The Transplant Patient



The Transplant Patient


Susan A. Scherer



Key Terms







The ability to transplant an organ from one individual to another is a relatively new phenomenon. New advances in surgical techniques and immunosuppressive drugs, ability to detect and treat rejection, and improved outcomes have made transplantation of solid organs a viable treatment option for patients with end-stage cardiac and pulmonary conditions. The increased life expectancy of transplant patients means that physical therapists have many opportunities for patient intervention both before and after transplant in various settings. Trends in patient demographics indicate that a physical therapist may see a transplant patient not only in a regional medical center setting but also in outpatient and rural clinics. This chapter contains guidelines for managing patients with heart or lung transplants.



Background


Transplantation of tissues and organs has been of interest to physicians and surgeons since the 18th century. Advances in our understanding of the immune system, development of immunosuppressive medications, and techniques such as cardiopulmonary bypass have provided the opportunity for successful organ transplants. In 1954, the first kidney was successfully transplanted. Other successful organ transplants include the first heart transplant in 1968, combined heart-lung transplant in 1981, and single-lung transplant in 1983.1


Organ transplantation has become a viable alternative to medical treatment of many conditions. Because of the success rates, many types of transplants are no longer considered experimental but are considered appropriate treatment for organ failure. As a result of improved survival, long-term outcomes are as important as short-term outcomes as a measure of successful transplantation. The number of Medicare-approved medical centers that perform lung and heart-lung transplants has grown to 50 in the United States, and there are 110 certified heart transplant centers.2 Over 2000 heart transplants and 1000 lung transplants have been performed annually since 2000. The 5-year survival rates for heart transplants of all status levels are reported as 70.9%; for lung transplants, 43.1%. Other national data on median waiting time and survival rates are presented in Table 40-1.




Organ Donation


The major cause of limitation in the number of organ transplants is the lack of organ supply with an increasing demand for organ transplantation. The number of patients who could benefit from transplant significantly exceeds the number of organs available. The Organ Procurement and Transplantation Network (OPTN) is an organization whose primary goal is to increase the availability of donated organs available and improve organ sharing. OPTN was established by the National Organ Transplant Act of the United States Congress in 1984 and is administered by the private, nonprofit organization United Network for Organ Sharing (UNOS), under contract with the U.S Department of Health and Human Services. An organ procurement organization (OPO) coordinates the management of the organ donor and family, the transplant center, and the recipient.3


The number of organs available for transplant remains well below the need for donor organs. Currently, there are over 110,000 individuals on the national waiting list for all organs, with over 3200 candidates waiting for heart transplant and approximately 1800 candidates waiting for lung transplant. A general list of criteria for patient selection for transplant is presented in Box 40-1. Names of patients on the waiting list are filed in the UNOS Organ Center, a centralized database that links transplant centers with OPOs. Once an organ donor has been identified, a computer-generated list of potential recipients is ranked, according to the criteria established for each organ. Criteria may include blood or tissue type, size of organ, medical status of the patient, and amount of time a patient has been on the waiting list. The organ procurement coordinator confers with the transplant surgeons until a potential recipient is identified. Surgical teams then travel to the donor hospital while the recipient is concurrently prepared for surgery. Heart, lung, and liver transplantation success is optimized when transplant occurs within 6 hours after removing the donated organ. Surgical methods that allow for longer travel times or changes in management of the donor organ have increased the number of available organs; however, the number of available organs still remains significantly below the need.



Box 40-1   General Criteria for Transplant Waiting Lists




Policies were updated by the UNOS in 2006 to decrease the number of patients dying while waiting for transplant. These changes increased the number of transplants for the most severely ill patients awaiting heart transplant.4



Issues Associated with Transplantation


There are many ethical, psychological, and social concerns surrounding organ transplantation. Ethical issues relate to increasing potential donor sources and distributing available organs. Psychological issues include stress due to an unknown waiting time, the potential of moving from one’s home to a location near a transplant center, and possible employment disruption. The transplant process affects not only the individual patient, but the patient’s social support systems as well. This is highly significant because adequate social support is a factor in long-term transplant success and quality of life.5



Ethical Considerations


The ethical considerations of organ transplantation relate to increasing potential donor sources and distributing available organs. The bioethical issues involved in the selection of appropriate organ donors continue to generate considerable debate. For example, one important issue is whether the donor’s family should be compensated monetarily for the organ donation. Currently, there can be no legally accepted monetary gain from organ donation in this country.


Other bioethical considerations include how to allocate the available organs to individuals waiting for transplant. All patients are screened for medical and psychological conditions that would adversely affect the outcome of transplantation. The specific acceptance criteria are different for each organ; lung transplant criteria differ from heart transplantation criteria. OPTN policies specify that each transplant center will create its own specific policies.6 In general, waiting list time remains the primary factor that determines who is next in line to receive an available organ; however, other matching factors are considered for each available organ. Patients who are current smokers are not candidates for lung transplantation, although most centers allow former smokers to qualify for a lung transplant. Patients with documented alcohol abuse are not candidates for transplantation. Criteria are used so that individual preferences of team members are not given priority. In addition, ethnicity, gender, religion, and financial status are not part of the transplant criteria.



Psychological and Social Considerations


There are many psychological issues associated with organ transplantation, such as feelings of uncertainty, upheaval associated with moving, and issues of psychological adjustment. The time spent waiting for a transplant can vary considerably. During the waiting period, patients struggle with the need to carry on their lives, knowing that at any moment they may be called to the hospital for transplant. In addition, the patient is torn between wanting to remain hopeful that a transplant will provide new life and the reality of knowing they have a terminal condition. Anxiety and depression have been identified as prevalent psychological issues related to transplant.7


The number of transplant centers in the United States is limited. Because donor organs are viable for only hours after removal from the donor, patients waiting for transplant are frequently required to live within a several-hour radius of the transplant center. Patients need information and logistics assistance for relocation to a transplant center. They may also require emotional and financial support for this transition.8 The demands of waiting and relocation to the transplant city put considerable stress on the patient and their significant others. Those patients who relocate to transplant centers may have the most difficult time psychologically, especially when they leave family and significant others behind. The psychological stresses are somewhat different for spouses. Spouses speak of the struggle to remain hopeful, yet plan for a future that may not include their loved one. If the patient and spouse move together to a new city to wait for transplant, they may find themselves with more time together than previously. In this “forced retirement” situation, new stresses are added to relationships. Transplant teams usually include a psychologist or social worker to whom patients may be referred for individual or family counseling if needed.


Other concerns include psychological adjustment and the effect of social supports on mediating coping skills. Feelings of being useless are common because patients waiting in a new city are outside of their own environment and must find some meaningful activities. Coping strategies appear to strengthen psychological outcomes. After transplant, patients are often emotionally overwhelmed with a feeling of gratefulness that they are alive and feelings of guilt that someone else’s grief has given them a chance to rejoice. A strong support system is considered an essential component of a successful transplant and improves psychosocial outcomes after transplantation.9 Therapists can assist patients by listening to feelings, being supportive, and encouraging participation in support groups. Support groups that include patients waiting for transplants as well as posttransplant patients can offer significant psychosocial support. Spouses and significant others also benefit from group support.



Physical Therapy Considerations


As important members of the transplant team, physical therapists need an understanding of the physiological components of both the pretransplant disease and posttransplant state, as well as knowledge of the influence of surgery, medications, or rejection on musculoskeletal structure and function. In addition, physical function may be decreased due to the primary cardiopulmonary condition and overall deconditioning. Knowledge of medical management, including medications, ventilatory support, and hemodynamic monitoring, assists the therapist in determining whether modifications are needed during rehabilitation.


Physical therapists have a role in the management of the transplant patient in all stages of transplant: before transplant, during the acute postoperative phase, and throughout the rehabilitation phase. The purpose of physical therapy before transplant is to identify baseline function and to screen for impairments that may limit rehabilitation goals. The pretransplantation period offers an opportunity to address limitations in strength and range of motion or endurance and to improve physical function. Because of the surgical intervention, bed mobility, ventilation, secretion management, range of motion, and pain control are important areas to address in the immediate postoperative phase. In the posttransplantation rehabilitation phase, physical therapy goals are to return the patient to the highest functional level. Upper and lower extremity muscle strength and range of motion are addressed, as well as posture, shoulder and trunk mobility, breathing pattern, breath sounds, and functional mobility.



Oxygen Transport


Cardiac and pulmonary conditions leading to transplant produce limitations in the oxygen transport pathway. An understanding of the limitations in the oxygen transport pathway assists the therapist in designing a plan of care specific for each individual. Oxygen transport may be affected by the primary disease process, the surgical or medical intervention, or the medications used posttransplant. Cardiac conditions lead to impairments in myocardial function, leading to decreased oxygen availability for daily activities. Peripheral muscle dysfunction often occurs concurrently with the myocardial condition.


Pulmonary conditions lead to impairments in the mechanics of the lungs and chest wall, as well as diffusion abnormalities, producing a low blood oxygen content that is inadequate for daily activities. Myocardial function may be decreased secondary to increased vascular resistance in the lung. Likewise, peripheral utilization of oxygen may be decreased as a result of the pulmonary condition or inactivity.



Surgical and Medical Considerations


Physical therapists need to consider the effect of surgery, medication, or rejection on oxygen transport and functional ability. In patients who have undergone a surgical procedure, physical therapists must identify and manage problems related to anesthesia, pain control, hemodynamic instability, and alterations in muscle function, depending on the site of surgical incisions. The medication regimen for patients following organ transplant is complex and, in many cases, more cumbersome than the medical management of the underlying condition. Patients must take immunosuppressant medications for the rest of their lives. These medications, along with others used to manage the symptoms related to the immunosuppressants, have consequences for peripheral muscle function and energy production. Limitations in physical function may be due to the primary condition, the lack of physical activity, and the side effects of medications. Specifics will be covered later in this chapter.


The principal limitation to survival is graft rejection. Although advances in immune suppression have been successful, graft rejection remains a difficult medical problem. During the first year after transplant, the primary causes of morbidity and mortality relate to acute cellular rejection and infection. In the long term, chronic rejection is problematic. In heart transplant patients, cardiac allograft vasculopathy, an accelerated form of atherosclerosis, remains a primary limitation to long-term survival.



Rehabilitation of the Transplant Patient


To assist in management of the patient with transplant, rehabilitation is categorized into the following four phases: (1) pretransplant, (2) surgery and the postoperative acute phase, (3) postoperative outpatient phase, and (4) community- or home-based phase. Although the ultimate goal of transplant rehabilitation is to improve the patient’s function and quality of life, each phase of rehabilitation has its own emphasis.



Pretransplant Rehabilitation


Heart Transplant and End-Stage Cardiac Disease


Patients are referred for heart transplantation for end-stage cardiac conditions. The primary diagnoses for adults requiring a heart transplant are severe coronary artery disease (38%) and end-stage cardiomyopathy/heart failure (53%). In children under 1 year, the primary diagnosis requiring transplant is congenital cardiac abnormalities; for ages 1-10, cardiomyopathy.10


Patients with heart failure report symptoms of fatigue, dyspnea, and orthopnea. Physical signs include the presence of a third heart sound, pulmonary rales that do not reverse with coughing, jugular venous distension, peripheral edema, and hepatomegaly. Compensatory mechanisms include increased sympathetic nervous system activity, increasing resting heart rate, and activation of the rennin-angiotensin system, increasing blood pressure.


Patients with heart failure generally meet the heart transplant selection criteria if they have New York Heart Association (NYHA) class III or IV heart failure that is unresponsive to medical management. Specific criteria for recipient status vary somewhat from center to center, although International Society for Heart and Lung Transplantation (ISHLT) criteria for listing are generally followed.11 Exercise testing criteria can be used to guide transplantation. Patients who complete a maximum test may be eligible for a heart transplant if peak image is ≤14 mL/kg/min, or ≤12 mL/kg/min if on a beta blocker.11


Recipients waiting for heart transplantation are classified based on severity of disease. Patients in the worst medical condition (Status IA) are placed higher on the transplant recipient list. Table 40-2 outlines the criteria for each level of heart transplant recipient status.



Pretransplant management of the patient with heart failure is designed to preserve cardiac output until the transplant can be completed. Outpatient medical management includes medications and supplemental oxygen. Hospitalization may be needed for inotropic medication support such as dobutamine. The increased use of left or right ventricular assist devices (LVAD or RVADs) augments cardiac output and allows the patient a bridge to transplantation.


The main rehabilitation goal in the preoperative period is to prevent losses of physical function. Maintenance of range of motion, soft tissue extensibility, and muscle strength are suggested goals. Although patients with severe disease may be unable to participate in therapy, cardiac rehabilitation is an effective treatment for improving functional status of patients with significant heart failure and those with LVADs, whether or not transplantation is anticipated.12,13 Recent literature demonstrates that medically supervised exercise training is both safe and effective at improving aerobic capacity and physical function in patients with LVAD devices awaiting heart transplantation.



Lung Transplant and End-Stage Pulmonary Disease


Patients are referred for lung transplantation for end-stage pulmonary conditions. The primary diagnoses for adults requiring a lung transplant are severe chronic obstructive pulmonary disease (COPD) (44%), idiopathic pulmonary fibrosis (IPF) (17%), and cystic fibrosis (CF) (15%). Other conditions include pulmonary arterial hypertension (PAH). The guidelines for selection of patients for the lung transplant waiting list were updated by the ISHLT in 2006 and include specific criteria for the most common pulmonary conditions.14,15 Within the disease-specific listing criteria for COPD, the guidelines include a BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) score of 7-10. The BODE is more useful than measures of airflow obstruction in predicting mortality from COPD; higher scores are associated with increased mortality.16 Before 2005, patients who had accrued the most time on the waiting list were given priority for lung transplants. The change to a lung allocation score now gives priority for transplants to those patients who have a greater medical urgency for transplant. The lung allocation score is based on “(i) waitlist urgency measure (expected number of days lived without a transplant during an additional year on the waitlist), (ii) posttransplant survival measure (expected number of days lived during the first year posttransplant), and (iii) transplant benefit measure (posttransplant survival measure minus waitlist urgency measure).”17 The urgency and survival measures are based on factors that predict risk for death in patients with lung transplant and include functional status as well as physiological measures. This change has increased the number of transplants for patients with IPF and slowed the number of transplants for COPD.14


Idiopathic pulmonary fibrosis is characterized by scarring of lung parenchyma leading to decreased lung volumes and decreased diffusing capacity. Risk factors for mortality include the lung pathology, pulmonary function results, physical function from the 6-minute walk test, and respiratory failure.14 Criteria for listing of patients with IPF include a decrease in FVC of 10% or more during 6 months and pulse oximetry less than 88% during a 6-minute walk test.15 Patients with IPF waiting for lung transplant who walked less than 679 feet had higher mortality than those who walked longer distances.18


Recent advances in vasodilator therapy for patients with pulmonary artery hypertension and poor survival of patients with PAH after transplant have reduced the number of patients with PAH who receive lung transplants. The criteria for listing patients with PAH include an NYHA class III or IV status on the maximal vasodilator therapy and 6-minute walk test of less than 350 meters.15


In patients with cystic fibrosis, the predictors of mortality include declining FEV1 and chronic infection. The current criteria for transplant include FEV1 less than 30% of predicted, as well as other markers of declining pulmonary function.19


Pulmonary rehabilitation is an essential component of management of patients with chronic lung conditions even without transplant, and it is becoming an accepted requirement for patients awaiting lung transplantation. Clinical data from pulmonary rehabilitation programs suggest that patients with better physical function before transplant have improved posttransplantation outcomes.


The causes of exercise limitation in people with chronic lung conditions are both ventilatory and musculoskeletal. Muscle changes in pulmonary conditions include decreased muscle oxidative capacity and muscle weakness.20 Reasonable goals for pretransplant rehabilitation include improvement in muscle strength in lower extremity musculature, functional upper extremity muscle strength and endurance, functional shoulder and chest wall range of motion, demonstration of coordinated diaphragmatic breathing with exercise and activities, and improved cardiovascular endurance. Because of the significant effect of immunosuppressive medications on muscle strength, a greater emphasis is placed on resistance training in a patient awaiting lung transplantation than in most typical pulmonary rehabilitation programs. An example of a preoperative pulmonary rehabilitation program is outlined in Table 40-3.






Surgical Implications


Surgical procedures have implications for the physical therapist in the areas of pain, abnormal hemodynamic responses, and movement patterns. The surgical approach for transplant is chosen to provide the surgeon the optimal working area and visual field. The choice of incision may affect patient comfort and function after surgery. Patients may experience pain in the area of the incision, and they may present with decreased muscle function and joint pain related to the muscles that were incised during surgery. The physical therapist should be familiar with the surgical incisions and their impact on rehabilitation. Other related complications from thoracic transplant include injury to the phrenic nerve, brachial plexus injury, and peroneal nerve injury secondary to prolonged positioning during surgery and recovery.


Heart transplants are usually performed through a median sternotomy incision and require cardiopulmonary bypass.21

Related posts:

  1. Intensive Care Management of Individuals with Secondary Cardiovascular and Pulmonary Dysfunction
  2. Cardiovascular and Pulmonary Manifestations of Systemic Conditions
  3. Epidemiology as a Basis for Informing Contemporary Physical Therapy Practice
  4. Individuals with Acute Surgical Conditions

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Jun 11, 2016 | Posted by in RESPIRATORY | Comments Off on The Transplant Patient

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