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Getting on the Waitlist August 29, 2014 Rhonda Duggan, BSN, RN, CCTC Living Donor Coordinator Carolinas Medical Center Why Choose Transplant? •It’s expensive •There’s not enough donors •Quality of life issues •Patient Survival Advantages of Successful Transplantation Increased strength & ability to engage in a more physically active lifestyle Fewer dietary restrictions Improved blood counts & improvement of symptoms of specific disease Improved life satisfaction, physical & emotional well being Potential to return to work or school without disability Disadvantages of transplantation Unfortunately, there are no guarantees in transplantation. Need to take anti-rejection medications as long as transplanted is functioning. These medications have potential for significant adverse effects. Anti-rejection medications are very expensive. If disability is dependent upon end stage organ disease, it will be discontinued after a successful transplant. Frequent & chronic follow-up with Transplant Physician, as often as 2-3 times a week following discharge from hospital. Worsening of current medical problems Organ may not work The BIG Questions???? Who can be evaluated? When to begin the evaluation? When is Liver Transplant Evaluation Initiated? •Patients with a Model of End-stage Liver Disease score (MELD) of greater than 10. •Patients who have developed end-stage liver disease of all types and have had evidence of life-threatening complications such as: ascites/fluid retention, variceal hemorrhage, encephalopathy requiring medication, spontaneous bacterial peritonitis, worsening renal •Patients with hepatic decompensation •Patients with Hepatocellular carcinoma (HCC) Early referral is essential, allowing for pre-transplant problems to be addressed and resolved while the liver disease is relatively well-compensated. There is no advantage, however, of early referral in terms of waiting time. Children with liver disease should be referred for liver transplant evaluation when they fall off their growth curve, or when their liver decompensates. Referrals sources: Primary Care Physicians Hepatologist/Gastroenterologist Insurance Companies When is Cardiac Transplant Evaluation Initiated? NYHA Class III-IV heart failure symptoms on maximal heart failure medications Maximal Oxygen Consumption (MVO2) <14 Severe, limiting ischemia, not amenable to surgical or catheter intervention Recurrent VT Referral sources: • CMC’s Heart Failure Service (in and outpatient referrals) • Outlying cardiology practices with or without heart failure programs • Patients in outlying hospitals in cardiogenic shock When is Kidney Transplant Evaluation Initiated? Once a patient has lost nearly 90% of their kidney function, the only treatment options are dialysis or a kidney transplant. While dialysis replaces failed renal function, a transplant replaces a diseased kidney. Referral Sources: Dialysis units are regulated/mandated by CMS to address transplant as a treatment option for every patient CMC has contracts with most major insurance companies 6 Inhibiting Factors to Transplantation Nearly 135,000 people are waiting for an organ transplant Lack of supportive care for patients Lack of knowledge of the transplant process Religious beliefs Cost of healthcare continues to rise and more patients have limited financial resources Contraindications to Transplantation Active malignancy Severe myocardial dysfunction Active mental illness/Dementia Severe Pulmonary Hypertension Active substance abuse Extreme obesity Non-adherence No support/ financial or social Core Evaluation Appointments RN/NP – Transplant Coordinator Social Worker Financial Coordinator Dietician Nephrologist/Hepatologist/Cardiologist Surgeon Consults as indicated (Pulmonary, Urology, Endocrine, ID, Psychiatry) Evaluation Tests Labs (organ specific) EKG Chest X-Ray Other tests as indicated Patient responsible to complete Yearly Dental if indicated Yearly Pap (Females) Yearly Mammogram (Females > age 40) Colonoscopy (> age 50) Yearly TB skin test (PPD) Cardiac Evaluation Tests Right and left heart catheterization MVO2 Pulmonary function tests Abdominal ultrasound Ankle/arm indices* Carotid ultrasound* *(age >50 or ischemic heart disease) Liver Evaluation Test Renal & Carotid Ultrasound Abdominal & Chest CT Scan MRI of liver/MRA of arteries, veins & mesenteric vessels EGD/Colonoscopy Echo and/or Adenosine Myoview and/or Cardiac Cath PFT with ABG APPROVAL/LISTING Present to Selection Committee Final Insurance Approval UNOS Wait Listing Phone notification & Letter to the patient and their referring MD Monthly blood work is required by UNOS to update MELD/PELD score, update listing status, and assess immunologic status And now the waiting begins……