Download Intestinal Transplantation - Blog

An Introduction to Transplantation
Lauren Walker, RN, BSN, CCRN
Other Contributors:
Lisa Dreyfuss, RN, BSN
Hilary Poan, RN, BSN
Goals and Objectives:
*By the end of the lecture, students will have
an understanding of:
-The history of pediatric GI transplant
-The qualification of being listed for transplant
-Common diagnosis indicating a need for a liver or small bowel
transplant
-Signs and symptoms of liver and small bowel failure
-Common preop/postop medications
-Signs and symptoms of organ rejection
-Lifetime management concerns after transplant
History

Transplants have been performed for over
50 years in United States:

1950s


First Successful Kidney 1954
1960s



First Successful Liver 1967
First Successful Heart 1968
First Successful Pancreas 1968
--UNOS http://www.unos.org/whoWeAre/history.asp
Transplant History


Then nothing until….
1980s
Why? CYCLOSPORIN (early generation Prograf) introduced 1983




First Successful Single Lung 1983
First Successful Double lung 1986
First Successful Intestine 1987
First Living donor liver 1989
--UNOS www.unos.org/whoWeAre/history.asp
Organ Allocation: Getting Listed

United Network for Organ Sharing
(UNOS) maintains the transplant list.

Transplant centers do a thorough evaluation of a
candidate

When a person is accepted for transplant by a
transplant center, the center contacts UNOS and
they are added to the list.

Once listed, the transplant center contacts the
candidate to let them know they are listed.
Organ Allocation: Allocation

When an organ is available, UNOS tracks and allocates the organ

Organs are allocated by status. For Georgetown criteria is based on
the Pediatric End Stage Liver Disease (PELD) Scoring System




Status 1A – fulminant liver failure (no previous liver failure)
Status 1B – liver failure necessitating the need for a blood
transfusion within a 24 hour period for liver candidates
Score from 1-40 based on labs including bilirubin, albumin, INR,
age, growth failure. Pt. in need of SB get an automatic 23 points.
Priority is as follows:

Local

Regional (DC is in region 2 , which also includes - Delaware, Maryland,
New Jersey, Pennsylvania, West Virginia)

National
Who needs a Transplant?
As of 06/6/11 111,502
people are waiting for transplants

16,487 waiting for a liver
Mean waiting time kids < 1 yr 223 days
Mean waiting time kids 1-5 yrs 262 days
221 waiting for an intestine
Mean waiting time kids < 1 yr 358 days
Mean waiting time kids 1-5 yrs 425 days
National pediatric (up to 17yrs) survival from 1 to 5 years:
over 83%
Liver Transplant

Common indications for liver
transplant seen on our unit include:





Biliary Atresia
Alagille’s Syndrome
Hepatitis B
Hepatoblastoma
Hemochromatosis
Signs of Liver Failure











Increased Liver Function Tests (ALT, AST, Alk
phos, bilirubin (direct and indirect)
Jaundice
Bleeding
Ascites
Spleno/Hepatomegaly
Glucose Intolerance
Increased Infection
Malnutrition (Vit. A, D, E, K)
Dark Urine
Puritis
Osteoporosis/Fractures
Liver Transplant
A liver transplant can be done in 3 ways:
1) Cadaver
2) Living-Related Donor
(generally left lobe)
3) Cadaver Split Liver
Intestinal Failure: Definition


The inability of the gastrointestinal
system to maintain fluid,
electrolyte, and nutritional balance
of the body
Condition requires
supplementation from sources
outside of the GI tract
History of Intestinal Transplant

1988 1st successful transplant. Why so late?




Large organ
Lots of lymphoid tissue in intestinal system = immunity
Bacterial flora
Outcomes have improved with new medications
(Prograf)
Currently 23 centers have patients listed for
intestinal transplant. Pittsburgh and GUH are the
largest.
National pediatric (up to 17yrs) survival rate from 1 to
5 yrs: over 71.5% (63.8% for kids under a yr)

Diagnosis leading to a SB
Transplant

Structural: NEC, Gastroschisis,
malformation/volvulus, trauma, atresia,
tumor

Functional: Pseudo-obstruction,
Megacystis, Microcolon, Intestinal
Hypoperistalsis, Hirschsrpung’s
disease
Indications in Children for Small
Bowel Transplant
Motility Other Tumor
1%
Aganglionosis/
2%
Hirshsprung's
7%
Re-Tx
7%
Other
2%
Volvulus
18%
PseudoObstruction
9%
Malabsorption
Other
4%
Microvillus
Inclusion
Short Gut
6%
Other
4%
Gastroschisis
21%
Intestinal Atresia
7%
Necrotizing
Enterocolitis
12%
Management of Intestinal
Failure

Gut Rehabilitation





STEP procedure
Intestinal stretching
Time (as patient grows, gut grows and
absorbs more)
Lifetime TPN – Will lead to liver failure
Intestinal Transplant
Signs of Intestinal Failure









Diarrhea
Constipation
Emesis
Fluid Imbalance and signs and symptoms of fluid
imbalance
Electrolyte Imbalance and signs and symptoms of
electrolyte imbalance
Malnutrition and signs and symptoms of
malnutrition
Failure to Thrive (FTT)
Skin breakdown r/t diarrhea
Liver failure and its signs and symptoms if TPN
cholestatis occurs
Criteria for transplantation

Can only be listed for Intestinal
transplant with:




Loss of access
Irretractable dehydration
Multiple septic infections
Liver failure r/t TPN
Types of Intestinal Transplant



Isolated Intestine
Liver/Bowel
Multivisceral

Liver, intestine, pancreas, stomach
The transplanted organ





Must be at least 70% size of recipient
Minimal downtime/ischemic time
(intestine 10 hours or less, liver 24
hours)
minimal pressor support before
harvest
ABO compatibility
Negative crossmatch (PRA)
Pre Transplant Care Issues







TPN Dependent
Infection
Dehydration
Malnutrition
GI bleed r/t portal hypertension
Waiting Time
Socialization
Pre-transplant Medications




Vitamins (ADEK)
Calcitriol
Nystatin
Iron
Post-Transplant Medications

Immune Suppression: Prograf,
Prednisolone, Rapamune, Cellcept,
Baxiliximab

Other Common Meds: Prevacid,
Imodium, Lomotil, Reglan, Norvasc,
Propranolol
Post Transplant Issues






Immunosuppression
Rejection
Infection
Education
Adherence
Support
Rejection

The immune system protects the body from
anything that is not self.

Because a transplant is foreign to the body,
without intervention, the immune system will
attempt to destroy it.

Goal of immunosuppressants is to inhibit
immunological response and therefore prevent
rejection.
Early signs and Symptoms of
rejection

General





Fever greater than 38°C
Tachycardia
High or low immunosuppressant levels
Lethargy/irritability
Abdominal pain or distention
Liver Rejection

Liver





Increased liver function tests
Nausea and/or vomiting
Dark urine
Jaundice
Itchy skin
Intestine Rejection

Intestine









Increased stools and/or ostomy output
Dehydration
Increasing WBC
Falling hemoglobin, albumin, or iron saturation
Weight loss
Bloody stools/ostomy output
Pale, black, or bleeding stoma
Output with clots or chunks of tissue
Sepsis
Rejection Monitoring




LFTs for Liver
Output and stoma for SB, appearance
during scopes
ONLY SURE WAY TO KNOW is
through a biopsy
Rejection is treated with high dose
Steroids and Thymoglobulin
Major Complication: Infection






Most common complication because of
immunosuppression
HAND WASHING
Avoid sick contacts
No raw foods, no live vaccines, no
cleaning up after pets
Prophylactic Meds
Surveillance labs for EBV, CMV,
Adenovirus
Life after Transplant








Scope twice a week for the first month
Once a week for the next two months
Annual scope
Blood draws twice a week for the first 3
months
Labs once a week until labs are stable
Labs at least once every three months
Lifetime of immunosuppressants
Rejection can happen at any time
Lifetime Management Issues





Quality of Life
Lifetime medication regime
Lifetime laboratory surveillance of
immunosuppression levels
Lifetime surveillance for rejection
Annual visits to transplant center
Resources


Unos: http://unos.org/
Georgetown University Hospital
Transplant Center for Children
http://www.georgetownuniversityhospit
al.org/body.cfm?id=555650