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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