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

Recipient
Workup
From Authorization to
Allograft

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Describe the criteria that is utilized for patients to be placed on the waitlist.
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Identify the factors involved for transplant candidate evaluation. What are the considerations for living donors?

Kidney Disease Outcome Quality
Initiative ( K/DOQI) Staging
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K/DOQI created the standardization of clinical practice guidelines.
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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).

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Stages of Kidney Failure- K/DOQI Staging:
Stage Description
1 Kidney damage with normal or
increased GFR
2 Kidney damage with mild decrease in GFR
3 Moderate decrease in GFR
4 Severe decrease in GFR
5 Kidney failure
GFR (ml/min)
Equal to, or > 90
60-90
30-59
15-29
Less than 15

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A patient must be in stage 4 or 5 End
Stage Renal Disease (ESRD)
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Renal failure must be chronic and irreversible
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GFR must be <20 to accrue wait time
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A live renal transplant may be completed prior to the initiation of dialysis and GFR does not need to be <20.

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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:
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Gastroparesis
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Renal Failure
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Retinopathy
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Neuropathy
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Accelerated Cardiovascular disease
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Improves quality of life
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Patients receive a kidney/pancreas transplant as Type 1 diabetes has caused irreversible damage to both pancreas and kidney

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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.
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If the potential candidate is able to resolve contraindications found at initial assessment, then they may be re-assessed.
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Older age, in itself, is not a contraindication.

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Physical Exam
Medical/Surgical
History
Chest X-ray
Ultrasound
Blood Tests
Blood Typing
Tissue Typing (HLA)
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Viral Testing
Pap/Mammogram
Echocardiogram
Cardiac Stress Test
Dental Evaluation
Psychosocial
Evaluation
Dietary Evaluation

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Transplant Surgeon
Transplant
Nephrologist
Transplant
Coordinator
Transplant
Pharmacist
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Transplant Social
Worker
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Cardiologist
Floor Nurse
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Transplant
Registered Dietitian
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Financial Counselor
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Office Staff

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CBC
PT/PTT, inr
CMP
LFT’s
U/A, urine Cx, UPC ratio (If not anuric)
Serologies
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HBsAb, HBsAg,
HBcAb, HIV, HCV pcr, CMV, EBV, HSV,
VZV
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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
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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
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Severe, untreatable heart or lung disease
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Active or uncontrollable cancer
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Current alcohol abuse or drug addiction
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Uncontrollable infection
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Uncontrollable HIV infection
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Failure of other organs that will not improve with transplant.
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Limited life expectancy
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History of non-compliance medical/dietary recommendations pre-transplant

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:
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That he or she will undertake risk and will receive no financial benefit from the donor nephrectomy
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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.

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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
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Cardiac stress test for donors >50 years
MRI, angiography, 3D CT, CT angiogram/Urogram
Psychosocial evaluation

Transplant procedure
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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.

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.
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Induction Therapy
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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
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Lymphocyte count will drastically decrease.
Anti-fungal, anti-viral and anti-bacterial prophylaxis is required
Effect may last for months
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Maintenance Immunosuppression
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Medications will be taken for the life of the allograft
Patient compliance is critical to graft survival
Goal is to prevent rejection

Enteric Drainage (Panreaticojejunostomy)
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Anastamosis of pancreas to Jejunum via a
Roux-en-Y loop
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Mimics normal enteric drainage of pancreatic enzymes
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Difficult to diagnose rejection, can't measure secretion of enzymes

Urinary Diversion
(Pancreaticoduodencystostomy)
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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:
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Metabolic acidosis from bicarbonate loss into urine
Ulceration/bleeding at duodenal segment
Cystitis
Volume imbalance due to excretion of ~ 2000 ml pancreatic fluid daily.

Scott Bunting, RRT, CPTC
Procurement Transplant Coordinator

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

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

• Policy & Procedure
 State Law
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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

• Resuscitation Phase
 First 6 – 12 hrs
• Plateau Phase
 12 – 24 hrs
• Recovery Phase
 Next 24 – 36 hrs

• 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

• Organ specific testing
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Bronchoscopy, CT
Echo, Angio,
 Abd Ult
• Organ Allocation
 Kidney & Pancreas Lists
• Crossmatch

Organ Allocation
• PTC uploads chart to UNOS - Donornet
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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
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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

• Who gets choice of kidney?
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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

• 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?
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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

• Optimize thoracic organs prior to testing
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ECHO, bronch, angios
Repeat tests as required

• Donor Management
 fluid shiftingencourage diuresis
• Albumin, Lasix
• Recovery Phase
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Organ Allocation of heart Lungs completed
OR set

• Assess Family needs
 Out of town
 Children
• Directed Donation requests
• Provide Coroner information
• Funeral Home
• Time Frames / updates

• 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