Hello and welcome to the University of Kentucky transplant center. I'm Michael
Daily the surgical director of kidney and pancreas transplant here at the
transplant center. You are here today for a kidney transplant consultation. The
video will take you through the entire transplant process. Today you will be
introduced to your transplant coordinator. This person will be your
contact person for everything you do in your transplant and we'll help you
through the transplant process. Throughout your transplant experience
you may come in contact with many of the transplant team members including but
not limited to our transplant surgeons, advanced practice providers,
nephrologists, coordinators, pharmacists, dietitians, social workers, and financial
counselors. This multidisciplinary team meets once a week to discuss every
patient that comes through clinic ,any concerns or issues that may arise during
the evaluation process, and to determine your candidacy for transplant. You will
be thoroughly evaluated for candidacy for transplant . The United Network for
Organ Sharing has specific criteria defining who may and may not be listed
for kidney and kidney pancreas transplant which we'll review with you.
We regularly review the candidate selection criteria for our program to be
sure is up to date and with current best practice. There may be health related
issues that would make it unsafe to perform a transplant. We hope that none
of these apply to you, however if they do we will be discussing them with you
personally during your appointment. These issues may include medical, social, or
financial concerns. In some cases patients may choose the transplant is
not for them or the multidisciplinary team may decide that they are not a
candidate for transplant. Or the patient may still be working through the
evaluation phase while their kidney is failing. In these cases there are
alternative therapies to transplant. For those experiencing kidney failure your
nephrologist may treat you with hemodialysis or peritoneal dialysis.
While this is ongoing it will be important to remain in the best physical
shape possible, staying active and working with your doctors to manage any
chronic medical conditions such as diabetes, hypertension, and obesity.
After your initial clinic visit the transplant multidisciplinary committee
will meet to discuss if you qualify to continue with the evaluation testing
phase of the process. Sometimes dialysis is a better, safer treatment than
transplant. This is often the case when patients have other health problems or
if they cannot care for themselves at home. If it's felt that you are not a
candidate at this time your coordinator will send you a letter in the mail
explaining why you're not a candidate. You will also get a phone call and have
the opportunity to have your questions answered. Sometimes patients may need to
meet a certain goal, decrease surgical risk, and increase the chances of a
positive outcome prior to starting the evaluation phase. If this is the case you
will receive a letter in the mail that explains what goals must be met with in
the next year to move forward to the evaluation phases. Your referral is open
for one year from today's visit. If you do not complete the evaluation phase
within that year, you will need to be re-referred so that your medical
information can be updated. If the multidisciplinary committee decides that
you qualify for the evaluation phase of the process we will begin your testing
and consultations. The evaluation phase will tell our team if you are a
transplant candidate. During the evaluation process you will meet with
many team members. You will have a Social Work evaluation. You need to bring your
support person to this appointment. the social worker will need to discuss the
caregiver responsibilities and obtain a verbal consent from your support person
in order for you to be cleared. You will also talk with our dietician, financial
counselor, and pharmacist. It is your responsibility to send in your general
health screenings that are performed by your primary care doctor, referring
doctor, or dialysis center. These items include mammograms and pap smear for
women, prostate cancer screening for men, and colonoscopy if you are over 50 years
old. You will also need a pneumonia vaccine. Your coordinator will provide
you with a list of items that you will be required to submit as part of your
evaluation. We will schedule the remainder of your testing in our center
unless you indicate a desire to have these tests perform closer to home. Any
testing that we request to be performed locally will need to be ordered by your
local doctor. We will provide you with a list of required testing and billing
letter, however you will be responsible for getting the results to your
coordinator once the testing has been completed.
Testing will be ordered to check your major organs and systems. It is important
that we make sure that your other major organs are healthy and that you are free
of infections and cancer. We will evaluate your lungs with a chest x-ray
and possibly a breathing test. We will perform a cardiac stress test and
echocardiogram to evaluate your heart. Sometimes we may need to consult a
cardiologist. We will do blood flow testing, which may include an abdomen and
pelvic CT scan, ultrasound of neck arteries, and ultrasound of leg arteries.
We will also perform blood tests to check your kidneys, liver, and immune
system. Depending on your health history we may need to add more tests or consult
with a specialist. Please let your coordinator know if you have had any of
these tests performed in the past year. We may be able to use those results and
not repeat the testing. Included in the blood work that will be performed will
be a drug and nicotine screen. We may not move forward with your evaluation if
either of these tests as positive for a non prescribed drug. If one of these
test comes back positive your coordinator will review our nicotine
and/or drug policy with you. Also included in your blood work will be
blood typing, HLA typing, and antibody typing. HLA typing is a very important
part of the transplant evaluation. Our immune system naturally forms antibodies
as a protective response against bacteria and viruses. Antibodies are good
when they are ready to attack foreign invaders that can lead to illness. The
antibodies can also be ready to attack foreign tissues such as the new kidney
transplant. Having a high number of different antibodies can mean that you
are at high risk of rejection if you receive a transplant from a certain
kidney donor. If you have antibodies against your particular kidney donor to
the cross-match will likely be positive meaning that transplant with that donor
will be a high risk for rejection. Antibodies are measured by a percentage.
If your antibodies are more than 20% UNOS now gives you extra points on
the waiting list. Points are then translated into extra waiting time which
pushes you further up the list. If your antibodies are 99% you will have
regional priority and if they are a hundred percent you will have national
priority.
Once you have completed all requested testing and consults and have turned in
your primary care items your case will be discussed in our weekly selection
committee. Our multidisciplinary committee will discuss all of your
evaluation results. There are three possible outcomes from this discussion.
1. You are a candidate for transplant, which means you will move on to the
listing phase. 2. You are not a candidate for transplant
at this time in which case your coordinator will contact you to inform
you and we'll mail you a letter with the committee decision. 3. You need more tests
or a visit with a specialist and your coordinator will notify you of our
concern and schedule these items for you. Once the committee decides that you are
a candidate for transplants you have two possible options for transplant, live
donation or deceased donation. Both require that you be placed on the
waiting list. When you are on the waiting list it is important that the transplant
center can get in touch with you at a moment's notice.
You must provide us with correct phone numbers for yourself and as many family
members or friends that you can provide. If you receive an organ offer and cannot
be reached you will be skipped and we will have to
discuss your eligibility to remain on the waiting list in our
multidisciplinary committee. It is also important that you update your
coordinator with any changes in your health. If you are sick it is important
to tell your coordinator as a transplant may not be a safe option until the issue
is resolved. This includes hospitalization, blood transfusion, a foot
ulcer, or any health issue. If you change your phone number or address you need to
let the coordinator know as this can affect our ability to notify you of
important appointments or transplant opportunities. It is also important to
notify us of changes in your insurance. If you do not notify us about insurance
changes and come in for transplant you could potentially be required to pay
out of pocket for the transplant. If in doubt call your coordinator.
As a transplant patient you have the right to be listed at as many centers as
you would like. This may increase your chance of receiving a deceased donor
transplant. It is only a benefit however to listed multiple centers that are in
separate local areas. For example, you would not need to list at UK and Jewish
Hospital in Louisville because we are in the same local area. This means that our
waiting lists are combined. When a local donor organ is offered you may benefit
by going to another area such as the Cincinnati area, Tennessee, or Indiana.
Please keep in mind that if you decide to be listed at multiple centers you
will be required to go through the evaluation process at each center and
keep up with each center's requirements for listing. One major reason that
patients usually decide to pursue Multiple Listing is being highly
sensitized or having high percentage of antibodies. If your antibodies are above
20 percent your coordinator will discuss this with you and may suggest multiple
listing at another center. Some centers offer something called desensitization
for patients that have a lot of antibodies. Due to the fact that
desensitization increases the risk of rejection we do not perform this
procedure here at UK. Furthermore, if you choose to go through desensitization at
another Center it may impact your listing with us. Please notify your coordinator.
Live of donation should always be your first priority due to
improved outcomes. Live donor transplants tend to have better outcomes and the
transplant itself tends to last longer for many reasons. Some of those reasons
come from the fact that 1. a live donor has to be very healthy and have
virtually no risks of kidney disease later in life . 2.The transplant can be
performed once the donor is approved which decreases your waiting time and
will mean that you are likely in better health for transplant. 3. There is
very little time that the organ is outside of a circulating blood system
because your donor is in the next operating room while you are getting
ready for surgery. Our deceased donor waiting times are unpredictable in the
UNOS kidney allocation system and are currently several years. By obtaining a
live donor you can be transplanted much sooner.
The sooner you receive the transplant most likely the better your outcomes
will be. It is well known that the longer you are on dialysis your life expectancy
goes down and more complications can arise. It is in your best interest to be
transplanted as quickly as possible if you are getting close to or are on
dialysis. Live donation allows you and your donor to schedule your surgeries
when you are both in the best possible condition for your surgery. If a live
donor presents themselves and you may think they may not match or may have
something that keeps them from being a donor still encourage that person to
call. If it's a matching issue we can discuss with them if they would be
interested in the paired exchange program. In this program we match
patients who have live donors approved that do not match them to others in the
same situation. This is a way of still getting the benefit of a live donor even
if your donor doesn't match you. Never rule out a potential living donor on
your own. This can be a complicated process, always have them call.
As mentioned a living donor should be everyone's first priority. If a live
donor transplant is not a possibility the back-up plan is the deceased donor
waiting list. A deceased donor is someone who has had a major injury or illness
that is not survivable. Individuals may register as an organ donor or their
families may consent to organ donation. The waiting list for deceased donors is
long and donated organs are a limited resource. Once the committee has reviewed
your evaluation and you have been approved for listing you will
automatically be placed on the UNOS national waiting list for a deceased
donor. If you are not on dialysis, your waiting time will start the moment you
are placed on the waiting list. If you are on dialysis your waiting time will
backdate to the day you started regular dialysis. You can be placed on the
waiting list as an active or inactive status. Active means that you are healthy,
ready for transplant, and could receive a call at any moment. Inactive means
something is going on that makes transplant impossible at the moment. It
may be a safety factor where you have an infection, cold, flu, or recent hospitalization.
The medications we use can make the condition much worse. So it
would not be safe to receive a transplant if you have an active
infection of any kind. Another reason you may be made inactive is traveling more
than five hours from the transplant center. Transplant is very time-sensitive.
UK requires that you must be within five hours of the transplant center to be
listed active. If you are placed on the inactive list you are still on the
waiting list and still gaining waiting time. The only time you are taken off the
list is if you hear the words removed from the waiting list. Patients sometimes
get in activation and removal confused so we like to stress that the inactive
status is temporary and can be changed to the active status once the concern is corrected.
The kidney transplant list is very complex there are many rules that govern the order on the list a new list is run for each donor and your place on
these lists may vary slightly. While time on the waiting list remains very
important it is not the only factor. Other important factors on the waiting
list have to do with donor criteria. Donors come in all shapes and sizes some
of them are old, some of them have medical problems, sometimes they even
have kidney disease. We will be evaluating each of these donors kidneys
for suitability for transplant. Kidney function declines with age when a donor
is particularly old it may not be reasonable to use their kidneys to
transplant a younger person. One of the questions we will be discussing today is
whether you would be willing to accept the kidney from an older donor. If you
are young this may not be in your best interest except under special
circumstances. If you are older this may allow you to cut in line in front of
some younger people and save you some time to transplant. We will only use
these older donors it would feel the kidney will last long enough to help you out.
Sometimes these donors have engaged in behaviors that increase the risk of
them becoming infected. We worry these infections could be transferred with the
transplanted kidney, fortunately our ability to detect these
infections such as HIV or hepatitis C has gotten very good.
We can now find very small amounts of
these infections in the donor blood if they're even present. Generally what this
means is that if the donor has been in the hospital for more than several days
we can usually find these viruses if they are present. There remains however a
very small risk of transmitting these viruses because of that we will only
offer these organs to patients who are willing to consider this small risk.
The risk is generally considered to be much less than the risk of dying on dialysis.
So I encourage you to consider them. We will be able to discuss this with you at
length if you are interested in learning more. If you are receiving a live donor
transplant you will come to the transplant clinic one week before your
scheduled surgery date. You will meet with the surgeon, have a final cross
match performed, and go to a pre-op anesthesia appointment. The night before
your surgery the operating room staff will call you with instruction on what
time you need to arrive the following morning for your surgery. The deceased
donor transplant process is very different. If you are active on the
UNOS deceased donor waiting list you could receive a call anytime day or
night. When that call comes a coordinator will ask you some questions over the
phone to make sure there are no major contraindications to transplant. If
everything sounds ok the coordinator will instruct you to come to UK hospital
where you will be sent to a hospital room. At this time it is important to
have your blood drawn as soon as possible. This blood will be used to
perform the cross match. The cross match tells us if you match the donor. If you
do not match we would have to send you home because you would reject the organ.
Sometimes we call two patients for one organ in case the first person in line
for the transplant does not match. We will always inform you when we call if
you are going to be the backup patient. Which means there is at least one person
in front of you for this transplant. If you match are the first person on the
list for the transplant and the organ is in good condition you will be taken to
the operating room. If the organ is not in good condition
the transplant will be canceled. This can happen at any time up until the
transplant is complete. Once the surgery is finished you will wake up in the
recovery room and then be transferred to the transplant floor. If there are
complications or if you receive a kidney and pancreas transplant you will go to
the ICU to be monitored more closely before moving to the transplant floor. Most
patients that receive a kidney only transplant or in the hospital for an
average of four to five days. During this time you will be receiving a large dose
of immunosuppression medication which means that you are at high risk for
infection. While you are in the hospital the entire team will be teaching you how
to take care of yourself, take your medication, prevent infection, monitor for
cancers, and other important ways to care for your transplant. Once it is deemed
safe you will be discharged to your home.
Now comes the good part
The transplant surgery itself. If you made it this far is because you've been
evaluated and discussed, you have been listed, you have received an acceptable
kidney donor offer, and come into the hospital. You are not currently ill and
you have a compatible cross-match. Now that seems like a lot you're right. It's
pretty tricky to get this far but if you do it's time for surgery. There's
generally one more opportunity for you ask your surgeon any last minute
questions because of confidentiality laws we may not be able to tell you
everything about your donor. We will tell you what we can. Before surgery will be
taken to the preoperative holding area where you will meet with your
anesthesiologist. When an operating room is available they will take you to it
and put you to sleep. We commonly also require a deep line in your neck, an
arterial line in your arm, and a Foley catheter in your bladder. All of these
will be placed while you are asleep. We then prepare your skin for surgery
and start the operation. The kidney will be placed in your lower abdomen. We will
not put it where your old kidneys are because the ureter or urine tube will
not reach. We will sew the kidney blood vessels to the blood vessels of your leg.
We will then sew the ureter to your bladder.
When we are done we will let the rest of your organs sit on top of it which will
hold it in place. These organs sitting on top of the kidney is part of the reason
we may require some weight loss from somewhere obese patients. We know that
significant obesity decreases the likelihood that these kidneys will work
right away or even at all. Some of the theories behind that are transplanting
obese patients it's more complicated and it takes a longer time to sew in the
kidney. Another theory is that the weight of the organ sitting on top of the
kidney affects its blood flow. Either way we may require some weight loss. While we
are sewing the kidney on to your bladder we'll be assessing it because the
bladder can stretch becoming much bigger when it is full or smaller when it is
empty and the ureter cannot, where we connect these two together is prone to
leak. Because of that I will ask you to leave your Foley catheter in for several
days after the transplant. How long depends on how healthy your bladder is.
You should plan on being in the hospital for four days although that can vary
quite a bit. You will be able to a private room and your family will be
welcome to join you. By the time you leave the hospital you will have a
pretty good idea of how to take care of yourself and your new transplant. Once
you are discharged you can expect to have follow-up visits in the transplant
clinic twice a week for the first few weeks. If everything is stable with your
visits, you will then be moved to once a week
and every other week thereafter. This is where your support person comes into
play. Your support person will be responsible for bringing you to clinic
visits, helping you manage your medications, and helping you with
activities of daily living such as laundry, grocery shopping, and household
chores. The risk of rejection and infection are the highest during the
first three months after transplant. Therefore it is important that we
monitor you closely. In addition to your lab work we will also be monitoring you
for side-effects from your medications. Common side effects include hand tremors,
diarrhea, and changes in your electrolytes or blood counts. At three
months, we will automatically schedule you with your referring physician and
will begin to alternate appointments with them. You should expect to always
followed by the transplant center so that we can monitor your kidney function
and adjust your immunosuppression to optimize your outcomes from the
transplant. Rejection is a major complication after transplant. To try and
prevent rejection is a very important that you never miss the medication. Your
medications are your lifeline to your transplant. By missing medications or not
taking them on time every day you increase your risk of rejection. It's
also very important to attend all doctor visits and lab appointments. With a
transplant we have lowered your immune system this means that your body may not
show significant signs of infection or rejection until the process is very
advanced. Our goal is to pick up on rejection or infection in your lab work
before you ever show signs or symptoms. If you do not have your labs drawn or
come to clinic as ordered you are putting yourself at an increased risk of
complication. Rejection can be acute or chronic. Acute
rejection happens suddenly and often is not associated with symptoms. It has
commonly found on regularly scheduled lab work and can often be treated
effectively if caught early. Chronic rejection is a gradual increase in your
creatinine overtime. There is no treatment for chronic rejection and
eventually the organ may fail requiring either retransplant or dialysis. After a
transplant you have staples in your abdomen.
These will be removed in clinic once the provider feels that your incision is
healed well enough. You will also have a ureteral stent in place. It is important
that this is removed after transplant so it does not become infected. You will be
given a urology appointment to have this removed usually about five weeks after
your transplant . Due to your immunosuppression medications you will
be at higher risk for cancers as our immune system is responsible for
protecting against cancer. 50% of transplant patients will develop at
least one skin cancer after transplant. It is important to monitor your skin
monthly on your own, protect against burning, and see a dermatologist yearly
after your transplant. You will also need to make sure you are doing your general
cancer screenings such as mammograms, pap smears, prostate
exams, and colonoscopies for general guidelines. Your primary care doctor is
responsible for these tests since the transplant team does not follow them
after transplant. Dental care is also very important after transplant to
prevent infection. Wow that was a lot. Thank you for watching and for your
interest in transplant at the University of Kentucky Transplant Center. We hope
this video was helpful. Please feel free to ask questions at any
point during your visit, we want this to be a pleasant and informative experience
for you. Please let us know if there's anything that we can do to assist you in
your journey to transplantation
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