De-mystifying the Transplant Process

Penny Viater, MSN, ANP-BC Lung Transplant Nurse Practitioner

Referrals

   Outside Referrals Within institution Patient driven The patient is contacted, information packet mailed & phone interview done Barring any absolute contraindications a clinic appointment is made

Timing of Referral

   Less than 50% 2 year predicted survival Blood type, size affect the timing of transplant Early referrals are ideal

Selection Criteria

    Severe end stage disease that is not treatable Absence of other serious medical illness Rehabilitation potential Acceptable nutritional state (>80 % to <120% ideal body weight)

Selection Criteria

   Last resort therapy with all alternative therapy being excluded.

Patient has an unacceptable quality of life and a limited life expectancy.

Patient satisfies the general guidelines for transplantation.

Contraindications

        Unresolvable psychological issues or noncompliance Lack of availability of social support system Active tobacco use Presence of drug or alcohol dependency Acutely ill or unstable clinical status Presence of HIV (Ongoing research) Malignancy Multi-organ or CNS dysfunction ** Notice NO age limit

The Basic “3” Rule

1) 2) 3) Do you need it Do you want it Do we want to give it to you

Do we want to give it to you?

   Is transplantation the only reasonable option for success?

Is there a good chance of successful outcome?

Is there anything the care providers need to know prior to take better care of the recipient after the transplant?

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The Work-Up (Lungs)

Hepatitis A Virus Antibody Hepatitis B Core Antibodies Hepatitis B Surface Antibodies Hepatitis B Surface Antigen Hepatitis C Antibodies CMV IGG Antibody EBV IGG Antibody Toxoplasma Antibody Varicella Zoster IGG Antibody Herpes Simplex Virus Antibody PRA HLA ABO, RH & Antibody Screen RPR HIV          Fasting Lipid Profile PT/PTT Chemistry Profile-CMP CBC w/ Differential IgE, IgM, IgA PSA-only in men over 50 years of age.

Serum Beta HCG for women <50 years of age.

Alpha 1 Antitrypsin- all obstructive diseases TPMT Thyopurine methyltransferase level to check prior to giving Imuran

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The Work-Up (Lungs)

Chest X-ray PA & Lateral Psychosocial Evaluation Nutrition Evaluation Pap Smear – women 18 & older Mammogram – women 35 & old PPD skin test Complete Pulmonary Function Tests Dobutamine Stress Echo – all patients 35 years of age or older Left Heart Cath & Right Heart Catheterization for all patients 45 years or older.

Left Heart Cath & Right Heart Catheterization under 45years, if Dobutamine echo is abnormal, cardiac symptoms are present or if patient has a strong family history of cardiac disease.

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Right Heart Catheterization except low risk patients who should undergo a 2D echocardiogram with Doppler study MUGA & Mini-MUGA Quantitative VQ Scan Carotid Duplex DEXA Scan Random urine cotinine for former smokers - initially ,then every 3 months .

CT Scan of Chest - with & without contrast Six Minute Walk Test Sputum C & S Stool for Occult Blood X3 Colonoscopy if age greater than 45 EGD with pH manometry

The Team

         Medicine Surgery Psyche Social Work Infectious Disease Endo GI Financial Coordinator Procurement Coordinator          Social Worker Dietician Hematology PharmD Physical Therapy Pathology RN APN PA

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Patient Education

Work-up consent Listing consent Surgery consent    The Transplant process The meds Lifestyle changes Transplantation may be “trading in one disease for another.”

Listing Criteria

    ABO Height Weight HLA (for some organs)

Listing with UNOS

Each organ is separate, but patients can be listed for multiple organs   

Status on waitlist

Heart 1A, 1B, 2 Kidney: HLA + time Lung LAS 0-100 Pancreas: HLA + time Liver MELD 6-40

The Wait

     Different for each organ Different for each Blood type Based on Population Seasonal Dry runs GETTING LONGER!!!

The Surgery

   Bilateral vs. Single lung  Total between 4-16 hours Recipient in OR & opened while procurement in donor hospital going on Timing is critical

Organ Specific Ischemic Times

CIT:

Time donor heart stops to time organ is reperfused in recipient Heart = 4 to 6 hrs Lungs = 4 to 6 hrs Liver = 18 to 24 hours Pancreas = 18 to 24 hrs Kidney = 72 hrs

Lung Transplant

     Hemodynamic Management Oxygenation Pain Control Chasing labs Rejection vs. infection

Transplant Medications

- Immunosuppression - Antibiotics - Antivirals - Antifungals - Protozoan Diuretics CCB, Dig PPI Anti-nausea + Pre-txp meds

Lung Transplant

Infection - Leading cause of Lung Txp deaths - Donor source vs. recipient - Think rejection - Environmental exposure - Anastomosis sites - Prevent, Recognize, Treat

Post Transplant Rejection

Hyperacute rejection occurs minutes to hours after transplantation.

Acute rejection occurs weeks to months after transplantation… sometimes years Chronic rejection occurs progressively over years

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Long-Term Care

Lifestyle changes Medication side-effects Compliance Rejection vs. infection Vaccination concerns Going back to work: the insurance fight Having children after a transplant Risk for Cancer Other chronic health problems after transplant