Chapter 79 Transplantation
Organ
PATHOPHYSIOLOGY
Tremendous strides have been made in pediatric transplantation in the last decade. Organ transplantation is an acceptable form of treatment for end-stage organ failure. Advances in immunosuppression, improvements in surgical techniques, and experience in postoperative management have contributed to the improved results. Kidney, liver, and heart transplantations have become routine, and lung and small bowel transplantations are increasing in numbers. Primary diseases that can lead to the need for renal transplantation include acquired diseases such as chronic glomerulonephritis, lupus erythematosus, pyelonephritis, hemolytic-uremic syndrome, and bilateral Wilms’ tumor. It is also the treatment for congenital conditions such as polycystic disease, obstructive uropathy, cystinosis, and Alport syndrome. The major indications for liver transplantation include biliary atresia, alpha1-antitrypsin deficiency, tyrosinemia, and posthepatic cirrhosis. Indications for cardiac transplantation include cardiomyopathy, hypoplastic left heart syndrome, and other lethal, complex, congenital heart anomalies.
The major problem associated with transplantation is rejection. Rejection can result from any of a variety of causes: cellular and/or humoral immune response, infection, and noncompliance with treatment regimen. Other causes of graft failure include technical failure, infection, and medication toxicity.
The survival rates have improved significantly in recent years and range from 85% to 95% at 1 year after transplantation. Factors restricting transplantation currently are the limited availability of organs and the need for lifelong immunosuppression. Growth may be delayed, but pubertal development proceeds normally after successful transplantation.
INCIDENCE
LABORATORY AND DIAGNOSTIC TESTS
Preoperative Evaluation
1. Extensive serologic studies including chemistry panel, complete blood count (CBC) with differential, platelet count, viral screening, blood cultures
2. Meticulous search for infection, including dental examinations, sinus radiography
3. Electrocardiogram, chest radiographic study, echocardiogram, possible cardiac biopsy
MEDICAL MANAGEMENT
Immunosuppression regimens vary by center, but most include a combination of cyclosporine, azathioprine, tacrolimus, mycophenolate mofetil, sirolimus, and corticosteroids to prevent rejection. Rejection is treated with high-dose steroids or polyclonal or monoclonal antibodies. Other medications include nystatin as a prophylactic for Candida infection, antihypertensives and diuretics for hypertension and edema, antibiotics, and antacids. The average length of hospital stay following transplantation is 2 weeks. Medications must be taken for life, and close medical follow-up is required.
NURSING INTERVENTIONS
Postoperative Care
1. Monitor for and report signs of rejection.
2. Monitor vital signs and report significant changes, because they may be indicators of rejection, bleeding, infection, or hypovolemic shock. Check vital signs every hour for 24 hours; if stable, then check vital signs every 4 hours.
3. Monitor urinary output; report any significant changes.
4. Observe for drainage on dressing.
5. Observe for child’s therapeutic response to and untoward effects of medications.
6. Observe for and report signs and symptoms of possible complications.
Discharge Planning and Home Care
1. Instruct child and family about therapeutic responses and untoward reactions to medications.
2. Reinforce necessity of complying with medical regimen.
3. Reinforce information provided about nutritional needs.
4. Instruct about proper dental care (brushing and flossing).
5. Refer to appropriate community resources, clinics, agencies, or personnel for psychosocial needs.
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Harmon W, et al. Trends in immunosuppressive strategies in pediatric transplantation. Am J Transplant. 2003;3(5):285.
Harmon W, et al. Pediatric transplantation. Am J Transplant. 2005;5(4 Part 2):887.
Magee J, et al. Pediatric transplantation. Am J Transplant. 2004;4(Supplement 9):54.
Saunders R, et al. Rapamycin in transplantation: A review of the evidence. Kidney Int. 2001;59(1):3.
