Download Transplant Objectives

APPENDIX IV –
AIMS, OBJECTIVES, COMPETENCIES & OUTCOMES
Aims
During the Transplant rotation, the trainee should acquire the knowledge, skills and attitudes
needed to independently care for both stable and ill renal transplant patients. This is to include;
patient and donor evaluation for transplantation, acute pre and post operative care, care of
patients in the initial months after transplantation, stable patients well-removed from
transplantation, and patients with a failing allograft.
Objectives
At the end of the rotation, the trainee will be able to demonstrate knowledge in the following
areas:
Basic Sciences
i)
Transplant Immunology:
A)
Describe the HLA system and its’ relevance to transplantation.
B)
Describe mechanisms of rejection including mechanisms of allorecognition and
the processes involved in the effector arms of the immune system.
ii)
The role of the Transplant Immunology Laboratory:
A)
Describe techniques for HLA typing and their significance.
B)
Describe techniques for anti HLA antibody screening (PRA testing and cross
matching) and their significance.
C)
Demonstrate the ability to interpret the results of tissue typing, antibody
screening and cross match procedures.
iii)
Transplant Pathology:
A)
Develop a working knowledge of the Banff schema of allograft pathology.
B)
Describe the histologic findings in rejection as well as causes of allograft
dysfunction other than rejection (i.e. drug toxicity, recurrent disease, and
infection).
C)
Interpret renal allograft biopsy findings in a clinical setting.
iv)
Immunosuppressive Therapy:
Develop a broad understanding of immunosuppressive therapy including; drug
mechanisms of action, side effects and toxicities, drug interactions, indications and
clinical practice of induction and maintenance immunosuppression, practice therapeutic
drug monitoring and management, and relevant intra-class differences of the following:
A)
Calcineurin inhibitors (Cyclosporine and Tacrolimus).
B)
Anti-metabolites (Mycophenolate and Azathioprine).
C)
Corticosteroids.
D)
Rapamycin.
E)
Anti-IL2 receptor monoclonal antibodies (Basiliximab and Daclizumab).
F)
OKT3 and polyclonal depleting antibodies (Thymoglobulin and ATG).
Donor & Recipient Evaluation & Organ Allocation
i)
Recipient Evaluation:
A)
Describe the recipient risks, benefits and contraindications of transplantation.
B)
Perform a complete recipient evaluation.
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C)
D)
E)
Demonstrate knowledge of how prior malignancies, co-morbid cardiovascular
disease, and other specific conditions or patient variables affect eligibility and
outcomes in transplantation.
Demonstrate the ability to counsel a potential kidney transplant recipient.
Describe the indications and contraindications, advantages and disadvantages of
kidney-pancreas transplantation.
ii)
Live Donor Evaluation:
A)
Describe what comprises a transplant donor evaluation; appreciating absolute
and relative contraindications.
B)
Describe the operative procedure as well as short and long term risks and
outcomes of transplant donor nephrectomy.
C)
Demonstrate the ability to counsel a potential live kidney donor.
iii)
Cadaveric Donor Evaluation:
A)
Explain who may be considered an eligible cadaveric donor including the
diagnosis of brain death and non-heart beating donors.
B)
Describe the absolute and relative contraindication to cadaveric donation.
C)
Describe the ICU care of the brain dead donor.
iv)
Organ Allocation:
A)
Describe the issues regarding transplant waiting lists and donor supply.
B)
Describe relative advantages and disadvantages of live donor vs. cadaveric
donor transplantation.
C)
Describe the issues of allosensitization, including how allosensitization occurs,
it’s impact on patient and transplant outcomes, and how it affects recipient
access to transplantation integrating knowledge of tissue typing and
histocompatibility testing in potential recipients.
D)
Describe the relevance of donor and recipient matching.
E)
Demonstrate the ability to rationally allocate a cadaveric organ.
Clinical Care of the Transplant Patient
The transplant operation and immediate post-operative care:
i)
Describe the operative technique of kidney transplantation.
ii)
Demonstrate the ability to care for the stable acute transplant patient.
iii)
Demonstrate an approach to delayed graft function, understand it’s potential causes and
significance, and demonstrate the ability to manage patients with delayed graft function.
iv)
Be able to diagnose and manage other complications in the immediate posttransplantation period.
Early Post-Transplant Management
i)
Demonstrate the ability to monitor and mange the transplant patient in the initial
outpatient period including:
A)
The prescription of immunosuppression including the ability to adjust drug doses
to maximize effectiveness, recognize and respond appropriately to drug toxicities
and side effects, and describe the role of individualizing protocols for a particular
patient’s needs.
B)
Demonstrate a differential diagnosis and approach to early allograft dysfunction.
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C)
D)
ii)
Demonstrate the ability to diagnose and manage acute rejection, integrating
clinical science, immunobiology and pathology.
Describe the pathogenesis and clinical impact of rejection.
Describe the impact of CMV infection in transplant recipients including:
A)
The clinical impact of CMV infection.
B)
Strategies for monitoring and prophylaxis.
C)
Treatment of CMV disease.
Long-Term Post-Transplant Care
i)
Demonstrate an understanding of transplant outcomes including average patient and
graft survivals in different patient subsets and appreciate the determinants of each (JJ).
ii)
Describe the issues involved in prescribing maintenance immunosuppression, including,
but not limited to:
A)
Risks of inadequate or excessive immunosuppression.
B)
Long term toxicities of individual immunosuppressive agents.
C)
Strategies and clinical considerations for minimization of long term
immunosuppression.
iii)
Develop an understanding of the pathogenesis, importance, and clinical management of
long-term post-transplant complications including:
A)
Cardiovascular disease/HTN/dyslipidemia.
B)
Malignancies: PTLD, skin Ca, other.
C)
Recurrent disease.
D)
Fertility and pregnancy in transplant recipients.
E)
Transplant RAS.
F)
Post-transplant erythrocytosis.
G)
Bone and mineral metabolism – osteoporosis and parathyroid disorders.
H)
Polyoma virus infection.
I)
Gout.
The Failing Allograft
i)
Describe the determinants of declining allograft function due to chronic allograft
nephropathy.
ii)
Demonstrate an approach to management of the patient with a failing allograft including
strategies aimed at optimizing graft survival and managing complications of CRF.
iii)
Describe the impact of the failed allograft and outline the management of the patient
returning to dialysis including strategies for the withdrawal of immunosuppression.