailability in hospital and clinic Involved pre- and post-transplantInvolved pre- and post-transplant Facilitate educationFacilitate education

PharmacistPharmacist

Medications After TransplantMedications After Transplant Anti-rejection drugsAnti-rejection drugs

• Prograf (tacrolimus)Prograf (tacrolimus)• Cellcept (mycophenolate mofetil)Cellcept (mycophenolate mofetil)• PrednisonePrednisone

Anti-infective drugsAnti-infective drugs Take all medications as prescribedTake all medications as prescribed

PharmacistPharmacist

1.1. Call with any insurance changes.Call with any insurance changes.2.2. Call with any changes in employment of you or your Call with any changes in employment of you or your

spouse if it will affect your insurance coverage.spouse if it will affect your insurance coverage.3.3. If you are in the process of obtaining Medicaid please If you are in the process of obtaining Medicaid please

notify us for further assistance.notify us for further assistance.4.4. Insurance benefits are monitored every month by our Insurance benefits are monitored every month by our

office.office.5.5. Approval for transplant will be obtained through our Approval for transplant will be obtained through our

office.office.

Financial CounselorFinancial Counselor

Social WorkerSocial Worker Support System / CaregiverSupport System / Caregiver Substance Abuse PolicySubstance Abuse Policy Insurance / Medication Coverage Post-Insurance / Medication Coverage Post-

TransplantTransplant TransportationTransportation

For More InformationFor More Information UK Transplant CenterUK Transplant Center(859) 323-6544(859) 323-6544 http://www.mc.uky.edu/transplant

Kentucky Organ Donor Affiliates (KODA)Kentucky Organ Donor Affiliates (KODA)

(800) 525-3456(800) 525-3456 http://www.kyorgandonor.org

National Kidney FoundationNational Kidney Foundation

(800) 622-9010(800) 622-9010 http://www.kidney.org

For More InformationFor More Information Transplant Patient Partnering ProgramTransplant Patient Partnering Program(800) 893-1995(800) 893-1995 http://www.tppp.net National Foundation for TransplantsNational Foundation for Transplants(800) 489-3863(800) 489-3863 http://www.transplants.org United Network for Organ Sharing (UNOS)United Network for Organ Sharing (UNOS)(888) 894-6361(888) 894-6361 http://www.unos.org

Relatively unrestricted dietRelatively unrestricted diet Freedom to travelFreedom to travel Ability to become pregnant and bear childrenAbility to become pregnant and bear children Can engage in training for athletic Can engage in training for athletic

competitioncompetition Lifestyle free of dialysis constraintsLifestyle free of dialysis constraints

Transplant-Related Quality-of-Life BenefitsTransplant-Related Quality-of-Life Benefits

Questions?Questions?