DTS2013_04_02B_Honoring_101513

Report
Donation Process:
Honoring the Gift
Breakout Session B
Presenters:
Scott Snider, RN, Multi-Organ Transplant Coordinator,
St. Vincent Medical Center
Scott Bunting, RRT, CPTC, OneLegacy
Moderator:
Ervin Ruzics, MD, Saint Joseph Hospital
Objectives:
• Identify the various entities that support the
donation process
• Review the three phases of donor management
and the corresponding timeframes
• Review the criteria that is utilized for patients to
be placed on the waitlist
• Discuss the factors involved for transplant
candidate evaluation
Questions to Run On:
How can I utilize this information
on donor management and
transplant candidate criteria to
improve donation practice in
my hospital?
Recipient
Workup
From Authorization to
Allograft
Questions to Run On
Describe
the criteria that is utilized for
patients to be placed on the waitlist.
Identify the factors involved for transplant
candidate evaluation. What are the
considerations for living donors?
Kidney Disease Outcome Quality
Initiative ( K/DOQI) Staging
 K/DOQI
created the standardization of clinical
practice guidelines.
 Two primary markers are used to stage Chronic
Kidney Disease (CKD).
Abnormalities in serum and urine lab tests:
BUN, Creatinine
Level of Kidney function as measured by
Glomerular Filtration Rate (GFR).
Who Are Our Patients?
 Stages
of Kidney Failure- K/DOQI Staging:
Stage
Description
GFR (ml/min)
1
Kidney damage with normal or
increased GFR
2
Kidney damage with mild decrease in GFR
60-90
3
Moderate decrease in GFR
30-59
4
Severe decrease in GFR
15-29
5
Kidney failure
Equal to, or > 90
Less than 15
Who can be listed?
A
patient must be in stage 4 or 5 End
Stage Renal Disease (ESRD)
Renal failure must be chronic and
irreversible
GFR must be <20 to accrue wait time
A live renal transplant may be completed
prior to the initiation of dialysis and GFR
does not need to be <20.
Kidney Pancreas Transplant
 The
goal of kidney pancreas transplant is to cease the
need for insulin dosage and to ease the suffering of
sequelae of diabetes such as:
 Gastroparesis
 Renal Failure
 Retinopathy
 Neuropathy
 Accelerated Cardiovascular disease
 Improves quality of life
 Patients receive a kidney/pancreas transplant as Type 1
diabetes has caused irreversible damage to both
pancreas and kidney
Candidate Evaluation
 Physiologically
the potential candidate needs
to be able to withstand the transplant
procedure itself and have a lower risk of long
term morbidity and mortality.
 If the potential candidate is able to resolve
contraindications found at initial assessment,
then they may be re-assessed.
 Older age, in itself, is not a contraindication.
Pre-Transplant Workup
 Physical
Exam
 Medical/Surgical
History
 Chest X-ray
 Ultrasound
 Blood Tests
 Blood Typing
 Tissue Typing (HLA)
 Viral
Testing
 Pap/Mammogram
 Echocardiogram
 Cardiac Stress Test
 Dental Evaluation
 Psychosocial
Evaluation
 Dietary Evaluation
Multi-Disciplinary Team
 Transplant
 Transplant
Surgeon
Nephrologist
 Transplant
Coordinator
 Transplant
Pharmacist
 Transplant Social
Worker
 Cardiologist
 Floor
Nurse
 Transplant
Registered Dietitian
 Financial Counselor
 Office Staff
Pre-Transplant Lab Tests
 CBC
 PT/PTT,

inr

 CMP

 LFT’s

 U/A,
urine Cx, UPC
ratio (If not anuric)
 Serologies

HBsAb, HBsAg,
HBcAb, HIV, HCV
pcr, CMV, EBV, HSV,
VZV



PSA (males over 50)
PPD
HgB A1c
Pregnancy eval if
appropriate
ABO x 2
HLA tissue typing and
identification of
potential DSA’s
Panel of Reactive
Antibodies (PRA)
Pre-Transplant Waitlist & Evaluation Process
•
•
•
•
•
•
Potential recipient meets with Multi–Disciplinary Team
Potential recipient receives education regarding the risks and
benefits of transplant, medical and financial acceptability, tests
that will be required, and the organ allocation process.
Potential recipient completes work up and lab tests.
All candidates added to the transplant waitlist must be
approved through the Patient Selection Committee.
Testing for any potential living donor will be done after the
patient waiting for an organ is placed on the active transplant
waitlist.
When a patient is on the active waitlist, he/she must follow up
with transplant team bi-annually until the transplant has
occurred.
Absolute Contraindications To Transplantation
 Severe,
untreatable heart or lung disease
 Active or uncontrollable cancer
 Current alcohol abuse or drug addiction
 Uncontrollable infection
 Uncontrollable HIV infection
 Failure of other organs that will not improve with
transplant.
 Limited life expectancy
 History of non-compliance medical/dietary
recommendations pre-transplant
Living Donation – Informed Consent
Education is imperative to enable the potential living donor to
understand all aspects of the donation process, especially the
risks and benefits. The goal of informed consent is to ensure
that a potential donor understands:
 That he or she will undertake risk and will receive no
financial benefit from the donor nephrectomy
 That he or she may be at risk for psycho/social issues:
depression or anxiety related to complication from surgery,
feelings of burden, body image, family tensions, loss of
employment and related financial or emotional concern.
 That there are general risks of the operation.
Living Donor Testing







H&P
Labs: CBC, CMP, LFT’s, Serologies, HLA tissue
typing, Cross match, Lipid panel, U/A, Urine
culture, UPC ratio, pregnancy evaluation, ABO,
and any other lab tests that may be indicated.
Nephrology/Urologic evaluation
CXR
ECG
 Cardiac stress test for donors >50 years
MRI, angiography, 3D CT, CT angiogram/Urogram
Psychosocial evaluation
Transplant procedure









The patient is anesthetized and a central venous catheter and urinary
catheter are placed.
The bladder is decontaminated with antibiotic solution
The usual placement of the kidney is extraperitoneal in the iliac fossa.
Pancreas will also be placed extraperitoneally
Vascular anastamosis will be to iliac artery and vein. The kidney should turn
pink and produce urine immediately.
Pancreas head will either be anastomosed to small bowel (enteric drained)or
to bladder (bladder drained)
Approximated 2 liters of pancreatic fluid will be reabsorbed if enteric
drained. If bladder drained, these pancreatic fluids will be excreted and may
cause fluid depletion.
The donor ureter is anastomosed to the recipient bladder and a double J
stent is placed. This stent facilitates healing across the anastamosis and will
be removed in the transplant clinic in 4-6 weeks via cystoscopy
After organ(s) are placed a final check for hemostasis and the positioning of
the vessels is done and a standard wound closure is done.
Immunosuppressive Therapy
All patients who receive a transplant are placed on a medication regime that
suppresses the bodies’ natural immune response to protect the integrity of the graft.
There are many possible combinations of medication regimes, depending on the
center’s protocol.

Induction Therapy
 Initial potent prophylactic immunosuppression at the time of transplant to
prevent hyper-acute or acute rejection
 Agent of choice is dependent on recipients pre-existing medical conditions,
donor characteristics, and the maintenance immunosuppressive regimen to be
used
 Lymphocyte count will drastically decrease.
 Anti-fungal, anti-viral and anti-bacterial prophylaxis is required
 Effect may last for months

Maintenance Immunosuppression
 Medications will be taken for the life of the allograft
 Patient compliance is critical to graft survival
 Goal is to prevent rejection
Renal Transplant
Enteric Drainage (Panreaticojejunostomy)
 Anastamosis
of pancreas
to Jejunum via a
Roux-en-Y loop
 Mimics normal enteric
drainage of pancreatic
enzymes
 Difficult to diagnose
rejection, can't measure
secretion of enzymes
Urinary Diversion
(Pancreaticoduodencystostomy)



Pancreas anastomosed to the
recipients bladder
Offers a direct method for
assessing graft exocrine
function (urine amylase
decreases earlier than changes
in blood glucose if graft is
rejecting)
Complications:




Metabolic acidosis from
bicarbonate loss into urine
Ulceration/bleeding at duodenal
segment
Cystitis
Volume imbalance due to
excretion of ~ 2000 ml
pancreatic fluid daily.
Authorization to Procurement
Scott Bunting, RRT, CPTC
Procurement Transplant Coordinator
4 Primary responsibilities/duties
•
•
•
•
Hospital Development- DDC, PTC
Donor Management – PTC, MD, RN
Organ Allocation – PTC, DAC
Family Support – FCS, PTC
Umbrella Organizations
United Network for Organ Sharing
Maintains the National Organ Transplant Waiting
List under contract with the U.S. Department of
Health and Human Services
American Association of Tissue Banks
Provides tissue banking standards to promote
quality and safety in tissue transplantation
Association of Organ Procurement
Organizations
Recognized as the national representative of
organ procurement organizations (OPOs)
The EBAA is the nationally recognized
accrediting body for eye banks
United Network for Organ Sharing (UNOS)
• Maintains U.S. organ transplant waiting list
• Determines national organ donation policy
• Private, non-profit organization that operates the
Organ Procurement & Transplantation Network &
U.S. Scientific Registry of Transplant Recipients
• Under contract with Centers
for Medicare & Medicaid
Services (CMS) of the
U.S. Dept. of HHS
Hospital Development
• Policy & Procedure



State Law
Regulations
Hospital Policy
• Staff education - DDC, PTC


Real time
Inservices
• Medical Record review– DDC
Pre-Donor Management Recommendations
• Maintain SBP > 100 (MAP > 60)


Maintain euvolemia
Vasopressor support
• Maintain Urine Output > 0.5/mL/kg/hr

•
•
•
•
Treat DI with vasopressin or DDAVP
Maintain PO2 > 100 and pH 7.35-7.45
Monitor and treat electrolytes
Monitor and treat blood glucose
Monitor and treat anemia, coagulopathy, and
thrombocytopenia
• Maintain temp 36.5-37.5 C
3 Phases of Donor Management
• Resuscitation Phase

First 6 – 12 hrs
• Plateau Phase

12 – 24 hrs
• Recovery Phase

Next 24 – 36 hrs
Resuscitation Phase
• Resuscitation Phase 6 - 12 hrs
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Lab testing, Radiology
A-Line, Central line
Fluids- Colloids-Hespan, Blood
Free Water Gavage
Hormone Replacement
• Vasopressin, Solumedrol, T4

Reduction of vasopressors
• Add Dobutamine 0.5 mg
• Serologic & HLA testing
• Coroner Release
Plateau Phase
• Organ specific testing



Bronchoscopy, CT
Echo, Angio,
Abd Ult
• Organ Allocation

Kidney & Pancreas Lists
• Crossmatch
Organ Allocation
• PTC uploads chart to UNOS - Donornet



Confirm Height, Weight, DCD vs BD
ABO, HLA, Serologies
Labs, CXR, EKG, Echo, Angio
• UNOS Regulations –Minimum requirement for organ offers
• Timeout prior to generating match runs


Timeout between field coordinator (PTC) and off-site
coordinator (DAC)
Reduction of errors
UNOS – United Network for Organ sharing
Donornet – Web based system maintained by UNOS for organ offers
Kidney Placement (cont’d)
• Who gets choice of kidney?


Direct donation
Life saving organ (heart kidney, liver kidney)
• What do you do if you have both?
Who accepted the organ first






Pancreas
0mm
Local High PRA
Pediatrics
Payback
Local list
Liver Placement
• Minimum information for Liver Offer

UNOS Policy 3.6.9
• When do you re-run the liver list?

Splitting the liver from a pediatric donor
• Which livers can we split?




Less than 40 years of age
On a single vasopressor or less
Transaminases no greater than 3 times normal
BMI of 28 or less
• Share 35
Heart/Lung Placement
• Optimize thoracic organs prior to testing


ECHO, bronch, angios
Repeat tests as required
Recovery Phase
• Donor Management

fluid shiftingencourage diuresis
• Albumin, Lasix
• Recovery Phase


Organ Allocation of
heart Lungs completed
OR set
Family Support – FCS, PTC
• Assess Family needs


•
•
•
•
Out of town
Children
Directed Donation requests
Provide Coroner information
Funeral Home
Time Frames / updates
Web Resources
• OneLegacy
www.onelegacy.org
• United Network for Organ Sharing
www.unos.org
• Organ Procurement and Transplantation Network
www.optn.transplant.hrsa.gov
• Donate Life California Registry
www.donateLIFEcalifornia.org
Questions to Run On:
How can I utilize this information
on donor management and
transplant candidate criteria
to improve donation practice
in my hospital?

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