Second Chances
Advances in transplant techniques and immunosuppressive medication enable quicker recovery and a shot at a normal life for organ recipients

By Rebecca Ray
September 12, 2003


Terri Cook, RN, has met patients with such advanced stages of lung disease that they couldn't even sneeze. But, after these patients-some of whom were in wheelchairs-had undergone lung transplants, Cook has seen them ride horses in horse shows, run farms and play basketball.

"It's exciting when it works and people feel they have such a benefit from transplants, and I guess that's what keeps me doing [my work as a transplant coordinator]," said Cook, coordinator and member of the lung transplant team at Johns Hopkins Hospital in Baltimore.

Transplant nursing is becoming even more exciting, as medical professionals have developed strategies within the last few decades that have expanded the living donor pool. The strategies also have allowed medical professionals to perform rescue therapy on patients who produced antibodies after their transplants to attack the donated kidney.

Gone are the days when kidney donors and recipients had to be related and have compatible blood types with a negative crossmatch-meaning that the recipient could not have preformed antibodies against the donor's blood.

Today, medical professionals use plasmapheresis, which removes antibodies, on kidney recipients whose blood types are incompatible with their donors' or who have positive crossmatches with their donors.

Then, kidney recipients undergo a procedure called intravenous immunoglobulin (IVIG) to restore the antibodies that would protect them from infection but not attack the donated kidney. IVIG modulates the immune system so that it either no longer makes the antibodies or no longer responds to the donor's antigens, said Mary Jo Holechek, MS, CRNP, CNN, nurse practitioner in the adult abdominal organ transplant service at Hopkins.

The living donor pool also has increased because of the advent of living liver donor transplants and the laproscopic procedure for kidney donors.

Although only a handful of facilities in the United States perform plasmapheresis, IVIG, living liver donor transplants and laproscopic procedures, Holechek said she sees more facilities using the procedures within the next five to 10 years. As more facilities adopt the procedures, more patients should receive transplants and live longer, better-quality lives.

Medical professionals have used plasmapheresis, or the procedure of removing a patient's plasma, where antibodies reside, to treat various diseases since the 1970s. Hopkins began using the procedure on kidney patients in 1994.

During the first plasmapheresis on a kidney patient at Hopkins, the donor and recipient had a negative crossmatch before the transplant; however, the procedure was used on the recipient after the transplant because the recipient had begun to produce large quantities of antibodies to attack the donated kidney.

From this form of "rescue therapy," where antibodies are removed after the kidney transplant, pre-emptive therapy-or removing the antibodies before the transplant-evolved, so that plasmapheresis could be used even on recipients who showed a positive crossmatch before the transplant. Hopkins first used the pre-emptive procedure in 1998.

The first ABO-incompatible transplant at Hopkins took place one year later.

Generally, patients involved in the Hopkins ABO-incompatible and positive crossmatch treatment programs are those who have exhausted all the normal transplant options and have come to Hopkins as a last resort. Usually, patients either couldn't find an ABO-compatible donor, or they were sensitized to a potential donor's antigens.

Sensitized patients include mothers who have been exposed to their children's antigens during pregnancy and have formed antibodies to them, and patients who have formed antigens to the antibodies they received during blood transfusions and previous organ transplants.

Hopkins has transplanted 53 kidney patients with positive crossmatches, 12 with incompatible blood types and three with both positive crossmatches and incompatible blood types. The Hopkins patients' 95 percent one-year survival rate is equivalent to the nationwide one-year survival rate for patients who received kidneys from live donors, but did not have to undergo plasmapheresis and IVIG, according to Hopkins data.

Still in demand

The biggest obstacle, though, to organ transplants is not enough donors-living or deceased. Although 82,404 patients in the United States awaited transplants as of Aug. 1, only 10,450 transplants had been performed this year from January to April, according to the Organ Procurement and Transplantation Network. In that same time period, only 5,831 organs had been recovered.

In recent years, only about 26 percent of kidney patients nationwide who were on the waiting list received a transplant from a cadaver, Holechek said.

Because the cadaveric donation rate has remained flat for years, according to Holechek, the transplant nurses at Hopkins spend considerable time trying to spread awareness about the importance of living organ donation, because patients who receive organs from living donors have a greater chance of experiencing a successful outcome.

Living donors

About 50 percent of kidney transplants come from living donors, Holechek said.

The living donor pool doubled shortly after Hopkins physicians Lloyd Ratner and Louis Kavoussi developed the laproscopic donor nephrectomy procedure. The physicians first used it at the hospital's Bayview campus in Baltimore in February 1995.

The procedure involves making several half-inch incisions around the abdomen and then going through the incisions to cut the kidney free. This is much less invasive and painful than open nephrectomy, which involves making a 10- to 12-inch incision through major muscle groups to remove the kidney.

It would take months before donors who underwent open nephrectomy could return to work. With the laproscopic procedure, however, most donors go home on the second or third postoperative day and can return to work two weeks after transplant, Holechek said.

So far, the only transplant patients for whom plasmapheresis and IVIG have been used are kidney patients. However, Denise Burrell-Diggs, RN, transplant nurse coordinator at Hopkins, has witnessed the dawn of living donor liver transplants, which, she said, have probably been the biggest liver transplant advancement in the past 10 years. Living donor liver transplants are possible because the donor's liver regenerates after part of it is given to the recipient.

No major advances in lung transplants have occurred in recent years, but survival rates have increased during the past 15 years, Cook said, because of advances in immunosuppressive medications. These advances are responsible for nonrelatives being able to donate kidneys.

About 15 years ago, doctors considered only immediate family members as donors, and would consider more distantly related family members only if more closely related individuals' blood types didn't match, said pre-transplant coordinator Susan Turton-Weeks, RN, CNN, CCTC, of the University of Arkansas for Medical Sciences in Little Rock, Ark.

Holechek said that what she likes best about being a transplant nurse is "to see people who've had no real hope" of receiving a transplant "make it" by achieving goals they weren't able to achieve before, such as finishing college.

"To see people [being] able to get on with their lives is one of the most rewarding things for us," she said.

Contact Rebecca Ray at rebeccar@nurseweek.com