Small Bowel Transplant
Vignette Kaltsas, Ashley Smith, Taylor Kendall, Brennan Baker, Eskedar Asamnew, Savannah Boggs
Old Dominion University School of Nursing
Small Bowel Transplant
Small bowel organ transplantation is a procedure where a diseased or shortened small bowel is replaced with a healthy bowel from a donor, however, in many cases liver transplants are also indicated. In this paper, the focus is on isolated small bowel transplants which are indicated for patients with irreversible intestinal failure and the small bowel is the only organ transplanted (Filho et al., 2015). The purpose of this paper is to describe recipient and donor criteria, contraindications, and nursing care to include therapeutic regimen and discharge teaching for patients with short bowel transplantation.
Pathophysiology
In the adult population, intestinal failure is mostly seen as a result of one of several conditions, including Short Bowel Syndrome (SBS) (Parrish & DiBaise, 2017). Regence Medical Policy Manual (2018) explains the pathophysiology of SBS: SBS is a disease process that is caused by a large removal or resection of intestine. A significant loss of this organ can affect the small bowels' ability to absorb vitamins and nutrients, therefore patients with SBS are generally put on parenteral nutrition (PN) and weaned off to enteral feedings as their bowel adapts. Complications and the depth of impact of SBS will vary among patients depending on how much intestine they have remaining and its ability to maintain nutritional and fluid/electrolyte homeostasis; loss of this function is considered intestinal failure. Patients who have intestinal failure and are unable to nourish and hydrate their bodies with therapeutic regimens such as enteral feedings or PN are candidates for small bowel transplantation (Regence Medical Policy Manual, 2018).
Recipient Criteria
For candidacy for a SBT, patients must have complications from medically required TPN such as recurrent catheter related infections, thrombosis of two or more venous accesses, growth and development changes, electrolyte imbalances or liver disease which may require a concurrent liver transplant (Gurkan, 2017). Before a patient can receive a small bowel transplant, a series of tests and evaluations must be performed to determine eligibility. This includes a person's overall health status as well as psychosocial factors; these are important when determining the success of a transplantation versus possible mortality or other complications. To begin the evaluation process, an ABO blood test is done to determine which blood types the recipient is able to receive in order to be matched with a donor. A human leukocyte antigen (HLA) typing is also performed to determine which proteins, or antigens, a person carries on their cells. If the recipient makes antibodies against non-matching donor antigens, the chance of organ rejection is high. In addition, recipients will undergo a series of routine laboratory and serology testings including complete blood count (CBC), hepatic and renal function tests, coagulation profile, Cytomegalovirus (CMV), Epstein Barr virus (EBV), HIV, and Hepatitis A, B, and C testing (UC Davis Transplant Center, 2018).
Other diagnostic screenings are essential to further evaluate the function of the GI tract and bowels. This includes a radiographic evaluation of the entire GI tract in order to determine bowel length, function and transit time. A duplex doppler sonography of the intra-abdominal vascular system is also performed to visualize major abdominal arteries and veins. Additionally, a thorough assessment is performed for the presence of infection in any portion of body and the appropriate consults are made if needed. If any red flags present during the evaluation and assessment process, organ specific investigations will be completed (UC Davis Transplant Center, 2018).
To complete the psychosocial piece of the assessment, patients will meet with a clinical social worker or donor advocate. This is vital because of the effects that a transplant can have on a person's daily life. This part of the donor process helps determine the donor's ability to cope and adhere to a medical regimen post-transplant, while also assessing the need for additional education or resources prior to the transplant (UC Davis Transplant Center, 2018). Being able to comply to medical management post transplantation is an absolute requirement (Regence Medical Policy Manual, 2018). This assessment also prioritizes a patient on the transplant list. If their risk for complications are high, then the organs may be allocated elsewhere until the patient is able to comply (Schulz & Kroencke, 2015).
Donor Criteria
Organ donors, just like organ recipients, must go through a series of tests and evaluations prior to being approved for transplantation. Donors may either be living or cadaveric (non-living). The testing and evaluations can differ depending on the type of donor (Gurkan, 2017).
Living donors for a SBT are considered only medically necessary when a patient requires a SBT and a cadaveric donor is unavailable. However, this type of donor is becoming more commonly used. Typically, living donors are ideally under the age of 55 and are 30-40% under the recipient's weight. This is to ensure that the organs fit properly in the recipient's abdomen, which is often retracted due to intestinal failure (Gurkan, 2017). Living donors begin by completing a health history and physical with their physician to determine their general overall health status. This is important to determine any risks or complications that could arise from the transplant or reduces eligibility to donate. The same psychosocial type assessments are completed for the donor to ensure medical compliance post-transplant. They also screen for drug or alcohol abuse and smoking, which are contraindicated for organ donations (UC Davis Transplant Center, 2018).
Similar to recipient evaluation, donors will also undergo a series of tests; these include ABO blood and HLA typing, laboratory tests such as CBC, hepatic and renal function tests, coagulation profile and serologic tests such as CMV, EBV, HIV, and Hepatitis A, B, and C. In addition, a number of other screenings will be performed including a colonoscopy to rule out colon cancers,and an EKG along with other cardiac testings to determine cardiac rhythm, function and health (UC Davis Transplant Center, 2018). It is important to perform a full, in-depth history and physical assessment of the donor because donor safety is just as important as recipient safety. Even though the focus can often drift to the recipient, the donor's health should be just as much of a priority.
Cadaveric donors are the preferred donor for a SBT. Cadaveric donors must also undergo blood and HLA typing, cross matching, and serum and lab testings as stated above. These donors must be between 20% and 50% of the recipient's weight to ensure that the organ will fit (Gurkan, 2017).
In some instances, donor and recipient evaluations can reveal components that make a person ineligible to donate or receive an organ. Contraindications can include systemic, local and untreated infections, malignancies such as cancers, cardiac and pulmonary diseases, or cognitive conditions that could interfere with the transplant and or complicated medication regimens (Regence Medical Policy Manual, 2018). Though HIV has been considered a contraindication in the past, it is now considered a relative contraindication due to antiretroviral therapy. This patient population is considered case by case. Other relative contraindications to consider are multiple abdominal surgeries and advanced age (Filho et al., 2015). Thorough assessments, testing and evaluations are crucial to assess for such contraindications.
Organ Rejection
Eighty percent of our body's immune function cells lie within the small bowel. Because of this, SBT has one of the highest risks of organ rejection (Gurkan, 2017). There are three types of organ rejection: hyperacute, acute, and chronic. Hyperacute rejection occurs within the first few minutes of transplantation. This arises when the patient's organ transplant is completely unmatched to the patient's antigens, ultimately from receiving the incorrect blood type. Due to its life-threatening state, the remaining tissue needs to be removed immediately to prevent death. ABO blood typing and HLA typing are essential in preventing this type of rejection. The greater similarity between transplant antigens, the lower the risk of rejection. Unfortunately, no two people have identical tissue antigens, expect identical twins, so matches will not be perfect (US National Library of Medicine, 2018).
Acute organ rejection appears anywhere from a week to three months after the transplantation. This is a response driven by T lymphocytes that recognize foreign HLA antigens (Benzirma, Calligaro, Glanville, 2017). With this procedure, all transplant patients go through some form of acute rejection, but severity depends on the patient and how close the tissue antigens match the patient. Signs and symptoms (s/s) of a rejection include generalized discomfort, pain, cramping or swelling in the abdomen, as well as flu-like symptoms including body aches, chills, nausea, vomiting, and fever (US National Library of Medicine, 2018). Patients may also experience weight loss, decreased appetite, bleeding or an increase/decrease in ostomy output (Jackson Health, n.d). According to Jackson Health System, the most effective diagnostic tool to discover rejection is twice weekly surveillance endoscopy during the first couple weeks after transplantation and monthly thereafter. Through the ileostomy, the doctor is able to analyze the organ at a magnified view as well as biopsy for signs of rejection. Biopsy is the key component to diagnosing rejection during this procedure. Citrulline levels, an amino acid produced by the small intestines, are also monitored through a finger stick for patient status. At three months post-transplant, these levels should be stable (Jackson Health, n.d).
Chronic organ rejection appears years after transplantation. This occurs as the patient's immune system slowly attacks the organ, ultimately damaging the transplanted tissues or organ (US National Library of Medicine, 2018). Nursing implications include monitoring patients for s/s of possible rejection during their hospital stay and paying attention to temporary gas distension after endoscopies (Jackson Health, n.d.). Nurses must also educate patients on foods to avoid and when to contact their doctor if adverse s/s arise.
Post-transplant immunosuppression therapy
There are a number of medications used for immunosuppression therapy post-transplant procedures; their purpose is to avoid acute and chronic allograft rejection. Induction immunosuppression therapy is initiated immediately post-transplant. The common medications used for induction therapy include thymoglobulin and alemtuzumab; both of which work by depleting T and B-lymphocytes (Minneci, 2014). In addition, basiliximab and daclizumab are used for induction therapy and work by blocking the receptor sites of interleukin -2 receptors. Maintenance immunosuppression therapy is used for long term immunosuppression. Transplant patients usually receive triple maintenance immunosuppressive therapy. The common immunosuppressive medication classes for patients with SBT include calcineurin inhibitors, antimetabolites, and corticosteroids (Comerford, 2018).
Tacrolimus is the most commonly used immunosuppressant calcineurin inhibitor for patients undergoing SBT (Comerford, 2018). Tacrolimus inhibits T-cell activation and binds to an intracellular protein known as FKBP-12, initiating immunosuppression (Lilley, Collins, & Snyder, 2017) . Tacrolimus is used to prevent allograft rejection and is a treatment option for existing rejection; it is given with corticosteroids and is available in both oral and injectable forms (Lilley et al., 2017). The dose for this medication is individualized for each patient and adjustment is needed based on trough level for optimum therapeutic effect (Comerford, 2018). Tacrolimus is associated with several cardiovascular adverse effects, including peripheral edema, hypertension, atrial fibrillation, palpitation, tachycardia, and thrombosis. It also affects the central nervous system and can cause headache, insomnia, pain, anxiety, tremor, confusion, neuropathy, hypoesthesia, and depression. Other adverse effects can include nephrotoxicity, diabetes mellitus, electrolyte imbalances, hyperlipidemia, and thrombocytopenia (Lilley et al., 2017). Hypersensitivity reactions can also occur including anaphylactic shock. This medication has several drug-drug interactions including antacids, cyclosporine, a live-virus vaccine, aminoglycosides due to nephrotoxicity, and potassium-sparing diuretics (Comerford, 2018). Nursing implications includes assessing patient's baseline functions of all body system and vital signs. This will allow the nurse discover new changes in the patient's condition. The nurse should continue to monitor kidney function by evaluating the patient's laboratory reports including Blood Urea Nitrate (BUN), creatinine and serum electrolyte level due to tacrolimus nephrotoxic effect (Lilley et al, 2017). Assess patients for any s/s of adverse effects as well as screen and monitor any patient for allergic reaction. Patient teaching should include avoidance of grapefruit juice, St. John's wort because it may decrease the drug level, and avoiding certain medications to avoid side effects and optimize therapeutic effects of tacrolimus. If a dose is missed, advise the patient to take the medication as soon as they remember. If more than 14 hours have passed, wait until the next scheduled time to avoid double dosing (Comerford, 2018).
Mycophenolate mofetil is an antimetabolite immunosuppressant (Lilley et al., 2017). It impedes proliferative response of T and B -lymphocytes, subdues antibody development by B-lymphocytes and may inhibit recruitment of leukocytes into areas of inflammation and rejection (Comerford, 2018, p. 1043). This is available in capsule, tablet and powder form for oral use. Intravenous (IV) form is also available and can be given for up to 14 days at which the patient can be switched to oral forms (Comerford, 2018). The most common adverse effects of this medication on the cardiovascular system include increased blood pressure, heart rate, and peripheral edema (Lilley et al., 2017). Additional side effects include headache, abdominal pain, dyspnea, cough, electrolyte imbalance, hyperglycemia, hyperlipidemia, leukopenia, and thrombocytopenia (Lilley et al., 2017, p. 776). Black box warnings for use on pregnant woman include increased risk of first-trimester pregnancy loss, congenital malformation, polyomavirus-associated nephropathy, and progressive multifocal leukoencephalopathy (Lilley et al., 2017). The nursing implication for mycophenolate includes obtaining the baseline physical assessment, vital sign results, lab results, including liver function test and kidney function tests, to use as a comparison tool to see any changes in the patient's condition from the treatment. When administering IV Mycophenolate mofetil, nurses should never give a bolus or rapid IV injection and always infuse over at least two hours (Comerford, 2018). Nurses need to educate on drug interactions with food, drugs, and herbs as well as black box warnings. Warn patients to not open capsules or chew extended-release tablets and swallow whole medication to avoid toxicity. Furthermore, take medication on empty stomach because food can decrease absorption (Comerford, 2018). Patients should follow up with their primary care provider and report any adverse effects.
Corticosteroids are another class of medication that are used post SBT in adjunct with Calcineurin inhibitors and antimetabolites for maintenance immunosuppression therapy. Corticosteroids lower cell-mediated and humoral immunity by reducing the level of leukocytes, monocytes, and eosinophils. This occurs by decreasing immunoglobulin attaching to cell surface receptors thereby inhibiting interleukin synthesis (Comerford, 2018 p. 44). Prednisone is the most commonly used corticosteroid for maintenance immunosuppression for patients with SBT. Corticosteroids' adverse effects may include adrenal suppression and other systemic effects such as diabetes, osteoporosis, muscle weakness, heart failure, edema, hypertension, psychosis, GI upset, fragile skin, and weight gain (Comerford, 2018). A patient who receives corticosteroids should be monitored closely for hyperglycemia and s/s of fungal infections as steroid treatments are known to cause hyperglycemia which put patients at risk for fungal infections (Lilley et al., 2017). Teach the patient to never abruptly stop steroid therapy because abrupt cessation of exogenous steroid therapy causes adrenal crisis; therefore, treatment should be tapered off gradually (Lilley et al., 2017). If a dose is missed, inform the patient to take the missed dose as soon as remembered (Comerford, 2018). Provide teaching on the expected changes in physical appearance with long-term use such as obesity on trunk area, "moon face", "buffalo hump", and thinning of extremities (Lilley et al., 2017, p. 530). Nurses should educate to take this medication with food to avoid GI upset (Comerford, 2018). Also, instruct patient to seek care immediately should any adverse effect occur. With any of these medications, emphasize to patients that maintenance immunosuppressants are lifelong treatments and that patients must adhere to proper and accurate medication management to sustain the transplanted organ.
Nutritional Considerations
The goal for small bowel transplant patients is to transition patients towards clinical nutritional autonomy (CNA). Early CNA has been shown to boost enterocyte recovery and prevent GI barrier dysfunction (Bharadwaj et al., 2017). When teaching the patient about their feedings and prognosis, data shows that patients were "off of parenteral feedings at a median of about 3 weeks after transplant and off of supplemental tube feeds at a median of 60-70 days, with some patients requiring as much as 272 days for complete oral autonomy" (Mercer, 2014, p. 617-618). The transplant team will provide patients with specific nutrient management plans to restore nutritional autonomy. Enteral feeds should be implemented as soon as tolerated, which normally occurs within 1-2 weeks of transplantation (Mercer, 2014, p. 617-618). Additionally, patients are encouraged to eat healthy, high protein foods to assist in the healing process. Nurses must educate to use food safety to avoid food-related infections. In addition, patients should keep hydrated with water and non-caffeinated, low calorie drinks while avoiding consumption of grapefruit to decrease effect on tacrolimus levels (Johns Hopkins Medicine, 2017).
Discharge Teaching
Johns Hopkins Medicine (2017) addresses medical teaching for small bowel transplant patients: Post-transplant coordinators will be the chief point of contact for patients after discharge from the hospital and patients are advised to call their coordinators whenever they have a concern about their health. In order to monitor acceptance of the transplant, lab tests and clinical visits are required. Labs will be drawn biweekly upon discharge to two months post-surgery and then tapers down to once a week after 3-4 months. At 5-6 months, it moves to every other week and then once a month for the duration of the patient's life. Patients must also schedule regular clinical visits for a physical exam and review of the most recent labs. The first clinical visit will take place within the 1-2 weeks of discharge, then every 2-4 weeks after the first visit to 3 months. Regimen changes to 1-4 months after 4 months to a year, and then every 6-12 months after a year to the duration of the patient's life (John Hopkins Medicine, 2017).
Johns Hopkins Medicine (2017) also addresses physical activity needs and limitations for small bowel transplant patients: Post-transplant patients are encouraged to gradually increase their physical activity after leaving the hospital to reduce risk of infection; they must "move at least every 2 hours, avoid lifting more than 10 pounds for 8 weeks after surgery, not drive for 4-6 weeks after surgery" (John Hopkins Medicine, 2017, p.16). While on pain medication such as narcotics, patients should talk over driving and returning to work at clinical visits. Patients must avoid international travel during the first year, avoid cruises for their lifetime, notify their coordinator if planning to travel by plane or travel internationally, and wear face masks and practice hand-hygiene while in the airport or on planes. Anti-rejection medications can cause increased risk for skin cancer, so patients need to avoid direct sun exposure, wear sunscreen of at least SPF 30+, and wear protective clothing while outside (John Hopkins Medicine, 2017).
Avoidance of infection, driving, and sexual activity is also addressed by Johns Hopkins Medicine (2017): To avoid infection after transplantation, practice hand-washing & sanitizing, patients must take appropriate food safety measures, get yearly flu shots, avoid sick people, wear face masks inside places such as hospitals, wear masks and gloves during gardening and digging dirt, avoid cleaning up feces such as cat litter, bird droppings, and diapers, and check water quality prior to swimming in bodies of water. Sexual activity can be resumed when the patient can walk up a flight of stairs with ease and safe sex practices should be followed to prevent risk of infections (John Hopkins Medicine, 2017).
Schulz & Kroencke (2015) describe discharge teaching for psychological aspects of care: After the transplant, the stressors of possible rejection, guilt of accepting an organ, or post-traumatic stress disorder can cause a patient to experience anxiety and depression. A psychological consultation is available to transplant patients to include supportive therapy, cognitive-behavioral interventions, and educational therapy. Patients may also experience a change in their family dynamics due to the limitations of the transplant which is why family counseling is also available (Schulz & Kroencke, 2015).
Nursing Research
Medication Adherence
Treatment regimen adherence, which typically involves immunosuppressive medications, is necessary for intestinal graft survival (Kung, Yeh, Lia, & Liu, 2017). Kung et al. (2017), conducted a study which examined the influences associated with immunosuppressive therapy noncompliance among renal transplant recipients. Kung et al. recruited 122 patients, exhibiting no signs of rejection or infection, for a cross-sectional study. A self-reporting survey based on the Rosenstock's Health Belief Model was used to measure adherence behavior. Lower rates of adherence were dependent on the number of drug-induced side effects, severity of infections, and increased time elapsed since transplant (Kung et al., 2017). The article suggests additional follow up care is needed for patients with older transplants to reinforce previous education and reduce noncompliant behavior. In addition, participants who had past experiences of transplant rejection exhibited higher rates of treatment adherence likely due to their profound understanding of the consequences associated with graft loss (Kung et al., 2017). Nurses should evaluate the health beliefs of organ transplant recipients and enhance patient education according to perceived vulnerability and attitudes toward therapeutic regimens.
Coping
The process of organ transplantation can be emotionally taxing for patients and families (Nilsson, Forsberg, Lennerling, & Persson, 2014). Nilsson et al. (2014), conducted a longitudinal study examining patient coping skills and the influences of perceived health status on quality of life among organ transplant recipients. The study included 185 participants who had undergone either kidney, liver, heart or lung transplantation. Self-report measures, including the General Coping Questionnaire (GCQ), the Short Form Health Survey (SF-36), and the Perceived Threat of Risk for Graft Rejection (PTRG) interview, were used to gather clinical data. Nilsson et al., did not find significant differences in coping between organ groups; in addition, patients with pessimistic views and participants experiencing a higher level of fear for graft rejection were more likely to use emotion-focused coping or isolation to deal with stressors. The study suggests the need for a person-centered nursing approach, focusing on the individual rather than the organ, involving patient collaboration, positive coping education, and encouragement of social support seeking behavior (Nilsson et al, 2014).
Self-management
Interactive health technology (IHT) is a possible solution to the self-management concerns associated with chronic conditions, such as SBT (Vanhoof et al., 2017). A cross-sectional, descriptive study conducted by Vanhoof et al. (2017) investigated the likelihood of patient engagement in technology-based applications to improve health outcomes among solid organ transplant recipients. The study included 122 participants who had undergone heart, liver, kidney, or lung transplantation. Overall, participants were interested in using IHT to assist with medication adherence, physical activity engagement, and weight control (Vanhoof et al., 2017). These findings suggest that IHT is a viable option to increase patient knowledge and improve self-efficacy in SBT patients. The study also highlights patient preferences for future development of IHT programs catering to organ transplant recipients.
Conclusion
Nurses tend to focus on the somatic changes of a disease process; however, organ transplant recipients are faced with many challenges that can significantly alter their lives and the lives of their families. Nursing management is vital to facilitating positive outcomes for transplant recipients by providing a source of support and knowledge for patients and their families. This is a lesson that can be applied throughout nursing practice.
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Vignette Kaltsas, Ashley Smith, Taylor Kendall, Brennan Baker, Eskedar Asamnew, Savannah Boggs
11/5/2018