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Transplant Journal of Australasia Volume 21 No 3 December 2012

“Things don’t have to change the world to be important” Steve JobS

O f f i c i a l j o u r n a l o f t h e Tr a n s p l a n t N u r s e s ’ A s s o c i a t i o n I n c .

TRANSPLANT JOURNAL OF AUSTRALASIA

CO NTE NTS Journal of the Transplant Nurses’ Association Inc.

TNA National Executive report

Editorial 3

National Executive President Claire West Tel (02) 9515 7274 Fax (02) 9515 3606 Email president@tna.asn.au

Guest editorial

Articles

Secretary Libby John Tel (08) 8204 5819 Fax (08) 8204 6959 Email secretary@tna.asn.au

Secretariat Nicole Williams Tel (08) 8204 5819 Fax (08) 8204 6959 Email secretariat@tna.asn.au

32nd Annual Meeting and Scientific Sessions of the ISHLT (International Society for Heart and Lung Transplantation)

Treasurer Julie Pavlovic Tel (03) 9496 3972 Fax (03) 9496 3487 Email treasurer@tna.asn.au Editor Tracey Mackay Email TJAeditor@tna.asn.au ISSN 1323-5109 Published by the Transplant Nurses’ Association Inc. All correspondence to: Nicole Williams, TNA Secretariat

High-risk multi-organ donor – a case study 7 F Zani and ML Harkess

Sara Shaw

Cardiovascular risk factors associated with cardiac allograft vasculopathy following cardiac transplantation: A longitudinal follow-up

Yvonne H Cristiano, Geraldine A Lee and Peter J Bergin

2012 TNA Conference report – TNA21 21

Published by

2012 TNA conference winning abstracts

Cambridge Publishing – a division of Cambridge Media

2012 TNA Conference photos

Diary Dates

Copy Editor Rachel Hoare

State Executive

Graphic Designer Gordon McDade

Editorial Board

10 Walters Drive Osborne Park, WA 6017 Tel (08) 6314 5222 Fax (08) 6314 5299 Web www.cambridgemedia.com.au

Disclaimer: Neither the Transplant Nurses’ Association nor the Editorial Board of the TJA assumes responsibility for the opinions expressed by the authors. The description of products and acceptance of advertising does not indicate or imply endorsement by the Association. Our gratitude and special thanks to Novartis Pharmaceuticals Australia Pty Ltd, Jannsen Cilag and Roche Products Pty Ltd, all of which support the TNA and its activities.

Transplant Nurses’ Association website:

www.tna.asn.au

Journal submission details for 2 0 1 3 For 2013 the Transplant Journal of Australasia (TJA) will be produced in March, July and December. Papers are submitted to the Editorial Board, which provides feedback to the author prior to publishing. All papers will be sub-edited to journal style before publication – please refer to Guidelines for Authors for more details on this and for detailed submission information.

Volume 21 Number 3 – December 2012

TRANSPLANT JOURNAL OF AUSTRALASIA

TNA N a t i o n a l E x e c u t i v e R e p o r t I would like to thank you all for electing me as

During my term as President I would like to

National President. I am excited and honoured

continue to move the association forward by

to represent our members. I have been the

progressing the work to develop an education

NSW/ACT President for the past three years and

programme; develop a social media profile for

look forward to working with the members at a

TNA; increase membership and continue to

national level.

strengthen our links with local and international organisations.

I’ll start by introducing myself. Some of you may know me as Claire Baker, now I am known

Thank you to those members that have

Claire West

as Claire West (I recently got married). I have

volunteered for the Patient Education Project

been working in the area of renal and liver transplantation

Working Party. This working party will look at the best

in varying roles since 1997 at Royal Prince Alfred Hospital

practices for transplant patient education and produce a

in Sydney. My experience includes working on the inpatient

flexible, relevant and evidence-based patient education tool

unit including clinical nurse specialist, clinical nurse educator

for distribution to transplant units around Australia. The

and relieving the nursing unit manager. After completing

working party has been formed representing all areas of solid

my Master of Nursing (majoring in education) degree, I

organ transplantation including social work. Updates will be

spent several years working as a nurse educator, both in

reported in the journal as the project progresses.

the hospital and working at a couple of universities. I then returned to the transplant unit as a transplant coordinator. This role varied and included live kidney donation (Paired Kidney Exchange, ABOi programme) and liver coordination.

I have just returned from attending the annual International Transplant Nurses Society symposium in Seattle with fellow members Fiona Burrell and Sue Rixon. Fiona and I presented papers and Sue proudly carried the Australian flag in the

My current role is working as the senior liver transplant

opening ceremony. The conference was a great opportunity

coordinator including deceased donation and coordinating

to network and we enjoyed a lovely evening with Linda Ohler.

the living donor programme. I am also a member of the Australasian Transplant Coordinators Association (ATCA), the Transplant Society of Australia and New Zealand (TSANZ) and the International Transplant Nurses Society (ITNS).

I would like to take this opportunity to thank A/Prof Bronwyn Levvey, our outgoing National President for her dedication and commitment to the role. She has devoted an enormous amount of time to the TNA and her enthusiasm and professionalism has been greatly appreciated. Thank you to the organising committee of the recent TNA annual conference in Melbourne. It was a wonderful opportunity to share issues and ideas with other transplant nurses across the country. The conference was a wonderful celebration of our 21st year and the organising team’s efforts are greatly appreciated. We look forward to seeing you in Sydney for the 2013 conference. Once again, I look forward to working with all members and the National Executive. We welcome your feedback and are happy to be contacted with any suggestions.

Linda Ohler and Claire West at the annual International Transplant Nurses Society symposium in Seattle

Thank you, Claire

Volume 21 Number 3 – December 2012

TRANSPLANT JOURNAL OF AUSTRALASIA

EDITORIAL Things don’t have to change the world to be important

to the implementation of the National Reform package and the subsequent increase in organ and tissue donation.

Steve Jobs

In their article, “High-risk multi-organ donor – a

Welcome to the final edition of TJA for 2012.

case study”, Fleur Zani and Michelle Harkess

Yes, we have come to the end of another year. Some of us have witnessed miraculous successes

describe the importance of donor screening via

and some have experienced times of loss and

methodical history taking and clinical investigation.

disappointment, but I am certain that all of us have

This article highlights a number of challenging

dealt with hardship and challenges throughout the year. So, with this in mind, the articles I have

Tracey Mackay

chosen for this edition are themed around the

circumstances for those caring for the donor and family as well as the potential recipient and transplant team. It also discusses the relevance of

concept of challenge.

nucleic acid testing (NAT) in donor screening.

Steve Jobs was a liver transplant recipient, but he was better

Yvonne Christiano, Geraldine Lee and Peter Bergin have

known worldwide as an American entrepreneur, co-founder,

written an article from the results of a retrospective audit of

chairman, and later chief executive officer of Apple Inc. He made many motivational speeches regarding the challenges of business and drive for accomplishment to companies and universities in America and around the world, but as he stated, “Things don’t have to change the world to be important”. I have used this quote as the title of this edition because the work we do is important; it may not change the world, but our work changes the world for individuals, for families and for our communities. Placing the term ‘challenge’ into the context of our work, the

cardiovascular risk factors present in post-heart transplant patients. “Cardiovascular risk factors associated with cardiac allograft vasculopathy following cardiac transplantation: A longitudinal follow-up”. This article identifies the challenges faced by medical and nursing teams as they manage the long-term care of post-transplant cardiac patients. Finally, Sara Shaw has provided a conference report from her experiences at the 32nd Annual Meeting and Scientific Sessions of the International Society for Heart and Lung

Thesaurus online dictionary (2012) describes it as: “difficulty

Transplantation held in Prague. Her report discusses a

in a job or undertaking that is stimulating to one who is

variety of presentations from the challenges of caring

engaged in it”. Not sure if I would use the word “stimulating”

for pre-transplant cardiac patients requiring mechanical

in this description – it could be replaced by frustrating,

circulatory support devices to the new and innovative

tumultuous, complicated or possibly “easier said than done”

treatment modalities that are, or soon will be available for

or even “easier done by someone else”!

our patients.

Our work is very challenging. It’s like a juggling act. We are

This year, Melbourne hosted the Annual National Transplant

juggling management of pre-transplant patients with chronic

Nurses’ Association conference – TNA21. Congratulations

illness, immediate post-transplant patients embarking on the

to the organising committee for an eventful and informative

frightening journey of recovery and those who are well into the journey, with all the possible comorbidities associated with long-term immunosuppression and maintenance of graft viability. As you all appreciate, there are multiple, multifactorial challenges with each, individual donation

conference. In this edition of TJA, I have included the abstracts from the award-winning presentations. Be sure to check out the photos of the gala dinner – a great time was had by all!

case. Add to the day – clinic assessments, education

Challenges in our work are comparable to connecting the

sessions, family support and interaction with the medical/

dots, until the task or process is completed. Steve Jobs uses

surgical teams – and we start to visualise the challenges that

the analogy of connecting the dots to describe how to face

we face and accept every working day. Time to take a deep breath and pat ourselves on the back … job well done.

challenges: You can’t connect the dots looking forward; you can only connect them looking backwards. So you have to trust

I have invited Mr Graham Starkey (liver transplant surgeon

that the dots will somehow connect in your future. You

– Austin Health) to write the guest editorial for this edition.

have to trust in something – your gut, destiny, life, karma,

Graham has written about the common challenges that

whatever. This approach has never let me down, and it has

transplant units throughout Australia are experiencing due

made all the difference in my life.

Volume 21 Number 3 – December 2012

PBS Information: Section 100 Public Hospital Authority Required (STREAMLINED) and Private Hospital Authority Required: initiation, stabilisation and review of therapy. Section 85 Authority Required: maintenance therapy. Refer to PBS Schedule for full authority information.

See approved Product Information before prescribing. Approved Product Information available on request. Please note change(s) in Product Information in italics. CERTICAN® (everolimus): Indication: Prophylaxis of organ rejection in adult patients at mild to moderate immunological risk receiving an allogeneic renal or cardiac transplant. Dosage: Recommended general daily dose is 1.5 mg administered twice daily (0.75 mg bid). Patients with mild to moderate hepatic impairment should be carefully monitored; dose reduction may be necessary in those patients. Routine Certican whole blood therapeutic drug level monitoring is recommended. Very limited experience in children. See full Product Information before prescribing. Contraindications: Hypersensitivity to everolimus, sirolimus or to any of the excipients. Precautions: • Caution is advised with the use of thymoglobulin (rabbit anti-thymocyte globulin) induction and the Certican/cyclosporin/steroid regimen. • Increased risk of developing lymphomas and other malignancies, particularly of the skin. • Oversuppression of the immune system with increased susceptibility to infections, especially infections with opportunistic pathogens (bacterial, fungal, viral, protozoal) which can include BK virus-associated nephropathy which can lead to kidney graft loss and the potentially fatal JC virus-associated progressive multiple leukoencephalopathy (PML). • Patients should be monitored for hyperlipidaemia. • Angioedema has been observed with Certican, in the majority of cases reported, patients were receiving ACE inhibitors as co-medication. • Proteinuria is increased in transplant recipients and may increase in severity when Certican is substituted for a calcineurin inhibitor in a maintenance therapy renal transplant patient with pre-existing mild proteinuria. • Reduced doses of cyclosporin are required for use in combination with Certican in order to avoid renal dysfunction. Regular monitoring of blood drug levels (everolimus and cyclosporin), proteinuria and renal function is recommended. • Co-administration of everolimus with known strong CYP3A4 inhibitors and inducers is not recommended unless the benefit outweighs the risk. • Increased risk of kidney arterial and venous thrombosis, resulting in graft loss, mostly within the first 30 days post-transplantation. • Certican, like other mTOR inhibitors, can impair healing increasing the occurrence of post-transplant complications. Lymphocele is the most frequently reported such event in renal transplant recipients and tends to be more frequent in patients with higher body mass index. The frequency of pericardial and pleural effusion is increased in cardiac transplant recipients. • The concomitant administration of Certican with a calcineurin inhibitor (CNI) may increase the risk of CNI-induced haemolytic uraemic syndrome/thrombotic thrombocytopenic purpura/thrombotic microangiopathy. • Cases of interstitial lung disease, some fatal, have been reported with Certican. Adjustment of treatment regimen including Certican discontinuation if drug induced interstitial lung disease is diagnosed. • Certican may increase the risk of new-onset diabetes mellitus. Blood glucose concentrations should be monitored closely in patients treated with Certican. • There are literature reports of reversible azoospermia and oligospermia in patients treated with mTOR inhibitors. Potential risk for male infertility with prolonged Certican therapy. • Excipients: Patients with rare hereditary problems of galactose intolerance, severe lactase deficiency or glucose-galactose malabsorption should not take this medicine. Women of childbearing potential: Effective contraception must be used. Should not be used during pregnancy unless clearly necessary and when breastfeeding. Interactions: • Caution should be exercised when coadministering everolimus with CYP3A4- and CYP2D6-substrates having a narrow therapeutic index. Caution with concomitant use with rifampicin, rifabutin or ketoconazole, itraconazole, voriconazole, clarithromycin, telithromycin or ritonavir as dose of Certican may need to be modified. Caution with concomitant use with midazolam, St John’s Wort, macrolide antibiotics (e.g. erythromycin), fluconazole, anticonvulsants (e.g. phenytoin, carbamazepine, phenobarbitone), calcium channel blockers, protease inhibitors and anti-HIV drugs. Grapefruit and grapefruit juice should be avoided. Avoid use of live vaccines. Side effects: Very common - Infections (viral, bacterial, fungal), upper respiratory tract infection, leucopenia, hyperlipidaemia (cholesterol and triglycerides), new onset diabetes mellitus, hypertension, abdominal pain, pericardial and pleural effusion, peripheral oedema and incisional hernia. Common - urinary tract infections, lower respiratory tract infection, wound infection, sepsis, thrombocytopenia, pancytopenia, anaemia, coagulopathy, thrombotic thrombocytopenic purpura/haemolytic uraemic syndrome, lymphocele, venous thromboembolism, graft thrombosis, diarrhoea, nausea, vomiting, stomatitis/mouth ulceration, oropharyngeal pain, pain, impaired healing, angioneurotic oedema, acne surgical wound complication, pancreatitis, proteinuria, erectile dysfunction, and hepatic enzyme abnormal. Uncommon - haemolysis, male hypogonadism, interstitial lung disease, hepatitis, hepatic disorders, jaundice, rash, myalgia, renal tubular necrosis, and pyelonephritis. Rare pulmonary alveolar proteinosis and leukocytoclastic vasculitis. 23/11/11 PBS dispensed price (Section 85): $282.89 for 60 x 0.25mg, $543.93 for 60 x 0.5mg, $1,578.72 for 120 x 0.75mg, and $2,068.86 for 120 x 1mg tablets. Repeats: 3.

See approved Product Information before prescribing. Approved Product Information available on request. Please note change(s) in Product Information in italics. myfortic® (mycophenolic acid) Indication: Prophylaxis of acute transplant rejection in adult patients receiving allogeneic renal transplants. Dosage and administration: Recommended dose is 720 mg administered twice daily. Patients with severe chronic renal impairment (GFR < 25 mL.min-1.1.73M-2) should be carefully monitored. See full PI before prescribing. Contraindications: Pregnancy, patients with a hypersensitivity to mycophenolate sodium, mycophenolic acid or mycophenolate mofetil or to any of excipients of formulation. Precautions: Increased risk of developing lymphomas and other malignancies, particularly of the skin. Oversuppression of immune system with increased susceptibility to infection. Cases of progressive multifocal leukoencephalopathy (PML) and pure red cell aplasia have been reported in patients treated with mycophenolate mofetil. Patients should be instructed to report any signs of bone marrow depression. Full blood counts should be performed on a regular basis to monitor for neutropenia. Administer with caution in patients with active serious digestive system disease. Avoid in patients with rare hereditary deficiency of hypoxanthine-guanine phosphoribosyl-transferase (HGPRT). Increased risk of congenital malformations if used in pregnancy. Sexually active men are recommended to use condoms during treatment and for a total of 13 weeks after their last dose of Myfortic. Female partners of male patients are recommended to use highly effective contraception during treatment and for a total of 13 weeks after the last dose. Myfortic should not be started in women of child bearing age until a negative pregnancy test has been obtained. Highly effective contraception must be used in these women before beginning Myfortic, during therapy and for 6 weeks after their last dose. Not recommended for use in pregnancy. Should not be used by breastfeeding mothers. Interactions: Live attenuated vaccines, tacrolimus, oral contraceptives, cholestyramine and drugs that interfere with enterohepatic circulation; aciclovir, ganciclovir; antacids containing magnesium and aluminium hydroxide. In a PK study no interaction was demonstrated with pantoprazole; concomitant administration with azathioprine has not been studied. Adverse effects: Increased risk of developing lymphomas and other malignancies, particularly of the skin; increased risk of opportunistic infections such as CMV, candidiasis, herpes simplex. Adverse effects associated with the administration of Myfortic in combination with cyclosporin microemulsion and corticosteroids include: Very common: viral, bacterial and fungal infections, leukopenia, diarrhoea. Common: Upper respiratory tract infections, pneumonia, anaemia, thrombocytopenia, pyrexia, fatigue, nausea, dyspepsia, vomiting, constipation, abdominal pain, abdominal distension, flatulence, loose stools, abdominal distension, gastritis, abnormal liver function tests, increased blood creatinine, headache, cough. The following adverse reactions to are attributed to mycophenolic acid derivatives as a class effect: colitis, oesophagitis, CMV gastritis, pancreatitis, intestinal perforation, gastrointestinal haemorrhage, gastric ulcers, duodenal ulcers, ileus, serious infections including meningitis, infectious endocarditis, tuberculosis, atypical mycobacterial infection, neutropenia, pancytopenia, Polyomavirus associated nephropathy (PVAN) especially due to BK virus infection. Cases of progressive multifocal leukoencephalopathy (PML) and pure red cell aplasia have been reported. Other adverse effects - see full Product Information dated. 31/08/11. PBS Dispensed Price: Section 85: $225.18 for 120 x 180 mg, $425.93 for 120 x 360 mg Section 100 Private: $394.80 for 240 x 180 mg, $783.16 for 240 x 360 mg Section 100 Public: $373.44 for 240 x 180 mg, $746.86 for 240 x 360 mg. Designed by .com.au 1318/0812 Novartis Pharmaceuticals Australia Pty Ltd ABN 18 004 244 160 54 Waterloo Road North Ryde NSW 2113 ® Registered trademark of Novartis Pharmaceuticals. MYF0029

Novartis is very proud to support the Transplant Nurses Association

TRANSPLANT JOURNAL OF AUSTRALASIA

G UEST EDITORIAL Graham Starkey • Liver Transplant Surgeon, Austin Health, VIC Organ transplantation saves hundreds of Australian lives every year. Following transplantation, Australians enjoy some of the best survival rates in the world. However, transplant programmes remain limited by organ donor numbers and demand continues to outstrip supply. Liver transplant units in this country, for example, have waiting list mortality rates of around 15%. The shortage of organs for transplantation led to the formation of DonateLife by the Rudd government. Increased funding was aimed at improving the donor rate in Australia. Given the shortage of donor organs, any potential increase in donation would be welcome news for the transplant community. Several strategies have been employed to try to improve donor rates. These include aiming to: • identify all potential donors • improve consent rates • use organs from more marginal donors • introduce donation after cardiac programmes.

death

(DCD)

The rate of “missed” brain dead potential donors is already low and raising consent rates notoriously difficult. Therefore, using extended criteria or marginal donors, including DCD, has probably the greatest potential to result in more transplants. However, this strategy does result in significant challenges for both donor and recipient teams. Pursuing the potential for donation from older patients with more comorbidities results in a diminishing outcome for the time and effort invested. At the recipient end, the use of marginal grafts results in longer hospital stays, risk of poor graft function and increased morbidity. When DonateLife was created in 2009 there was concern amongst the transplant community that increased resources would not flow into transplant units to match the anticipated growth in donor numbers. Since that time, there has indeed been a growth in donation, although this has not been uniform around the country. In Victoria we have seen quite a substantial increase in organ donation. The number of liver transplants performed has also increased over time but not as significantly as the donor rate. This reflects the increase in numbers being predominantly in marginal and DCD donors from which the livers are frequently not suitable. Where DCD infrequently results in liver transplantation, it is often possible to use kidneys and lungs from these donors. The Alfred Hospital in Melbourne has experienced a large growth in lung transplant numbers resulting in a well-documented strain on the hospital’s resources. Cases have doubled between 2006 and 2011. There may be several reasons behind this increase in numbers but no doubt the increased donor rate and introduction of DCD programmes are amongst them. It would seem that the Alfred’s experience may be a case in point of the broader transplant community’s concern – an increase in workload without enough extra 6

resources being allocated. Hopefully the attention generated by the media has helped to redress this balance. The Victorian Liver Transplant Unit has not experienced a dramatic increase in transplant numbers like the Alfred’s lung programme. However, there are still workload issues as the donor numbers increase. DCD presents liver units with particular challenges due to the low (approximately 20%) yield of liver grafts. In other words, 80% of the time a planned liver transplant will not proceed – necessitating a recipient admission to hospital (potentially from rural Victoria or interstate), donor and recipient surgical teams to be prepared and theatre staff called in for the transplant procedure. Particularly on weekends and after hours this may cost the hospitals thousands of dollars and involve a number of on-call staff. Relying on a small team of experienced and specialised staff, it is important that goodwill is maintained and unnecessary calls minimised. Liver donor surgery is generally performed by experienced transplant surgeons. In the UK there has been a move away from sending less experienced fellows on retrievals to a consultant-led system. With smaller programmes in Australia it is difficult to have dedicated liver transplant surgeons. To “fill in” their week, most Australian liver transplant surgeons perform other general and hepatobiliary work. As donor surgery is by its nature unpredictable, the demands of retrieval services are difficult to marry with a busy schedule of non-transplant work. Of course, an increase in workload for donor surgery is welcome news. Any potential increase in the supply of organs may reduce the mortality on transplant waiting lists around the country. There may be ways to mitigate the impact of increasing donor numbers on the surgeons’ workload. Improved prediction models for DCD donors progressing to cardiac arrest may reduce futile trips to donor hospitals (as well as the hours spent by the donation agency team). However, there is no current system of reliably predicting this. Attempting to perform DCD retrievals in early morning timeslots helps to reduce the impact of calling in staff for recipient surgery as they may be at work already. However, this aim may conflict with the interests of families and donor ICUs who may prefer more immediate withdrawal. Compromise, as always, is vital. Everyone working in the transplant community hopes that organ donation rates continue to increase. It is important that governments and hospitals do recognise the extra work this creates for transplant units. For liver transplantation, the majority of the increasing work may be using marginal or DCD grafts and this comes at an increased resource demand – not just for surgical teams but for anaesthetics, ICU and other hospital departments. Although welcome, this extra workload needs careful workforce planning to ensure the sustainability of our transplant programmes.

Volume 21 Number 3 – December 2012

TRANSPLANT JOURNAL OF AUSTRALASIA

ARTICLE

High-risk multi-organ donor – a case study F Zani and ML Harkess • Heart and Lung Transplant Unit, St Vincent’s Hospital, Sydney, NSW

Abstract Heart and lung transplantation is the accepted treatment option for end-stage cardiac disease and respiratory failure. The Australian and New Zealand Cardiothoracic Organ Transplant Registry reported nine patient deaths on the heart transplant waiting list and 13 patient deaths on the lung transplant waiting list for 2011, while mean days on the waiting list for heart and lung transplant were 171 and 197 respectively1. The shortage of donors combined with increasing mortality and waiting list times has resulted in more frequent utilisation of extended criteria donors. There are ethical implications in how informed consent is gained from transplant candidates regarding such donors and debate continues as to whether prospective screening using nucleic acid testing (NAT) is used for all organ donors or only high-risk donors. Transmission of disease from organ donation has occurred with rare frequency in the United States of America and Europe. As a result of these cases, improvements have been made to screening procedures to reduce the risk of disease transmission to transplant recipients.

Introduction Utilisation of high-risk organ donors carries an associated risk for transmission of hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Despite the accuracy of current serological testing and NAT, there are no guarantees donor-derived infections will not occur. We present the case of a high-risk organ donor and describe the process of candidate selection, transplant

questionnaire, the SNOK stated the donor was heterosexual and not currently sexually active. Questions later arose when a male visitor disclosed to an intensive care nurse that he was in an open homosexual relationship with the donor. Given the uncertainty around the sexual history, he was now classified as a high-risk donor. Standard antibody testing would not entirely eliminate the risk of disease transmission – due to the window period between infection and seroconversion. Therefore, NAT testing was ordered and

candidate consent and discuss local practices.

the results were expected in six hours.

Case study

The donor information was relayed to the cardiothoracic

The donor was a 26-year-old male who died from a spontaneous subarachnoid haemorrhage. Echocardiography reported normal cardiac function with ejection fraction 65% on minimal inotropic support. Noradrenaline was running at 9 ml/hr (concentration of 4 mg in 100 ml) or 0.08 mcg/kg/ min. This was within acceptable criteria of Noradrenaline <0.2 mcg/kg/min. Chest radiology reports were clear and good gas exchange on the standard ventilator parameters. Medical history was unremarkable as expected from a previously fit, young male having only had a tonsillectomy as

surgeon, cardiologist and lung transplant physician. The lungs were declined as medically unsuitable due to risk factors; however, the heart was accepted for a candidate that was critically unwell receiving triple inotrope therapy in the coronary care unit (CCU). Virology specialists were consulted and the risk of HIV transmission in a homosexual in an unacknowledged relationship was quantified as 2 in 100. The cardiologist and transplant coordinator went to the candidate’s bedside to discuss the possibility of transplantation and seek informed consent.

a child. The donor was a non-smoker, did not drink alcohol

The potential candidate, a 33-year-old male with dilated

and had previously travelled to Cambodia and China in

cardiomyopathy was a husband and father to a young child.

2008. Serology results were negative for HBV, HCV, HIV and

He was informed of the potential donor and advised there was

human T-cell lymphotrophic virus (HTLV1). His serology was

a high risk for transmission of infection. Further information

positive for cytomegalovirus (CMV) and Epstein-Barr virus (EBV) which was performed retrospectively.

was provided explaining the donor HIV, HBV and HCV serology had returned a negative result. It was explained that exposure in high-risk activities in the last month may

Medical and social history was provided by a parent as

not show in standard serology testing and that blood results

the senior next of kin (SNOK). During the social history

were pending that would reduce but not eliminate the risk

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TRANSPLANT JOURNAL OF AUSTRALASIA

for transmission of infection. He was reminded that he had

transmission of cancer in the patient information manual. It

received hepatitis B vaccinations and was advised he had a

was crucial our information stated that donor testing could

2% chance of contracting HIV. The candidate was reassured

not provide 100% accuracy in the prevention of donor-derived

the decision to accept or decline the heart was his and that

infections. We also included the heart transplant consent

he would not be penalised for saying no. Acknowledgement

form as an appendix in the patient information manual. Our

was given that it was a very hard decision, at which point

heart transplant consent form specifically seeks consent for

he began to cry. It was recommended he telephone his wife

HBV donors (antibody and antigen not included to keep it

to discuss the options and he was given an hour to think it

simple) and cancer donors. Potential candidates are directed

over and ask the team any further questions. The cardiologist

by the transplant coordinators to read these sections before

also went on to explain how seriously ill he was and that his

final consultation with the cardiologist and cardiothoracic

condition was rapidly deteriorating.

surgeon. The cardiologist completes this form with the

Incidentally, before the candidate made an informed decision to accept or decline, he returned a positive cross-match result. This effectively prevented the candidate having to make an emotional life-saving decision. When the candidate was informed, his relief was obvious that he no longer had to decide. The heart was considered for another candidate then declined when the first NAT test result was positive for HIV. The team decided against waiting for confirmatory second and third NAT results, as the back-up candidate was not

transplant candidate before they are placed on the active waiting list. In the event that a candidate indicates “No” on the consent form to accept a heart from an HBV donor, they will be given the option to reconsider their decision if a match becomes available. This allows for time on the waiting list where deteriorating health and decreased quality of life may lead to re-evaluation of a previous decision6. Our heart transplant consent form not only includes HBV and cancer donors but also other factors associated with transplantation, which are listed in Table 1.

critically unwell. The local liver transplant unit also declined because of the risk factors following the NAT result.

Table 1. Heart transplant consent.

Discussion

HIV, hepatitis B and hepatitis C donors

Cancer donors

It is impossible to completely eliminate the risk for

Risk of death

Permanent pacemaker

Surgical complications

Infection of any type

where transplant is not urgent, a greater margin of safety is

Mechanical devices

Rejection

appropriate. Conversely, where transplant is potentially life-

Extracorporeal oxygenation

Cancer risks

saving, a higher risk of disease transmission may be regarded

Medication adherence

Renal failure

Data for collection, quality assurance and research

Tissue used for research

transmission of disease and this must be balanced by the urgency of transplant for potential candidates. Therefore,

as acceptable – as was the case with our heart transplant candidate2-4. The term high-risk donor is often difficult for candidates to comprehend, especially if conversations about organ quality have not occurred early at transplant assessment. High-risk donors should be discussed in terms of risk versus benefit of remaining on the waiting list (wait list mortality) and waiting for another donor. At the core of informed consent is communication of potential complications, outcomes and the alternative options5. Policies state the transplant unit must disclose risks and consequences associated with acceptance or non-acceptance of an organ from a high-risk donor in order to attain informed consent3. Decisions about transplantation are sometimes made quickly and candidates have little time to evaluate the

Moreover, consent at the time of transplant must reflect the candidates’ acceptance of a potentially infectious organ and notation made in the medical records2,3. Candidates that have been on the waiting list for over a year should also be kept informed of changes or latest information regarding organ donation that may influence their informed consent7. Donors fall into the high-risk category if they meet any of the criteria for high-risk behaviours that present an increased chance of HBV, HCV and HIV transmission3. High-risk behaviours in the last 12 months include: • Intravenous drug use.

risks and benefits2,3. Our transplant unit addressed this issue

• Tattoos and body piercings.

by including detailed information about organ donation and

• Sexual contact with a high-risk partner, including male to

high-risk donors, including transmission of infection and

male sex and sexual activity with a male who is bisexual.

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TRANSPLANT JOURNAL OF AUSTRALASIA

• Sexual activity with a male or female sex worker.

The disadvantages of NAT testing include cost, availability, turnaround time for testing and incidence of false positive.

• Time in a correctional facility.

While confirmatory tests are helpful in determining risk, the

Transplant Society of Australia and New Zealand mandatory

time required to perform these tests may well impact donor

testing for disease transmission is:

stability10. New South Wales (NSW) and Victoria routinely

• HIV type 1 antibody.

their medical history or serology results and organ retrieval

perform NAT testing if a donor is deemed high risk from will not progress until NAT results are known. However,

• HIV type 2 antibody.

prospective NAT is not always available in other states and

• Hepatitis B surface antibody (HBsAb).

territories8. Notably, Baleriola et al. and South Eastern Area Laboratory Services (SEALS) in NSW has a paper in press

• Hepatitis B surface antigen (HBsAg).

reporting their experience using real-time parallel assay

• Hepatitis B core antibody (HBcAb).

screening results using NAT11. They developed a screening

• Hepatitis C antibody (HCcAb).

algorithm that tested NAT using three assays in real-time

Recommended investigations include CMV IgG antibody,

dealing with potential false positives. High-risk donors were parallel screened using: COBAS Ampliscreen assay (CAS),

EBV IgG antibody, HTLV1 and 2 antibody (especially for

AmpliPrep Total Nucleic Acid Isolation/CAS, and AmpliPrep/

high-risk groups), syphilis antibody and NAT testing for

TaqMan assays. Baleriola et al. reported a turnaround time

HIV, HBV and HCV using polymerase chain reaction assay

from receipt of sample to result reporting of 7.67 hours at a

(PCR) .

cost of $2200 for three assays per donor. Moreover, from a

The DonateLife coordinator will assess donor risk factors

positive rate and 102 additional organs utilised11.

19-month period and 35 donors they reported a 1.7% false

during the interview with the SNOK8. Ascertaining donor medical and social history is vital in prevention of disease

More often transplant retrieval services are forced to progress quickly due to donor instability, logistical reason or at the

transmission. However, as our case study highlights, history

request of the donor family. It is this scenario that has

provided by the SNOK can be inaccurate or incomplete if

potential for transmission of disease. Time is a critical factor

the SNOK is not aware of a family member’s lifestyle. NAT

in terms of coordinating donor theatre and transplant theatre

testing would not have occurred in this case if the donors’ male partner had not visited the intensive care unit (ICU) prompting further questioning from the ICU nurse. Therefore,

start times, including departure times of organ retrieval teams from the transplant centres. Theoretically, delays would be decreased if prospective NAT were routine, because NAT would be commenced earlier. However, further consideration

should NAT testing be performed prospectively and routinely

should be taken when considering routine NAT for all organ

for all organ donors?

donors in relation to false positive results and loss of organs12.

NAT directly detects the virus (instead of the antibodies that

Recent addition of NAT for HIV screening to routine donor

develop post-viral infection) shortening the window period; (time between infection and detection) and thus, may reduce the risk of disease transmission from a serologically negative

testing by international organ procurement organisations has resulted in the loss of donor organs due to false positive results13. In one study, the false positive HIV test rate ranged from 35.7% to 85.7% of the initially reactive HIV tests. False

donor7.9. Humar et al. estimated time frames for infection

positives can result from multiple sampling issues, bacterial

window periods as presented in Table 2.

contamination, haemolysed samples and also technical

Table 2. Estimates of window period length for different testing methods.

Pathogen

Standard serology

Enhanced serology(combined antibody-antigen tests)

NAT

HIV

17–22 days

~7–16 days

5–6 days

HCV

~70 days

~40–50 days

3–5 days

HBV

35–44 days

Not applicable

20–22 days

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TRANSPLANT JOURNAL OF AUSTRALASIA

problems such as cross-contamination from positive controls,

have not been informed and provided with all the appropriate

and inappropriate reagent addition. Repeat testing of initially

information concerning organ donation15.

reactive enzyme immunoassays identifies many, but not all false positives. Often any positive result of an HIV test will halt the donation process due to time constraints required for repeat testing and also fear of liability and repercussions on the transplant units9. There are big differences in false positive results internationally and in the recent NSW Baleriola et al. study, differences could be explained by

Delivery of the information is as important as the information being provided and this may require specific training. McCulloch’s study looking at users’ actual experience found that senior clinicians have good communication skills and used appropriate language when it comes to breaking difficult news. However, maintains that improvements need to be

utilisation of different testing agents and laboratories.

made for the setting of delivering the news. In most cases

A recent report by Humar et al.7 concluded the evidence is

phone and often the candidate is at home when contacted16.

insufficient to recommend universal prospective screening

In our case, the candidate was in the ward setting in a four-

for organ donors with no identified risk factors citing a

bed room without family support and no privacy except for

concern for lost organs due to false positive NAT results and

the curtain pulled to screen him. The ideal situation would

that further study of viral screening techniques may reduce

have been to find a private room and allow time for a family

disease transmission without excessive donor loss. This work

member to arrive15. At the time of information delivery there

by Baleriola and colleagues with real-time parallel testing can further reduce false positive results and a subsequent loss of donated organs. Even if the risk is negligible with supporting test results, the potential candidate should have the final choice.

the transplant coordinator delivers information over the

was no availability of a single room or private area and his wife lived an hour away. If time was not a factor, greater care would have been taken to ensure his comfort, privacy and confidentiality. Waiting for the cross-match result may have prevented psychological stress for the transplant candidate.

At our institution, the transplant coordinator routinely

Transplant teams should consider waiting until the cross-

notifies candidates of potential donors, including high-

match is known before notification. However, variables such

risk donors. This may involve the physician or senior

as donor stability and candidate logistics may mean this

transplant coordinator making the organ offer and engaging

is not possible. Additionally it would be prudent to have a

in conversations regarding risk versus benefit with the

social worker or pastoral care worker available to support

transplant candidate. Further challenges can appear

the candidate and their family and provide follow-up the

when communicating complex donor information over

next day, regardless of the outcome. Our case highlights the

the telephone to candidates where English is a second

psychological stress that candidates can experience when

language . Transplant coordinator phone notification and

receiving the offer of a second chance at life only to be faced

delivery of donor information is a verbal acceptance by

with the possibility of disease transmission.

the transplant candidate to come to hospital for transplant surgery. Experienced transplant coordinators make this notification with ease in a supportive and informative manner. However, transplant coordinators relatively new to the role will require guidance and training by the team when communicating complex information that can influence a candidate’s decision. The cardiothoracic surgeon obtains final written consent for organ acceptance and transplant just before the candidate goes to theatre. Consent processes vary between states and transplant centres and individual candidates have different expectations. Volk et al.4 believe that high-risk organs can be facilitated if transplant centres present risks of organ failure in respect to average organs and provide feedback regarding organ quality and availability4. As previously mentioned, discussions should first occur during assessment and at the time of listing, preparing the candidate for the possibility of a high-risk organ offer. Transplant candidates cannot truly make an informed consent if they 10

Further review by national stakeholders for NAT accessibility and current practice in all states and territories is under way. Feasible recommendations following the literature review and our unit’s experience are: • Provide patient information and regular education about organ donation, high-risk donors and associated risk factors. • Have open discussions about organ quality, including high-risk donors during assessment and at the time of listing for transplant. • Use standardised transplant (organ-specific) consent forms that include consent for high-risk donors. • If consent is sought for a high-risk organ, the hospital setting of privacy and comfort should be a priority, ideally discussions should occur in a private area with family present.

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TRANSPLANT JOURNAL OF AUSTRALASIA

• Access 24/7 to a social worker or pastoral care worker for transplant candidate and family support.

10. Grossi RA & Fishman JA. Donor Derived Infections in Organ Transplant Recipients. American Journal of Transplantation 2009; (4)S19–S26.

• Remain current with health policy directives, national and international protocols and literature.

11. Baleriola C, Tu E, Johal H et al. Organ donor screening using parallel nucleic acid testing allows assessment of transmission risk and assay results in real time. Transplant Infectious Diseases 2012; 14:278–287.

• Continued monitoring of recipients that receive organs from high-risk organ donors.

Conclusion Where possible, every measure should be taken to facilitate organ donation from high-risk donors. The risk of death on the waiting list will only increase the longer time the candidate is listed. Transplant units should provide education and information about organ quality and highrisk organ donation and present it in a format that is easy to understand. Transplant coordinators and associated transplant staff are responsible for ensuring candidates understand the information provided before they consent for transplantation. Discussions regarding organ quality should never occur for the first time at transplant. Continued education is the key – including transplant candidates that have been on the waiting list for over a year. On a final note, two days after the candidate received the initial heart offer, his condition deteriorated and he received a biventricular assist device and later went on to be successfully bridged to heart transplantation within a 12-month period. He is alive and well.

References

12. Kakaiya R, Gordon S, Zimmerman A, Verlinsky R, Ahmed S & Phillips M. False positive nucleic acid test results for human immunodeficiency virus RNA and hepatitis C virus RNA: an underappreciated problem. Transfusion 2011; 51:225–226. 13. Shafer T, Schkade D, Schkade L, Geier S, Orlowski J & Klintmalm G. Zero risk tolerance costs lives: loss of transplantable organs due to human immunodeficiency virus nucleic acid testing of potential donors. Progress in Transplantation 2011; 3:236–246. 14. Cupples S & Ohler L. Transplantation Nursing Secrets. Questions and Answers Reveal the Secrets to transplantation Nursing. Published by Elsevier Health Sciences 2002. 15. Bruzzone P, Giannarelli D, Nunziale A et al. Extended Criteria Liver Donation and Transplantation Recipient Consent: The European Experience. Transplantation Proceedings 2011; 43:971–973. 16. McCulloch P. The patient experience of receiving bad news from health professionals. Nursing Times; 2004. http://www. nursingtimes.net/nursing-practice/clinical-specialisms/ma… ence-of-receiving-bad-news-from-health-professionals/199310. article (accessed 26 July 2012).

TNA SPECIAL INTEREST G ROUPS Do you work in a transplant speciality? Would you like to network with colleagues in a similar field from all around Australasia? If yes, the TNA special interest

1. Australian and New Zealand Cardiothoracic Organ Transplant Report. http://www.anzcotr.org.au/ uploadedFiles/1279001464281-56522.pdf

groups (SIG) are just for you.

2. Transplant Society of Australian and New Zealand Organ Transplantation from Deceased Donors: Consensus Statement on Eligibility Criteria and Allocation Protocols. V1.1, 23 June 2011.

and maintains contact through the year via various

3. Organ Donation and Transplantation: managing risks of transmission of HIV, HCV and HBV, 2010. Health Policy Directive PD2010_002. 4. Volk ML, Tocco RS, Pelletier SJ, Zikmund-Fisher BJ & Lok ASF. Patient Decision Making About Organ Quality in Liver Transplantation. Liver Transplantation 2011; 17(12):1387– 1393.

Each group meets annually at the TNA conference modes of communication. The groups aim to foster collaboration, education, sharing of resources and research opportunities in the various transplant specialities. For more information or to join a SIG, please contact one of the following group chairpersons.

5. Freeman R & Cohen J. Transplantation risks and the real world: what does high risk really mean? American Journal of Transplantation 2009; 9:23–30.

• Cardiopulmonary – Trevor Cherry

6. Reese et al. Determinants of the decision to accept a kidney from a donor at increased risk for blood borne viral infection. Clinical Journal American Society Nephrology 2010; 5:917–923.

• Liver – Julie Pavlovic

7. Humar A et al. Nucleic acid testing (NAT) of organ donors: is the “best” test the right test? A consensus conference report. American Journal of Transplantation 2010; 10:889–899. 8. National Guidelines for Organ and Tissue Donation. Australasian Transplant Coordinators Association Incorporated. 4th edn, 2008. http://www.atca.org.au/downloads/ATCA%20 National%20Guidelines%20for%20Organ%20&%20Tissue%20 Donation.pdf 9. Malek S. Preventing donor-derived infections: Still room for improvement. Nephrology Times 2011; 10–11.

Volume 21 Number 3 – December 2012

Email trevtrev@it.net.au

Email julie.pavlovic@austin.org.au • Nurse Practitioner – Julie Pavlovic Email julie.pavlovic@austin.org.au • Renal – Christine Ellis and Charlotte Gibson

Email c.ellis@alfred.org.au charlotte.gibson@suhm.org.au

TRANSPLANT JOURNAL OF AUSTRALASIA

ARTICLE

32nd Annual Meeting and Scientific Sessions of the ISHLT (International Society for Heart and Lung Transplantation) 18–21 April 2012 – Prague, Czech Republic Sara Shaw • RN, Recipient Transplant Coordinator St Vincent’s Hospital, Sydney, NSW

I received a Transplant Nurses’ Association (TNA) scholarship award to attend an international conference. This report will give readers an overview of the conference and highlight a number of key speakers. The International Society for Heart and Lung Transplantation (ISHLT) is a not-for-profit, multidisciplinary, professional organisation dedicated to improving the care of patients with advanced heart or lung disease through transplantation, mechanical support and innovative therapies via research and education. It was created in 1981 at a small gathering of approximately 15 cardiologists and cardiac surgeons. Today, there are over 2700 members from over 45 countries, representing more than 15 different professions. This multinational, multidisciplinary mix is one of the biggest strengths of the society as it brings breadth and depth to the educational offerings and provides an exceptional environment for networking and exchanging information. Members include scientists, cardiologists, cardiothoracic surgeons, ethicists, pathologists, pulmonologists, perfusionists, transplant coordinators and nurses. Despite the differing specialisations, all ISHLT members share a common dedication to the advancement of the science and treatment of end-stage heart and lung disease1. I have worked in the area of cardiothoracic nursing since I graduated as an RN in 2001 in the UK, more specifically in heart and lung transplantation medicine as a recipient transplant coordinator, at St Vincent’s Hospital, Sydney, since 2004. On arriving at the Conference Centre in Prague, I was overwhelmed by the vast number of people and enthralled by the different nationalities and languages that surrounded me. Once the final programme was released, I began the difficult task of deciding which presentations and speakers to attend. I decided to attend a mixture of heart transplant, lung transplant, mechanical circulatory support, adolescent adherence and donor management presentations – but my primary focus was the discussion regarding quality of life for both the patient and carer. This is an area that I am 14

very passionate about and was pleased to see a variety of presentations that focused on this topic. There were 10 rooms, ranging from the imposing forum hall down to a number of smaller areas for speakers to present and at any one time there were up to eight sessions to choose from. The programme was diverse, with different daily plenary sessions – such as: overcoming political barriers, ISHLT traditions and the impact on ethics, economics and resource allocation of an ageing population. Some presentations gave a glimpse into the future with a variety of research programmes progressing in key areas and, finally, a fascinating session discussed incorporating information technology into pre- and post-transplant care. An interesting presentation on Wednesday 18 April was “Respiratory Viruses – Beyond RSV”2, which discussed the increasing prevalence of respiratory viruses in the lung transplant population. This is directly impacting us at present at St Vincent’s Hospital, with a huge increase in hospital admissions for IV antibiotic treatment, especially during winter. It was suggested that 41% of lung transplant patients suffer from at least one respiratory virus over six years, including human metapneumovirus (HPMV), respiratory syncytial virus (RSV), rhinovirus, adenovirus, influenza and parainfluenza. It also highlighted that certain viruses are more prevalent during high levels of rainfall and, therefore, are not necessarily prevalent during winter alone. It was also reported that respiratory viruses are more prevalent in patients with bronchial obliterans syndrome (BOS) that is associated with chronic rejection. Having this information will assist me when assessing patients with respiratory symptoms. The following day, Thursday 19 April, the presentation that I found particularly interesting and relevant to my practice was “Family Caregivers of Mechanical Circulatory Support Patients”. This presentation looked into the health and wellbeing of the carer, caring for a patient requiring mechanical circulatory support (MCS). It acknowledged how

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TRANSPLANT JOURNAL OF AUSTRALASIA

they can often be torn between providing care to the patient whilst maintaining other responsibilities. It also discussed the financial sacrifice and the distress caused through being away from home. This highlighted to me how carers are often overlooked by our focus on the patient, and that these carers can often suffer from poor health, high levels of stress, financial burden and sleep deprivation themselves. It is clear that carers do require a great deal of support and this is something I am hoping that we can focus on as we move forward with the mechanical circulatory support programme. On Friday 20 April, “Effects of Exercise Training on Exercise Capacity and Quality of Life in Patients with a Left Ventricular Assist Device (LVAD): A Randomised Controlled Trial”3 presentation described an eight-week exercise training programme trial involving 14 LVAD patients, looking at peak VO2, six-minute walk (6MW) exercise and quality of life. The exercise programme included gym-based exercises plus walking, where seven patients exercised and seven did not. The results indicated a big improvement in 6MW in the exercise group (but not statistically different) and also a reported increased quality of life (again not significant). This presentation was of particular interest to me, as there has been a recent increase in number of LVAD patients at St Vincent’s Hospital. I can now use evidence-based research to assist in my education of this patient group and can explain how and why exercise is so important. Finally, on Saturday 21 April, the plenary session about information technology was extremely well attended and covered a variety of new and exciting technologies. The

featured abstract (369) was a presentation by Jo MaddicksLaw on the use of telehealth in cardiac transplant patients4. This study required the nurse practitioner to fly to remote patients (who lived >4 hours from the transplant centre) and perform a “clinic visit” using telehealth informatics. Patients were surveyed and reported high levels of satisfaction, less stress and were pleased with the time and money that they saved by not having to travel into the transplant centre. This programme is something that I would like to implement into practice for St Vincent’s heart/lung transplant patients, but I am acutely aware of the need for increased staffing and funding to implement such a programme. Overall, the conference was fascinating and a chance to learn valuable knowledge and information in order to improve practice. I am grateful to the TNA for the opportunity to attend this conference.

References 1. ISHLT. Final Program – 32nd Annual Meeting and Scientific Sessions. ISHLT, Texas, 2012. 2. Hopkins P. Respiratory Viruses: beyond RSV. The Prince Charles Hospital, Brisbane, 2012. 3. Hayes K, Leet AS, Bradley SJ & Holland AE. Effects of Exercise Training on Exercise Capacity and Quality of Life in Patients with a Left Ventricular Assist Device (LVAD): A Randomised Controlled Trial. La Trobe University, Melbourne, 2012. 4. McKenzie SC, Maddicks-Law J, Gururujan R, Brown M, Platts D, Hickey A & Javorsky G. Initial Experience of Cardiac Transplant Recipient Follow Up Using Telehealth. The University of Southern Queensland, Toowoomba, 2012.

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Volume 21 Number 3 – December 2012

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ARTICLE

Cardiovascular risk factors associated with cardiac allograft vasculopathy following cardiac transplantation: A longitudinal follow-up Yvonne H Cristiano • CCRN, MN Registered Nurse, Alfred Hospital, Dept AIRMed (5B), Alfred Hospital, Melbourne, VIC Geraldine A Lee • PhD, BSc, RGN Arrhythmia Research Nurse, Heart Centre, Alfred Hospital, Melbourne, VIC Peter J Bergin • MBBS, FRACP. Head, Heart Failure Centre, Heart Centre, Alfred Hospital, Melbourne, VIC

Abstract Background: Cardiac allograft vasculopathy (CAV) in the post-cardiac transplant population is partially attributed to the presence of traditional cardiovascular (CV) risk factors. In order to provide optimal care post-transplant, early identification of modifiable CV risk factors needs to be undertaken and managed appropriately. The purpose of this retrospective project was to: (1) examine the incidence of the CV risk factors of hyperlipidaemia, hypertension, diabetes and obesity in this population, and (2) compare the results with those reported worldwide by the International Society of Heart and Lung Transplantation (ISHLT). Methods: A retrospective audit was undertaken to determine the prevalence of the CV risk factors up to five years after orthotopic heart transplant. A non-random convenience sample was utilised at the Alfred Hospital, Melbourne, Australia. Results: Changes in CV risk factors from baseline to five years after cardiac transplantation were observed in 25 patients (mean age 50 years ±13 with a majority males, n=21). Primary diagnoses were cardiomyopathy, ischaemic heart disease (IHD) and congenital heart disease. Significant differences were observed from baseline to five years post-transplant in systolic blood pressure (BP) (p=.001) and body mass index (BMI) (p<0.001). Five years after transplant, raised cholesterol levels and BMI greater than 25 kg/m2 was observed in over 80%, with raised systolic BP in 42% and diabetes in over a quarter of subjects. Conclusion: This retrospective audit supports monitoring traditional CV risk factors in this vulnerable population. The incidence of CV risk factors identified correlates with ISHLT’s reports on this population. Keywords: Cardiac transplantation, cardiovascular risk factors, cardiac allograft vasculopathy. Abbreviations: Cardiac allograft vasculopathy (CAV), cardiovascular (CV), coronary artery disease (CAD). Ethics: The project was conducted under the approval of the Alfred Hospital Ethics Committee and the Faculty Human Ethics Committee of Latrobe University.

Introduction The Australian and New Zealand Cardiothoracic Organ Transplant Registry (ANZCOTR) reports approximately 80 cardiac transplantation annually (range 14–115) in Australia and New Zealand, with 2,137 cardiac transplant performed between 1984 and 20101. Of the 2,120 cardiac transplant recipients (re-transplants excluded), 36% (n=760) of patients had ischaemic heart disease (IHD) as their indication for transplant1. Similar results are seen in the International Heart and Lung Transplantation Registry (ISHLT) with 44% of 97,411 transplantations with underlying coronary 16

artery disease (CAD)2. Cardiac allograft vasculopathy (CAV), also referred to as accelerated coronary artery disease or transplant coronary artery disease, is reported as the leading cause of death in patients post-heart transplantation in Australia and New Zealand, contributing to 18% (n=165) of all deaths and 23% (n=112) of deaths occurring more than five years post-transplant1. All cardiac transplant recipients’ are at risk of CAV and it has been reported as the primary cause of death in greater than 15% (n=2183) of all long-term survival of cardiac transplantation recipients between January 1992 and June

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2010, and its prevalence was reported as 30% at five years2. The two possible distinctive causes of CAV are immunological and non-immunological factors3-7. CAV

non-immunological

risk

factors

include

the

traditional cardiovascular (CV) risk factors of age, gender, hyperlipidaemia, hypertension, diabetes, obesity and smoking

. The ISHLT 2011 report presented the post-

3,4,6

transplant rates of CV comorbidities in those with known responses. At one and five years post-cardiac transplantation respectively: 58.2% (n=15,581) and 87.9% (n=10,972) of patients had hyperlipidaemia, 72.9% (n=18,542) and 92.9% (n=10,363) had hypertension and 26.9% (n=7239) and 37.4% (n=4560) had type 2 diabetes2. The aim of this review was to identify the prevalence of modifiable CV risk factors (specifically hyperlipidaemia, hypertension, diabetes and obesity) in the transplant population at a single transplant

SPSS version 17 was used for data analysis using paired t-tests for continuous data and chi-squared analysis for categorical data. A two-sided p value of 0.05 was deemed significant.

Study definitions For the purposes of the study, the CV risk factors were defined using the National Heart Foundation of Australia (NHF) guidelines: Plasma cholesterol <4.5 millimoles/litre (mmol/L), HDL >1.0 mmol/L and LDL <2.5 mmol/L, normotension was defined as BP <140/90 millimetres of mercury (mmHg) and in those patients who are at greater CV risk: BP <130/85 mmHg8. The World Health Organization (WHO) and Diabetes Australia definitions were used: a fasting blood glucose level of 4–7 mmol/L and glycated haemoglobin (HbA1c) of 6.5% or less9,10. The WHO goal of a BMI of less than 25 kilograms per metre squared (kg/m2) was used9.

centre via a retrospective audit.

Results

Methods

The patients were all Caucasian, 84% were male with a mean age at transplant of 50 years (Table 1). Dilated cardiomyopathy (DCM) was the primary diagnosis (52%), followed by IHD (36%) and congenital heart disease accounted for 12% of transplants. All patients received an orthotopic cardiac transplant with one recipient undergoing re-do cardiac transplantation secondary to transplant CAD. Prior to cardiac transplantation, six patients (24%) were supported by ventricular assist devices as a bridge to transplantation.

Participants Patients (n=25) were from a non-random convenience sample who received a cardiac transplant between 1 January 2003 and 30 June 2004 at the Alfred Hospital, Melbourne, Australia. The inclusion criteria were recipients greater than 18 years and had follow-up at the Alfred Hospital, Melbourne between 1 January 2003 and 30 June 2004. As the Alfred Hospital performs approximately 25 heart transplants per year, this provided a small sample group for a retrospective review of our current patients who had recently reached five years post-transplantation. The Alfred Hospital transplants all Victorian patients as well as patients from the states of

Table 1. Transplant recipients: demographic and transplant-related data (n=25).

Demographics and clinical data

± SD

±13.5

172

±9.6

±13.7

Bypass time at transplant (mins)

185

±109.2

is 730 km (450 miles). Thus the non-random convenience

Donor heart ischaemic time (mins)

238

±100.2

sample was utilised as patients from South Australia and

Donor age (years)

±11.7

South Australia and Tasmania. Unfortunately, many patients do not return to the Alfred Hospital for follow-up due to the geographical distances involved. For example, the distance between Melbourne, Victoria, to Adelaide, South Australia,

Tasmania were excluded from this review.

Data collection Following ethics approval from the hospital ethics committee and the university, data were collected retrospectively for demographic analysis and episodes of rejection (based on endomyocardial biopsy findings). Various CV risk factors were examined from pre-transplant to one year, three years and five years post-transplantation. These risk factors included total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), systolic and diastolic blood pressure (BP), blood glucose level, body mass index (BMI) and smoking status. Other clinical data measured included left ventricular ejection fraction (LVEF) as determined by gated pool scans and renal function (creatinine and urea).

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Age at transplant (years)

Mean

Height (cm) Pre-transplant weight (kg)

The incidence of pre-existing risk factors prior to transplantation included hypercholesterolaemia in 10 patients (40%), hypertension in six patients (24%), five patients had type 2 diabetes (20%) and 13 patients had a BMI >25 kg/m2 (52%). Significant statistical differences were evident with systolic BP, BMI and creatinine (p<0.001) and diastolic BP (p<0.05) with increases from the pre-transplant results to five years after transplantation. No differences were observed with the other variables (urea), although the total plasma cholesterol had increased from baseline to five years post-transplant, the changes did not reach statistical significance, probably due to the majority of patients having statins prescribed five years post-transplant (88%). 17

TRANSPLANT JOURNAL OF AUSTRALASIA

Table 2. Changes in cardiovascular risk factors from pre-cardiac transplant to five years post-cardiac transplant.

Pre-transplant

One year posttransplant

Three years posttransplant

Five years posttransplant

Cholesterol (mmol/L) Total cholesterol HDL LDL

4.3 (±1.75) 1.2 (±0.27) 2.3 (±1.47)

5.4 (±1.43) 1.6 (±0.4) 2.7 (±0.86)

4.9 (±1.16) 1.5 (±0.27) 2.4 (±0.92)

5.1 (±1.33) 1.7 (±1.1) 2.7 (±1.3)

BP (mmHg) Systolic BP Diastolic BP

110 (±16) 66 (±12)

129 (±15) 77 (±9)

125 (±16) 76 (±8)

126 (±14)** 77 (+7)*

Blood glucose HbA1c (n=5)

5.8 (±1.98) 6.4 (±1.16)

6.1 (±3.06) 6.4 (±1.04)

5.4 (±1.04) 6.0 (±1.00)

5.4 (±1.21) 6.6 (±1.12)

BMI

25.6 (±3.98)

27.4 (±3.03)

28.6 (±3.23)

28.8 (±3.40)**

**p<0.001, *p<0.05 The majority of patients were normotensive preoperatively (88%) and at five years post-transplant with four recipients having systolic BP greater than 140 mmHg. The low number of hypertensive subjects is probably attributed to medication such as diuretics, beta blocker and angiotensin-converting enzyme (ACE) inhibitors with single therapy (n=12, 47%), dual therapy (n=8, 32%) and triple therapy (n=4, 16%). The number of subjects with diabetes did not differ significantly from pre-transplant to five years post-cardiac transplant nor did blood glucose levels (range from 4 to 7 mmol/L). Glycosylated haemoglobin (HbA1c) was not routinely undertaken in this sample, even in those with established diabetes. In those who had their HbA1c tested, their results were within the recommended range of <6.5%. Changes in BMI were detected in patients from preoperatively to the time intervals post-transplant. Preoperatively, 48% of patients had a BMI of less than 25 kg/m2, with the results showing an increase in BMI measurements of these patients over their five years post-transplantation. Only four patients had a BMI within the normal recommended range. Statistical analysis identified significant differences between the pre-cardiac transplants BMI to five years post-cardiac transplantation (25.6 vs 28.8, p<0.001).

Discussion Pre-existing CV risk factors were evident in the sample, with 40% having raised cholesterol, a quarter of the subjects were hypertensive, one-fifth had type 2 diabetes and over half were overweight, with BMI >25 kg/m2. Examining the data five years post-transplant revealed significant increases in systolic BP, BMI and creatinine (all p<.001) and diastolic BP (p<.05). The ISHLT 2011 report presented the posttransplant morbidities, describing the increase in rate of hyperlipidaemia, hypertension and diabetes post-cardiac transplantation2. At five years, ISHLT reports that of known responders: 87.9% of patients had hyperlipidaemia; 92.9% 18

had hypertension; and 37.4% had diabetes2. Of note, a BMI >25 kg/m2 was associated with an increased risk of five-year mortality. Our results are comparable to ISHLT data, with 84% of patients having raised total cholesterol levels, 42% had a systolic BP outside the recommended range and the majority (95%) were taking a diuretic, beta blocker or ACE inhibitor, 26% had diabetes and 83% with a BMI >25 kg/m2. Thus, the prevalence of CV risk factors prior to transplantation was similar to the ISHLT pre-transplant population2. The evidence that hyperlipidaemia is associated with increased mortality and morbidity related to CAV is conflicting, with two studies demonstrating the contribution of hyperlipidaemia to the development of CAV but others failed to identify an association11-13. A statistical association between LDL cholesterol was reported but no association between total cholesterol or HDL cholesterol levels and CAV development14. Several risk factors are associated with the development of hyperlipidaemia, including a previous diagnosis of IHD, use of cyclosporine or diuretics and renal insufficiency15. The use of statins in post-cardiac transplantation patients is common. A meta-analysis conducted on three randomised controlled trials (n=246) into statin therapy within three months of transplantation demonstrated a decrease in all causes of mortality at one year post-transplant (RR 0.31; p=0.006)16. A retrospective study examined the five-year follow-up of patients identified a reduced incidence of CAV in patients who received pravastatin (11%) to the control group (24%) (p=0.05)16. Our results showed that there was an increase in the number of patients taking lipid-lowering medications from 44% pre-cardiac transplant to 84% of patients at five years post-cardiac transplant. These patients were prescribed a statin (atorvastatin or pravastatin) and on two occasions, statins were combined with ezetimibe. Comprehensive management approaches for modifying hyperlipidaemia for the prevention of CVD is provided by the

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NHF, including pharmacological and lifestyle modification methods. While our patients are being provided statins as recommended in this population, their exposure to lipid clinics and dieticians was inconsistent17. While hypertension is extremely common after cardiac transplantation, the evidence to link hypertension to the development of CAV is absent in recent literature. Two studies failed to identify any association between hypertension and CAV12,13. While one study demonstrated that hypertension, when found in conjunction with other risk factors reduced post-cardiac transplant survival18. Despite the lack of a correlation between CAV and hypertension in this population, the studies showed that both the CAV group and the non-CAV group had a large proportion of their population with hypertension, supporting the ISHLT prevalence of hypertension post-cardiac transplantation2,13. There are several risk factors associated with cardiac transplantation that impact on the development and management of hypertension such as the use of cyclosporine and renal insufficiency. ISHLT reports the prevalence of hypertension at five years post-cardiac transplant to be 92.9%; this is reflected in our sample, with 42% of our patients having a systolic BP levels outside the NHF recommended range2. A total of 95% of the sample were receiving antihypertensive therapy at five years post-cardiac transplantation. Despite the difficulty in identifying a significant link between hypertension and CAV, the incidence of hypertension in this population suggests that optimal hypertension management post-cardiac transplant is warranted. Hypertension was found to be a CV risk factor regularly discussed with these patients during their routine follow-up appointments and medication therapy initiated to control this risk factor, yet patientsâ&#x20AC;&#x2122; dietary advice from health care professionals regarding lifestyle modification was not routine. Diabetes, both pre-existing and post-cardiac transplant is known to impact on transplant outcomes. ISHLT reported a significant risk of five-year mortality in cardiac transplant recipients with a history of diabetes (RR=1.38, p=0.0016)2. The registry also reported that 34.8% of patients five years post-heart transplant have diabetes which is associated with the known impact of immunosuppressive drugs, particularly cyclosporine and corticosteroids. Our results showed that the incidence of diabetes in our population was 26% at five years. Our ability to assess HbA1c in this study was limited by the number of tests performed on this sample. As HbA1c has been determined to be an accurate identifier for the diagnosis and management of diabetes19, the use of this test needs to be considered further for the glycaemic management of these post-cardiac transplant recipients. Weight gain associated with steroid medication is not unusual but should be closely monitored in this population.

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There is a paucity of literature providing conclusive evidence between the association of diabetes and the CAV postcardiac transplantation. Two studies failed to find a statistical difference between the group with a history of diabetes to those without a history of diabetes in the freedom from CAV20,21. However, one study did show a clinical difference of 69.5% freedom from CAV in the group with pre-existing diabetes, compared to 81.6% in the group without21. A second study showed a significant difference in freedom from CAV between their two groups, with freedom from CAV greater in patients without diabetes (p=0.035)22. While a further study found that diabetes was a significant risk factor to CV-related events or death (RR 2.11; p=0.022) in the postcardiac transplant population23. Another study identified a link between diabetes and CAV, identifying the presence of CAV in 45.5% of their subjects at one year, and a significant link between current diabetes and CAV (p=<0.01)12. In relation to renal function, due to the small numbers of patients, analysis was not performed as the data would not provide any meaningful conclusion. Although management of CV risk factors by health care professionals is important, adherence to medication, diet and physical activity regimens is also important posttransplantation. There is evidence that assisting patients post-cardiac transplant to incorporate a healthy lifestyle as part of their post-transplant life may help to reduce the mortality and morbidity by improving their health status24. A study of non-adherence in cardiac transplant patients focusing on medication adherence concluded that non-compliance is a continuous risk factor to the patient after cardiac transplantation25. The adherence of cardiac transplant patients to their lifestyle modifications and health status is not maintained consistently post-transplantation and, despite attempting to maintain a healthy lifestyle, they continue to present with a health status that encompasses many of the traditional CV risk factors24,26. Limitations of our research include that this was a retrospective review of patient histories and not all data were documented. Our sample size was small, from non-random convenience sample at a single centre, therefore potentially reducing the applicability of the results. Factors that contribute to morbidity and mortality after cardiac transplantation are complex, particularly in the development and progression of CAV, and it remains unclear as to the effect CV risk factors have on outcomes after cardiac transplantation. A key issue in Australia is the huge distances involved, with many patients living in rural and remote areas with poor access to specialised cardiac facilities. Often in these areas, cardiologists only visit once every three to four weeks. This lack of appropriate, specialised cardiac services demonstrates the inequity between those living in a metropolitan area and a remote area and has previously been demonstrated in heart failure services in Australia27. Another 19

TRANSPLANT JOURNAL OF AUSTRALASIA

important factor to consider is poverty and socio-economic deprivation and this has previously been reported in those with CV disease28. Our findings demonstrated increased prevalence of CV risk factors from time of transplant to five years post-transplant. However, we found that the prevalence of these CV risk factors in our patient population was similar to ISHLT data. This research has raised future questions for further research, including how to optimise what has been shown to be a high prevalence of CV risk factors, examination of the outcomes of patients with these CV risk factors and examination of the psychosocial risk factors in relation to these risk factors.

Conclusion While CAV is influenced by both immunological and nonimmunological factors, this small, non-random, single-centre, retrospective audit demonstrated a need to closely monitor and manage the traditional CV risk factors in this vulnerable population. Cardiac transplantation provides recipients with a chance for improved cardiac function, but in doing so, can provide the patients with a range of potentially chronic diseases to manage and that health care professionals need to be cognisant about.

Disclosure statement None of the authors has a financial relationship with any commercial companies or other conflicts of interest to disclose.

References 1.

Australian and New Zealand Cardiothoracic Organ Transplant Registry (ANZCOTR) 2010 Report. Australia: ANZCOTR, 2010. 2. Stehlik J, Edwards LB, Kucheryavaya AY et al. The Registry of the international society for heart and lung transplantation: twenty-eighth adult heart transplant report – 2011. Journal of Heart and Lung Transplantation 2011; 30(10):1078–1094. 3. Lietz K & Miller LW. Current understanding and management of allograft vasculopathy. Seminars Thoracic Cardiovascular Surgery 2004; 16:386–394. 4. Mehra MR. Contemporary concepts in prevention and treatment of cardiac allograft vasculopathy. American Journal of Transplantation 2006; 6:1248–1256. 5. Schmauss D & Weis M. Cardiac allograft vasculopathy: recent developments. Circulation 2008; 117:2131–2141. 6. Valantine H. Cardiac allograft vasculopathy after heart transplantation: risk factors and management. The Journal of Heart and Lung Transplantation 2004; 23(5S):S187–193. 7. Vassalli G, Gallino A, Wies M et al. Alloimmunity and nonimmunologic risk factors in cardiac allograft vasculopathy. European Heart Journal 2003; 24:1180–1188. 8. National Heart Foundation of Australia. Hypertension Guide of Doctors. [online] Australia, 2004. Available from: www. heartfoundation.com.au 9. World Health Organisation. Prevention of cardiovascular disease: guidelines for assessment and management of total cardiovascular risk. Switzerland: WHO Press, 2007. 10. Diabetes Australia. Diabetes Management in General Practice 2008–09. [online] Australia, 2008. Available from: www.racgp. org.au 11. Sánchez Lázare IJ, Almenar Bonet L, Moro López J et al. Influence of traditional cardiovascular risk factors in the recipient on the development of cardiac allograft vasculopathy after heart transplantation. Transplantation Proceedings 2008; 40:3056–3057.

12. Chamorro CI, Almenar L, Martinez-Dolz L et al. Do cardiovascular risk factors influence cardiac allograft vasculopathy? Transplantation Proceedings 2006; 38:2572– 2574. 13. Haddad M, Pflugfelder PW, Guiraudon C et al. Angiographic, pathologic, and clinical relationships in coronary artery disease in cardiac allografts. Journal of Heart and Lung Transplantation 2005; 24:1218–1225. 14. Pethig K, Klauss V, Heublein B et al. Progression of cardiac allograft vascular disease as assessed by serial intravascular ultrasound: correlation to immunological and nonimmunological risk factors. Heart 2000; 84:494–498. 15. Akhlaghi F, Jackson CH, Parameshwar J, Sharples LD & Trull AK. Risk factors for the development and progression of dyslipidemia after heart transplantation. Transplantation 2002; 73:1258–1264. 16. Mehra MR & Raval NY. Metaanalysis of statins and survival in de novo cardiac transplantation. Transplantation Proceedings 2004; 36:1539–1541. 17. National Heart Foundation of Australia. Lipid Management Guidelines 2001 – Summary Paper. [online] Australia, 2001. Available from: www.heartfoundation.com.au 18. Almenar L, Cardo ML, Martinez-Dolz L et al. Risk factors affecting survival in heart transplant patients. Transplantation Proceedings 2005; 37:4011–4013. 19. Colagiuri S, Dickinson S, Girgis S & Colagiuri R. National Evidence Based Guideline for Blood Glucose Control in Type 2 Diabetes. Canberra: Diabetes Australia and the NHMRC, 2009. 20. Kobashigawa JA, Starling RC, Mehra MR et al. Multicenter retrospective analysis of cardiovascular risk factors affecting long-term outcome of de novo cardiac transplant recipients. Journal of Heart and Lung Transplantation 2006; 25:1063–1069. 21. Marelli D, Laks H, Patel B et al. Heart transplantation in patients with diabetes mellitus in the current era. Journal of Heart and Lung Transplantation 2003; 22:1091–1097. 22. Russo MJ, Chen JM, Hong KN et al. Survival after heart transplantation is not diminished among recipients with uncomplicated diabetes mellitus: an analysis of the united network of organ sharing database. Circulation 2006; 114:2280– 2287. 23. Kübrich M, Petrakopoulou P, Kofler S et al. Impact of coronary endothelial dysfunction on adverse long-term outcome after heart transplantation. Transplantation 2008; 85(11):1580–1587. 24. Salyer J, Sneed G & Corley MC. Lifestyle and health status in long-term cardiac tranpslant reciepients. Heart and Lung 2001; 30(6):445–457. 25. Dobbels F, DeGeest S, Van Cleemput J, Droogne W & Vanhaecke J. Effects of late medication non-compliance on outcome after heart transplantation: A 5-year follow-up. The journal of heart and lung transplantation 2004; 23(11):1245–1251. 26. Flattery MP, Salyer J, Maltby MC, Joyner PL & Elswick RK. Lifestyle and health status differ over time in long-term heart transplant recipients. Progress in Transplantation 2006; 16:232–238. 27. Clark RA, Driscoll A, Nottage J et al. Inequitable provision of optimal service for patients with chronic heart failure: a national geo-mapping study. Medical Journal of Australia 2007; 186(4):169–173. 28. Lee G & Carrington M. Tackling heart disease and poverty. Nursing Health Science 2007; 9(4):290–94.

HAVE YOU VISITED THE TNA WEBSITE? www.tna.asn.au The site has been redesigned to provide easy access to TNA information. Download membership forms, scholarship forms, conference information and TJA articles all with a click of the mouse.

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TNA CONFERENCE REPORT

2012 TNA Conference report – TNA21 The 2012 TNA Conference was held on 15–16 November at

the theme of moving forward into the 21st century. We thank

The Rydges Hotel in Melbourne. This year marks TNA’s 21st

Susan for taking the time to present at our conference.

birthday. The theme was transplantation, moving forward into the 21st century.

During the conference, free papers and poster sessions were held covering many topics ranging from organ donation

One hundred and forty-five delegates celebrated 21 years

and transplantation in both the adult and paediatric fields.

of the TNA. It was great to see new faces at this year’s

Presentations were given by transplant coordinators, nurses,

conference, as well as the “older” crowd. The conference

organ donation specialists and organ donor coordinators

committee was inundated with abstracts, which led to a

from around Australia and New Zealand. The papers and

programme that had something for everyone.

posters presented were of a very high standard, thus

The conference was opened by a controversial human

making judging a very hard task. The 2012 TNA Conference presentation winners were:

headline act: Mr Derryn Hinch. Derryn gave us an insight into the patient experience throughout the transplantation

• Best Oral Presentation: Kate Hamilton – “The nutritional

process. It wasn’t long before the controversial issues were in

management of Australia’s first intestinal transplant

discussion. This provided the foundation for many great and

recipient – a case study”.

varied presentations. Susan Chernenko, nurse practitioner at Toronto Lung Service, Canada, provided us with an insight into nursing in the 21st

• Best Poster Presentation: Greta McKenzie – “Coming out of the fog”. • Best First Time Presenter: Cath Bradley – “Education/

century. How have we changed? It turns out that we haven’t

support groups to enhance the patient experience in liver

changed much – just matured! Her presentation gave us a

transplantation”.

great insight into how nursing began and the foundation it has been built on and where we may be headed.

Congratulations to all winners. We look forward to seeing your abstracts in the TJA.

Invited speakers covered many topics: donation – where to from here; addiction medicine – what we need to understand in order to treat our patients; and hand transplant – an update. Special interest groups formed and discussed the value of these groups and determined the need for these groups. Stay tuned for the results of the discussions.

The day was reserved for education, debate and discussion, while the night was reserved for networking and socialising. Welcome drinks were held on Wednesday at the institution Bobby McGees – many people reminisced on what could have been and what had been. It was great to catch up with the old timers and relive memories of years gone by,

Day two of the conference moved us into the 21st century.

but it was great to see many new faces attending this year’s

Topics such as womb transplantation, which is a new

conference. The TNA is in great hands.

technology in the 21st century, and liver preservation, which was a hot topic. Paediatric bone marrow transplant, expanding the donor pool – what else can we do? Pregnancy and transplantation, intestinal transplantation – an update and for the IT-savvy – Twitter and Facebook were covered as well.

The conference dinner, a 21st birthday party, was held in Studio 3 at Crown Casino. It gave us all a chance to frock up and kick up our heels. It was time to test our general knowledge and TNA knowledge in a trivia quiz. Funky Bunch Trivia brought out the competitive side in all of us – table against table. After a fantastic meal it was time to have

Susan provided another fantastic presentation on telehealth

dessert. What would a 21st party be without a birthday cake?

transforming health care. This certainly was in keeping with

Bronwyn, our outgoing TNA National President, Claire West,

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the incoming TNA National President and the conference

Thank you to the TNA 21 Conference committee: Chris Ellis,

committee, cut the cake. Now it was time to cut loose on

Bronwyn Levvey, Elaine Kennedy, Laura Gasbarre and Julie

the dance floor – a few people have been hiding other skills!

Pavlovic. The abstracts committee worked hard to mark the

DJ Stuart Lemmont kept us on the dance floor, ensuring

abstracts, which were all of a very high standard, covering

we burned the calories we had just eaten. A few night owls burned the midnight oil, but most were home in time for breakfast and for day two of the conference. Putting together a conference takes a team. A big thank you to Steve Angel from Instinct international, our conference organiser.

very interesting and varied topics. A big thank you to all those who submitted the many abstracts received. It was also great to see so many first-time presenters attending the conference and presenting. We encourage you to keep doing so. A big thank you to all the delegates who registered and attended the conference. It is great to see the enthusiasm of

A special thank you to Novartis for providing sponsorship for Susan Chernenko to travel from Canada to Melbourne to

all those involved in the organ donation and transplantation sector. We look forward to seeing you all in 2013 in Sydney.

2012 TNA National Conference Committee

present at the conference.

2 0 1 2 TNA CONFERENCE w i n n i n g ABSTRACTS

The nutritional management of Australia’s first intestinal transplant recipient – a case study Kate A Hamilton & Brooke Chapman Austin Health, Heidelberg, Melbourne, VIC

Background: In July 2010, Austin Health surgeons completed

The aim of dietary modification was to reduce stoma output

Australia’s first intestinal transplant. Indications for intestinal

and ensure adequate hydration. Post-transplant nutritional

transplantation include intestinal failure combined with

outcome measures included weight and handgrip strength.

one or more life-threatening complications related to total parenteral nutrition (TPN) such as loss of adequate vascular access or parenteral nutrition-induced liver failure. Aim: This paper describes the patient’s nutritional management and highlights the positive outcomes of referral to a specialist service resulting in intestinal transplant. Body: The recipient was a 33-year-old male with short bowel syndrome secondary to Hirschsprung’s disease and TPN-induced liver disease. His nutritional management

Postoperative management during a 40-day inpatient stay focused on the weaning of parenteral nutrition, introduction of nasojejunal feeds (NJF) and transition to oral intake. The patient was discharged at day 40 weighing 86 kg, with 50% of requirements met orally and 50% met via NJF. He successfully transitioned to full oral intake at day 59. Conclusion: Transplantation was deemed a success as evidenced by the patient enjoying adequate oral diet with

pre-transplant included home parenteral nutrition (HPN),

independence from TPN. His weight is stable at 84 kg (within

which met 100% of his nutrition requirements to maintain

HWR) and upper arm muscle strength continues to improve

weight within the healthy weight range (HWR) at 90 kg.

18 months post-discharge.

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2 0 1 2 TNA CONFERENCE w i n n i n g ABSTRACTS

Education/support groups to enhance the patient experience in liver transplantation Catherine Bradley Victorian Liver Transplant Unit, Austin Health, Melbourne, VIC Aim: To demonstrate how group work with transplant patients can be an effective intervention for both staff and patients.

• a means of normalising and validating an individual patient’s experience • a means of offering support, hope and encouragement

Body: Discussion of the history, features, aims, objectives, benefits and challenges of group work in liver transplantation. The Victorian Liver Transplant Unit has a long history of group work involving allied health, medical and nursing staff. The nature of group work is always evolving and includes pre- and post-transplant groups and special interest groups such as children/grandchildren of patients, carers, fulminant, patients with hepatoma and hepatitis and those who have

• an opportunity for staff to undertake multiple individual interventions at one time. Conclusion: Although presenting some challenges, group work has proven to be an effective means of providing support and reinforcing patient learning about surgery, medications, diet, exercise, physical, emotional and spiritual coping and recovery. Patient evaluations affirm that for those attending, groups provide support, additional learning and enhance

experienced disturbing hallucinations. The aims of the groups are multifaceted and include: • an opportunity to reinforce and extend previous individual education sessions • a self-help, support group experience where patients learn from and support each other

coping and the overall patient transplant experience. By enhancing emotional, psychological and information needs, there can be a positive impact on adjustment and coping as well as the potential to enhance patient compliance pre- and post-transplantation.

Coming out of the fog Greta H Mckenzie Austin Health, Melbourne, VIC Background: Rifaximin is an oral antibiotic that has been

minimal absorption from the gut; decreased likelihood of

found to provide more benefits to the body besides its

systemic effects; and ability to take rifaximin in the long term.

primary benefits in treating travellers’ diarrhoea . Rifaximin 1

is increasingly being used at Austin Health to prevent hepatic

Comparison of rifaximin usage across two major metropolitan

encephalopathy episodes in patients with chronic liver

hospitals will be explored and a local Austin Health case

disease (CLD).

study will be presented. The literature review will use search

Aim: To inform and educate liver transplant nurses about rifaximin: its effectiveness, usage, dosage and side effects. Body: A literature review will be undertaken to determine effectiveness of treatment and recommended usage, dosages and side effects. Rifaximin will be explained in its main

databases: CINAHL, Ovid and PubMed. The case study will provide a brief patient profile and outline rifaximin usage, as well as highlighting the improvement in patient condition in comparison to treatment prior to rifaximin. Conclusion: By undertaking this body of work using

composition as an antimicrobial agent that decreases the

evidence-based practice and clinical studies, we anticipate

ammonia levels in the gut. It will be reviewed with regard

a greater awareness and understanding of the usage of

to how it differs from other antibiotics in treating hepatic

rifaximin to treat hepatic encephalopathy in patient with

encephalopathy. The key points that will be explored include:

CLD within the transplant nursing population.

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5 4

6 9

11 10

Conference Photos 1.

Welcome Drinks

Austin Crew

Chris & Julie

TNA Banner

5. Chris, Bron, Elaine & Laura Welcome Drinks 6. Addiction Medicine - A/Prof Alan Gijsbers 7.

Conference room

Derryn Hinch Opening Conference

Conference Committee

10. Hand Transplant Dr Angela Webb 11. Bobby McGees welcome drinks 24

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22 12. Chris Ellis Opening conference 13. Susan Chernenko, Key note speaker

14. Tracey, Nicole & Julie 15. Strike a pose 16. Greta Mckenzie Best Poster & Cath Bradley Best First time presenter 17. NSW delegates at conference dinner 18. WA delegates at conference dinner 19. TNA 21 Cake 20. Conference room 21. Claire West Something to Tweet about 22. Dr Ash Hanafy 23. Happy Birthday TNA Volume 21 Number 3 â&#x20AC;&#x201C; December 2012

TRANSPLANT JOURNAL OF AUSTRALASIA

DIAR Y DATES 2 0 1 2 – 2 0 1 4 For more information, check out the links on the TNA website http://www.tna.asn.au 2013

26–29 June 2013 XIII International Small Bowel Transplant Symposium

24–27 April 2013

(ISBTS 2013)

ISHLT – The International Society for Heart and Lung

Oxford, UK

Transplantation 33rd Annual Meeting and Scientific Sessions

Web www.isbts2013.org 13–16 July 2013

Palais des Congrés de Montréal

International Paediatric Transplant Association(IPTA) 7th

Montréal, Quebec, Canada

Congress on Pediatric Transplantation

18–23 May 2013

Building Bridges

American Transplant Congress

Warsaw, Poland

Seattle, WA, USA

2014

Web www.a-s-t.org

9–12 April 2014 ISHLT – The International Society for Heart and Lung

12–15 June 2013

Transplantation 34th Annual Meeting and Scientific Sessions

International Liver Transplantation Society (ILTS) 19th

Manchester Grand

Annual International Congress

San Diego, CA, USA

Sydney Convention & Exhibition Centre

World Transplant Congress 2014

Sydney, NSW, Australia

San Francisco, CA, USA

STATE EXECUTIVE NSW/ACT

SA/NT

President & Treasurer

President

Allyson Newman

Jane van der Jeugd

Allyson.Newman@sswahs.nsw.gov.au

jane.vanderjeugd@health.sa.gov.au

(02) 9515 7549

(08) 8204 6617

Secretary Jane Mawson jane.mawson@email.cs.nsw.gov.au (02) 9515 7630 QLD President Phil Bettens Phillip_Bettens@health.qld.gov.au

Secretary Nicole Williams

Treasurer Emily Langley emily.langley@austin.org.au (03) 9496 5841

nicole.williams2@health.sa.gov.au

(08) 8204 5819

President Corina Jary corina.jary@health.wa.gov.au (08) 9224 2244

Treasurer Libby John libby.john@health.sa.gov.au (08) 8204 5819

Secretary Trish Leishfield

VIC/TAS

trish_leisfield@health.qld.gov.au

President

Treasurer

Jennifer Hislop

Sue Rixon

J.Hislop@alfred.org.au

sue_rixon@health.qld.gov.au

(03) 9076 2823

Secretary Lauren Mitchell l.mitchell@alfred.org.au (03) 9076 2164

Secretary Robyn Kovac robyn.kovac@health.wa.gov.au (08) 9224 2244 Treasurer Trevor Cherry trevor.cherry@health.wa.gov.au (08) 9224 2244

Volume 21 Number 3 – December 2012

Volume 21 Number 3 â&#x20AC;&#x201C; December 2012

TRANSPLANT JOURNAL OF AUSTRALASIA

JOIN THE EDITORIAL BOARD OF THE TJA Previous editorial experience is not essential The TJA Editorial Board has positions available for new members with renal, pancreas or tissue experience. Being part of the Editorial Board involves working with a dynamic team that aims to provide a relevant and informative journal in organ and tissue donation and transplantation. • Use your knowledge in clinical aspects of transplantation. • Improve your editing and critiquing skills. • Get to know other specialist transplant nurses around Australia. • Be up to date with what’s going on in donation and transplantation in Australia and internationally. The Editorial Board members will provide ongoing support and mentoring where required. The Editorial Board meets via teleconference three times each year prior to each publication of the TJA. However, much communication between members is via email. All expressions of interest are welcome. Please contact Libby John (National Secretary) for any enquiries regarding the TJA positions. Email secretary@tna.asn.au Phone (08) 8204 5819

EDITORIAL BOARD The following people are members of the Transplant Journal of Australasia Editorial Committee • Carrie Alvaro Donor Coordinator

ATCA Representative

NSW

carrie.alvaro@sesiahs.health.nsw.gov.au

Member

NSW

mharkess@stvincents.com.au

Member

VIC

tracey.hughes@austin.org.au

• Michelle Harkess Heart/Lung Transplant • Tracey Hughes Liver Transplant • Tracey Mackay Organ Donation Editor

VIC tracey.mackay@mh.org.au

• Nick Nuttall Eye Bank

Member

QLD

nichalas_nuttall@health.qld.gov.au

Member

catherine.o’driscoll@health.wa.gov.au

Member

NSW

myra.sgorbini@sswahs.nsw.gov.au

Member

VIC

rosemary.snell@bigpond.com

TNA Secretariat

secretariat@tna.asn.au

• Catherine O’Driscoll CNC, Surgery • Myra Sgorbini Donor Coordinator • Rose Snell Heart/Lung Transplant • Nicole Williams Secretariat

Volume 21 Number 3 – December 2012

For nurses and health professionals interested in organ donation and transplantation ...

Transplant Nurses’ Association Inc. Your opportunity to contribute significantly to standards of care for donors, recipients and their families.

Goals

✦ Education to heighten public awareness of the issues surrounding organ donation and transplantation and to increase the knowledge and skills of health professionals involved in the transplant process. ✦ Participation in policy decisions in relation to transplantation for all health professionals specialising in this field. ✦ Networking with health professionals locally and globally in the areas of bone marrow, heart and lung, kidney, pancreas, liver and tissue transplantation.

Activities

✦ The TNA Annual Conference is held on a rotational basis between states, with members invited to present papers or other material for discussion. ✦ Meetings are held quarterly by each state branch and feature guest speakers, with supper provided. ✦ The Transplant Journal of Australasia is published triannually, provides a forum for enquiry into ethics, advances in transplantation, nursing research, patient outcomes and issues of interest to health professionals in this field. Of international standing and listed with CINAHL, the TJA is researched and produced by TNA members. ✦ The TNA website at www.tna.asn.au provides up-to-date information on the Association’s activities, including the annual conference, the TNA state branch meetings, membership and lots more.

Benefits

✦ Grants are offered to provide financial assistance for members pursuing research projects. ✦ Funding can be provided for relevant educational endeavours. ✦ Associate membership is available for allied health professionals. ✦ Reciprocal arrangements with other professional organisations to allow entry to their relevant conferences.

Membership

Return form with credit card details, or cheque/money order made payable to: Transplant Nurses’ Association National Treasurer, TNA Inc. Box M94, PO Missenden Road Camperdown, NSW 2050 Australia

Fees:

1 year membership $66 ■ ■ 2 year membership $120 Fees include GST, payable annually on 31 August

Name: Address: Suburb: State: Country: Post/zip code: Tel: (work) (home) Fax: Email: Hospital: Special interests: Position held: Nurse? Yes/No

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Expiry date:

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TJA ■ Work ■ O t h e r

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