Progress in Transplantation

A Care Multidisciplinary Action Plan was developed at a 300-bed rural medical center in 1994. Once a potential organ donor is identified and referred to the organ procurement organization and the family has consented to donation, the ICU nurse initiates the Care Multidisciplinary Action Plan, which is based on an 8-hour time frame for ICU care that may be adjusted as needed. The first hour includes prompts for coroner notification, billing changes, and completion of hospital-specific death notice forms. The remaining hours are spent administering tests and preparing the donor for organ retrieval. Collaborative issues such as donor family support also are addressed. ICU nurses who used the donor care Multidisciplinary Action Plan were interviewed to determine its effectiveness.

Donor card/brochures have not had a major impact on donation, though considerable resources have been invested in their development and distribution. One reason for this may be that they have not been evaluated by the people expected to sign them: the American public. A focus group format was used to develop a quantitative survey to assess the public's perception of an appropriate donor card/brochure. Several donor card/brochures were studied to compare and evaluate their effectiveness, content, format, and acceptance of the message. A donor card/brochure was designed that was based on the results of the survey; it included a business reply card for further evaluation. The newly developed donor card/brochure continues to be viewed positively by those returning business reply cards. Most have signed the card and discussed donation with family members.

Many important advances in transplantation have been made during the last decade. The introduction of Orthoclone OKT3 into clinical trials and its subsequent approval by the Food and Drug Administration in 1985 for use as an antirejection agent for renal transplantation were landmarks in the field of clinical transplantation of solid organs. In the decade since the approval of OKT3 for clinical use, much has been learned and written about OKT3. OKT3 now is considered a safe and effective agent for prophylaxis and first-line treatment of acute rejection of solid organ allografts. In this article, the development and use of OKT3 over the last 10 years, as well as the present status and future implications of immune therapy with OKT3, are reviewed.

The purpose of this study was to evaluate the safety, efficacy, and transplant outcomes associated with FK506 rescue and maintenance therapy in pancreas transplant recipients. A chart review was conducted on 10 patients receiving FK506 after pancreas transplantation. Transplant outcomes were compared with an equivalent group of patients receiving cyclosporine. Medication dose, side effects, infections, rejection episodes, glycemic control, and graft survival were recorded from 2 to 28 weeks after transplant. Rescue therapy was successful in the patients who were converted to FK506 prior to a significant decline in glycemic control, whereas those patients who were converted after a decline in glycemic control were required to return to exogenous insulin administration. Neurological complications, nephrotoxicity, incidence of infection, hypertension, rejection, and graft survival were similar for both groups. Use of FK506 is comparable to cyclosporine in pancreas allograft recipients and successful conversion from cyclosporine to FK506 can be undertaken for rescue therapy.

This phenomenological study examined the lived experience of an individual who underwent end-stage liver failure and liver transplantation. The participant was asked to respond to the question, What was it like for you having experienced end-stage liver failure and liver transplantation? Permission was granted to tape-record the interview. Themes derived from the data analysis were identified, analyzed, and sorted. As a result, four categories were delineated: (1) uncertainty, (2) control, (3) social support, and (4) spirituality. Categories and themes contributing to a description of one individual's experience with end-stage liver failure and liver transplantation may provide direction for interventional studies designed to effect change in the lived experiences of those undergoing similar phenomena.

Liver transplant has been the treatment of choice for people with end-stage liver disease since the mid-1980s. The theme of returning to work after liver transplantation emerged from the data of a phenomenological study examining the lived experience of people with liver transplants. Thirteen liver recipients were interviewed using a semistructured approach. Only one of the first nine participants was able to return to work after the transplant; therefore, the last four participants were purposely chosen because they had been able to return to work. The possibility of losing health insurance benefits and disability benefits prevented many participants from working. Those able to return to work had professional careers that afforded them flexibility in their work schedule. Some implications for health professionals lie in the area of healthcare and health insurance policy change. Avenues for health insurance reform could be explored in an effort to empower the transplant recipient.

Hypertension develops soon after organ transplantation using cyclosporine- or FK506-based immunosuppression. Sustained rises in blood pressure require intervention to reduce the risk of intracranial bleeding and other cardiovascular complications. Antihypertensive treatment is complicated by reduced renal function and potential interference with absorption and/or metabolism of cyclosporine or FK506. To manage early and long-term hypertension related to immunosuppression with cyclosporine or FK506 and prednisone following orthotopic liver transplantation, a comprehensive nurse-managed hypertension clinic was developed. Blood pressure, heart rate, and antihypertensive and immunosuppressive regimens were evaluated according to a standard protocol at 1, 4, 12, 24, and 36 months after orthotopic liver transplantation. Data indicate that posttransplantation hypertension develops within the first months after orthotopic liver transplantation and persists indefinitely. If comprehensively managed by the hypertension nurse-clinician, the percentage of controlled hypertension patients can increase over time.

A retrospective review was done to evaluate the detection of hepatocellular carcinoma preoperatively, using ultrasonography and α-fetoprotein in patients awaiting orthotopic liver transplantation. Sixteen of the 187 patients who underwent 209 orthotopic liver transplantations at the Ochsner Transplant Center from 1987 to 1994 were diagnosed with hepatocellular carcinoma, 3 preoperatively and 11 at the time of pathological inspection of the liver explant. Two developed metastatic hepatocellular carcinoma while awaiting orthotopic liver transplantation. Ultrasonography detected abnormalities in the region where hepatoma was identified in 5 of 11 (45%) patients with incidental hepatocellular carcinoma, in all 3 with overt hepatocellular carcinoma, and in neither of the 2 who developed metastatic hepatocellular carcinoma while awaiting orthotopic liver transplantation. Hepatocellular carcinoma was present in 5 of 23 (22%) patients with an α-fetoprotein greater than 20 ng/mL and in 3 of 10 (30%) with an α-fetoprotein greater than 50 ng/mL.

Drug interactions involving cyclosporine following transplantation are a challenging issue for the transplant clinician. This is especially true when ketoconazole is the second agent used in conjunction with cyclosporine. Because both agents are metabolized by the cytochrome P-450 IIIA4 enzyme system, cyclosporine levels rise dramatically in the presence of ketoconazole. Many other agents interact with ketoconazole, either by competitive enzyme inhibition in the liver and gastrointestinal tract, or by reducing the absorption of ketoconazole by agents that increase the pH of the gastrointestinal tract. Despite the potential cost savings when using ketoconazole to reduce cyclosporine doses, adverse effects associated with ketoconazole put patients at risk when using this combination. Close monitoring of cyclosporine levels is imperative when adding ketoconazole to cyclosporine, and once the dosage adjustments are complete, the addition of a third drug that interacts with either cyclosporine or ketoconazole could result in an unexpected rejection episode or toxic cyclosporine side effect.

Single lung transplantation is an effective treatment for patients with severe chronic obstructive pulmonary disease. Pulmonary hyperinflation, which is seen in most patients with severe chronic obstructive pulmonary disease, makes the task of appropriately matching the donor and recipient difficult. It seems that the optimal matching strategy remains undefined. No correlation between donor/recipient size match (actual and predicted) and the degree of functional improvement after single lung transplantation was found. There were no significant differences noted when comparing the functional outcomes of right and left lung transplant recipients. It was concluded that the chronic hyperinflation associated with severe chronic obstructive pulmonary disease allows for the use of significantly larger donors. The use of expanded donor/recipient size match criteria in patients with severe chronic obstructive pulmonary disease may shorten the waiting period prior to single lung transplantation and provide better utilization of donor organs.