Mar 31, 2017 - In the United States alone, there were approximately 122,000 people on the waiting list at the end of 201
Organ and Tissue Donation and Transplantation
Contact Hours: 2 hours First Published: March 31, 2017 This course expires on: March 31, 2019
Course Objectives - Upon completion of this course the nurse will be able to • • • •
Have knowledge of the organs and tissues that can be donated Describe the process of organ donation Discuss the screening required for organ donors and recipients Provide Nursing care for organ recipients and donors
Caleb was born with prune belly syndrome, a serious birth defect that caused his kidneys to fail. A year later, the infant started dialysis and to stay alive he had to endure dialysis for ten hours every day for two years. When Caleb was three, Caleb's mom, Monica, donated a kidney to him. He is now a thriving boy and is becoming more independent in taking his medications. Caleb was also born with cerebral palsy and needs a walker for mobility. In spite of these challenges, he has participated in the Marine Corps Marathon Healthy Kids Run two years in a row. He enjoys T-ball and “all things superheroes.”
The need for lifesaving organ transplantation keeps on increasing. In the United States alone, there were approximately 122,000 people on the waiting list at the end of 2015. 30,970 transplants were performed in 2015, with organs received from 15,068 donors. On average, 22 people die each day, while waiting for organ transplantation (United Network for Organ Sharing, 2016).
The waiting list grows Every 10 minutes another person is added to the waiting list. Each year, the number of people on the waiting list continues to grow, while the number of donors and transplants grows slowly.
A single tissue donor can save the lives of approximately 50 people. More than 1 million tissue transplants are performed each year. In the U.S, the most commonly transplanted tissues are bones, tendons, ligaments, skin, heart valves, blood vessels and corneas. More than 48,792 corneas were transplanted in the U.S. in 2015. More than half of all people on the transplant waiting list are from a racial or ethnic minority group. Some diseases that cause end-stage organ failure are more common in these populations than in the general population.
African Americans, Asians, Native Hawaiians and Pacific Islanders, and Hispanics/Latinos are 3 times more likely than Whites to suffer from end-stage renal (kidney) disease, often as the result of high blood pressure. Native Americans are 4 times more likely than Whites to suffer from diabetes. An organ transplant is sometimes the best—or only—option for saving a life.
History of Organ & Tissue Transplantation Doctors first experimented with organ transplantation on animals and humans in the 18th century. There were many failures over the years, but by the mid-20th century, scientists were performing successful organ transplants. Transplants of kidneys, livers, hearts, pancreas, intestine, lungs, and heart-lungs are now considered routine medical treatment. Important medical breakthroughs such as tissue typing and immunosuppressant drugs allow for more organ transplants and a longer survival rate for recipients. The most notable development in this area was Jean Borel's discovery of an immunosuppressant drug in the mid-1970s. Cyclosporine was approved for commercial use in November 1983. Hands and faces have recently been added to the list of organs that can be successfully transplanted. These complicated surgeries are technically called vascularized composite
1st Successful Transplants 1954: Kidney Dr. Joseph E. Murray Brigham & Women's
1966: Pancreas/kidney Drs. Richard Lillehei, William Kelly University of Minnesota
1967: Liver Dr. Thomas Starzl University of Colorado
1968: Pancreas Dr. Richard Lillehei University of Minnesota
allografts (VCAs) because they are surgeries composed of grafting many kinds of tissue: bone, muscle, nerves, skin, and blood vessels.
1968: Heart
In 2005, the first hand transplants were performed, and in 2007, the first face transplant was performed. Developments in immunosuppressive drugs help to keep these and all transplants from being rejected.
1981: Heart/lung
Fewer than 125 hand and face transplants have been performed worldwide. But for the people who now have hands to use or a face to show the world, VCA transplants are transforming lives. Source: Johns Hopkins Medicine
Dr. Norman Shumway Stanford University Hospital Dr. Bruce Reitz Stanford University Hospital
1983: Single lung Dr. Joel Cooper Toronto General Hospital
1986: Double lung Dr. Joel Cooper Toronto General Hospital
1989: Living liver
One organ donor can save 8 lives.
Dr. Christoph Broelsch University of Chicago
1990: Living lung Dr. Vaughn A. Starnes Stanford University Medical Center
Tissue donation must be initiated within 24 hours of death. However, tissue can be processed and stored for an extended period of time.
ORGANS AND TISSUES THAT CAN BE TRANSPLANTED
Eight organs can be donated: heart, kidneys (2), pancreas, lungs (2), liver, and intestines. In 2014, hands and faces were added to the organ transplant list. Tissues that can be donated: bones, tendons, ligaments, skin, heart valves, blood vessels and corneas. Bone marrow and stem cells, umbilical cord blood, peripheral blood stem cells (PBSC) Donated tissues save or dramatically improve the quality of life for the people who receive them. Corneas, the middle ear, skin, heart valves, bone, veins, cartilage, tendons, and ligaments can be stored in tissue banks and used to restore sight, cover burns, repair hearts, replace veins, and mend damaged connective tissue and cartilage in recipients. Heart valves can be transplanted to save the lives of children born with heart defects, and adults with damaged heart valves. Skin can be used as a natural dressing for people with serious burns. It can even save lives by stopping infections. Bone is important for people receiving artificial joint replacements, or replacing bone that has been removed due to illness or injury, for example in hand and face transplants. Tendons can be donated to help rebuild damaged joints.
Blood Stem Cells Healthy adults between the ages of 18 - 60 can donate blood stem cells. In order for a blood stem cell transplant to be successful, the patient and the blood stem cell donor must have a closely matched tissue type or human leukocyte antigen (HLA). Since tissue types are inherited, patients are more likely to find a matched donor within their own family or racial/ethnic group. There are three sources of blood stem cells that healthy volunteers can donate: Bone marrow: It is a major site of blood cell production and is removed to obtain stem cells. Cord blood stem cells: The umbilical contains blood that has been shown to contain high levels of blood stem cells. Cord blood can be collected and stored in large freezers for a long period of time and, therefore, offers another source of stem cells available for transplanting into patients. Peripheral blood stem cells: The same types of stem cells found in marrow can be pushed out into a donor's bloodstream after the donor receives daily injections of filgrastim. Filgrastim increases the number of stem cells circulating in the blood and provides a source of donor stem cells that can be collected in a way that is similar to blood donation. Blood is stored in a blood bank according to type (A, B, AB, or O) and Rh factor (positive or negative). Blood can be used whole, or separated into packed red cells, plasma, and platelets, all of which have different lifesaving uses. It takes only about 10 minutes to collect a unit (one pint) of blood, although with the testing and screening, the process of donating It is safe to donate blood takes about an hour. blood every 56 days Platelets can be donated without donating blood. When a specific patient needs and platelets every platelets, but does not need blood, a matching donor is found and platelets are four weeks. separated from the rest of the blood which is returned to the donor. The donor's body will replace the missing platelets within a few hours.
WHO CAN BE AN ORGAN DONOR? All adults in the U.S. and in some states people under the age of 18 can indicate their commitment to donation by signing up to be an organ donor. Whether or not someone is suitable for donation is determined at the time of death. Authorization by a parent or guardian is generally necessary for individuals under 18 who have died to become an actual donor. There are no age limitations on who can donate. Newborns as well as senior citizens have been organ donors. Non-resident aliens—people who don't live in the U.S. or aren't citizens—can donate and receive organs in the United States. Organs are given to patients according to medical need, not citizenship. However, only about 1 in 100 people who receive transplants are non U.S. residents.
Absolute Contraindications to Organ/Tissue Donation: •
Age older than 80 years for corneal transplant
•
Age older than 60 for heart values and tendon donations
•
Presence of HIV infection
•
Encephalitis
•
Creutzfeldt-Jakob disease
•
Malaria
•
Tuberculosis
•
Active metastatic cancer
•
Prolonged hypotension or hypothermia
•
Disseminated intravascular coagulation
•
Sickle cell anemia or other hemoglobinopathy
The National Organ Transplant Act (Public Law 98-507) makes it illegal to sell human organs and tissues in the United States. Violators are subject to fines and imprisonment. One reason Congress made this law was to make sure the wealthy do not have an unfair advantage for obtaining donated organs and tissues. (Source: OPTN white paper on bioethics—Financial Incentives for Organ Donation, June 30, 1993)
Relative Contraindications (use caution): •
Malignancy other than in the central nervous system or skin that is in remission (>5 years)
•
Hypertension
•
Diabetes mellitus
•
Physiologic age older than 70 years
•
Hepatitis B or C
•
History of smoking
The transplant team will determine what can be used at the time of death based on a clinical evaluation, medical history and other factors. Even if there's only one organ or tissue that can be used, that's one life saved or improved.
Blood and Compatibility Tests Before Organ Recovery Matching is an important part of donor evaluation. Blood tests, cross matching, HLA testing, and other compatibility tests are performed. The first test that is conducted for finding out the suitability of a donor is blood typing. If this is positive, then tissue typing is carried out. However, even if the donor’s blood is not an exact match with the recipient, the process may still take place through the paired exchange donation process. Tissue Typing or HLA Typing The tissues of each and every individual are different from the other with the sole exception of identical twins. It is assumed that if the tissues of the donor and the recipient match with each other closely, the chances of the success rate of transplantation increases. The blood sample for tissue typing is taken from the white blood cells. Tissue typing is also known as HLA (Human Leukocyte Antigen) typing. There are over 100 unique identified antigens. Only six are extremely crucial for organ transplants. Crossmatching Crossmatching is conducted to make sure that the recipient’s body will not react to the donor organ/tissue by producing antibodies. For the transplant surgery to take place, the test has to come out negative. If the test results are positive, this means that the antibodies are present and the organ/ tissue is not compatible. The basic technique for this test involves mixing cells and serum together and checking if the recipient’s body has the tendency to reject the transplant.
The probability of getting a flawless six-antigen match between an unrelated donor and a recipient is 1 in 100,000. The similarity between tissue types between different members of the same family range from 100% to 0%. Each parent has at least a 50% match.
Donor Screening While some organ transplantations are life-saving procedures, serious illness, graft loss and death can occur from undetected infections in donor organs and tissues. It is important to determine if the potential donor has an infection that could be transmitted to recipients through the transplanted organs and/or tissues. Although infrequent, infectious pathogens (i.e., viruses, bacteria, fungi, or protozoa/parasites) have been unknowingly transmitted through transplants such as human immunodeficiency virus (HIV), hepatitis C , rabies virus , tuberculosis and Balamuthia mandrillaris. The Organ Procurement and Transplantation Network ( OPTN ) policy for Organ Procurement Organizations ( OPOs) and FDA regulations for tissue and eye banks, require a medical and social history interview to be conducted with the deceased donor’s next-of-kin, and may include other persons who knew the potential donor. The intent is to gather information about 1) behaviors that may have exposed the potential donor to certain diseases and 2) the potential donor’s past medical history. This interview is one of several ways the donor’s risk for having an infectious disease is assessed; however, its usefulness depends on how well the person being interviewed knew the potential donor.
Laboratory Testing for Infectious Diseases OPTN policy requires OPOs and living donor recovery centers to perform the following tests to see if the potential donor may have the following infections: human immunodeficiency virus (HIV) , hepatitis B (HBV) or hepatitis C (HCV) virus, syphilis , cytomegalovirus ( CMV ) and Epstein Barr Virus ( EBV ). Living potential kidney donors at increased risk for tuberculosis are also tested for this infection. Additional steps are taken to rid tissue of pathogens that might be present on or within the tissue. Corneas are stored in a solution to reduce bacterial growth. Other tissues go through a disinfection process. Some tissues, such as corneas, blood vessels, heart valves and skin cannot be sterilized because the treatment could damage the tissue. According to federal law, transplant centers are only prohibited from accepting and transplanting organs from donors infected with human immunodeficiency virus (HIV) .
Because the number of donor organs is not sufficient to meet the need, intentional transplantation of organs from HBV - and HCV - infected donors is accepted medical practice. These organs are typically offered to transplant patients known to have the same infection, or in rare circumstances, to uninfected patients in cases of urgent medical need. The medical director, or designated person, of the tissue or eye bank performs a final review of the documents, such as records on donor eligibility, test results and tissue processing, before deciding if tissues from a particular donation are safe to be released for transplantation.
The Deceased Donation Process Even though millions of people have registered to become organ donors, very few of us die in a way that lets us share the gift of life. The process of donation most often begins with the potential donor registering in their state. Signing up does not guarantee that they will be able to donate their organs, eyes, or tissues—and registering usually takes place many years before donation becomes possible. But it is the first step to being eligible to save lives.
Only 3 in 1,000 people die in a way that allows for organ donation.
For someone to become a deceased donor, he or she has to die in very specific circumstances. Most often, a patient comes to a hospital because of illness or accident, such as a severe head trauma, a brain aneurysm or CVA. MEDICAL CARE OF POTENTIAL DONORS The medical team does everything possible to save the patient's life. At this point, whether or not the person is a registered donor is not considered. Only after brain death has been confirmed and the time of death noted, can organ donation become a possibility.
Clinical Diagnosis of Brain Death The clinical diagnosis of brain death is determined after it is established that the patient’s condition is due to irreversible brain damage and the patient is not in a coma. When both of these criterions are established, the following examination is conducted to be certain that all important reflexes are not present (Machado, 2010): •
No motor response with application of painful stimuli
•
No papillary response when light is applied
•
No corneal reflexes when touched
•
Absence of the following reflexes: pharyngeal, laryngeal, oculovestibular, and oculocephalic
•
An Apnea test is conducted in the absence of other reflexes but it may not be done in cervical cord injury patients
The hospital notifies the local Organ Procurement Organization (OPO) of every patient that has died or is nearing death. This is in keeping with federal regulations. The hospital gives the OPO information about the patient to confirm whether he or she has the potential to be a donor. If the person could be a candidate for donation, a representative from the OPO travels immediately to the hospital.
Nursing Care and Management of Brain Death To ensure that the organs will be viable after they are harvested, the following nursing care is provided: •
The patient is maintained on a ventilator to ensure oxygenated blood continues to flow to the organs
•
The head is elevated by 30 degrees
•
The patient’s position is changed in order to avoid decubitus ulcers
•
Vital signs are monitored
•
Suctioning is performed to make sure that the pulmonary secretions maintain fluidity
•
The cornea is kept moist
•
Infections are prevented and patient hygiene is maintained
•
Blood coagulation and glycemic values are monitored
The condition of each organ is carefully monitored by the hospital medical staff and the OPO procurement coordinator.
Prevention of Hypothermia Upon brain death, a severe thermal imbalance occurs. Conditions that hypothermia may cause include: •
Cardiac arrhythmia
•
Myocardial and vasoconstriction depression
•
Electrolytic imbalance
•
Coagulation problems
•
Hyperglycemia
•
Ketosis
A core body temperature should be obtained for accuracy and should not be measured from the mouth, rectum, or axilla but from the pulmonary artery, nasopharynx, esophagus, or tympanic membrane.
Maintain Electrolyte Balance Electrolytic disorders are common in brain dead patients, usually manifesting in abnormal levels of calcium, sodium, magnesium, and phosphate. Metabolic disorders like hypomagnesemia and hyperkalemia may occur, resulting in cardiac arrhythmia. Electrolytes should be monitored and levels addressed accordingly.
Kidney Function In order to maintain proper kidney function, diuresis must be evaluated carefully, and hydration must be maintained.
Authorizing donation The OPO representative searches to see if the donor candidate is registered as a donor on their state registry. If so, that will serve as legal consent for donation. If the potential candidate has not registered, and there was no other legal consent for donation, such as a notation on the driver's license, the OPO will ask the next of kin for authorization. After authorization, a medical evaluation takes place, including obtaining the potential donor’s complete medical and social history from the family.
The matching process If potential donor’s evaluation allows donation, the OPO contacts the Organ Procurement and Transplantation Network (OPTN). The OPTN operates the national database of all patients in the U.S. waiting for a transplant. The OPO enters information about the potential donor into the computer system and the search begins. The computer system generates a list of patients who match the donor (by organ). Each available organ is offered to the transplant team of the best-matched patient.
Organs remain viable for a short period of time after removal from the donor, so minutes count. Heart: 4 hours – 6 hours Lungs: 4 hours – 8 hours Intestines: 6 hours – 10 hours Liver: 12 hours – 15 hours Pancreas: 12 hours – 24 hours Kidneys: 24 hours – 48 hours
When matching organs from potential donors to patients on the waiting list, many of the factors taken into consideration are the same for all organs. These usually include: •
Blood type
•
Body size
•
Severity of patient's medical condition
•
Distance between the donor's hospital and the patient's hospital
•
Length of time on the waiting list
•
Whether the patient is available (for example, whether the patient can be contacted and has no current infection or other temporary reason that transplant cannot take place)
Depending on the organ, however, some factors become more important. For example, some organs can survive outside the body longer than others. So the distance between the donor's hospital and the potential recipient's hospital must be taken into consideration. The transplant surgeon determines whether the organ is medically suitable for that patient or may refuse the organ—for example, if the patient is too sick to be transplanted or cannot be reached in time. Most organs go to patients in the area where the organs were recovered. The others are shared with patients in other regions of the country.
The OPO representative arranges the transportation of the organs to the hospitals of the intended recipients. Transportation depends on the distance involved, and can include ambulances, helicopters, and commercial airplanes.
HEARTS People waiting for a heart transplant are assigned a status code, which indicates how urgently they need a heart. Because the heart can survive outside the body for only 4 to 6 hours, they are given first to people who live near the hospital where organs are recovered from the donor. If no one near the donor is a match for the heart, the transplant team starts searching progressively farther away to identify a recipient. Body size also is especially important in heart matching, as the donor's heart must fit comfortably inside the recipient's rib cage.
LUNGS The lung allocation system uses information such as lab values, test results, and disease diagnosis—to arrive at a number which represents an estimate of the urgency of a candidate's need for transplant and the likelihood of prolonged survival following the transplant. This lung allocation score, and the common factors listed above, are considered to determine the order in which a donated lung is offered to potential recipients. Body size and distance between hospitals are especially important because lungs also must fit within the rib cage, and can survive outside the body for only 4 to 8 hours. Lungs are therefore offered first to people near the donor's hospital. If no one near the donor is a match for the lung, the recovery team starts searching progressively farther away.
HEART-LUNG Candidates for a heart-lung transplant are registered on both the OPTN Heart Waiting List and the OPTN Lung Waiting List. If a donor heart becomes available, the patient will receive a lung to go with it from the same donor. If a lung becomes available, the donor's heart will be given to the heart/lung patient as well.
LIVER Candidates who need a liver transplant are assigned a MELD or PELD score (Model for End-Stage Liver Disease or Pediatric End-Stage Liver Disease) that indicates how urgently they need the organ. A donor liver is offered first to the candidate who matches on the above common elements and has the highest MELD or PELD score first (indicating the most need). If the first recipient's surgeon does not accept the organ then the liver is offered to matching patients with the next highest MELD or PELD scores until the organ is accepted. Geographic factors are also taken into consideration, but livers can remain outside the body for 12 to 15 hours so they can travel farther than hearts and lungs.
KIDNEYS The identification of potential recipients for a donor kidney involves the common elements noted above including whether the recipient is a child, and whether the body sizes of the donor and recipient are a good match. Other factors used to match kidneys include a negative lymphocytotoxic crossmatch and the number of HLA antigens in common between the donor and the recipient based on tissue typing. Many kidneys can stay outside the body for 36-48 hours so many more candidates from a wider geographic area can be considered in the kidney matching and allocation process than is the case for hearts or lungs.
PANCREAS Candidates who are waiting for a pancreas transplant are matched to an available organ primarily based on blood type compatibility and the length of time the patient has been on the waiting list. Since most pancreas transplants are performed at the same time as a kidney transplant, it is also necessary to match the kidney using the matching criteria described above for the kidney.
INTESTINES When matching the donor intestine to a waiting list candidate, the ABO blood group must be identical because of the higher risk of graft-versus-host-disease (GVHD), a violent immune reaction by the lymphocytes within the donor organ against the recipient's body that can lead to death. Also, the abdominal cavity shrinks up in many patients waiting for an intestinal transplant so the donor must usually be considerably smaller than the recipient so that the intestine will fit into the smaller space. Finally, because intestinal transplant recipients can easily get a severe infection from cytomegalovirus (CMV) and Epstein Barr virus (EBV), patients who have never been exposed to CMV or EBV before are usually matched with donors who are similarly CMV-negative or EBV-negative respectively.
RECOVERING AND TRANSPORTING ORGANS A transplant surgical team replaces the medical team that treated the patient before death. (The medical team trying to save the patient’s life and the transplant team are never the same team.) The surgical team removes the organs and tissues from the donor's body in an operating room. First, organs are recovered, and then additional authorized tissues such as bone, cornea, and skin. All incisions are surgically closed. Organ donation does not interfere with open-casket funerals. The transplant operation takes place after the transport team arrives at the hospital with the new organ. The transplant recipient is typically waiting at the hospital and may already be in the operating room awaiting the arrival of the lifesaving organ. Surgical teams work around the clock as needed to transplant the new organs into the waiting recipients.
The Living Donation Process Most organ and tissue donations occur after the donor has died. But some organs and tissues can be donated while the donor is alive. Nearly 6,000 living donations take place each year. That's about 4 out of every 10 donations.
Most living donations happen among family members or between close friends. Some people become altruistic living donors by choosing to donate to someone they don’t know.
Types of Living Donation Directed Donation
Altruistic Donation
Paired Donation
• The donor is biologically related to the person receiving the organ/tissue such as siblings, parents or an adult child • The donor can also be unrelated biologically, such as a spouse, a friend or a colleague • The donor is an unrelated individual who came to know about the needs of the recipent
• The donor is not related to the recipient • The donation is made purely out of altruistic concerns • The matching of the organs and tissues is based upon compatibility • The donor and the recipient may or may not meet with each other personally
• a living donor who cannot donate to his or her loved one because of ABO or crossmatch incompatibility donates an organ/tissue that is distributed to the deceased donor wait list, and in return, his or her loved one receives increased priority on the deceased donor wait list. In this scenario, a deceased donor organ/tissue is received in return for the donated live donor organ/tissue.
LIVING ORGAN DONATION •
One kidney A kidney is the most frequently donated organ from a living donor. The donor's remaining kidney provides the necessary function needed to remove waste from the body.
•
One lobe of their liver. Cells in the remaining lobe of the liver regenerate until the liver is almost its original size. This regrowth of the liver occurs in a short period of time in both the donor and recipient.
•
A lung or part of a lung, part of the pancreas, or part of the intestines. Although these organs do not regenerate, both the donated portion of the organ and the portion remaining with the donor are fully functioning.
LIVING TISSUE DONATION Some of the tissues donated by living donors are: • • • • •
Skin, after certain surgeries such as an abdominoplasty Bone after knee and hip replacements Healthy cells from bone marrow and umbilical cord blood Amnion, donated after childbirth Blood, including white and red blood cells, platelets, and plasma
A healthy body can easily replace some tissues such as blood or bone marrow. Both blood and bone marrow can even be donated more than once since they are regenerated and replaced by the body after donation.
SUITABILITY TO DONATE Potential living donors are evaluated by the transplant center where they intend to make the donation to determine whether they are suitable to be a donor. The evaluation is performed to make sure that no adverse physical, psychological, or emotional outcome will occur—before, during, or following the donation. Generally, living donors should be physically fit, in good health, between the ages of 18 and 60, and should not have (or have had) diabetes, cancer, high blood pressure, kidney disease, or heart disease. The benefit of saving another by becoming a living donor must be weighed carefully against the risks that come with any major surgical procedure, as well as financial considerations. A healthy donor faces the risk of an unnecessary major surgical procedure and recovery. •
A small percentage of patients have had problems maintaining life, disability, or medical insurance coverage at the same level and rate as previously.
•
There can be financial concerns due to possible delays in returning to work because of unforeseen medical problems.
•
As with any major surgical procedure, there is a small risk of complications and/or death.
THE RISKS OF LIVING DONATION Even though living donation cannot take place without the consent of the donor, there are several risks associated with the surgery. These risks are concerned with both psychological and medical aspects. Living
donation is a major surgery, and it is the responsibility of the transplant team and the nurses to educate the donors about the risks and healthcare before and after the surgery. It is imperative that the surgical risks, potential short term and long-term risks are communicated with the donors.
Short Term Complications These complications vary according to the organ that is being donated. Anesthesia related problems are the most common short-term complications along with: •
Side effects caused by allergic reactions to the anesthesia
•
Hemorrhaging
•
Blood loss, which may require transfusion
•
Chances of developing infections at the incision site
•
Coagulation problems
•
Damage to nearby tissues and organs
•
Pain
•
Pneumonia
•
Death
Long Term Complications Living donation has several different long-term complications, which also may vary depending upon the type of organ recovery. Refer to the table below for the long term complications of various living organ donation:
LONG-TERM POSSIBLE RISKS AND COMPLICATIONS OF ORGAN DONATION
Type of Organ Donation
Long Term Risks
Kidney
•
Hernia
•
Hypertension
•
Kidney failure or reduced function, resulting in the need for dialysis or transplant
•
Proteinuria
•
Ventricular fibrillation
•
Inflammation of the pericardium
•
Pleural effusion and bronchopleural fistula
•
Diabetes
•
Splenectomy
•
Inflammation of the pancreas
•
Bowel obstruction
•
Short gut syndrome
•
Severe weight loss
•
Depletion of vitamins from the body
•
Leakage of bile
•
Hernia
•
Organ failure or impaired function, requiring a transplant
•
Intestinal problems
•
Abdominal bleeding
Lung
Pancreas
Intestine
Liver
Organ/Tissue Donor Recovery Process The recovery process is different for each living donor. Liver donors have to remain under observation in the hospital for seven days, or longer in some cases. The liver is an organ that re-grows after the surgery. It takes approximately 2-3 months for the liver to return to normal size again, and then the donor can return to daily activities. Kidney donors may have to remain in the hospital for 3-7 after the surgery. They may resume their daily activities after four weeks to six weeks (“United Network for Organ Sharing | Living Donation”, 2016).
There are lifting and driving restrictions, and most donors experience fatigue for undefined periods of time. The transplant center evaluates and collects followup data from the living donor every six months for a year after the surgery, to monitor the health and recovery process of the donor.
Psychological Problems Some donors may experience psychological issues soon after the organ recovery surgery. Most psychological symptoms arise following surgical complications and medical reactions. The recipient may also suffer from depression if the transplanted organ does not immediately function in a desirable manner. Donors may become anxious or depressed after the surgery due to post-op pain, permanent scarring at the incision site and depression. It is possible that the relationship status of the donor and the recipient becomes strained after the surgery. It is crucial that living donors are made aware of the possible post-op complications and consequences.
Financial and Insurance Complications Financial aspects after the surgery are often overlooked by the living donors. Despite the fact that the health insurance policy of the recipient covers the immediate cost of the organ recovery surgery and the follow up cost, other medical charges that are incurred because of long term surgical complications may or may not be covered, and in most cases, the donors health insurance may not also cover these costs (“United Network for Organ Sharing | Living Donation”, 2016).
Organ Rejection Organ/tissue rejection is a process in which the immune system begins “attacking” the transplanted tissue or organ. Since cornea does not have any blood supply, these transplants rarely encounter a rejection. Usually, transplants from identical twins are not rejected. The immune system detects the protein coating (antigens) on foreign matter entering the human body and immediately recognizes it and starts attacking the harmful organisms or cells. When a person undergoes a transplant with a donated organ or tissue, the body may consider it as “foreign matter”. The immune system detects that the cells of the transplanted organ/tissue do not match, thus triggering a blood transfusion reaction, or worse a rejection.
Signs and Symptoms of Organ/Tissue Rejection The symptoms of the organ/tissue rejection typically depend upon the type of the organ/tissue. Typical symptoms of organ/tissue rejection include: • • • • • • •
Decreased functionality in the performance of the organ/tissue Feelings of uneasiness Swelling and severe pain at the surgical site Body chills, and flu-like symptoms Shortness of breath and cough Nausea and body aches In rare case the patient may also experience fever
The following chart depicts typical signs of organ malfunctioning post-transplant: Organ Transplant
Signs of Rejection
Heart
Shortness of breath and diminished ability to exercise
Kidney
Decreased amounts of urine excretion
Liver
Pale and yellowish skin tone along with easy bleeding
Pancreas
Escalating levels of blood sugar
Usually, a biopsy of the transplanted tissue or organ is done in order to confirm if it is truly in the rejection mode or not. Tests including abdominal CT scan, Chest x-ray, ultrasound of the kidneys, heart echocardiography, and arteriography may be done before the biopsy of the organ/tissue.
Types of Rejection Donated organ/tissue rejection is mainly classified into three types: • • •
HYPERACUTE REJECTION ACUTE REJECTION CHRONIC REJECTION
Types of Organ/Tissue Rejection Hyperacute Rejection • This type of rejection takes place within the first 24 hours after the transplant surgery takes place. • It happens when the antigens do not match at all. • Commonly, if an individual is transfused with the wrong blood type, hyperacute rejection takes place. • Screening for anti-graft antibodies earlier , prevents hyperacute rejection.
Acute Rejection • This type of rejection starts a week after the surgery . However, the risk is highest within the first three months after the transplant. • Almost all recipients undergo at least some sort of acute rejection. • Episodic treatment is used to combat the acute rejection.
Chronic Rejection • This type of rejection may start years after the transplant surgery. • The immune system of the individual's body slowly and gradually begins to harm the transplanted organ or tissue
Treatment and Prevention Treatment The main purpose of the treatment is to ensure that the organ or tissue that is transplanted is not rejected by the immune system’s response. Suppressing the way the immune system responds is one method of preventing a rejection. Anti-rejection medications are administered to accomplish the desired effect.
Prevention Blood typing and HLA typing (tissue antigen typing) are carried out beforehand in order to ascertain that a close match exists between the blood and tissues of the donors and the recipients. Immunosuppressive agents are also injected in the body to reduce the chances of organ rejection.
Types of Immunosuppressants Post-transplant immunosuppression almost always includes a combination of drugs and methods based upon a patient's individual condition, organ transplanted and current advances in the field of transplantation. Clinical immunosuppression usually occurs in three phases: induction, maintenance and anti-rejection.
Induction immunosuppression. This treatment plan consists of giving all medications immediately after transplantation surgery in increased doses with the rationale to prevent acute rejection. Although the medications may be continued after discharge for the first 30 days after transplant, they are not used long-term for immunosuppressive maintenance. Medications commonly used may include Methylprednisolone, Atgam, Thymoglobulin, OKT3, Basiliximab or Daclizumab.
Maintenance immunosuppression. This treatment plan consists of all immunosuppressive medications given before, during or after transplant surgery with the intent to maintain them on a continuing basis. Medications commonly used may include Prednisone, Cyclosporine, Tacrolimus, Mycophenolate Mofetil, Azathioprine or Rapamycin. In addition, maintenance immunosuppression does not include any medications used during the Induction phase or to treat rejection episodes.
Anti-rejection immunosuppression. This treatment plan includes all immunosuppressive medications given for the purpose of treating an acute rejection episode during the initial post-transplant period or during a specific follow-up period, usually up to 30 days after the diagnosis of acute rejection is confirmed. Common medications may include Methylprednisolone, Atgam, OKT3, Thymoglobulin, Basiliximab or Daclizumab.
Changing Immunosuppressants Some transplant patients change immunosuppressants for one or more of the following reasons: • • •
•
Lack of efficacy. Effectiveness of certain drugs can vary greatly in patients based on gender, past medical history, current treatment regimen and type of transplant. Positive and negative physical and psychological effects. There are both common side effects that many patients experience, as well as serious side effects, depending on individual patient intolerance. Short and long term health risks. Every patient's treatment program must be scrutinized to determine how changing their immunosuppressant therapy regimen may cause the patient to develop additional health concerns or risks. Financial costs. Changing Immunosuppressants may result in added costs due to an increased number of office visits in order to find the most effective combination of medications.
The following are some of the more common side effects associated with immunosuppressant medications:
•
Acne
•
Adverse reactions to prolonged sunlight
•
Anemia
•
Anxiety
•
Arthritis
•
Fat deposits around the waist and back of
•
Increased appetite
•
Increased blood sugar
•
Kidney damage
•
Mood swings
•
Nausea, diarrhea and/or vomiting
•
Osteoporosis
•
Puffy ("moon-faced") appearance
•
Skin peeling on palms and feet
•
Swelling of feet, hands, abdomen or face
•
Tingling hands and feet
•
Tremors (shaking)
•
Trouble sleeping
•
Unwanted hair growth
•
Weight gain
neck •
Gout
•
Gum overgrowth
•
Hair loss
•
Headache
•
High blood pressure
•
High cholesterol
The dosage of the administered drug depends upon the condition of the patient. Generally, high dosages are given if the transplanted organ or tissues are not being accepted by the human body. If the symptoms of rejection improve, the dosage is lowered. Some patients may have to continue taking anti-rejection medications for the rest of their lives. HOW TO BECOME A DONOR A person can sign up online or in-person at their local motor vehicle department. Registering online takes just a few minutes. All that is necessary is some identification information and a driver’s license or photo ID number. Anyone over the age of 18 is eligible to sign up, and in many states, people younger than 18 can register as well A potential donor should tell their family about their decision. If the time comes, they won’t be surprised and they can help carry out the potential donor’s wishes. They may be asked to provide information to the transplant team.
95% of U.S. adults support organ donation but only 48% are actually signed up as donors.
What can be done to save more lives? ✓ Register in your state. Just one donor can save up to 8 lives. ✓ Talk to your family and friends ✓ Make your wishes known to your friends and family. ✓ Get the word out on social media ✓ Help raise awareness of the importance of donation. ✓ Volunteer, there are lots of organizations that could use your help.
Expose the Myths about Organ Donation There are many myths related to organ and tissue donation circulating in our society. It is the responsibility of nurses to provide accurate information about the process of organ/tissue donation.
Here are some of the most popular myths regarding organ/tissue donation:
MYTH: Organs and tissues are sold to bidders and transplant agencies that propose the highest price. REALITY: The data is generated automatically, and no other socio-economic factors make a difference. A national computer system matches donated organs to recipients.
MYTH: Rich or famous people on the waiting list get organs faster. REALITY: The factors used in matching include blood type, time spent waiting, other important medical information, how sick the person is, and geographic location. Race, income, and celebrity are NEVER considered.
MYTH: Somebody could take my organs and sell them. REALITY: Federal law prohibits buying and selling organs in the U.S. Violators can be punished with prison sentences and fines.
MYTH: The body of the deceased donors is mutilated. REALITY: The body of the deceased donor is treated with utmost respect and care. Organs and tissues from the brain dead bodies are recovered by using the surgical methods implemented in the case of live surgeries, the environment and the tools are completely sterile.
MYTH: Care is not given to the critically ill patients who have a potential to become deceased donors. REALITY: The physicians, surgeons, and nurses are bound by the medical ethics to save the life of the critically ill patients. Also, the hospital administration and the surgical team are not part of the transplant or organ recovery process.
MYTH: I'm too old to be a donor. REALITY: There's no age limit to organ donation. To date, the oldest donor in the U.S. was age 92. What matters is the health and condition of your organs when you die.
MYTH: I don't think my religion supports donation. Most major religions in the United States support organ donation and consider donation as the final act of love and generosity toward others.
MYTH: My family will have to pay for the donation. REALITY: There is no cost to donors or their families for organ or tissue donation.
MYTH: People in the LGBT community can't donate. REALITY: There is no policy or federal regulation that excludes a member of the LGBT community from donating organs. What matters in donating organs is the health of the organs.
Gift of Life Donor Program 1-800-DONORS-1 (1-800-366-6771)
DONATE LIFE AMERICA ORGAN PROCUREMENT AND TRANSPLANTATION NETWORK U.S. GOVERNMENT INFORMATION ON ORGAN DONATION AND TRANSPLANTATION
While national rates of donation and transplantation have increased in recent years, more progress is needed to ensure that all candidates have a chance to receive a transplant. Unfortunately, the need for organ transplants continues to exceed the supply of organs. But as medical technology improves and more donors become available, the number of people who live longer and healthier lives will continue to increase each year.
REFERENCES (“United Network for Organ Sharing | Living Donation”, 2016). Retrieved 13 October 2016, from https://www.unos.org/wp-content/uploads/unos/Living_Donation.pdf Finger E. (2016). Organ procurement considerations in trauma. Retrieved from http://emedicine.medscape.com H. S. Adenwalla, S. (2012). Dr. Joseph E. Murray. Indian Journal of Plastic Surgery: Official Publication Of The Association Of Plastic Surgeons Of India, 45(3), 596. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3580381/ https://bloodcell.transplant.hrsa.gov/ https://bloodcell.transplant.hrsa.gov/DONOR/index.html https://medlineplus.gov/organdonation.html https://optn.transplant.hrsa.gov/ https://optn.transplant.hrsa.gov/learn/about-transplantation/history/ https://organdonor.gov/index.html https://organdonor.gov/statistics-stories/statistics.html#morestats https://www.cdc.gov/transplantsafety/overview/cdc-role.html https://www.cdc.gov/transplantsafety/overview/faq.html https://www.cdc.gov/transplantsafety/overview/key-facts.html https://www.cdc.gov/transplantsafety/protecting-patient/screening-testing.html https://www.cdc.gov/transplantsafety/protecting-patient/screening-testing.html https://www.cdc.gov/transplantsafety/protecting-patient/tracking-infections.html https://www.hrsa.gov/gethealthcare/conditions/donation.html https://www.organdonor.gov/statistics-stories/donation-stories.html Immunology of Transplant Rejection: Overview, History, Types of Grafts. (2016). Emedicine.medscape.com. Retrieved 13 October 2016, from http://emedicine.medscape.com/article/432209-overview#a7 Machado, C. (2010). Diagnosis of brain death. Neurol Int, 2(1), 2. http://dx.doi.org/10.4081/ni.2010.e2
OPTN: Organ Procurement and Transplantation Network - OPTN. (2016). Optn.transplant.hrsa.gov. Retrieved 10 October 2016, from https://optn.transplant.hrsa.gov/ Organ donation and transplantation fact sheet | womenshealth.gov. (2016). Womenshealth.gov. Retrieved 6 October 2016, from https://www.womenshealth.gov/publications/our-publications/fact-sheet/organdonation.html Organ donation and transplantation fact sheet | womensheaonlth.gov, 2016. Transplant Living | Living Donation. (2016). Transplantliving.org. Retrieved 13 October 2016, from https://transplantliving.org/living-donation/ TransWeb.org. (2016). Transweb.org. Retrieved 10 October 2016, from http://www.transweb.org/faq/q23.shtml United Network for Organ Sharing (2016). Unos.org. Retrieved 6 October 2016, from https://www.unos.org/data/
