Transplant Nursing Liver Intestines FINAL

TRANSPLANT NURSING
Liver and Intestinal Transplant
Copyright 2017. OnCourse Learning Corporation. All rights reserved.

•  What are the main causes of

end-stage liver disease?
–  Hepatitis (A-E)
–  Cirrhosis (varying types)
–  Autoimmune disorders causing
liver disease
–  Alcoholism, drug hepatotoxicity
© 2008 A.D.A.M., Inc.
Copyright 2017. OnCourse Learning Corporation. All rights reserved. 2

•  Why is hepatitis the leading

cause of end-stage liver
disease?
–  Multiple ways to acquire the
many types of Hepatitis
–  Spread through various routes of
blood contact, mother/child,
sexual contact
–  Cirrhosis is the most common
cause of liver transplant
© 2008 A.D.A.M., Inc.

•  What are non-hepatitis causes of liver disease that

can cause hepatic failure?
–  Primary biliary cirrhosis
–  Postnecrotic cirrhosis (alcoholic cirrhosis)
–  Primary sclerosing cholangitis
–  Cryptogenic cirrhosis (unknown causes)

•  Which other named diseases can cause liver failure?

–  Alpha 1-antitrypsin deficiency inherited disorder
–  Hemochromatosis inherited disorder of iron absorption
–  Non-alcoholic steatohepatitis (associated with fatty fibrosis
and diabetes)
–  Wilson’s disease
–  Primary liver tumor

What are the stages of liver failure?
Stage 4:
Liver Failure
Stage 3: and Advanced
Cirrhosis Liver Disease
Stage 2: of the Liver
Fibrosis of
Stage 1: the Liver
Ini%al Stage of
Liver Disease

•  What early signs and symptoms of liver disease

would be reported by the patient?
–  Constipation or diarrhea
–  Fatigue
–  Indigestion/loss of appetite
–  Itchy skin
–  Nausea/vomiting
–  Weight loss
–  Pain

•  Which objective signs and symptoms would be

developing?
–  Peripheral/dependent edema
–  Jaundice
–  Lab values:
•  Increased bilirubin
•  Decreased albumin and platelets
•  Anemia, leukopenia

•  How do liver failure complications increase as liver

functioning deteriorates?
–  Ascites
–  Esophageal or gastric varices
–  Portal hypertension
–  Developing renal failure simultaneously

•  What complications can pediatric patients

experience prior to transplant?
–  Encephalopathy from quickly elevating ammonia levels
(altered mental status)
–  Portal hypertension

•  When a patient develops encephalopathy, what

signs are monitored?
–  Changes in consciousness
–  Uncontrolled drowsiness
–  Confusion, may react to voice
–  Comatose

•  What laboratory assessments can a

potential liver transplant patient
expect?
–  CBC with differential/Lytes/BUN/
creatinine
–  Blood typing
–  PT/PTT with INR
–  Alcohol and drug level panels
–  Serum virology screen (Hepatitis,
CMV, EBV, HIV)
–  Liver function tests (LFTs)
–  ANA/AMA
–  Cholesterol

•  What other screening will be done prior to

discussing transplant options?
–  Endoscopy/colonoscopy
–  EKG
–  Liver biopsy
–  Liver ultrasound with follow up CT or MRI
–  Pulmonary function test

•  What restrictions for

transplantation are placed on
patients with alcoholic
cirrhosis?
–  Minimum of 6 months without
consuming alcohol before liver
transplant can occur

•  What reasons may contraindicate a patient for

receiving a transplant?
–  Metastatic hepatocarcinoma
–  Comorbidity of severe cardiac or pulmonary disease
–  Malignancy elsewhere in the body
–  Substance abuse
–  Severe or uncontrolled extrahepatic infection

•  By what system are liver transplant patients

categorized prior to transplant?
–  Model for end-stage liver disease (MELD)
•  Based upon serum bilirubin, creatinine and INR and Na
•  To quantify end-stage liver disease for transplant planning

•  What system is used to categorize

pediatric patients?
–  Pediatric end-stage liver disease
(PELD)
•  Serum bilirubin, albumin, INR
•  Age <1 and height average in
pediatrics
–  Score predictive of death in less than
3 months without transplant

•  When does pre-operative care begin?

–  Upon patients notification that an organ has been chosen
for them to be transplanted
–  Repeated serum laboratory values upon admission
–  CXR/EKG to measure for any changes since last testing

•  Which hemodynamics are

most important to monitor
post-operatively?
–  Cardiac index
–  Cardiac output
–  Systemic vascular resistance
–  TPR, blood pressure

•  Why might these measurements be abnormally

high?
–  Chronic liver disease increases these measurements in the
patient
–  As new liver begins to function, these levels should return
to that of normal

•  How can the nurse best monitor fluids?

–  Presence of dry membranes, poor skin turgor, edema or
ascites
–  Urine output >30cc/hr
–  Hypovolemia treated with blood products (RBC’s, albumin,
FFP, platelets)
–  Drain(s) output

•  What laboratory values need to be monitored closely post-

operatively?
ABGs
Glucose CBC
Liver func%on
PT/PTT tests:
•  AST/ALT, TB

•  What steps should be taken with any origination of fever?
C-reac%ve
proteins will
CBC increase with
Blood infec%on
cultures/
Timing of urinalysis/
transplant… urine culture
can it signify
rejec%on?

•  Why are neurological assessments important in liver

transplant patients?
–  Encephalopathy can signify:
•  Infection
•  Poor liver functioning
•  Non-recovery from pre-operative encephalopathy
•  Adverse effect from immunosuppression medications

•  What signs and symptoms can signify early

problems with the new organ post-operatively?
–  Abnormal coloration of patient
–  Edema around liver transplant site
–  Unstable hemodynamics
–  Poor reperfusion of the organ
–  Poor urine output
–  Poor bile output

•  What can be factors causing the transplanted liver

not to function?
–  Increased cold ischemic time of the liver from donation to
recipient
–  Increased age of the donor
–  Fatty liver of the donor

•  What is hepatic artery thrombosis?

–  Elevation in serum ALT/AST is seen
–  Treatment may be retransplantation or thrombectomy
–  Called “HAT” in pediatric transplantation, it occurrs more often in children
than adults
Mechanical thrombectomy

•  What other complications can develop early post-

transplant?
–  Post-operative bleeding (within 48 hours)
–  Pleural effusions (mostly right sided with surgical
procedure)
–  Renal dysfunction
–  Worsening ascites, initially
–  Edema

•  How are leaking bile complications resolved?

–  Biliary leaks can occur:
•  At the anastomosis site that will need to be repaired at some
point if does not self correct
•  Around the draining t-tube placement
–  Can replace the tube or leave in upwards of 3 months for
complete healing of site before removal
•  What are symptoms of a bile leak?

–  Severe abdominal pain
–  Referred pain to the shoulder

•  Why is early detection of biliary leaks in children so

important?
–  Highest cause of mortality in children
–  Mismatched adult sized organs partly to blame
–  Treatment will need insertion of stent coupled with
antibiotics

•  What if the biliary complication is obstruction of the

bile duct?
–  Serum bilirubin and alkaline phosphatase will rise
–  Complication at anastomosis site needing surgical
intervention
–  Can be treated by biliary stent placement

•  What fluid and electrolyte

imbalances need to be monitored?
–  Hypovolemia
–  Hypo/hyperglycemia
–  Hypo/hypertension
•  Both hypo /hyperglycemia and hypo/
hypertension can occur in response to
immunosuppressant medications
or corticosteroids

•  How are signs and symptoms of graft rejection

monitored?
–  Daily LFTs and medication levels (alteration from baseline
may indicate rejection)
–  Changes in urine (dark)/stool color (light)
–  Jaundice
–  Changes in t-tube drainage color/consistency
–  Pain
–  Fever

•  How may pediatric patients show early signs of

rejection?
–  Development of ascites
–  Pain
–  Irritability
–  Fever (low grade)
–  Increase in serum LFTs, bilirubin

•  Which immunosuppressant
medications might a liver
transplant patient be
prescribed?
–  Individualized per patient to
prevent rejection with minimal
side effects
•  Cyclosporine (Neoral, CSA) or
Tacrolimus (Prograf)
•  Corticosteroids
•  Azathioprine (Imuran) of MMF
(CellCept) Two generic azathioprine oral tablets, 50mg each
–  These are added if patient is
using triple therapy
Collins & Shapiro (2015)

By NLM [Public domain], via Wikimedia Commons;
https://commons.wikimedia.org/wiki/File%3A000040lg_Azathioprine_50_MG_Oral_Tablet.jpg

•  What frequent side effects of immunosuppressant

drugs do patients experience?
–  Calcineurin inhibitors (Tacrolimus, CSA)
•  Headache
•  Tremors
•  Hyperglycemia
•  Hypertension
•  Nephrotoxicity

Altera%on
in mobility
Altera%on
Self-care
in bowel
deﬁcit
habits
Which nursing
diagnoses may be
appropriate for
liver transplant
pa%ents?
Poten%al
Altera%on
for
in comfort
infec%on
Knowledge
deﬁcit

•  What are the main causes of end-stage intestinal

disease?
–  Short gut syndrome
–  Intestinal failure
–  More than half of intestinal transplants receive simultaneous
liver transplants

•  How is short gut syndrome defined?

–  Functional:
•  Disorders of intestines resulting in malnutrition that requires
TPN for nutritional intake
–  Structural:
•  Result of extensive surgical interventions for variety of
intestinal illnesses (Crohn’s disease, structural anomalies,
surgical adhesions)

•  What types of intestinal transplant are available?

–  Combined liver/intestine transplant
–  Isolated intestinal transplant without other associated
diseases
–  Multivisceral transplant includes multiple organs being
transplanted along with the intestine (liver, pancreas,
stomach)

•  What laboratory assessments can a potential

intestinal transplant patient expect?
–  CBC with differential
–  Serum electrolytes to identify imbalances that may be
present from disease or current use of nutritional solutions
–  Blood gasses to assess for metabolic acidosos or alkalosis

•  What other types of screenings will

be done prior to transplantation?
–  Infection
–  Fluid and electrolyte imbalances
–  Liver biopsy if liver failure involved
–  Upper and lower GI series barium
studies to identify abnormal
structures or vascularity to the area
–  Cardiology testing
–  Ultrasound

•  What should be involved in the physical examination

of the patient?
–  Appearance of skin or breakdown of skin
–  Signs and symptoms of kidney or liver dysfunction upon
exam
–  Assessment of HEENT identifying complications from
intestinal failure/electrolyte imbalances
–  GI assessment auscultate, palpate identify hepato or
splenomegaly

•  Why should particular attention be applied to the

pediatric patient growth and development?
–  Most intestinal complications are from anomalies from birth
causing delayed growth (height and weight)
–  Poor nutritional status may need attention prior to
attempting transplantation
–  Child may have never had oral feeding

•  What early signs and symptoms may patients

describe experiencing with intestinal failure?
–  Abdominal pain and distention
–  Diarrhea
–  Malaise and overall weakness
–  Mood swings
–  Weight loss
–  Poor growth

•  When does pre-operative care begin?

–  Intestinal transplant evaluations can take up to several days
to complete depending upon severity of current illness
–  Full assessment of the gastrointestinal system, current
nutritional status and other organ functioning
–  Evaluation of parental understanding and support if a
pediatric patient

•  What is important to teach the

patient prior to transplant?
–  What to do while waiting for
transplant (self-care and health
habits)
–  Surgical procedure and potential
complications
–  What physical changes to expect
following surgery, understanding of
immunosuppressant therapy, care of
ileostomy post-operatively

•  What laboratory values need to be monitored

closely post-operatively?
–  Arterial blood gases
–  CBC/Electrolytes
–  Glucose
•  low levels may indicate organ non-function
–  Liver function tests (LFTs) including bilirubin, AST, ALT, ALP
•  rising of these levels can signify non-functioning graft or biliary
complication

•  What types of surgical complications can occur?

–  Gastrointestinal leaks
–  Hemorrhage
–  Hypermotility or thrombosis of intestine
–  Fluid imbalances (hypo/hypertension)
•  Which gastrointestinal complications does the nurse

need to be aware of post-operatively?
–  Vital signs indicating potential bleeding activity
(tachycardia, hypotension)
–  Increasing abdominal pain
–  Frank bleeding from ileostomy site

•  What signs and symptoms would appear with a

developing gastrointestinal leak?
–  Distended abdomen
–  Fever
–  Pain and peritonitis

•  Where are common drainage

devices used with intestinal
transplantation?
–  Gastrostomy tubes, jejunostomy
tubes for feeding
–  Biliary drains (especially with
liver transplant)
–  Ileostomy
–  Jackson Pratt (JP)
–  Naso-gastric tube (NG)
Image of a jejunostomy
By Le67 (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia

Commons; https://commons.wikimedia.org/wiki/File%3AJejunostomy.jpg

•  How does the nurse assess for intestinal graft

functioning?
–  Auscultation for presence of bowel sounds
–  Visible abdominal distention
–  Patient reported pain
–  Assessment of ileostomy stoma and output (color, amount
and consistency)
–  Palpate to assess any firmness or abdominal rigidity

•  Why is rejection a common complication of >50% of

intestinal transplants?
–  Cadaver organs carrying bacteria and gastrointestinal flora
to recipient
–  Lymphoid tissue associated with intestinal site

•  What signs and symptoms of developing rejection

may appear?
–  Abdominal pain or distention
–  Abnormal appearance of stoma
–  Nausea and vomiting
–  Fever
–  Large decrease or increase in amount of stool
–  Cramping

•  What signs and symptoms of chronic rejection can

develop?
–  Slower developing symptoms:
•  Abdominal pain
•  Chronic diarrhea in large amounts
•  Fever intermittently
•  Weight loss

•  How is intestinal rejection treated?

–  Altering tacromilus (TAC) levels (Is the drug of choice for intestinal
transplant immunosuppression)
–  Solumedrol bolus and taper

•  How often are post-operative endoscopies done to

evaluate for rejection?
–  As often as biweekly following transplant
–  Necessary for bowel prep prior to procedure whenever
possible
–  Necessary for suspected infection, suspicion of rejection

•  What nursing interventions are necessary following

each endoscopic procedure?
–  Assessment of returning bowel sounds, post-operative
bleeding or pain
–  Slow advancement of diet as ordered
–  Assess return of normally functioning ileostomy

•  What symptoms may be indicative of a developing

bacterial infection?
–  Patient reporting feeling ill with or without cold-like
symptoms
–  Fever > 38.5 degrees C
–  Development of erythema or edema at drainage sites
•  What are symptoms of the highly fatal aspergillus

infection?
–  Shortness of breath
–  Facial/sinus pain
–  Fever without other symptoms
–  Alteration in CNS, mental status

Seronega%ve organ recipient

with a seroposi%ve organ donor
What puts an intes%nal

transplant pa%ent at higher
risk for developing CMV or
EBV infec%on?
Pa%ents with seronega%vity will
receive prophylac%c Ganciclovir
or immunoglobulins to lessen
risk of CMV infec%on

•  How can the nurse monitor for developing

cytomegalovirus (CMV)?
–  Awareness of patient CMV status
–  Fever
–  Gastroenteritis
–  Changes in serum blood lab values
•  i.e. low white blood count

•  What are signs and symptoms of developing

Epstein-Barr virus (EBV)?
–  Bloody diarrhea
–  Fever
–  Fatigue and weakness
–  Lymphadenopathy
–  Decreased appetite
–  Leukopenia
–  Pancytopenia

•  How is treatment of these viral infections

determined?
–  Decrease in immunosuppression
–  Addition of antiviral medications (Ganciclovir, IVIG)
–  Monitoring of labs weekly

•  Which nursing interventions are associated with the

nutritional needs of the intestinal transplant patient?
–  Long-term goals of providing oral feedings instead of the
relied upon enteral feedings most patients are used to
–  Monitoring of tolerance of advancing diet
–  Assisting children with oral aversion

•  Why might a patient feel prolonged nausea and vomiting when

attempting to reintroduce oral nutrition?
–  Changes in gastric volume following transplant
–  Many patients have never had food other than liquids for some time
–  Changes in motility following transplant leaving stomach full longer

•  What nursing care and instruction is necessary for

patients without knowledge of an ileostomy?
–  How to record intake and output
–  Self assessment of stoma normal appearance versus signs
of infection
–  Ileostomy care training with an enterostomal therapy nurse

•  How is the stoma important in monitoring care of

the intestinal transplant patient?
–  Patient awareness of normal color, drainage, stool output
can help in recognizing early signs of infection or rejection
–  Remains up to 12 months following transplant for biopsy
monitoring purposes

•  Which nursing diagnoses are

appropriate for the intestinal
transplant recipient?
–  Alteration in comfort
–  Activity intolerance
–  Alteration in body image
–  Knowledge deficit
–  Potential for infection

Bibliography
•  Bambha, Kiran & Kamath, Patrick. Model for End-stage Liver Disease.
In B. Runyon (Ed.), UpToDate. 2016. Retrieved from http://
www.uptodate.com/home/index.html
•  Florida Hospital. Liver Disease. (n.d.). Retrieved from Florida Hospital
Medical Center: www.floridahospital.com
•  Haberal M, Sevmis S, Karakayali H, et al. Pediatric liver transplant:
results of a single center. Exp Clin Transplant. 2008,6(1):7-13.
•  Ohler L, Cupples S. Core Curriculum for Transplant Nurses. Second
Ed. St. Louis, MO: Mosby; 2016.
•  Pomfret EA, Fryer JP, Sima CS, Lake JR, Merion RM. Liver and
Intestine Transplantation 1996-2005. Am J Transplant. 2007;7(5 Pt
2):1376-1389.
•  Tan HP, Marcos A, Shapiro R. Living Donor Transplantation. New
York, NY: Informa Healthcare; 2007.

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TRANSPLANT NURSING

Liver and Intestinal Transplant

Copyright 2017. OnCourse Learning Corporation. All rights reserved.

• What are the main causes of

© 2008 A.D.A.M., Inc.

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 2

• Why is hepatitis the leading

© 2008 A.D.A.M., Inc.

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 3

• What are non-hepatitis causes of liver disease that

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 4

• Which other named diseases can cause liver failure?

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 5

What are the stages of liver failure?

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 6

• What early signs and symptoms of liver disease

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 7

• Which objective signs and symptoms would be

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 8

• How do liver failure complications increase as liver

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 9

• What complications can pediatric patients

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 10

• When a patient develops encephalopathy, what

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 11

• What laboratory assessments can a

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 12

• What other screening will be done prior to

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 13

• What restrictions for

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 14

• What reasons may contraindicate a patient for

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 15

• By what system are liver transplant patients

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 16

• What system is used to categorize

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 17

• When does pre-operative care begin?

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 18

• Which hemodynamics are

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 19

• Why might these measurements be abnormally

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 20

• How can the nurse best monitor fluids?

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 21

• What laboratory values need to be monitored closely post-

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 22

• What steps should be taken with any origination of fever?

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 23

• Why are neurological assessments important in liver

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 24

• What signs and symptoms can signify early

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 25

• What can be factors causing the transplanted liver

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 26

• What is hepatic artery thrombosis?

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 27

• What other complications can develop early post-

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 28

• How are leaking bile complications resolved?

• What are symptoms of a bile leak?

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 29

• Why is early detection of biliary leaks in children so

Copyright 2017. OnCourse Learning Corporation. All rights reserved. 30

•  What are the main causes of

•  Why is hepatitis the leading

•  What are non-hepatitis causes of liver disease that

•  Which other named diseases can cause liver failure?

•  What early signs and symptoms of liver disease

•  Which objective signs and symptoms would be

•  How do liver failure complications increase as liver

•  What complications can pediatric patients

•  When a patient develops encephalopathy, what

•  What laboratory assessments can a

•  What other screening will be done prior to

•  What restrictions for

•  What reasons may contraindicate a patient for

•  By what system are liver transplant patients

•  What system is used to categorize

•  When does pre-operative care begin?

•  Which hemodynamics are

•  Why might these measurements be abnormally

•  How can the nurse best monitor fluids?

•  What laboratory values need to be monitored closely post-

•  What steps should be taken with any origination of fever?

•  Why are neurological assessments important in liver

•  What signs and symptoms can signify early

•  What can be factors causing the transplanted liver

•  What is hepatic artery thrombosis?

•  What other complications can develop early post-

•  How are leaking bile complications resolved?

•  What are symptoms of a bile leak?

•  Why is early detection of biliary leaks in children so

•  What if the biliary complication is obstruction of the

•  What fluid and electrolyte

•  How are signs and symptoms of graft rejection

•  How may pediatric patients show early signs of

•  What frequent side effects of immunosuppressant

•  What are the main causes of end-stage intestinal

•  How is short gut syndrome defined?

•  What types of intestinal transplant are available?

•  What laboratory assessments can a potential

•  What other types of screenings will

•  What should be involved in the physical examination

•  Why should particular attention be applied to the

•  What early signs and symptoms may patients

•  When does pre-operative care begin?

•  What is important to teach the

•  What laboratory values need to be monitored

•  What types of surgical complications can occur?

•  Which gastrointestinal complications does the nurse

•  What signs and symptoms would appear with a

•  Where are common drainage

•  How does the nurse assess for intestinal graft

•  Why is rejection a common complication of >50% of

•  What signs and symptoms of developing rejection

•  What signs and symptoms of chronic rejection can

•  How is intestinal rejection treated?

•  How often are post-operative endoscopies done to

•  What nursing interventions are necessary following

•  What symptoms may be indicative of a developing

•  What are symptoms of the highly fatal aspergillus

•  How can the nurse monitor for developing

•  What are signs and symptoms of developing

•  How is treatment of these viral infections

•  Which nursing interventions are associated with the