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Renal ultrasounds are performed to assess for fluid collections, and radionucleotide scans view the perfusion of the kidney. Other potential complications include post-transplant diabetes, renal artery thrombosis or leakage at the anastomosis, hypertension, hyperkalemia, renal abscess

or decreased renal function, and pulmonary edema.6.13.25 Thrombosis

most often occurs within the first 2 to 3 days after transplantation.25

The most common cause of decreased urine output in the immediate

postoperative period is occlusion of the urinary catheter due to clot

retention, in which case aseptic irrigation is required.12

Clinical Tip

Physical therapists should closely monitor blood pressure

with exercise. To ensure adequate perfusion of the newly

grafted kidney, the systolic blood pressure is maintained at

712

AClJrE CARE HANDBOOK FOR I'HYSICAL ll-IERAPISTS

greater than 1 10 mm Hg. Kidney transplant recipients

may be normotensive at rest; however, they respond to

exercise with a higher-than-normal blood pressure.'

Liver Transplantation

Indications for liver or hepatic transplantation include the

following6,28:

• End-stage hepatic disease

• Primary biliary cirrhosis

• Chronic hepatitis B or C

• Fulminant hepatic failure (FHF) resulting from an acute viral,

toxic, anesthetic-induced, or medication-induced liver injury

• Congenital biliary abnormalities

• Sclerosing cholangitis

• Wilson's disease

• Budd-Chiari syndrome

• Biliary atresia

• Confined hepatic malignancy (hepatocellular carcinoma)

If the cause of liver failure is alcoholic cirrhosis, the patient must

be free from alcohol use for a period determined by the transplant

center, which is typically 6 months or more.

Contra indications to hepatic transplantation include the

following '9,28:

• Uncontrolled extrahepatic bacterial or fungal infections

• Extrahepatic malignancy

• Advanced cardiac disease

• Myocardial infarction within the previous 6 months

• Severe chronic obstructive pulmonary disease

• Active alcohol use or other substance abuse

ORGAN TRANSPLANTATION

713

Pretrallsplalttatiolt Care

Man}' transplant candidates are debilitated and malnourished secondary to many years of chronic liver failure. Table J 2-2 provides some characteristics of liver failure, their clinical effects, and their implications to physical therapy.

Types of Liver Tra/lSplmlts

l .

Orthotopic cadaveric liver trallsplalltatiol1. Orthotopic liver

transplantation involves removal of the diseased liver and insertion of a

cadaveric liver into the normal anatomic position via a midline sternOtomy and continuous laparotomy.

2.

Livillg adult dOllar liver transplallt. A single lobe of the liver

from a living adult is transplanted into the recipient. The removal of

the lobe does not cause any decrease in liver function to the living

donor. 7 Because of the unique ability of the liver to regenerate, the

donor's and recipient's livers will grow back to normal size within

several months.7

3.

Split liver transplant. Split liver transplants are sometimes

used to expand the donor pool. Surgeons divide an adult cadaveric

liver in situ inro two functioning allografts. 29 Usual ly, the smaller

left lobe is donated to a child, and the larger right lobe is given to an

adultJO

4.

Domino liver transplant. Domino liver transplants are cur-

rently rare and are still experimental transplantations. They involve

patients with familial amyloidotic polyneuropathy (FAP). Patients

with FAP have a metabolic defect within the liver. The liver is StruCturally and functionally normal, but it synthesizes an abnormal protein, transthyretin, that forms amyloid fibrils and deposits them in the peripheral and autonomic nerves, heart, kidney, and intestine. The

domino liver transplant involves three people: the donor, the patient

with FAP, and a patient listed on the liver transplant waiting list. The

patient with FAP receives the donated liver. The removed liver (from

the patient with FAP) is then transplanted into the other transplant

recipient, hence the term domino transplant. Liver transplantation for

patients with FAP leads to normal transthyretin protein production.

The recipient who received the FAP liver will likely never experience

any of the symptoms associated with FAP, because they take 40-60

years to manifest.?

714

AClITE CARE HANDBOOK FOR I'HYSICAL THERAPISTS

Table 12-2. Medical Characteristics of Liver Failure, Their Related Clinical

Effects, and Physical Therapy Implications

Medical

Characteristics of

Physical Therapy

Liver Failure

Clinical Effects

Implications

t Bilirubin level

Jaundice.

None.

Dark, tea-colored urine.

May induce nausea and

anorexia .

.J.. Albumin

Accumulation of ascites

May cause pressure on

synthesis

fluid in the peritOneal

the diaphragm, leading

cavity causes

to respiratory and

abdominal swelling

nutritional difficulties.

and increased

Monitor for dyspnea

abdominal girth.

with activity.

May promote protein

Patient may have an

loss and a negative

altered center of

nitrogen balance.

gravity and decreased

May lead to anasarca

balance.

(rotal body edema).

Altered clotting

Increased prothrombin

Prolonged bleeding rime.

ability

time and parrial

Patient bruises easily.

thromboplastin time.

Monitor patient safety

and prevention of falls.

Impaired glucose

Low blood sugar.

Patient may have

production

decreased energy.

Porral

Presence of esophageal

Bleeding may occur

hyperrension

varices.

spontaneously.

May lead to hepatic

Patient may have altered

encephalopathy.

mental status and

decreased safety

awareness.

Diminished

Spontaneous bacterial

None.

phagocytic

peritonitis or

activity

cholangitis.

Failure to absorb

Osteoporosis may result.

May develop compresvitamin 0

sion or pathologic

fractures.

i = elevated; J.. = decreased.

Sources: Data from KM Sigardson-Poor, LM Haggerty. Nursing Care of the Transplant

Recipient. Philadelphia: Saunders, 1990; 149-151; and RL Braddom (cd). Physical

Medicine and Rehabilitation (2nd cd). Philadelphia: Saunders, 2000;1397.

ORGAN TRANSPLANTATION

715

illdicatioll of Liver FUllctioll Post Trmlsp/allt

I.

Once the graft is vascularized in the operating room, the functioning liver Starts to produce bile.12 Thus, prompt outflow of bile through the biliary T tube, which is inserted at the time of surgery, is an

early indicator of proper function of the transplanted liver.' Thick, darkgreen bile drainage indicates good liver function. A sudden drop in amount of bile or change to a light yellow color indicates an alteration in

liver function,9

2.

The most sensitive laboratory indices of liver function are