Organ and Tissue Transplantation

ORGAN AND TISSUE

DONATION AND RECOVERY

DANA BARTLETT, RN, BSN, MA, MSN

Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years of as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevire, Lippincott, and Thieme. He has written widely on the subject of toxicology and was recently named a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center and is actively involved in lecturing and mentoring nurses, emergency medical residents and pharmacy students.

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ABSTRACT

Organ transplantation rates have increased in the past several decades and yet nursing educationwith respect to the process of organ donation and posttransplant care has been inconsistent. Certain state jurisdictions, such as New Jersey, are now requiring nurses to receive continuing education on organ donation and transplantation to renew their license to practice. The goal of mandatory education is to increase nursing knowledge and participation in organ donation and transplantation programs, and to advance the role of nurses in this continuously growing area of health care.

Continuing Nursing Education Course Director & Planners

William A. Cook, PhD, Director, Douglas Lawrence, MS, Webmaster,

Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner

Accreditation Statement

NurseCe4Less.com is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Credit Designation

This educational activity is credited for 1 hour. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Course Author & Planner Disclosure Policy Statements

It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. All authors and course planners participating in the planning or implementation of a CNE activity are expected to disclose to course participants any relevant conflict of interest that may arise.

Statement of Need

Recent studies have shown that nurses' attitudes and advocacy to discuss transplantation among colleagues and with others increased following the appropriate education and practice support. Additionally, when encouraged to participate in organ donation and transplantation education, nurses demonstrated increased confidence in working with transplant patients and in addressing the need to educate their communities about organ donation, encouraging others to get involved in local organ donation and transplantation programs.

Course Purpose

This course will provide basic learning for nurses in the coordination of organ donation and transplantation; and, to increase nursing advocacy to increase the rates of organ donation in their local areas.

Learning Objectives

After finishing this module, the learner will be able to:

1. Identify different types of organ donation.

2. Identify common complications associated with transplantation.

3. Identify the organizations that coordinate organ donation and transplantation.

4. Identify the four basic steps of organ donation and transplantation.

5. Identify important steps in identifying potential organ donors.

Target Audience

Advanced Practice Registered Nurses, Registered Nurses, Licensed Practical Nurses, and Associates

Course Author & Director Disclosures

Dana Bartlett, RN, MA, MSN, William S. Cook, PhD, Douglas Lawrence, MS,

Susan DePasquale, CGRN, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC

Release Date: 1/1/2015 Termination Date: 12/10/2016

1. True or false: Registering as an organ donor or reviewing information about organ donation is mandatory for obtaining a driver’s license in NJ.

a. True

b. False

2. Most organ donations are from:

a. Living donors

b. Autolgous donors

c. Deceased donors

d. Xenogenic donors

3. Common complications associated with organ transplantation include:

a. Transfusion reaction

b. Hyper-metabolic state

c. Diabetes insipidus

d. Infection

4. Someone who is specifically allowed to discuss organ donation is a

a. Registered nurse

b. Designated requestor

c. Transplant coordinator

d. UNOS representative

5. CBIGs are intended, in part, to:

a. Keep the donor patient comfortable until organs can be obtained

b. Be diagnostic criteria for brain death

c. Help medical staff determine when to remove life support

d. Ensure that potential donor organs are well perfused and viable

INTRODUCTION

Organ and tissue donation and transplantation are life saving and life altering therapies. From 1988 to August 2013 over 580,000 people in the United States have received organ transplants, and the number of donors has been slowly but steadily increasing.Tissue transplantation is also quite common: approximately 750,000 are performed in the United States every year.The increasing incidence of both donations and transplants makes it imperative that nurses understand the processes of how organs and tissues are obtained. As of 2014,the New Jersey Board of Nursing requires every professional registered nurse to complete a one-hour course that covers organ and tissue donation and recovery. As organ donation and transplantation is more complex than tissue donation and transplantation (and in many ways the two proceduresare carried out in the same way) this module will primarily focus on organ donation and transplantation.

EPIDEMIOLOGY AND STATISTICS

The first successful organ transplant was performed in 1954. Since that time, organ and tissue donation and transplantation have become accepted treatments for a wide variety of diseases and medical conditions. The three most commonly donated and transplanted organs in descending order are kidneys, liver, and heart. The organs that can and are transplanted also include intestines, lungs, and pancreas and multiple transplants can be done, as well. Tissue transplantation can be done with amnion, bone, bone marrow, connective tissue, cord blood, corneas, heart valves, ovarian tissue, pancreatic islet cells, skin, and veins. Most donated organs are from the deceased.

Although the number of organ and tissue donations and transplantations is increasing every year, the demand far exceeds the supply. There are almost 120,000 people on the transplant waiting list and each day 18 people die that a transplant could have saved. In New Jersey in 2012, 551 transplants were performed. However, more than 5000 people are on the waiting list, and waiting for an organ is a long process. In the United States the median waiting time for a kidney is 1219 days, for a liver 361 days, and for pancreas 260 days.

Transplants and donations are well established in New Jersey, but there is a critical lack of registered donors. New Jersey ranks number 44 out of the 50 states in the percentage of registered organ and tissue donors, and only one-third of New Jersey drivers are registered as organ donors.Efforts have been made to increase the number of donors. New Jersey drivers must register through Donate Life NJ ( as someone that is an organ donor or review information about organ donation when applying for, or renewing a driver’s license; however, the need for organ donation is still not being met. As tissue donation can affect the lives of 50-75 people and one organ donor can save the lives of eight people, the need to increase participation is painfully clear.

ORGAN AND TISSUE DONATION AND TRANSPLANTATION:

BASIC INFORMATION

Organ Donation and Transplantation

Organ donation and transplantation can be divided into many different categories.

• Donation from deceased donors:

This is the most common type of organ donation. To date in 2013, there have been 5502 deceased donors and 3944 living donors.

• Donation from living donors:

A donation from a living donor offers several advantages. This approach increases the possible pool of donors. It allows for a thorough evaluation of the donor and the recipient and planning/organization of the surgery. A living donor also provides an organ that is, usually, well perfused.

• Allogenic donation:

An allogenic donation is the donation of an organ from another person.

• Isogenic donation:

The organ is donated from an identical twin.

• Autologous donation:

Tissue is transplanted from one site in the body to another. Autologous blood donations are relatively common.

• Xenogenic donation:

The organ or tissue has been harvested from another species, e.g., heart valves from pigs.

• Donation after brain death:

Donation after brain death is performed with an organ from someone who meets the criteria for brain death. These donations, usually, offer an organ that is well perfused. Also, these donors can donate multiple organs, such as, heart, both lungs, both kidneys, liver, pancreas, and the small intestine.

• Donation after cardiac death:

Donation after cardiac death increases the pool of possible donors: a 2012 Canadian study noted that the number of kidney transplants in some transplant programs increased by 40% when this approach was used. Typically only kidneys and the liver are transplanted from patients that have suffered cardiac death, but lung transplantation using this method is also possible. Donation of organs after cardiac death is usually considered to be less desirable and less successful than donation after brain death, as this method of donation and transplantation has an inherent risk of increasing ischemia to the donated organ. However, this issue is being actively investigated and some transplant centers have reported equivalent results for kidney and liver transplants when the two methods are compared.

Tissue Donation and Transplantation

Tissue donation and transplantation is performed in much the same way as is solid organ donation and transplantation. However, the types of tissues that can be used are more numerous, and composite transplantation – transplantation of several tissue types in one procedure - can also be performed.

Donation and Transplantation Complications and Risks

The most common complications and risks associated with donation and transplantation are: 1) Rejection; 2) Infection; and,3) Increased risk of disease. These are further explained as:

• Rejection:

Rejection can be acute - up to three months post-transplantation - or chronic. Immuno-suppressive drugs reduce the rate of rejections, but acute rejection rate for kidney transplants is still between 10-15% and between 15-25% for liver transplants.

• Infection:

Infection associated with transplantation is uncommon, but tuberculosis and other bacteria, Clostridium, HCV, Epstein-Barr virus, rabies, group A streptococci, Candida albicans and molds, and other microorganisms have all been transmitted during transplant procedures. The risk of infection associated with transplantation is very small, probably < 1%; however, surveillance for, and reporting of post-transplant infections is not ideal so the actual number of infections is not known. In addition, there are no universally agreed upon protocols for screening of organ or tissue donors.

Donors who have infectious diseases such as hepatitis B, hepatitis C, encephalitis, meningitis, pneumonia, tuberculosis, and other infectious conditions can be considered as donors if informed consent from the recipient is obtained and therapy and follow-up are possible.

• Increased risk of disease:

People who have had a transplant are at increased risk for developing bone disease and orthopedic problems, cancer, heart disease, and other medical problems.

THE PROCESS OF ORGAN AND TISSUE TRANSPLANTATION

The process of organ donation is usefully divided into the following steps.

1. Referral
2. Evaluation
3. Family discussion
4. Recovery and allocation

The process of organ and tissue transplantation starts with a referral. Suitable cases are referred to the local Organ Procurement Organization (OPO). There are two in New Jersey:

• New Jersey Organ and Tissue Sharing Network:

The New Jersey Organ and Tissue Sharing Network operates in northern and central New Jersey in Bergen, Essex, Hudson, Hunterdon, Mercer, Middlesex, Morris, Monmouth, Ocean, Passaic, Somerset, Sussex, Union, and Warren counties. Their 24-hour telephone number is 1-800-742-7365. Their website address is

• Gift of Life Donor Program:

The Gift of Life Donor Program operates in southern New Jersey in Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester and Salem counties. Their 24-hour telephone number is 1-800-366-6771. Their website address is

Referral

The referral starts with identification of a patient’s clinical situation in which organ donation may be likely or could be a possibility. These situations are recognized by the presence of imminent death and clinical triggers.

Federal regulations require that hospitals contact the local OPO about all patients that have died or are near death- imminent death. When the OPO has been contacted, it will start the process of evaluation and, possibly matching of donor to recipient.It was in the federal regulations that hospitals develop a definition of imminent death, and this definition is usually:

1. A patient with acute, severe, brain injury who requires mechanical ventilation,
2. A patient who is being evaluated for brain death, and
3. The presence of certain clinical findings

The clinical findings that are used most often are: 1) A Glasgow Coma Scale of

≤ 5, and; 2) The absence of two or more cranial reflexes, i.e., caloric response, cough/gag reflex, corneal reflex, failure to respond to pain, pupillary response to light, etc. The Glasgow Coma Scale and the cranial reflexes are used because they have a high degree of inter-observer reliability and they correlate well with outcome, i.e., the lower the Glasgow Coma Scale and the fewer intact cranial reflexes the worse the outcome is likely to be.

Taken as a whole, these conditions 1 and 2 listed above and the clinical findings are referred to as clinical triggers. The clinical triggers are identified incases in which the patient is critically ill and near death, and identify patients that may be donor candidates because they are likely to die or progress to brain death.

These clinical triggers may vary from hospital to hospital and between different OPOs. It is also considered necessary to contact the OPO prior to discussing organ donation with the patient’s family. In the case of a death and possible organ or tissue donation, the referral must be made within an hour of the death.

Donations can be made from a patient who has been declared brain dead or from a patient who has suffered cardiac death. If a patient has suffered a non-survivable injury but does not meet the criteria for brain death, the decision may be made to remove the patient from life support, and this would be considered donation after cardiac death. If this happens, organ donation is a possibility.

Evaluation

A donation specialist from an OPO does the evaluation of a patient and the clinical situation for the possibility of organ donation. Once the OPO has been contacted about a potential donor, the evaluation specialist will immediately go to the hospital. The evaluation specialist will examine the patient’s medical record, tests for infectious diseases may be ordered, and a decision will be made as to whether or not organ donation is possible. If the patient was enrolled in the state registry as a donor, that registration is considered to be the legal consent for the donation. If the patient was not registered as a donor and the patient’s driver’s license did not indicate that he/she wished to be a donor, family or next of kin will be contacted.

Viability of organs is obviously a critical concern in the donation process. Unfortunately, the majority of donated organs come from people who are brain dead and these organs are less viable than organs from living donors. In addition, many people who have suffered brain death are physiologically and hemodynamically unstable, decreasing the potential for maintaining organs in a condition suitable for transplant.

In response to this issue, OPOs and hospitals have adopted the use of catastrophic brain injury guidelines (CBIGs) in the evaluation process of organ donation. Catastrophic brain injury guidelines(CBIGs) are recommendations used to treat people who: 1) Have suffered a catastrophic brain injury, and; 2) Have been assessed by a neurologist and a neurosurgery specialist as having a non-survivable neurological injury or neurologic death. These guidelines are intended to ensure hemodyanamic stability and tissue perfusion. In this way, the patient’s clinical progress as it would naturally evolve can be observed and end of life decisions can be made. As viability of organs is obviously a critical issue in the donations process, these CBIGs are also used if the patient is deemed to be a potential organ donor; and, they have been shown to help OPOs and hospitals increase the number and quality of donated organs.