LIVER TRANSPLANT
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Liver Transplant
Corinne Mayer
043827089
ODU Main Campus
Submitted in partial fulfillment of the requirements in the course
NURS 450: Adult Health Nursing III
Old Dominion University
NORFOLK, VIRGINIA
Spring 2012
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Liver Transplant
Advances in technology have made organ transplantation possible and safer over the
years. It is now become a common procedure around the world as the final option of treatment
for persons with end stage organ failure who has not responded to conventional medical
intervention. According to Organ Procurement and Transplantation Network (OPTN), there are
72,873 active waiting list candidates and 113,682 waiting list candidates. Active candidates are
medically suitable and have completed all eligibility requirements, making them eligible for an
organ donation at any time; whereas inactive candidates are temporarily unable to accept an
organ donation due to unmet requirements (Organ Procurement and Transplantation Network,
2012). The purpose of this paper is to discuss liver transplant, recipient and donor criteria,
therapeutic regimen, organ rejection, discharge teaching, and related nursing research.
Organ transplantation
There are a number of different organ transplants that can be currently performed. In the
1950’s, liver transplants on other animals, such as canines, were being attempted. Success was
hindered by a number of issues including infection and graft failure. After years of trials, the
first successful human liver transplant was performed in 1967. The patient only lived one year;
however, new techniques and medications have revolutionized the procedure (Urden, Stacey, &
Lough, 2010). Survival rates began increasing by the 1980’s; in 1987, five year survival rates
were 52.5 percent. The most current data shows, that patients receiving a liver transplant in
2004, had a five year survival rate of 74.1 percent (OPTN/SRTR Annual Report, 2010). There
are a number of disease processes that may lead to the need for a liver transplant including,
cholestatic diseases, such as primary biliary cirrhosis.
Pathophysiology
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Primary biliary cirrhosis is an autoimmune disease which is characterized by
inflammation and the destruction of the small intrahepatic bile ducts with portal inflammation
and fibrosis. Women are generally more affected than men. Primary biliary cirrhosis begins
with inflammation, destruction, fibrosis, and obstruction of the intrahepatic bile ducts, followed
by nodular regeneration and cirrhosis. Portal hypertension occurs during the late stages. Many
patients have no symptoms; however, early clinical manifestation in those who do may include
pruritus, fatigue, hepatomegaly, fatty deposits under the skin and abdominal pain. Elevated
alkaline phosphatase levels, hyperbilirubinemia, and hyperlipidemia, may also be present. Late
manifestations include jaundice and light colored stool caused by intrahepatic obstruction of bile.
Confirmation of the disease may be made with a positive cholestatic liver test for 6 months,
presence of antimitochondrial antibody and a liver biopsy. Therapeutic treatment aims to relieve
symptoms and prevent impediments. Corticosteroids may help slow the progression by
suppressing the immune system; cholestyramine may relieve pruritus; and vitamin A, D, and K
may be replaced. Other symptoms can be treated individually as they develop. Liver transplant
is the only conclusive treatment. Without a liver transplant, life expectancy varies from eight to
ten years (McCane, Huether, Brashers & Rote, 2010).
Recipient Criteria
A recipient criterion varies among different transplantation facilities due to constant
revisions as treatment options and surgical techniques become more sophisticated. A person
must have end stage liver disease or acute liver failure to be eligible for a liver transplant.
Additionally, liver transplant is the final option for these patients; therefore conventional
medicine and surgical intervention must be attempted before consideration for a liver transplant
(Ignatavicius & Workman, 2010).
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Contraindications
Timing of the surgery must be taken into consideration. Patients should be well enough
that post-transplant survival expected. A person, who is not likely to survive surgery, is not
going to be a good candidate for transplantation. One consideration is that of the patient’s body
mass index (BMI). Patients, who have a BMI of below 20 or above 40, have an increased
incidence of mortality and should not be transplanted. Other exclusions include; persons who
are not able to survive long term immunosuppressive medications; persons who have a disease
that may reoccur and be fatal; persons with a history of noncompliance or are unwilling to
comply with post-transplant medications and interventions. In addition, there are physical
contraindications including: brain death, metastatic malignancy, extrahepatic malignancy, drug
or alcohol abuse, advanced cardiopulmonary disease, acquired immunodeficiency syndrome
(AIDS), and extrahepatic sepsis. Other considerations need to be taken into effect also,
including physiologic age, advanced renal disease, multiple hepatic malignancies, moderate
cardiopulmonary disease, peripheral vascular disease, behaviors indicating noncompliance,
human immunodeficiency virus (HIV) infection. It is important that these factors be taken into
consideration for successful outcome of liver transplantation (Urden, Stacey, & Lough, 2010).
Evaluations
Thorough evaluations of both physical and psychosocial status are conducted to evaluate
candidacy. Patient history is carefully assessed. This includes: family history of hepatic
dysfunction, current and past risk factors for hepatitis, related illnesses, medical history, history
of alcohol, drugs, and tobacco use, and immunization standing. In addition, signs and symptoms
of progression and complications are evaluated. These include the presence of jaundice, fatigue,
coagulation disorders, pruritus, change in mental status, ascites, edema, abnormal stool,
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abdominal pain, osteoporosis, and gynecomastia in men, and amenorrhea in women. Laboratory
testing is equally important. A chart with a summary of different laboratory tests and what they
are measuring is located in appendix A. It is important to note that not all patients will be
required to perform every test and consultation; physical and historical information will assist in
guiding which testing will be implemented (Urden, et al., 2010).
Tools
One evaluation tool that is used to assist with prioritizing the transplantation list is the
Modes for End Stage Liver Disease (MELD). This tool incorporates patient’s serum bilirubin,
creatinine, and international normalized ratio for prothrombin time (INR), into a calculation that
evaluates risk of mortality in candidates above the age of 12 (Organ Procurement and
Transplantation Network, 2010). The higher the MELD score, the greater the patient urgency for
a liver transplant. Patients with a higher MELD score or with acute fulminant hepatic failure are
placed at the top of the list (Urden et al., 2010)
Psychological Evaluation
According to Josephine Morana, a liver transplant has “deep psychological implications,
which may exist within the affective, social, an interpersonal relm of the individual’s personality.
In the postoperative phase, there may be manifestations of adjustment disorders,
psychopathological disturbances, problems with compliance, as well as non-adherence to
therapeutic plan” (2009). Therefore, psychological evaluation is a necessary step in the
transplant assessment. Several areas are evaluated, such as education level about disease
process, transplantation, and informed consent. Additionally, past and present psychiatric
history, surgical motivation, familial support, alcohol and drug abuse, and past treatment
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compliance are evaluated. Absolute contraindications for liver transplant include irreversible
neurologic deficits, current psychosis, and current alcohol and drug abuse (Morana, 2009).
While education is an important aspect of transplantation, it is feasible to wonder if the
patients are being properly educated about their upcoming surgery. In a study done by Myers
and Pellino, 433 patients completed surveys post-transplant (2009). The purpose of this study
was to identify patient’s knowledge gaps post discharge of a solid-organ transplant. This survey
also contained a modified Patient Learning Needs Scale (PLNS) used to measure patient insight
on learning needs. Categories included in the questioning included medications, health
complications, follow up care, and quality of life and psychosocial difficulties. Prior to the
scheduled transplantation, all participants were only educated at the beginning of their evaluation
visits. Another education session did not occur again until after the transplant had been
completed. Results showed that most PLNS were satisfactory, showing that patients had been
moderately educated regarding the transplant information. However, a noteworthy amount of
patients scored substantially lower in the quality of life category. This category included
questions on how to cope with feelings after transplant and long term implications of life and
health. This was not surprising to the researchers, since this area was not taught to the patient’s
pre or post-transplantation. Recently, health care providers have recognized that patients have
increased rates of depression and anxiety and may need an increased level of support (Myers &
Pellino, 2009). This research shows that patients are not educated enough in this area and should
be done so pre-transplantation. Education should be revised to include more information
regarding psychosocial and quality of life support available to decrease the amount of depression
and increase patient satisfaction.
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Donor
Living Donor
The liver is unique in its ability to regenerate. For this reason, it is one of the organs that can be
donated by a live donor. However, not just anybody can donate a part of their liver. Donors are
generally related to the patient, and must go under a thorough physical and psychological
evaluation in order to prevent complications to the patient or the donor. Exclusion criteria
include persons under the age of 18, BMI greater than 30, and other health related co-morbidities
(Nadalin, Bockhorn, Malago, Vanentin-Gamazo, Frilling & Broelsch, 2006). Additionally,
patients do not have to have matching human leukocyte antigens, as other organ transplants do.
The only physiological detail that is necessary is the same blood type and body size (Urden, et al.
2010). A live donor liver transplant must be based on the fact that the donor outcome is positive
and the survival rate of the recipient should be equal to that as a deceased donor liver transplant.
Several tests must be performed to a live donor prior to transplant. They include; donor vascular
and biliary anatomy; liver volume study; and liver biopsy. Psychological testing includes
looking for signs of self-sacrifice or coercion. Generally, this assessment is done once alone and
once with the recipient (Nadalin, et al., 2006).
A person who chooses to be a liver donor may have various different feelings before and
after the transplant. A qualitative study using semi-structured interviews was done on 18 donors
going through a liver transplant in Japan. This study aimed to explore pre and post
transplantation feelings of these donors. Donors were asked about their feelings before the
transplant, such as why they chose donation; and their feelings after such as, effects of the
donation. Additionally, anxiety and relationships were also questioned. The study found that
eight patients were eager to donate in order that they saved the recipient for their own and their
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family’s needs. These donors highlighted familial relationships and needs during their interview.
Seven donors expressed that they were the only existing donor for the recipient and three stated
that the recipient desired their liver. This finding shows that there may be a feeling of need
rather than desire to help the patient. Prior to the transplant, there were a variety of anxiety
levels. Nine donors stated they had minimal anxiety and that the procedure had minimal risk;
two donors expressed excitement, and four donors stated they were neutral with whatever the
outcome may be. The remaining three patients stated that they felt coerced because they were
the only available donor. After the transplant procedure, 14 patients expressed that their lives
have changed since, stating that they felt more grateful to others, more positive feelings toward
life, feeling more kind to others, and increased sense of maturity. Three patients stated that there
were no changes (Kusakabe, Irie, Ito & Kazuma, 2008). Overall, this study shows that there are
various feelings before and after donation. In addition, feelings may change after a donation has
taken place. Nurses should be aware of the difference in feelings and communicate the donor’s
feelings and needs appropriately. Also, since half of the donors expressed that the donation had
minimal risk, it may show that they may not be educated enough, or did not understand the
negative implications that may be associated with the procedure. Nurses should ensure that the
donors understand the effects of the transplant, without assuming the latter.
Deceased Donor
There are two different categories of deceased liver donors, standard criteria donor (SCD)
and extended criteria donor (ECD). A liver that comes from a SCD comes from a person who
has an irreversible loss of brain function, or brain death. This can occur from loss of blood flow
to the brain related to trauma, stoke, or other injury. Generally a neurologic exam by two
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physicians will declare brain death. Those who are brain dead are legally deceased (Beth Israel
Deaconess Medical Center).
Due to an extensive shortage of SCD donors, ECD’s are being used more commonly.
These livers come from a deceased donor who has certain risk factors. Different transplantation
centers have different extended criteria. At the Beth Israel Deaconess Medical Center, some of
these include:

Donor is over the age of 60

Donor is positive for Hepatitis C

The liver has been preserved for longer than 12 hours

There is an accrual of fat in the liver

The liver is partial or split liver

The liver function tests are abnormal

The donor is on blood pressure medications

Donor was admitted in the Intensive Care Unit for longer than five days
Due to these details, the liver recipient is at greater risk of early or late complications than
they would be with an SCD. Risk and benefits, including a MELD score, must be weighed
before patients elect for this type of transplant (Beth Israel Deaconess Medical Center, 2012)
One other type of deceased transplant is known as donation after cardiac death. This type
donor will have severe brain damage and will have no chance of recovery to have a significant
quality of life; however this patient is not brain dead. The donor’s family may decide to
discontinue life support. If this is the case, the organs can be removed after the patient has been
declared deceased (Beth Israel Deaconess Medical Center, 2012).
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Therapeutic Regimen
Organ Rejection
Organ rejection is a complication that may occur with any type of transplant. The health
care team tries to prevent this with immunosuppression; however, it is not always successful.
There are three types of liver rejection that can occur; hypercute, acute, and chronic. Hyperacute
happens right away within minutes to hours of the transplant. This occurs when the antigens are
not matched correctly and the body produces antibodies against the organ. The antibodies then
bind to the vascular endothelial cells. The liver must then immediately be removed to prevent
death (Medline Plus, 2012). Unlike hyperacute, chronic rejection occurs of a long period of
time. This type of rejection is progressive and cannot be reversed. This humoral episode is
caused by constant response to the organ. If the patient is a candidate, they will need another
liver transplant (Urden, et al., 2010).
Acute rejection is most common, can occur one week to three months after the
transplant. Post transplantation, liver function tests are a standard laboratory tests done to
monitor organ function. These tests are done frequently in the first days after the transplant.
Acute rejection is suspected if the patient’s liver function tests become elevated. Other early
signs of rejection include fever, decrease in bile output, and a color and thickness change of the
bile. Late signs and symptoms include fatigue, dark colored urine, and clay colored stool. All
transplant recipients will have at least one rejection incident. Acute rejection can be treated and
usually involves an increase in immunosuppressive therapy if caught early (Urden, et al.,2010).
Immunosupression
The goal of immunosuppression in transplantation is to prevent immune system from
rejecting the liver and maintaining enough function to regulate infection. The long term goal is
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to be able to withdrawal use of all immunosuppressive medications; however, only a small
number of recipients have been able to do this successfully. The type of immunosuppressive
therapy that is used is generally based on the recipients past history and the protocols for the
individual institution. The different medication regimens include; calcineurin inhibitors (CNI),
antimetabolites, steroids, and antibody based therapies. (Pillai & Levitsky, 2009).
CNI’s are the main immunosuppression medication for maintenance therapy, they
include cycolosprine and tacrolimus. Both of these inhibit calcineurin, which prevents the
translocation of nuclear factor of activated T cells and the “up-regulation of pro-inflammatory
cytokines” (Pillai & Levitsky, 2009). This inhibits the interleukin-2gene transcription and T-cell
activation and proliferation, thus suppressing cellular and humoral immunity. Both of these
CNI’s have numerous drug interactions, and will require careful drug monitoring. Numerous
toxicities are linked to these medications including; nephrotoxicity, neurotoxicity, diabetes,
hyperlipidemia, hypertension, hyperkalemia, metabolic acidosis. Also, cyclosporines are known
to cause gingival hyperplasia and hypertrichosis (Pillai & Levitsky, 2009). Besides educating
the patient on the effects of immunosuppression and how to avoid infections, signs and
symptoms of other side effects should be taught. Close monitoring of the patient’s lipids, blood
pressure, potassium, and glucose levels should be a priority. Additionally, because these
medications are known to have drug interactions, medications should be closely monitored in
order to avoid any negative effects. Signs and symptoms of nephrotoxicity and neurotoxicity,
such as decreased urine output and change in level of consciousness should also be monitored.
Antimetatabolites used are myophenolate mofetil and mycophenalate sodium, both of
which go through first pass metabolism in the liver and convert into the active compound
mycophenolic acid (MPA). MPA inhibits inosine-5’ monophosphate dehydronase, which results
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in blocking thus inhibiting T and B cell proliferation and antibody production. Both of these are
not used as secondary immunosuppressive therapy. Side effects to MPA’s are mainly
gastrointestinal and bone marrow suppression; however, viral infections such as cytomegalovirus
and herpes simplex virus have been noted. Additionally, spontaneous abortions in some
pregnant patients have been known (Pillai & Levitsky, 2009). Side effects of medications should
be well educated and alternative therapies to manage them should be discussed. Changes in diet
may help with certain aspects of gastrointestinal upset, such as diarrhea. Patients should be
aware of the risks of pregnancy and may be encouraged not to become pregnant at this time. As
with all the medications, patient should also be educated on the effects of immunosuppression.
Corticosteroids have been used for a number of different disease processes. They are
used often for their anti-inflammatory and immunosuppression properties. They control or
prevent inflammation by controlling the rate of protein synthesis, suppressing migration of
peripheral nerve myelin and fibroblasts, thus reversing capillary permeability and stabilizing
lysosomes. Intravascular corticosteroids are normally used for first line therapy for acute
rejection. It can be used for maintenance therapy; however, can usually be discontinued after
three to six months. Side effects include diabetes, hypertension, obesity, cushingoid disease,
osteoporosis, avascular necrosis, psychosis, poor wound healing, adrenal suppression, and
cataracts (Pillai & Levitsky, 2009). Again side effects of medication should be communicated
and understood. The patient should be well aware of compliance of these medications, as abrupt
withdrawal can cause serious side effects, such as an Adisonian crisis.
The antibody based therapy using polyclonal antibodies, such as, anti-thymocyte and
anti-lymphocyte globulins, have been used since the beginning of liver transplantation. They
cause prompt lymphocyte exhaustion due to complement mediated cell lysis. Additionally, they
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may also cause partial T cell initiation and block T cell proliferation. The most common side
effect that effects up to 80 percent of transplant recipients is a “first dose reaction” (Pillai &
Levitsky, 2009). This reaction is manifested by a febrile episode, which can be controlled by
pre-medicating with antipyretics, antihistamines, and intravenous steroids. Other possible side
effects include thrombocytopenia, anemia, cytomegalovirus, pruritis, and anaphylaxis (Pillai &
Levitsky, 2009). Due to the thrombocytopenia, patients are more at risk for bleeding. It is
important to recognize due to the increased risk for hemorrhaging or intracranial bleeding.
Prothrombin time, partial thromboplastin time, and international normalized ratio, should be
closely monitored for increased risk of bleeding. Nurses and patients should be aware of
worsening symptoms that may lead to other complications. Hematocrit and hemoglobin should
also be monitored in the event that other interventions are needed. Other medications that could
be included in a patient’s regimen are included in Appendix B.
Nutrition
Once bowel function has resumed, the liver recipient may begin consumption of foods
slowly; either orally or through a feeding tube and may progress slowly as tolerated (Urden, et al.
2010). Generally, a patient’s diet after the transplant is less restrictive than before. A high
calorie and protein rich diet is important for patients to promote healing and decrease risk for
infection. Assuming a patient does not have any other complications, such as diabetes or
hypertension, a diet of fruits, vegetable, whole grains, and low fat or fat free milk. Proteins are
also important and may include lean meats, poultry, fish, eggs, nuts and beans. Minimal
amounts of saturated fats, salt, added sugar, and cholesterol (Kosmach-Park, 2007).
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Discharge teaching
Discharge teaching for families and patients is essential in positive outcomes. One of the
most important areas of teaching are: compliance with medications; follow up appointments with
their care provider; and valuable self-care behaviors. Teaching about medications is an
imperative area prior to discharge. Patients should know all medication dosages, times of
administration, and what each medication is used for. Additionally, how to take the medication;
which ones can be divided or crushed if needed or which ones need to be taken with or without
foods. Side effects are also an important detail. Side effects are not experienced by everybody,
but it is important that patients be familiar with them in the case that a medication needs to be
changed or regulated. Furthermore, it is important for a patient to understand that they will be
immunocompromised and the implications. Not being able to go out into large crowds and
ensuring that they have good hand washing skills to prevent infection are two large consequences
of a compromised immune system. Safe food handling, including avoiding eating raw or
undercooked meat, scrub all fruits and vegetables before consumption, are also all important
teaching tips for these patients. Compliance with medical care is also critical. Transplant
centers will need to see patients regularly for routine laboratory work and physical examinations
to confirm continued health. Recipients will need to comply and cooperate with these
appointments for continued care. Moreover, self-care behavior is necessary for a successful
outcome. Not adapting to self-care behaviors recipients put themselves at great risk for
complications (Dal Sasso-Mendes, da Costa Zivianne, Rossin, Ribiero, Pace, Ohler, de Castro-eSSilva & Galvao, 2011). Taking responsibility for a person’s own care can be challenging for
some patients; however, coping and managing their care is a matter of life or death, and will
need careful planning.
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Self-efficacy is an important characteristic for patient compliance and self-care. In 2010,
a study of 100 patients enrolled in a liver transplant program in Brazil, identified the acceptance
of self-efficacy and compared them to demographic information. 50 of these patients were liver
transplant candidates and 50 were recipients. Some of the main demographic findings were, 87
percent were younger than 60 and 76 percent were male, and 24 percent were female. These
demographics give an insight to the patient population that is in need of liver transplantation. Of
a possible score of 1-60, self-efficacy scores for transplant candidates were 44.03 +/- 12.81 using
a Self-Efficacy for Managing Chronic Disease Six-Item Scale (Dal Sasso-Mendes, et al., as cited
in Lorig, Sobel, Ritter, Laurent, & Hobbs, 2011). The recipients overall scores were 50.1 +/10.33. This shows that liver recipients show more awareness of the importance of self-efficacy
than liver candidates (Dal Sasso-Mendes, et al. 2011). This research may help health care
providers identify patients who may not be compliant with medication or treatment.
Additionally, it could also help providers with identifying areas of education that are needed or
changes that need to be made within their educational programs.
It is important that patients be aware of signs and symptoms of complications and when
they should contact their physician. These include early signs of rejection, dysfunction,
infection, and tumors (Dal Sasso-Mendes, et al. 2011). For example, the recipient should be well
educated about transplant rejection and their signs and symptoms. Due to immunosuppression,
fevers should not be taken lightly and a patient will need to call a physician if their fever is above
38.4 degrees Celsius. Additionally, a patient is not to take any medications to treat the fever
unless a physician tells the patient otherwise (Kosmach-Park, 2007)..
Even though a patient has just gone through a major surgery, exercise is still important to
improve healing, overall health, control stress, and prevent infection. In addition, it allows for a
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more active routine and will assist in getting back to work or school. Recipients should discuss
how to start with their healthcare team to ensure that the plan is right for that patient’s specific
medical status (Kosmach-Park, 2007).
It is important that patients know that they will be able to return back to work or school;
however, times vary from person to person on a number of issues. Recovery time may vary due
to overall health or presence of complications. Furthermore, the type of job will also impact
when one can return to work (Kosmach-Park, 2007)..
Conclusion
It takes a multidisciplinary approach to care, treat, and support of liver transplant patients.
This lifelong commitment is essential for successful patient outcomes and satisfaction. Nurses
play an important role in a patient’s journey pre-transplantation as well as post-transplantation,
both physical and psychological. Research shows that patients are not as educated in the areas of
psychosocial support. In nursing practice, it is important to include information about outside
support systems and programs to help patients have support as needed. Moreover, nurses are
also important in the evaluations and support for living donors.
This information will help my own nursing practice by increasing my knowledge of
physical and mental implications of liver transplant patients pre- and post-transplantation. I will
be more sensitive to patient’s education levels and needs for support. Moreover, I have
increased my knowledge of medications and their side effects. I hope that this information will
increase my nursing scope to increase positive patient outcomes and satisfaction.
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Reference
Beth Israel Deaconess Medical Center. (2012). Donor criteria. Retrieved from
http://www.bidmc.org/CentersandDepartments/Departments/TransplantInstitute/Liver/W
hereDoestheDeceasedDonorOrganComeFrom/DonorCriteria.aspx
Dal Sasso-Mendes, K., da Costa Zivianne, L., Rossin, F. M., Ribiero, K. P., Pace, A. E., Ohler,
L., de Castro-e-SSilva, O., & Galvao, C. M. (2011). Perceived self-efficacy among liver
transplant candidates and recipients. Gastroenterology Nursing, 34(3), 236-241.
Ignatavicius, D. D., & Workman, M. L. (2010). Medical-surgical nursing: patient centered
collaborative care. (6th ed., p. 1363). St. Louis, Missouri: Elsevier Saunders.
Kusakabe, T., Irie, S., Ito, N., & Kazuma, K. (2008). Feelings of living donors about adult-toadult living donor liver transplantation. Gastroenterology Nursing, 31(4), 263-272.
Kosmach-Park, B. (2007). A guide to your health care after liver transplantation. Pittsburg:
Pennsylvania International Transplant Nurses Society. Retrieved from
http://www.itns.org/pdfs2009/ITNS_Liver_Transplant_Booklet.pdf
Medline Plus. (2012). Transplant rejection. In ADAM (Ed.),Transplant rejection Bethesda, MD:
United States National Library of Medicine.
Myers, J., & Pellino, T. A. (2009). Developming new ways to address learning needs of adult
abdominal organ transplant recipients. Progress in Transplantation,19(2), 160-166.
McCane, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2010). Pathophysiology: the
biologic basis for disease in adults and children. (6th ed., p. 1493). Maryland Heights,
Missouri: Elsevier Mosby.
Morana, J. (2009). Psychological evaluation and follow-up in liver transplantation. World
Journal of Gastroenterology, 15(6), 694-696.
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Reference
Nadalin, S., Bockhorn, M., Malago, C., Vanentin-Gamazo, C., Frilling, A., & Broelsch, C. E.
(2006). Living donor liver transplantation. HPB : The Official Journal of the
International Hepato Pancreato Biliary Association, 8, 10-21. doi:
10.1080/13651820500465626
Organ Procurement and Transplantation Network. (2010).About the meld/peld calculator.
Retrieved from http://optn.transplant.hrsa.gov/resources/MeldPeldCalculator.
asp?index=97
Organ Procurement and Transplantation Network. (2012, March 22). Data. Retrieved from
http://optn.transplant.hrsa.gov/
Pillai, A. A., & Levitsky, J. (2009). Overview of immunosuppression in liver
transplantation. World Journal of Gastroenterology, 15(34), 4225-4233. doi:
10.3748/wjg.15.4225
United States Department of Health and Human services, (2010). OPTN/SRTR annual report:
table9.13a:adjusted patient survival by year of transplant at 3 months, 1 year, 3 years, 5
years and 10 years deceased donor liver transplants. Retrieved from website:
http://www.srtr.org/annual_reports/2010/913a_li.htm
University Hospital of Cincinnati Liver Transplant Program. (n.d.). Commonly prescribed
medications following liver transplants. Retrieved from
http://www.cincinnatitransplant.org/patient_prescriptions.htm
Urden, L. S., Stacey, K. M., & Lough, M. E. (2010). Critical care nursing. (6th ed., pp. 10721080). St. Louis, Missouri: Elsevier Mosby.
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Appendix A

Liver function

Measures transaminases, alkaline
phosphatase, bilirubin, albumin, partial
thromboplastin time, clotting factors,
cholesterol, triglycerides

Kidney function

Blood urea nitrogen, creatinine, sodium,
potassium, carbon dioxide, chloride

Hematology

Complete blood count, reticulocytes,
erythrocyte sedimentation rate, blood
type, antibody screen

Thyroid function

T3, T4, thyroid stimulating hormone,


Serology studies
Immunologic profile



Nutrition profile


Tumor markers

Hepatitis A,B,C,D,E
Antinuclear antibody, antimitochondrial
antibody, anti-smooth muscle antibody;
immunoglobulin A, G, M
Vitamin levels: A, D, E, B12, folate; iron
studies
Alpha-fetoprotein, Carcinoembryonic
antigen, prostate-specific antigen
(Urden, et al., 2010)
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Appendix B


Lasix; protonix
Bactrim


Prevention or treatment of edema
Bacterial infection prophylaxis

Valcyte

Viral infection prophylaxis


Ursodiol
Diflucan



Bile thinner
Fungal infection prophylaxis
Increases uptake of tacrolimus
(University Hospital of Cincinnati Liver Transplant Program, n.d.)
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“I pledge to support the Honor System of Old Dominion University. I will refrain from any form of
academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a member of
the academic community it is my responsibility to turn in all suspected violators of the Honor Code. I
will report to hearing if summoned.”
Signature:
Corinne Mayer
Date: March, 27, 2012
LIVER TRANSPLANT
22
Transplant Paper Evaluation Form
N 450
Criteria / Points
Introduction
Overview (5)
Comments
Points
finances
-1
See note page 10
-4
Patho (5)
Recipient Criteria
Physical criteria (5)
Psychosocial criteria (5)
Donor Criteria
Physical criteria (5)
Psychosocial criteria (5)
Therapeutic Management
Organ rejection (15 )
Immunosuppression (10)
Nutrition (5)
Immunosuppression (found in DC
instructions)
Discharge teaching (10)
Nursing Research (15)
3 studies required
Study reviewed & applied
5
5
5
Study poorly reviewed or
applied
3
3
3
Study poorly reviewed and
poorly applied
1
1
1
Research omitted
0
0
0
Great job
integrating
research
studies
Conclusion (5)
APA Format (Cover page,
headings, margins, type)
.5
Split header / page break
LIVER TRANSPLANT
Format conforms to APA
Includes 1-3 APA errors
Has 4-6 APA errors
Format has >6 errors
23
3
2
1
0
APAReferences/Reference
Page
Conforms to APA Format
Includes 1-3 APA errors
Includes 4-6 APA errors
Includes >6 APA errors
Do not conform to APA
format
.5
caps
4
3
2
1
0
Writing Style (Grammar,
spelling, punctuation,
language)
Logical, organized, without
errors
3
Logical, organized minor
errors (<5)
2
Lacks logic/organization
OR major spelling /
grammar/errors (>5)
1
0
Lacks logic / organization
AND major spelling /
grammar / errors (>5)
94
Grade:
Comments:
Very nicely written paper. Good information. See comments throughout