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

• 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

Objectives:

How can I utilize this information on donor management and

transplant candidate criteria to improve donation practice in

my hospital?

Questions to Run On:

Recipient WorkupFrom Authorization to Allograft

Questions to Run OnDescribe 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

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 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

irreversibleGFR must be <20 to accrue wait timeA 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 Surgeon Transplant

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 ConsentEducation 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 TherapyAll 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

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)

Authorization to Procurement

Scott Bunting, RRT, CPTCProcurement Transplant Coordinator

4 Primary responsibilities/duties

• Hospital Development- DDC, PTC• Donor Management – PTC, MD, RN• Organ Allocation – PTC, DAC• Family Support – FCS, PTC

Umbrella OrganizationsUnited Network for Organ SharingMaintains the National Organ Transplant Waiting List under contract with the U.S. Department of Health and Human Services

American Association of Tissue BanksProvides tissue banking standards to promote quality and safety in tissue transplantation

Association of Organ Procurement OrganizationsRecognized as the national representative of organ procurement organizations (OPOs)

The EBAA is the nationally recognized accrediting body for eye banks

• 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

United Network for Organ Sharing (UNOS)

Hospital Development

• Policy & Procedure State Law Regulations Hospital Policy

• Staff education - DDC, PTC Real time Inservices

• Medical Record review– DDC

• 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

Pre-Donor Management Recommendations

3 Phases of Donor Management

• Resuscitation Phase First 6 – 12 hrs

• Plateau Phase 12 – 24 hrs

• Recovery Phase Next 24 – 36 hrs

• Resuscitation Phase 6 - 12 hrs 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

Resuscitation Phase

• Organ specific testing Bronchoscopy, CT Echo, Angio, Abd Ult

• Organ Allocation Kidney & Pancreas Lists

• Crossmatch

Plateau Phase

• 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

Organ Allocation

UNOS – United Network for Organ sharingDonornet – 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

• Donor Management fluid shifting- encourage

diuresis• Albumin, Lasix

• Recovery Phase Organ Allocation of

heart Lungs completed OR set

Recovery Phase

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

How can I utilize this information on donor management and

transplant candidate criteria to improve donation practice

in my hospital?

Questions to Run On: