Organ Transplant

by Dianne D. Glasscoe, RDH, BS

Organ transplant procedures are among the most exciting and rapidly expanding areas of medicine today. Transplants offer hope to individuals whose lives are changed drastically due to organ failure. Organ transplants give many recipients a second chance to live a normal life.

However, receiving an organ transplant is fraught with difficulty. The organ recipient is bound to a life of many medications, and many of these medications have oral implications.

My dad's foray into transplant technology began in 1999 when he received the heart-breaking news that his kidneys were failing. The diagnosis was "end-stage renal failure." His medical doctor had informed him four years earlier that his creatinine was creeping upward a little more each year. (Creatinine is a protein produced by muscle and released into the blood. The creatinine level in the serum is determined by the rate it is being removed, which is roughly a measure of kidney function. Normal is about one for an average adult.

My dad's creatinine was at six when he received the news of renal failure.) The medical doctor, a family friend, told me privately that he suspected that, if Dad lived long enough, he would have to go on dialysis in two to three years. The doctor's suspicions were right on target.

Although my dad had always been a robust, healthy individual — a real workaholic — he suffered from varying degrees of hypertension since the age of 32. No one can say for sure why his kidneys failed, but years of high blood pressure, his history of kidney stones, and hereditary influences are probably to blame.

When kidneys fail

Healthy kidneys clean the blood by filtering out extra water and wastes. They also make hormones that keep your bones strong and blood healthy. When both kidneys fail, the body holds fluid. Blood pressure rises, and harmful wastes build up in the body. Additionally, the body does not make enough red blood cells. When this happens, treatment is needed to replace the work of the failed kidneys.

There are two types of dialysis: hemodialysis and peritoneal dialysis. Hemodialysis uses a dialyzer, or special filter, to clean the blood. The dialyzer connects to a machine. During treatment, the blood travels through tubes into the dialyzer. The dialyzer filters out wastes and extra fluids. Then the newly cleaned blood flows through another set of tubes and back into the body. Hemodialysis usually is done three times a week via a surgically placed shunt in a dialysis treatment center. Each treatment lasts two to four hours.

Peritoneal dialysis is another procedure that replaces the work of the kidneys, removing extra water, wastes, and chemicals from the body. This type of dialysis uses the lining of the abdomen, called the peritoneal membrane, to filter the blood. A cleansing solution, called dialysate, travels through a surgically implanted catheter into the abdomen. Fluid, wastes, and chemicals pass from tiny blood vessels in the peritoneal membrane into the dialysate. After several hours, the dialysate gets drained from the abdomen, taking the wastes from the blood with it. Then the abdomen is filled with fresh dialysate and the cleaning process begins again. This process takes 30 to 40 minutes and is repeated four times a day. It can be done at home.

One serious complication of peritoneal dialysis is peritonitis. This is an infection of the peritoneum and can occur if the opening where the catheter enters the body gets infected. Peritoneal patients have to be extremely careful to observe strict infection control procedures while performing dialysis, such as wearing a mask and gloves. Additionally, no other people are allowed in the room while dialysis is being done.

My dad was on peritoneal dialysis. He experienced two serious bouts with peritonitis and was hospitalized for several days with each occurrence. His life consisted of a grueling, daily schedule of dialysis that had to be performed every four hours with no exceptions. For three and one-half years, he was tethered to dialysis.

Additionally, the fluid in his peritoneum added weight to his abdominal area and caused him to have acid reflux to such a degree that he often could not sleep in a supine position.

Early symptoms

Two of the early symptoms of renal failure are lethargy and pale, sallow skin. According to the doctor, healthy kidneys produce an important hormone called erythropoietin (EPO). This hormone helps the body produce red blood cells, which carry oxygen from the lungs to all parts of the body. When the kidneys do not function properly, they do not make enough EPO. This causes the red blood cell level to drop and the patient becomes anemic. So, most dialysis patients need the synthetic form of EPO. It is given by injection.

Another symptom of renal failure is pruritis, or itching skin. My dad would complain of intense itching at times, which was attributed (incorrectly) to dry skin. The itching comes from a build-up of excess phosphorus in the system due to inadequate filtering of the kidneys.

Transplant recommendation

Other than his renal failure, my dad was healthy. His heart and lungs were strong, and he was not a diabetic. Therefore, his nephrologist decided to refer him for transplant evaluation. Dad was put through a battery of tests and approved for a transplant. He was provided with a beeper to wear so the hospital could contact him at any time if a matching kidney became available. He was told that it would probably be at least two years. However, the waiting time was three years.

If I could, I would have given my dad one of my kidneys. However, two things prevented me from being a donor:

• I had hepatitis as a child

• My history of kidney stones. My only sibling, a brother, also has a history of numerous kidney stones, rendering him an unfit donor.

The telephone call!

The call came at 3 a.m. on Oct. 23, 2002. My mom answered the telephone. The caller identified herself as a nurse at Winston-Salem Baptist Hospital. "Mrs. Davis, is Mr. Davis well? Does he have a cold or has he run a fever in the last three days?" With rising anticipation, my mom answered, "No." "Great! Please come immediately to the hospital. We have a kidney for Mr. Davis!" Unless you've lived this scenario, I'm certain you cannot imagine the excitement!

Upon arriving at the hospital, Dad was slated for a CT scan, some other X-rays, blood work, and consultation with the transplant team.

Several hours later, he was wheeled into surgery. Our family waited ... and waited ... and waited. Every hour, a nurse from the transplant team would call to give us an update on Dad's condition. Six hours later, the transplant surgeon appeared through the doors of the waiting room with a big smile on his face. He told us that Dad had come through the surgery beautifully, and that the kidney had already begun to produce urine! To say we were overcome with joy is an understatement! Personally, I wanted to grab the surgeon and kiss him, but I restrained myself! However, our family all did a big group hug before we decided to go home and get a little sleep. It had been a long, emotional day and night.

Harvesting organs

When a person dies, there is only a brief window of time for organs to be harvested. For example, if a person dies in an automobile accident or suffers a major heart attack, the internal organs begin necrosis within minutes of blood flow stoppage, thereby rendering the organs unusable for transplantation. However, if a person is critically injured or suffers a massive stroke and is placed on life support, thereby maintaining blood flow, organs could be harvested should the decision be made to discontinue life support. Often in such cases, there is no brain activity, yet the heart continues to beat.

My dad's donor was a man in his sixties who suffered a massive stroke. It was decided that he would never be able to function, as there was no brain activity. This man had made the decision many years ago to be an organ donor, and he had two good kidneys. My dad received one, and another man received the other one.

When a kidney is transplanted, the diseased kidneys are not usually removed, except in cases of cancer or severe enlargement. The new kidney is attached below the diseased kidney.

A lifetime of medicine

Immunosuppressants can cause numerous side effects. These medications include: mycophenolate mofetil (Cellcept®), prednisone (Deltasone®), azathioprine (Imuran®), tacrolimus (Prograf®), cyclosporin (Neoral®, Sandimmune®) or sirolimus (Rapamune®). Often, the frequency or the significance of a side effect is related to the dose of the immunosuppressant as well as the effect upon the immune system.

Additionally, transplant recipients often have to take other medications, such as hypertension drugs, medications to control acid reflux or gastrointestinal problems, and numerous over-the-counter vitamins or supplements. Any or all of these medications can have oral side effects.

For a new transplant patient, there are weeks of close monitoring to arrive at the proper balance of medications. The patient's age, weight, past medication history, and need are all assessed when deciding which combination of medications will work best.

Here is a list of the medications my dad currently takes and their oral side effects:

o Labetalol® — hypertension. May cause persistent sore throat and easy bleeding/bruising.

o Catapress Patch® — hypertension. May cause dry mouth.

o Norvasc®— hypertension. May cause dry mouth.

o Cellcept — suppresses the body's immune system to prevent rejection of transplant. No specific oral side effects noted, but may cause dizziness, drowsiness, headache, nausea, vomiting, diarrhea, gas, tremors, sweating, flushing, insomnia, pain, rash, mood changes, or visual changes.

o Medrol® — corticosteroid (prednisone). Reduces swelling. No specific oral side effects noted, but may cause puffiness of the face, prolonged sore throat, unusual weight gain, muscle weakness, breathing difficulities, mood changes, and sleep disturbances.

o Bactrim® — antibiotic. Other names are Trimethoprim, Sulfamethoxazole, Septra®. Oral side effects include Stevens-Johnson syndrome (severe eruptions around the mouth, anus, or eyes) and inflammation of the mouth and/or tongue, candidiasis

o Protonix® — acid control. No specific oral side effects noted, but other effects are diarrhea, headache, abdominal pain, burping, gas, nausea, vomiting

o Sodium Bicarbonate tablet

o Magnesium Oxide tablet

Many transplant patients take cyclosporin. This medication can cause overgrowth of gingival tissue and bleeding. The excess tissue may overgrow the teeth if initial growth is ignored or dental hygiene is poor. Even though the tissue overgrowth is severe, the bone level is normal, as evidenced in the panoramic radiograph above.

Become an organ donor

Life! How thankful we should all be, especially if we have healthy bodies that function normally, that we can work, live, and play everyday. Dialysis gave my dad the opportunity to continue his life, so I thank God for dialysis and all the accompanying nurses and doctors who render this care. However, life since dialysis is infinitely better! How thankful I am that someone unselfishly decided that, should his own life come to an end, he would be willing to donate his organs to help someone else have a better quality of life.

Transplantations save lives, but only if you help. All you need to do is say "yes" to organ and tissue donation on your donor card and/or driver's license, and discuss your decision with your family. Each day about 63 people receive an organ transplant, but another 16 people on the waiting list die because not enough organs are available.

Talk to your family members about organ and tissue donation so they know your wishes. Even if you've signed something, your family may be asked to give consent before donation can occur. Be an organ and tissue donor. You could save or enhance the lives of more than 50 people!

Here are three excellent Web sites for those interested in learning more about organ donation (There is also a downloadable donor card available from the first Web site listed):

• http://www.organdonor.gov/
• http://www.shareyourlife.org/
• http://www.transweb.org/partnership/

Author's note: I would like personally to thank Dr. Michael Rohr, Dr. Robert Stratta, the complete transplant team, and all the wonderful support staff who are responsible for my dad's surgery and continued recovery.You will never know how you have blessed our lives through your skill and diligence.

Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Lexington, N.C. To contact Glasscoe for speaking or consulting, call (336) 472-3515, fax (336) 472-5567, or email [email protected]. Visit her Web site at www.professional dentalmgmt.com.

In addition to removing wastes, dialysis also removes nutrients that are essential to healthy body functioning. Four essential nutrients are monitored closely during dialysis. These nutrients are protein, sodium, potassium, and phosphorus.

Protein — Protein is needed to build and replace body tissues and make antibodies to fight infections. Adequate protein in the diet is essential to prevent malnutrition and maintain strength. Dialysis rids the body of protein, so the dialysis patient must eat enough high quality protein every day to meet the body's normal protein needs plus replace the protein that is lost in the drained dialysate. High quality protein comes from beef, fresh pork, lamb, poultry, fish, and eggs.

Sodium — Sodium is a mineral that helps to regulate the body's water balance. Although sodium is commonly referred to as salt, they are not the same thing. Table salt is sodium chloride; 40 percent sodium and 60 percent chloride. One teaspoon of salt (five grams) contains 2,300 mg of sodium. Sodium must be limited in a renal diet to help control thirst and blood pressure.

Potassium — Potassium is a mineral that helps the heart to beat normally and helps muscles and nerves work properly. Meats, dairy foods, fruits and vegetables are all good sources of potassium. Some low sodium products, especially salt substitutes, have extremely high potassium levels and should be avoided by all dialysis patients. Potassium that is removed during dialysis treatments has to be adjusted in the diet or with supplements. A low level of potassium in the blood may make a person feel weak. Both high and low potassium in the blood will affect the heart.

Phosphorus — Phosphorus is a mineral that has an important role in all cell functions and is combined with calcium to make bones. In dialysis patients, the balance between phosphorus and calcium is very important. High blood phosphorus levels upset the delicate phosphorus and calcium balance and can ultimately result in itching, bone pain, and brittle bones that break easily. Usually, dialysis alone cannot remove enough phosphorus to keep the blood phosphorus in the normal range. For this reason, dialysis patients need to limit the amount of phosphorus in the diet and take a medicine called a "phosphorus binder" that is prescribed by the doctor.

Infection — The immunosuppressive drugs the organ recipient takes protect the new organ from rejection. However, the suppression of the immune system makes the recipient at risk for infection. In some cases the physician will prescribe a prophylactic agent. Other factors that place the recipient at risk for infection are:

• post operative complications
• other invasive procedures
• status of the donor organ
• preexisting or undiagnosed infection
• development of acute rejection

Hypertension — Another leading side effect of the immunosuppressive drugs is hypertension. The patient's blood pressure needs to be monitored closely and treated with the appropriate medication.

Osteoporosis — Transplant recipients are at risk for osteoporosis due to prednisone, cyclosporin, and Prograf. Prevention of osteoporosis is possible by teaching the patient to include adequate amounts of calcium and vitamin D in their diet. Performing weight-bearing exercises, such as walking, can also reduce the risk of osteoporosis.

Osteoporosis patients should be monitored closely for periodontal disease, as a study conducted by the National Institutes of Health determined that "osteoporosis increased a patient's risk of periodontal disease by 86%."

Nephrotoxicity — Cyclosporin and Prograf® are the most nephrotoxic of the immunosuppressive drugs. Nephrotoxicity can be acute or chronic. Acute nephrotoxicity is generally associated with high blood levels of the anti-rejection medications. When acute nephrotoxicity is detected (increased creatinine levels), the medication dose is lowered and the renal function improves without any permanent damage to the transplanted kidney. Chronic nephrotoxicity is characterized by fibrosis (scarring) of the kidney. Renal function can improve after adjustments in medications, but the fibrosis process is irreversible.

Diabetes — The use of corticosteriods can cause hyperglycemia. Prograf is also a common cause of elevated blood glucose. Patients' lab work has to be monitored closely to detect rises in blood glucose levels. Often adjustments have to be made in the immunosuppressive medications.

Hyperlipidemia — High cholesterol levels and/or triglycerides are a side effect associated with cyclosporin, prednisone, and Prograf. Of course, other risk factors, such as increased age, existing diabetes, weight gain, etc., can predispose patients to increased lipid levels. Adjustments in the medication regime can correct the hyperlipidemia. Diet management, exercise, and weight loss can also lower cholesterol levels.

Hair loss/hair growth — Immunosuppressants can cause hair loss by weakening hair strands, which increases the hair's tendency to break off at the roots. Cyclosporin and prednisone are most frequently associated with excessive hair growth. Excessive hair growth can occur on any part of the body.

Tremors — A frequent and often worrisome side effect of some immunosuppressants is tremors. Tremors are an uncontrollable trembling or quivering of the limbs that is sometimes accompanied by numbness. Tacrolimus and cyclosporin most frequently cause tremors.

Headaches — Increased blood pressure, infection, organ dysfunction, allergies, stress, caffeine, and alcohol are among the numerous potential causes of headaches. In addition, high levels of tacrolimus and cyclosporin can cause headaches. Transplant patients can safely take acetaminophen (Tylenol®) for headaches but should avoid medications such as ibuprofen or naproxen, as the latter two can decrease kidney function.

Rejection — The body's natural immune system attempts to destroy the transplanted organ. The types of rejection are:

o Hyperacute Rejection — occurs within minutes after the organ is transplanted. Antibodies in the recipient react with the donor tissue and quickly leads to graft failure. The only treatment is to remove the organ.

o Accelerated Rejection — similar to hyperacute rejection but generally occurs within three to four days of the transplantation.

o Acute Rejection — occurs between 5 to 90 days after transplantation. The recipient's immune system attempts to reject the organ. Treatment involves adjustments or changes in the immunosuppressive drugs to prevent chronic rejection. Diagnosis is confirmed by renal biopsy. No fibrosis is noted in acute rejection.

o Chronic Rejection — can occur anytime three months after transplantation. This type of rejection damages the organ (fibrosis) and causes gradual decrease in graft function. Treatment involves adjusting or changing the immunosuppressive medications to prolong graft survival. Diagnosis is confirmed by renal biopsy. The recipient will eventually need retransplantation.

Patients need to understand that rejection does not always mean organ failure.

However, the patient must know the signs and symptoms of possible rejection, understand the importance of always taking the immunosuppressive drugs, and understand the importance of follow-up blood work and clinic visits.