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12

Organ Transplantation

Jennifer Lee Hunt

Inrroduction

With advances in technology and immunology, organ and tissue

transplantation is becoming more common. Approximately 35,000

organ transplants are performed in the world annually, and as

increasing numbers of hospitals perform transplantations, physical

therapists are involved more frequently in the rehabilitation process

for pre- and post-transplant recipients. ' Owing to limited organ

donor availability, physical therapists often treat more potential recipients than post-transplant recipients. Patients awaiting transplants often require admission to an acute care hospital as a result of their

end-stage organ disease. They may be very deconditioned and may

benefit from physical therapy during their stay. The goal of physical

therapy for transplant candidates is reconditioning in preparation for

the transplant procedure and postoperative course and increasing

functional mobility and endurance in an attempt to return patients to

a safe functional level at home. Other transplant candidates may be

too acutely sick and may no longer qualify for rransplantarion during

that particular hospital admission. These patients are generally unable

697

698

ActJfE CARE HANDBOOK FOR PHYSICAL THERAI>ISTS

to work and may need assistance at home from family members or

even require transfer to a rehabilitation faciliry.

Whether the patient is pre- or post-transplantation, physical therapists focus on recondirioning patients to their maximum functional level and should have a basic knowledge of the patient's end-stage

organ disease. The objectives for this chapter are to provide information on the following:

1 .

The transplantation process, including criteria for trans-

plantation, organ donation, and postOperative care

2.

Complications after organ transplantation, including

rejection and infection

3.

The various types of organ transplantation procedures

4.

Guidelines for physical therapy intervention with the

transplant recipient

Types of Organ Transplants

The kidney, liver, pancreas, heart, and lung are organs that are procured for transplantation. The most frequent of those are the kidney, liver, and heart.2 Double transplants, such as liver-kidney, kidneypancreas, and heart-lung, are performed if the patient has multiorgan failure. Although bone marrow is not an organ, bone marrow transplantation (BMT) is a common type of tissue transplant that will be discussed.

Criteria for Transplantation

Transplantation is offered to patients who have end-stage organ disease for which alternative medical or surgical management has failed.

The patient typically has a life expectancy of less than 1-3 years.J-5

Criteria for organ recipients vary, depending on the type of organ

transplant needed and the transplant facility.

The basic criteria for transplantation include the following':

• The presence of end-stage disease in a transplantable organ

• The failure of conventional therapy to treat the condition

successfu II y

ORGAN TRANSPLANTATION 699

• The absence of unrrearable malignancy or irreversible infection

• The absence of disease that would attack the ttansplanted organ

or tissue

In addition ro these criteria, transplant candidates muSt demon

Strate emotional and psychological stability, have an adequate

support system, and be willing to comply with lifelong immunosuppressive drug therapy. Other criteria, such as age limits and absence of drug or alcohol abuse, are specific to rhe transplant

facility. To determine whether transplantation is the best treatment

option for the individual, all transplant candidates are evaluated

by a team of health care professionals consisting of a transplant

surgeon, transplant nurse coordinator, infectious disease physician, psychiatrist, social worker, and nutritionist. The patient undergoes many laboratory and diagnostic studies during the evaluation process. Acceptable candidates for organ transplantation are placed on a waiting list. Waiting times for an organ may range

between 1 and 4 years.3•7

Many patients die waiting for a suitable

organ to become available.

Transplant Donation

Cadaveric Oa./Ors

Cadaveric donors are brain-dead individuals who have had severe

neurologic trauma, such as from head or spinal cord injury, cerebral

hemorrhage, or anoxia.8 Death must occur at a location where cardiopulmonary support is immediately available to maintain the potential organ donor on mechanical ventilation, cardiopulmonary

bypass, or both; preserve organ viability; and prevent ischemic damage ro viral organs." The cadaveric donor must have no evidence of malignancy, sepsis, or communicable diseases, such as hepatitis B or

human immunodeficiency virlls. 6.9,IO

Living DOllors

Because there are nOt enough cadaveric organs donated to meet the

needs of all potential recipients, living donor transplantation offers an

alternative means of organ donation. Living donors are always used

700

ACUTE CARE HANDBOOK FOR PHYSICAL THI:.RAI'ISl'S

for bone marrow transplants, often used for kidney transplants, and

sometimes used for liver, lung, and pancreas transplantation. They

may be genetically or emotionally related to the recipient-that is,

they are a blood relative (e.g., sister) or non-genetically related individual (e.g., spouse or close friend). Living donors also are evaluated by the transplant team to determine medical suitability.

The age of a potential donor can r.nge from a term newborn to 65

years, depending on the organ considered for donation and the recipient. Donors do not have a history of drug or alcohol abuse, chronic disease, malignancy, syphilis, tuberculosis, hepatitis B, or human

immunodeficiency virus infection. Ideally, the donor's height and

weight approximate those of the recipient for the best "fit."

Donor Matching

The matching of a cadaveric or living donor with a recipient depends

on the following factors:

• ABO blood typing

• Histocompatibility typing

• Size

The donor and recipient muSt be ABO blood type identical or compatible." The process of finding compatible donors and recipients is called tisslle typing or histocompatibility typing. Histocompatibility

typing attempts to match the human leukocyte antigens (HLAs),

which are the antigens that cause graft rejection. It is performed serologically by adding a standard panel of typing antisera, complement, and ttyphan blue stain to purified lymphocytes and then observing