1 / 62

ABO Incompatible Heart Transplantation

ABO Incompatible Heart Transplantation. Jami Steinmetz, RN – C-PNP Heart Transplant Coordinator Children’s Healthcare of Atlanta. OBJECTIVES. Why ABOi heart transplantation works with infants. Special care required pre and post transplant for ABOi transplants.

alaina
Télécharger la présentation

ABO Incompatible Heart Transplantation

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. ABO Incompatible Heart Transplantation Jami Steinmetz, RN – C-PNP Heart Transplant Coordinator Children’s Healthcare of Atlanta

  2. OBJECTIVES • Why ABOi heart transplantation works with infants. • Special care required pre and post transplant for ABOi transplants. • Explanation of new UNOS proposal guideline changes. • Increase general knowledge base of ABOi heart transplantation.

  3. ABO Incompatible Heart Transplant Giving an infant a heart that is not the same as their blood type

  4. Everyone is born ABO incompatible.

  5. A B O A B O

  6. How is it even possible to perform an ABO incompatible heart transplant?

  7. So…what are isohemagglutinins?

  8. OK then… what are titers?

  9. What causes the hyper acute rejection in an unintentional incompatible transplant? .

  10. Antibodies bind to the antigens Complement cascade Inflammatory reaction Thrombosis of the coronaries

  11. Infant’s Immune System Immature and naïve and the antigens are inexperienced.

  12. Infants eligible for an ABOi heart transplant require special blood products while they wait for a heart.

  13. Why… because its important to avoid passive exposure to Anti-A/Anti-B antibodies. If they aren’t making antibodies, we defintely don’t want to give them antibodies!

  14. The blood bank tests the infant’s plasma for antibodies and determines the infant’s back type.

  15. A negative back type means no Anti A or Anti B antibodies were detected in the plasma.

  16. Case Study 2/22/2013 11:35 ABO/RH(D) A POSITIVE NOTE : Anti B Does Not Titer 3/16/2013 06:00 ABO/RH(D) A POSITIVE ANTI-B TITER POSITIVE AT 1:8

  17. How do you test for isohemagglutinins?

  18. How is an isohemagglutinin titer determined? Titrations are done to determine the dilution at which the antibody is no longer detectable 1:1 1:2 1:4 1:8 1:16 1:32

  19. If the patient has EITHER no anti-A or anti-B antibodies and is a potential ABO incompatible heart transplant recipient, then washed O RBCs and AB platelets and plasma will be given to avoid the passive transfer of anti-A or anti-B antibodies.

  20. B.L. – currently waiting for a heart transplant Age – 4months 9/10/2013 12:50pm ABO/RH(D) O POSITIVE ANTI-A TITER POSITIVE AT 1:8 ANTI-B TITER ZERO TITER Case Study

  21. Washed Red Blood Cells

  22. Another example… 9/9/2013 22:50 ABO/RH(D) O POSITIVE ANTI-A TITER POSITIVE AT 1:8 ANTI-B TITER POSITIVE AT 1:4 Case Study

  23. Washing RBCs removes passive anti-A or anti-B in the plasma but also damages the RBCs, so the pros/cons must be carefully considered.

  24. Remember, FFP and Platelets can’t be washed THERFORE… ONLY AB PLASMA products can be given.

  25. ABO Incompatible Protocol Pre-Transplant Blood Products

  26. History of ABOi Heart Transplantation High risk of death in infants awaiting heart transplantation. Disproportionate risk in type O recipients due to the ratio of numbers waiting to donors available.

  27. 1996 -1st ABO intentional incompatible heart transplant was performed at Toronto Hospital for Sick Children. Toronto Hospital continued with ABOi transplants from 1996-2001 with outcomes similar to their ABO compatible transplants before the U.S began ABOi heart transplantation.

  28. 2001- 1st ABO incompatible heart transplant was performed in the United States at New York Presbyterian Hospital. Worldwide there are currently about 120 ABO incompatible heart transplant recipients.

  29. UNOS Proposal Changes Proposals were submitted this year to UNOS to change the guidelines of the current allocation policy.

  30. UNOS Proposal Changes Four guideline changes were submitted to UNOS and two were in direct response to the success of ABO incompatible heart transplants. 1. Increase qualifying isohemagglutinin titer. 2. Change the allocation priority.

  31. Current UNOS policy and the new Proposal Currently -Max age at listing for ABOi: 2 years of age Isohemagglutinin titers ≤ 1:4 for > 1 yr of age Must be status 1A or 1B Titer data must be within 30 days prior to listing Proposal -Increase qualifying isohemagglutinin titer to 1:16 for candidates > 1 year of age are older but are registered before their second birthday.

  32. Acceptable titers for ABOi transplant for patients less than one year of age vary among individual hospitals.

  33. Previous example… Patient B.B.D. 9/9/2013 22:50 ABO/RH(D) O POSITIVE ANTI-A TITER POSITIVE AT 1:8 ANTI-B TITER POSITIVE AT 1:4 1:1 1:2 1:4 1:8 1:16 1:32 Remember titrations are done to determine the dilution at which the antibody is no longer detectable.

  34. Case Study Listed for ABOi heart transplant at 11 months of age. Blood Type A - Anti B Did Not Titer Remained eligible for ABOi until 13 months of age when her ANTI-B TITER was POSITIVE at 1:8 With new UNOS proposal guideline changes, AH would continue to be eligible for a B donor heart until her isohemagglutinin titer is greater than 1:16

  35. Current UNOS Allocation Policy and Proposed Change BLOOD GROUPS O DONOR to O or B A DONOR to A or AB B DONOR to B or AB Priority ABO compatible – status 1A, 1B or 2 then ABO incompatible – status 1A or 1B then in utero compatible/incompatible 2. Change the allocation priority of ABO incompatibles

  36. The current UNOS algorithm prioritizes all ABO compatible heart recipients before ABO incompatible potential heart transplant recipients.

  37. If the new proposal is accepted, an organ (regardless of ABO compatibility) would be offered to the most urgent, local, recipient.

  38. PHTS Database Results Pediatric Heart Transplant Study (PHTS) Equivalent one year survival and freedom from rejection when comparing ABOi with ABOc

  39. Canada demonstrated a decrease in wait list mortality for infants under 6 months of age from 58% to 7% with ABO incompatible transplants.

  40. ABOcompatible vs ABOincompatible? ABO compatible or incompatible…how does it affect ME?

  41. Induction Protocol ABOi or ABOc SAME PROTOCOL

  42. Intra operatively – Steroids 30mg/kg and Thymoglobulin 1.5mg/kg Inpatient – Thymo and Steroids x 5 days Post transplant immunosuppressant medications - Prograf and Cellcept (unless not tolerated by patient).

  43. Difference between ABOi transplant and ABOc transplant? Plasmapheresis and isoheme testing

  44. At time of transplant, titers must be less than 1:16

  45. Isohemes titers must be checked TWICE in the OR prior to the transplant. Titers must be less than 1:4.

  46. ABO Incompatible Transplant Protocol Isohemagglutinins are then checked: Immediately post op day 1 Weekly x 4 weeks Every other month until 12 months post op Annually

More Related