Donation Process: Honoring the Gift - PowerPoint Presentation

Slide1

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 HospitalSlide2

Identify the various entities that support the donation process

Review the three phases of donor management and the corresponding timeframesReview the criteria that is utilized for patients to be placed on the

waitlist

Discuss the factors involved for transplant candidate evaluation

Objectives:Slide3

How can I utilize this information on donor management and transplant candidate criteria to improve donation practice in my hospital?

Questions to Run On:Slide4

Recipient Workup

From Authorization to AllograftSlide5

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?Slide6

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).Slide7

Who Are Our Patients?

Stages of Kidney Failure- K/DOQI Staging:

Stage

Description

GFR (ml/min)

1

Kidney damage with

normal

or

increased

GFR

Equal to,

or > 90

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

Less than 15Slide8

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.Slide9

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 kidneySlide10

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.Slide11

Pre-Transplant Workup

Physical ExamMedical/Surgical History

Chest X-ray

UltrasoundBlood TestsBlood TypingTissue Typing (HLA)

Viral Testing

Pap/Mammogram

Echocardiogram

Cardiac Stress Test

Dental Evaluation

Psychosocial Evaluation

Dietary EvaluationSlide12

Multi-Disciplinary Team

Transplant Surgeon

Transplant

NephrologistTransplant CoordinatorTransplant Pharmacist

Transplant

Social Worker

Cardiologist

Floor

Nurse

Transplant

Registered Dietitian

Financial

Counselor

Office StaffSlide13

Pre-Transplant Lab Tests

CBCPT/PTT, inrCMP

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)Slide14

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. Slide15

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-transplantSlide16

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. Slide17

Living Donor Testing

H & PLabs: 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

CXRECGCardiac stress test for donors >50 yearsMRI, angiography, 3D CT, CT

angiogram/

Urogram

Psychosocial evaluationSlide18

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.Slide19

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 rejectionSlide20

Renal TransplantSlide21

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 enzymesSlide22

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.

Urinary Diversion

(Pancreaticoduodencystostomy)Slide23

Authorization to Procurement

Scott Bunting, RRT, CPTC

Procurement Transplant CoordinatorSlide24

4 Primary responsibilities/duties

Hospital Development- DDC, PTC

Donor Management – PTC, MD, RN

Organ Allocation – PTC, DAC

Family Support – FCS, PTC Slide25

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 banksSlide26

Maintains U.S. organ transplant waiting list

Determines national organ donation policyPrivate, non-profit organization that operates the Organ Procurement & Transplantation Network & U.S. Scientific Registry of Transplant RecipientsUnder contract with

Centers

for Medicare & Medicaid Services

(CMS) of the

U.S

. Dept. of

HHS

United Network for Organ Sharing (UNOS)Slide27

Hospital Development

Policy & Procedure

State Law

Regulations

Hospital Policy

Staff education - DDC, PTC

Real time

Inservices

Medical Record review– DDCSlide28

Maintain SBP > 100 (MAP > 60)

Maintain euvolemiaVasopressor supportMaintain Urine Output > 0.5/mL/kg/

hr

Treat DI with vasopressin or DDAVPMaintain 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

Pre-Donor Management RecommendationsSlide29

3

Phases of Donor Management

Resuscitation Phase

First 6 – 12

hrs

Plateau Phase

12 – 24

hrs

Recovery Phase

Next 24 – 36

hrsSlide30

Resuscitation Phase 6 - 12 hrs

Lab testing, RadiologyA-Line, Central lineFluids- Colloids-Hespan, Blood

Free Water Gavage

Hormone ReplacementVasopressin, Solumedrol

, T4

Reduction of vasopressors

Add

Dobutamine

0.5 mg

Serologic &

HLA testing

Coroner Release

Resuscitation PhaseSlide31

Organ specific testingBronchoscopy, CT

Echo, Angio, Abd Ult

Organ Allocation

Kidney & Pancreas ListsCrossmatch

Plateau PhaseSlide32

PTC uploads chart to UNOS - Donornet

Confirm Height, Weight, DCD vs BDABO, HLA, Serologies

Labs, CXR, EKG, Echo,

AngioUNOS 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

Organ Allocation

UNOS – United

Network for Organ sharing

Donornet

– Web

based system maintained by UNOS for organ offersSlide33

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

listSlide34

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

35Slide35

Heart/Lung Placement

Optimize thoracic organs prior to testing

ECHO,

bronch

,

angios

Repeat tests as

requiredSlide36

Donor Managementfluid shifting- encourage diuresis

Albumin, LasixRecovery PhaseOrgan Allocation of heart Lungs completedOR set

Recovery PhaseSlide37

Family

Support

– FCS, PTC

Assess Family needs

Out of town

Children

Directed Donation requests

Provide Coroner information

Funeral Home

Time Frames /

updatesSlide38

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.orgSlide39

How can I utilize this information on donor management and transplant candidate criteria

to improve donation practice in my hospital?

Questions to Run On:Slide40