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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
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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