Intestinal Transplant Process

Intestinal transplant patients often have very extensive and complex medical histories. The transplant evaluation is a thorough process at the transplant center and involves many medical professionals. The team involved usually consists of: • Transplant nurse coordinator • Transplant surgeon • Gastroenterologist • Anesthesiologist • Financial counselor • Psychiatrist • Pharmacist • Dentist • Gynecologist • Infectious disease specialist • Social worker • Dietician • Advanced practice nurse • Mid-level provider • Child life specialist (pediatrics) • Physical therapy • Occupational therapy • General surgery • Hepatology • Psychiatry or psychology A comprehensive assessment of the patient is required during the evaluation phase of an intestinal transplant. This includes a thorough history and physical as well as a variety of lab tests, diagnostic tests, and consultations, which will vary by diagnosis, patient acuity, and history. Tests may include, but are not limited to: • Blood work • Chest x-ray • EKG • Urinalysis • Echocardiogram • Stress test and/or cardiac catheterization • CT scan and/or MRI • Endoscopy and/or colonoscopy • Motility studies • Pulmonary functions tests • Venous mapping • Pap smear • Mammogram • DEXA scan • Liver biopsy Patients with intestinal failure who have failed surgical and medical treatment options are usually referred for an intestinal transplant when they develop complications from parenteral nutrition, including more frequent line infections, which can be life-threatening, and progressive PN-induced liver disease. Clinicians may also refer patients for quality of life concerns. Please refer to (1,2) for more information.

Intestinal failure affects not only the digestive system, but the whole person. The stresses of extended and multiple hospitalizations, procedures, surgeries and the complexity of care can lead to significant disruptions in normal psychosocial development, family life, school/work, and relationships. During the evaluation for an intestinal transplant, it is important that the transplant team has an assessment of the patient’s emotional, cognitive and behavioral health through a comprehensive evaluation by psychology/psychiatry. Goals of Psychological Assessment: Comprehensively assess each patient for his/her ability to undergo an intestinal transplant, and their mental health, coping strategies, and family support. History should include: • Prior psychiatric illness • Suicidality • Adherence history • Substance abuse history • Adaptation to past stressors and presence and quality of social support Important Considerations to the Psychological Evaluation: • The use of a standardized psychiatric interview, such as the Mini International Neuropsychiatric Interview, is recommended. • In patients with liver disease who may have hepatic encephalopathy, a clinical interview and neuropsychological testing can help identify impairments.

Following the completion of the evaluation for intestine transplantation, the patient’s information is presented to the multidisciplinary selection committee. Recommendations for transplant are made by the committee after review and discussion of test results and consultations: • Intestine transplant may be recommended, and the patient will be formally listed with UNOS. • Transplant may be deferred and the patient will not be listed because additional information or tests are needed, medical management strategies may be indicated, or current psychosocial concerns are significant and must be resolved before listing. • In some cases, transplant may be denied due to medical issues that may affect survival or the patient will benefit from medical or other surgical interventions rather than transplant. The members of the committee will vary by center and patient diagnosis, examples of members includes: • Transplant surgeons • Gastroenterologists • Nutritionists • Social workers • Ethicists • Psychiatrists • Mid-level providers • Advanced practice nurses • General surgery • Pharmacists • Anesthesiologists If the selection committee determines the patient is an appropriate candidate for transplant, the proper paperwork is filed with UNOS, and the patient is placed on the national waiting list for organs. To learn more about UNOS, the waitlist, and organ procurement, please visit our site here.(javascript:void(0))

• Ascites requiring paracentesis • Hyponatremia • Variceal Bleeding • Encephalopathy • Hepatorenal Syndrome

Donor selection is based on the viability of the organs, ABO status, and donor and recipient size/weight. Donors are also screened for infection risks and CMV/EBV serology. (CMV and EBV mismatches are common – Adults are usually positive for both and kids are usually negative). Each organ is listed separately and by status/score with UNOS. • Intestine • Status 1: Deteriorating liver function and decreased or limited venous access. • Status 2: Normal liver function and adequate venous access. • Liver allocation is based on the candidate’s score as calculated by the Model for End-Stage Liver Disease (MELD) and the Pediatric End-Stage Liver Disease (PELD).

For another general overview of the operative steps, see pages 568-574 in: Kosmach-Park B, DeAngelis M. Intestine Transplantation. In Core Curriculum for Transplant Nurses. 2nd edition. Eds: Cupples S., Lerret S., McCalmont V., Ohler, L. Philadelphia: Wolters Kluwer, 2017. Or you may also refer to this article.(https://www.ncbi.nlm.nih.gov/books/NBK6902/)

Deceased Organ Donation: • Two Kidneys • Liver • Two Lungs • Heart • Pancreas • Intestines • Hands • Face Hand and face transplant is known as vascular composite allograft (VCA). These are surgeries composed of grafting many kinds of tissue: bones, muscles, nerves, skin, and blood vessels. As of January 2018, less than 200 VCA organ transplants had been performed around the world. Visit the organdonor.gov website to learn more about VCA transplants. (https://www.organdonor.gov/about/what/face-hands.html) Living Organ Donation: • One Kidney • One Lung • Portion of intestine • Portion of a liver • Portion of a pancreas Tissue Donation: can dramatically improve the quality of life for the people who receive them • Heart valves can help children born with defects or adults with damaged heart valves. • Skin can be used for those with serious burns and help to stop serious infection. • Bone is important in artificial joint replacements or those with illness or injury to bone. • Tendons can be used to help rebuild damaged joints. • Cornea can help to restore sight in those with scarred or diseased corneas. • Middle ear • Veins • Cartilage • Ligaments Tissue donation must be initiated within 24 hours of death. However, once processed, it can be stored for an extended period of time.

Before evaluation and allocation of organs for donation, brain death of an individual must be declared. Brain death is diagnosed as an irreversible loss of blood flow to the brain, causing the whole brain to die. Note: Federal law prohibits the patient’s physician and the physician who determines the patient’s death from taking any part in the transplantation process. Certain conditions that mimic brain death, but are reversible and a doctor may be on the look- out for, include, but are not limited to: • Severe imbalance of electrolyte, acid-base, and endocrine function. • Drug intoxication and poisoning. • Use of sedatives or neuromuscular blockades. • Hypotension (low blood pressure). • Hypothermia (extremely low body temperature). A physician will conduct the neurological testing numerous times to confirm the diagnosis of brain death.

When a patient is close to being declared as brain dead or has been declared brain dead, the local organ procurement organization is notified. At that point in time, the OPO checks the DMV to make sure the donor has made an anatomical gift. In the event the individual has not indicated their wishes, a trained member of the OPO contacts a family member, usually the next of kin, to make the decision of whether or not to donate the organs. Once the decision to donate has been made, then the OPO begins the screening and testing for the suitability of the donor. The organ procurement coordinator gathers all pertinent information about the donor, including determining whether or not he or she is considered high risk.

A high-risk donor is a donor that has a possible history of HIV or hepatitis including: • History of being incarcerated. • History of intravenous (IV) drug use. • Multiple past sexual partners.

Assessment of donor quality is based on many factors, some which include: • Donor age • Size and body mass index (BMI) • General medical history • Organ specific history • Smoking history • Malignancy and infection • High risk behaviors, including substance abuse, multiple sexual partners, incarceration • Cause of death • Length of hospital stay • Pulmonary (lung) function • Hepatic (liver) function • Urine output • Glucose level • Acid-base balance

Factors associated with increased risk of organ dysfunction and poor outcome post-transplant: • Increasing age. • High body mass index (BMI). • History of co-morbidities. • Prolonged ischemic time. • Hemodynamic instability (lack of adequate blood flow throughout the body).

When the OPO determines that an individual is medically suitable to be a donor, and authorization for the donation is confirmed, the OPO enters the donor’s information into the national organ allocation program called DonorNet. This system creates a set of rank lists to identify potential candidates. The OPO offers the available organs to the transplant center or centers of the listed recipients. The transplant center then has one hour to accept or express interest in the offer. Factors taken into consideration when matching organs include: • Blood type (ABO exact match) • Body size • Severity of patient’s medical condition • Distance between the donor’s hospital and the patient’s hospital • The patient’s waiting time • Whether the patient is available (for example, whether the patient can be contacted and has no current infection or other temporary reason that transplant cannot take place)

Specifically, for intestinal transplant surgeons consider: • ABO blood types must be an exact match due to the possibility of graft vs. host (GVHD) and the intense immune response of the intestinal tract. • Size of the organ, due to the fact the abdominal cavity often shrinks with intestinal resection or short bowel syndrome. • Cytomegalovirus (CMV) and Epstein-Barr (EBV) viral status, patients who have never been exposed to CMV or EBV before are usually matched with donors who are similarly CMV-negative or EBV-negative, respectively. • Note: This is not absolute since post-transplant prophylactic medications are available. Mismatched donor-recipients are transplanted and patients post-transplant may just require treatment for CMV and/or EBV infection.

• Individuals that require a liver transplant are assigned a MELD (Model for End Stage Liver Disease) or PELD (Pediatric End Stage Liver Disease) score that indicates how urgently they need an organ. • A donor liver is offered first to the candidate who matches on the above common elements (ABO blood type, body size, distance from the donor hospital) and has the highest MELD or PELD score (indicating the most need). Reference: 1. Matching Donors and Recipients. Organ Donor. https://www.organdonor.gov/about/process/matching.html. Published 2020. Accessed April 27, 2020.

The OPO is then responsible for coordinating the recovery of the donated organs, including making arrangements with the donor hospital for access to the operating room, necessary staff, packaging, and arranging transport of organs to the intended destinations. The organs are transplanted to the matched recipients.

After donation, the donor is taken to a funeral home, and the OPO works with the funeral director to honor the donor and donor family’s funeral wishes. An open casket funeral is possible after organ donation.

A few weeks later, the OPO sends a letter to the donor’s family, letting them know which organs were transplanted while keeping the names of the recipients confidential. Most OPOs continue to provide support to donor families, such as bereavement counseling and later, memorial events.