Living Donor Liver Transplantation NATCO Introductory Course

Transcription

1 Living Donor Liver Transplantation NATCO Introductory Course Patricia Harren, RN, ANP, MSN, PNP, CCTC New York Presbyterian Medical Center Center for Liver Disease & Transplant New York, NY Living Donor Liver Transplant (LDLT) Due to technological and medical advances live donors can donate a part of their liver to an individual who would likely die otherwise. WHY LIVING DONATION? Shortage of available deceased donors. 17,000 waiting for livers done last year. Availability and quality of organ obtained from a live adult donor. Minimal ischemic time. No negative effects from brain death. 1

2 Recipient Risks Technically a more complex surgery. Increased risk of bile leaks. Unknown impact of liver regeneration on rejection or recurrence of HCV/HCC. Risk of small for size syndrome. Adult/Pediatric LDLT Pediatric Adult TOTAL LDLT IN USA REGION 1 REGION 2 REGION 3 REGION 4 REGION 5 REGION 6 REGION 7 REGION 8 REGION 9 REGION 10 REGION

3 DONOR CRITERIA ABO compatible between 18 and 60 years of age. Emancipated minors in select cases. Absence of chronic disease/liver disease. Absence of severe psych disorders. No evidence of coercion or payment. Recipient consent prior to donor beginning evaluation DONOR CRITERIA Must have an emotional relationship to the recipient. Free from illicit drug or alcohol use. Able to understand risks and complications of surgery. Able to comply with short and long term follow up. IDAT - independent donor advocate team. 2 Week reflection period. Organized follow up system. Living Donor Regulations/NYS Perioperative care requirements. Postoperative care requirements. Written donor eligibility criteria. 3

4 Live Adult Liver Donation and Transplantation Regulations. Ammendment to NY State Public Health Law. Effective February 25 th, Choose Public Health Forum, then NY State Register. Independent Donor Advocate Team (IDAT) Internal medicine physician. Nurse clinician. Master Social Worker Psychiatrist Ethicist (To be available to the team as needed). IDAT RESPONSIBILITIES INFORMED CHOICE EXPLAIN EVALUATION INTERESTS & WELL BEING OF DONOR EVALUATE FOR COERCION 4

5 Evaluate for Coercion Rule out coercion to donate by the family and others. Provide adequate information to the recipient to ensure understanding of risks to the donor. Rule out coercion related to monetary or property enrichment of the donor. Explain Evaluation Process Provide information to the donor re: medical, psychosocial, and financial implications of live donation. Assess the donor s intellectual and emotional capability of discussing potential risks and benefits. INFORMED CHOICE Donor s understanding of right to decline donation at any time. Assist donor with letter of unsuitability for donation if requested. 5

6 EVALUATION OF LIVING DONOR Internist Social Work EKG Pap smear Nurse Surgeo n CAT Scan angio. Health Care Proxy Hepatologi st Labs MRI/MRA Donor consent document Psychiatrist Chest x-ray Mammogra m (>40 or +FH) EVALUATION OF LIVING DONOR Doppler ultrasound of the liver: Donors with BMI >30 or abnormal LFT s. Cardiology evaluation: all donors > age 60 yrs, HTN, family history of CAD, DM, chol. Liver biopsy as indicated Exercise stress thallium: all donors > age 50 yrs or pertinent history. PFT s: smoker or history of pulmonary disease. LABORATORY EVALUATION ABO, CBC w/diff, Pt/Ptt, basic metabolic profile, hepatic function panel. Hepatitis A, B, & C serologies. CMV IGG RPR, HIV antibody. Lipid profile Thyroid function Iron, ferritin, TIBC, iron saturation. Ceruloplasm, alpha-1 antitrypsin level and phenotype. ANA (if positive: extensive autoimmune evaluation). PSA, CEA, HCG, U/A 6

7 LABORATORY EVALUATION Factor 5 liden, protein S rule out clotting disorders. Antiphospholipid antibody predictor for cardiac risk. Psychological/Psychosocial Evaluation competency age ability to understand presence of psychosocial illness coercion relationship to recipient medical out financial incentives LIVER ANATOMY Divided into 2 lobes grossly. Divided into 8 segments functionally. Division corresponds anatomically with portal blood supply and bile duct system. Anatomical structure allows for surgical division of liver. while preserving portal blood flow and biliary drainage to all segments. 7

8 Right Lobe Resection Left Lateral Segment Left Lobe Resection Resection Options for Living Donor Liver Transplant Type of Resection Left Lateral Segment Left Lobe Right Lobe Hepatic Segments Segment Segment 2, Segments 5, 6, Approximate % of Total Liver Volume 20% 40 % 60 % Choice of Resection for LDLT Donor/Recipient Size Degree of illness of recipient Degree of portal hypertension Minimum Functional Graft Required Graft volume 40-50% of recipients expected liver volume Graft volume/standard liver volume GV/SV = 30-50% Graft weight/recipient body weight ratio GRWR = 0.8% to 1% 8

9 Risks of LDLT to the donor: Early Post-operatively Complications of general anesthesia, intubation, line placement, DVT, pulmonary emboli, pleural effusions, pneumonia. Wound infection, wound dehiscence, intestinal obstruction, adhesions, ileus, severe pain. Acute liver failure, bleeding, biliary leaks, bilomas, HAT, PVT, severe fatigue. Risks of LDLT to the Donor: Late Post-operatively Bile duct strictures Adhesions Complications of gall bladder removal Affects of scar, keloid tissue Impact on health and life insurance availability Disability, employment status, lost earnings Miscellaneous out of pocket expenses PERIOPERATIVE CARE Donor surgeon to have primary responsibility for donor. Allow donors to bank at least one unit of blood prior to surgery. Surgery scheduled only when sufficient staff available. Surgeons at new programs to visit an established program. Observe minimum of five cases. 9

10 POSTOPERATIVE CARE Designated transplant unit. 24/7 coverage by PGY2 or higher, transplant fellow, NP s or PA s. 6pm - 8am cover only transplant service. Nursing care ratio of 1:2 in ICU/PACU 1:4 after transfer from ICU/PACU. Guided tour of units prior to surgery. Complications of Partial-Liver Donation in 449 Donors Type of Complication No. of Donors (%) Death 1 (0.2) Need for rehospitalization 38 (8.5) Bile stricture or leak 27 (6.0) Nonautologous blood transfusion 22 (4.9) Need for reoperation 20 (4.5) Major postoperative infection 5 (1.1) Other 10 (2.2) Total 65 (14.5) *Some donors had more than one complication (Brown 2003) Advantages of LDLT to the Donor Sense of well being Complete medical/psych evaluation Opportunity to save the life of a loved one Opportunity to benefit society (increasing the donor pool) 10

11 SYSTEMATIC PROSPECTIVE DATA COLLECTION. STUDY RELATION OF DONOR & RECIPIENT TRAITS & OUTCOMES OPTIMIZE INFORMED CONSENT 11