THE PATIENT’S JOURNEY TO TRANSPLANT AND BEYOND Chris Lillesand, RN, MSN, CCTC Kidney Transplant Coordinator Don Hawes, RN Lung Transplant Coordinator Polly Boynton, RN, BSN, CPTC Heart Transplant Coordinator 1

Evaluation Referral to UWHC Talk with organ specific coordinator Lab testing Surgeon, coordinator, social work, nutrition, dental, financial consults Arrange for organ specific testing - specialty coordinators for each organ divided by the diaphragm (thoracic and abdominal) - 2.5 heart following 210 patients, 2.5 lung following 151 patients, - Lab testing: HLA typing (genetic markers), ABO x 2, PRA (panel of reactive antibodies), basic organ function, infectious disease - each organ will have specific testing but all patients have to have basic testing regardless of organ

Heart Evaluation Support person Radiology testing Age based preventive screening Cardiac function testing Vascular screening Pulmonary function testing Radiology: Chest CT, Chest x-ray, panorex, bone density, gallbladder ultrasound Age based:mammogram, colonoscopy, pap & pelvic, opth Heart function testing: Echo, Heart Cath, EKG, Exercise Stress Test Vascular Screening: Carotid dopplers and ABIs

Lung Evaluation Support person Radiology testing Lung function testing GI testing Cardiac testing Radiology Testing: CXR 2 view, CXR single, Chest CT, Panorex, Bone mineral density, Sinus CT for CF pts Lung Function: PFTs, Lung Perfusion Scan, 6 minute walk GI testing: Manometry, PH Impedance Cardiac testing: Echo, Heart Cath, EKG

Case Specific Additional Testing Urine cotinine screening for former smokers AODA counseling Psychiatrist Referrals to other specialties based on abnormal results nicotine alcohol/cocaine

Listing for Transplant Have insurance coverage verified Approval by a multi-disciplinary committee Listed with UNOS (United Network of Organ Sharing) multi-disciplinary committee: surgeon, MD, NP/PA, coordinator, social work, nutrition, pharmacy, health psych, financial

Absolute Contraindications Recent or active cancer Active smoking (heart & lung) Obesity Current alcohol use (liver) Irreversible pulmonary HTN (heart) Uncontrolled DM No support person HIV (heart & lung) Iliac disease (kidney) Cancer w/in 5 months Heart and Lung require 6 months of documented abstinence Obesity: (Kidney-BMI 35 or less; Lung-BMI 18-30; Heart-140% of IBW

Organ Specific Listing Status Kidney – HLA & wait time Liver – Model for End-Stage Liver Disease (MELD) & Pediatric End-Stage Liver Disease (PELD) Pancreas – HLA & wait time Heart – 1A, 1B, 2, 7 Lung – Lung Allocation Score (LAS)

Average Wait Time for Thoracic Organs Heart – 161 days Lung – 176 days Heart: 264 days O, 82.5 days AB, 119 days A, 206 days B (shortest time in 2010 28 days) Lung: 187 days A, 7.5 days AB, 148 days B, 181 days O (shortest time in 2010 5 days)

Average Waiting Time for Kidneys Depends on the recipient blood type and antibody levels O - 3 Years B - 3-4 Years A - weeks to months AB - weeks to months 15

Organ Allocation UNOS matches donors with recipients based upon (differs depending on organ) blood type height & weight medical urgency tissue typing time on wait list Generates a list of potential recipients Heart: A goes to A & AB, B goes to B, O goes to O & B

Organ Allocation Organ Procurement Organization (OPO) coordinator calls transplant coordinator with offer Transplant coordinator calls surgeon patient admissions surgery fellow blood bank inpatient unit tissue typing for crossmatch attending physician clinical trials

The Recipient Recipients need to be available 24/7 Transplant coordinator has 1 hour to locate patient At time of offer transplant coordinator provides instruction timing for travel arranging ambulance/flight NPO status What if the patient refuses? -Sheriff (Chris), snow storm (Don) -Status 7 if patient refuses for heart & lung and consider de-list

Special Circumstances CDC High Risk Donor men who have sex with men, prostitution, hemophiliacs, potential HIV exposure, non-medicinal needle use, inmates specific risk information is confidential and not released to the recipient will require additional infectious disease testing after transplant

Special Circumstances Expanded Criteria Donors (ECD) based upon age, mechanism of death, history of hypertension and creatinine only applies to kidney Donation after Cardiac Death (DCD) patients that do not meet brain death criteria but are still able to donate applies to all organs but heart -all donors over 60 yrs are expanded criteria and have to have 2 of the other criteria -for each of the special circumstances the patient has to sign a special consent except for kidney

Preparation for Transplant The patient arrives and has typical pre-surgical prep CXR, EKG, labs Anesthesiology Transplant Fellow PA/Resident Transplant Surgeon Pharmacy Nursing Clinical Trials

A Dry Run Patient is aware that there is always a possibility that the transplant will not occur change in donor condition organ not suitable for transplant recipient condition No change in patient’s waitlist status Lung: Insuring adequate oxygen and supplies for round-trip Heart: Have VAD batteries and supplies

Post-Transplant Encourage contact with donor family initially anonymous Patient followed by transplant program for life monitor for rejection/infection biopsies lab work testing

Questions or Comments?