NURSING CARE OF PATIENTS WITH INFECTION

LEARNING OUTCOMES1. Explain the components and functions of the immune system and

the immune response2. Compare antibody-mediated and cell-mediated immune

responses3. Describe the pathophysiology of wound healing, inflammation,

and infection4. Identify factors responsible for nosocomial infections5. Discuss the purposes, nursing implications, and health education

for medications and treatments used to treat inflammations and infections

6. Explain the nursing care necessary to prevent and/or monitor the status of infections

CLINICAL COMPETENCIES

1. Apply standard precautions, particularly hand hygiene, to prevent the spread of infection within the patient, to other patients in the facility, and to members of the interdisciplinary team and visitors

2. Use the nursing process as a framework to provide safe, effective individualized care for patients with inflammation and infection

3. Collaborate with the interdisciplinary care team to integrate care of patients with infection

4. promote therapeutic levels and complete dosage of antiinflammatory and anti-infective medication through prompt administration and patient and family teaching

5. Assess for hypersensitivities to anti-infectives prior to administering and during administration

6. Participate in quality improvement processes to reduce the rates and risk of infection for a patient group or population

KEY TERMS

1. Acquired immunity2. Active immunity3. Adaptive immune response4. Anergy5. Antibodies

6. Antibody-mediated (humoral) immune response

7. Antigens8. B lymphocytes (B cells)9. Cell-mediated (cellular) immune response10.cytokines

11.Endotoxins12.Exotoxins13.Immunity14.Immunocompetent15.Immunoglobulin (Ig)

16.Infection17.Innate adaptive immunity18.Lymphocyte19.Macrophages20.Natural killer cells (NK cells, null cells)

16.Nosocomial infections17.Passive immunity18.Pathogens19.Phagocytosis20.T lymphocytes (T cells)21.Vaccines

Foreign Substances That Threatened the Human Body

Immune system is the body’s major defense mechanism against infectious organisms and abnormal or damaged cells

Emergence of resistant microorganisms1. Methicillin-resistant Staphylococcus aureus (MRSA)2. Altered strains of familiar diseases like Multiple-Drug-

Resistant Tuberculosis3. Lyme Disease4. Clostridium difficile5. Human Immunodeficiency Virus (HIV)

UNDERSTANDING THE FOLLOWING:

1. Local and systemic inflammatory response2. Resistance to infectious disease3. The importance of immunization

OVERVIEW OF THE IMMUNE SYSTEM

IMMUNE SYSTEM = is a complex and intricate network of specialized cells, tissues, and organs

Cells of the immune system seek out and destroy damaged cells and foreign tissue

Recognize and preserve host cells Immune system protects the body from infection by:1. Bacteria2. Viruses3. Fungi 4. Parasites

Removes and destroys damaged or dead cells Identifies and destroys malignant cells, thereby

preventing their further development into tumors The immune system is activated by minor injuries

such as1. Lacerations2. Bruises the immune system is also activated by major

injuries such as1. Burns2. Surgeries3. Systemic diseases (Pneumonia)

The response of the immune system maybe innate or adaptive Innate immunity = provides a nonspecific , generic response to

harmful events Adaptive immunity = provides a specific response to unique

organisms and includes memory as well as active and limited responses

Innate adaptive immunity = responses prevent or limit the entry of invaders into the body, thereby limiting the extent of tissue damage and reducing the workload of the adaptive immune system

Inflammation is an innate, nonspecific response activated by both minor and major injuries

When the inflammatory process is unable to destroy invading organisms or toxins, a more specific response, called the ADAPTIVE IMMUNE RESPONSE, is activated

IMMUNE SYSTEM COMPONENTS

The immune system consists the following that produce the immune response

1. Molecules2. Cells3. Organs These components may be involved in the

innate inflammatory response, the adaptive immune response, or both

1. LEUKOCYTES Leukocytes (white blood cells, WBCs) are the primary cells

involved in both innate and adaptive immune system responses

It is derive from stem cells, the hemocytoblasts, in the bone marrow

Red blood cells (RBCs) are confined to the circulation But Leukocytes use the circulation to transport themselves

to the site of an inflammatory or immune response As the mobile units of the immune system, LEUKOCYTES

detect, attack, and destroy anything that is recognized as “FOREIGN”

They are able to move through tissue spaces, locating damaged tissue and infection by responding to chemicals released by other leukocytes and damaged tissue

2. GRANULOCYTES

3. MONOCYTES, MACROPHAGES, AND DENDRITIC CELLS

4. LYMPHOCYTES

ANTIGENS

LYMPHOID SYSTEM

INNATE IMMUNE RESPONSE

IMMUNOGLOBULINS

THE PATIENT WITH NATURAL OR ACQUIRED IMMUNITY

ADAPTIVE IMMUNE RESPONSE

INTERDISCIPLINARY CARE

IMMUNIZATIONS

NURSING CARE

NORMAL IMMUNE RESPONSE

THE PATIENT WITH AN INFECTION

PATHOGENIC ORGANISMS

NOSOCOMIAL INFECTIONS

ANTIBIOTIC-RESISTANT MICROORGANISMS

MEDICATIONS

STANDARD PRECAUTIONS

TRANSMISSION-BASED PRECAUTIONS

COMMUNITY-BASED CARE

NURSING CARE OF PATIENTS WITH ALTERED IMMUNITY

I. LEARNING OUTCOMES1. Review the normal anatomy and physiology of

the immune system2. Compare and contrast the four types of

hypersensitivity reactions3. Explain the pathophysiology of autoimmune

disorders and tissue transplant rejection4. Discuss the characteristics of

immunodeficiencies

5. Identify laboratory and diagnostic tests used to diagnose and monitor immune response

6. Describe interdisciplinary therapies and medications used to threat patients with altered immunity

7. Correlate the pathophysiologic alterations with the manifestations of HIV/AIDS infection

CLINICAL COMPETENCIES

1. Assess functions health status of patients with altered immunity and monitor, document, and report abnormal manifestations

2. Assess for hypersensitivities and anticipate interdisciplinary interventions if manifestations develop

3. Provide patient teaching about hypersensitivities, avoidance of sensitizing agents, and prophylactic treatment

4. Use appropriate interventions to protect patients who are immune suppressed

5. Recognized the burden and benefit of highly active antiretroviral drug therapy (HAART) for the patient with HIV infection

6. Use the nursing process as a framework to provide safe and individualized care to patients with altered immune responses

7. Revise plan of care as needed to provide safe and knowledgeable interventions to promote or restore functional health status to patients with altered immunity

EXAMPLES OF HYPERRESPONSIVENESS IMMUNE FUNCTION

A. ALLERGIESB. AUTOIMMUNE DISORDERSC. REACTIONS TO ORGAN OR TISSUE TRANSPLANTSD. AIDS E. IMMUNODEFICIENCY DISORDERS Altered immune system response include those

characterized by an impaired immune response Immunodeficiency disorders result from impairment

of the immune system

OVERVIEW OF THE IMMUNE SYSTEM

1. The immune system protects the body from invasion by foreign antigens

2. Identifies and destroys potentially harmful cells 3. Removes cellular debris These functions are accomplished by the

lymphoid organs and specifically designed lymphocytes through the processes of antibody-mediated immune response and cell-mediated immune response

The effectiveness of the immune system depends on its ability to differentiate normal host tissue from abnormal or foreign tissue

The following have unique antigenic properties recognized by the immune system as “SELF”

1. Body cells2. Tissues 3. FluidsANTIGENIC SUBSTANCES = stimulate an immune

system response, but when identified as “self”, the competent immune system does not react

ANTIGENIC SUBSTANCES RECOGNIZED BY THE IMMUNE SYSTEM AS “NONSELF”

1. External agents, such as microorganisms2. Cells and tissues from other humans or animals3. Some inorganic substances Each body cell displays specific cell surface

characteristics, or markers, that are unique to each person

These are known as HUMAN LEUKOCYTE ANTIGENS (HLAs)

A person’s HLA characteristics are coded within a large cluster of genes known as the MAJOR HISTOCOMPATIBILITY COMPLEX (MHC) located on CHROMOSOME 6

Chromosomes are paired, with each person inheriting one member of the pair from each parent

A chromosome pair contains multiple genes, each carrying instructions for production of one polypeptide chain

The number of genes in the MHC results in a multitude of HLA combinations

As a result, the possibility of two people having the same HLA type is extremely remote

Identical twins may be the exception , and some siblings have very similar HLA patterns

In tissue grafting and organ transplants, matching the HLA type as closely as possible tends to decrease rejection

Immunocompetent people have an immune system that identifies antigens and effectively destroys or removes them

When the immune system functions improperly, the result may be an overreaction or a deficiency, resulting in health problems

Overreaction of the immune system leads to hypersensitivity disorders, such as allergies

When the immune system loses the ability to recognize self, autoimmune disorders may ensue

When the immune system is incompetent or unable to respond effectively, as in the case of ACQUIRED IMMUNODEFICIENCY disorder, immunodeficiency diseases or malignancies can develop

ANTIBODY-MEDIATED IMMUNE RESPONSE = is accomplished by B lymphocytes (B cells)that are further divided into memory cells and plasma cells

They are activated by contact with an antigen and by T cells

B cells produce antibodies, also known as IMMUNOGLOBULINS, and serve to inactivate an invading antigen

IgM forms natural antibodies, such as those for ABO blood group antigens, and is an important component of the immune system complexes seen in autoimmune disorders

Memory cells “remember” an antigen, and, when exposed to it a second time, immediately initiate the immune response

This action provides the foundation of acquired immunity

The T cell component of the immune system identifies cells containing antigens and signals B cells and other components of the immune system to attack infected cells

T lymphocytes do not secrete antibodies T lymphocytes are subdivided into effector cells

and regulator cells

The CYTOTOXIC CELL or KILLER T CELL is the primary effector cell

Regulator T cells are divided are divided into two subsets known as HELPER T CELLS and SUPPRESSOR T CELLS

Cytotoxic T lymphocytes also attack malignant cells and are responsible for the rejection of transplanted organs and grafted tissues

Immune function is also affected with aging

MEMORY CUE

1. B lymphocytes produce antibodies and cytokines to cause extracellular immunity and acquired immunity

2. T lymphocytes produce cytokines to cause intracellular immunity and acquired immunity

ASSESSING ALTERED IMMUNE SYSTEM FUNCTION

Optimal immune function depends on intact skin and mucous membrane barriers, adequate blood cell production and differentiation, a functional system of lymphatics and the spleen, and the ability to differentiate foreign tissue and pathogens from normal body tissue and flora

Because of this diversity of organs and function, assessment of the immune system is often integrated throughout the history and physical examination

HEALTH HISTORY Before conducting the health history, review the

biographic data including:1. Age 2. Gender3. Race4. Ethnic background Many autoimmune disorders are more prevalent in

women than in men Family history is also important because there is a

genetic component in the etiology of many disorders affecting the immune system

Many interview questions related to the immune system and disorders that affect it are of a sensitive nature

Be sure to provide privacy prior to the interview If family members are present, request that they

leave Ask the least sensitive questions before moving

into those that are more sensitive, such as thgose related to the use of illicit drugs or sexual activity

Cultural sensitivity is necessary for effective communication

PHYSICAL ASSESSMENTThe techniques of INSPECTION and PALPATION are

used to assess a patient’s immune sytem1. Assess the general appearance; evident fatigue or

weakness may indicate acute or chronic illness or immunodeficiency

Note whether the stated and apparent age coincide Assess height, weight, and body type for apparent

weight loss or wasting Observe ease of movement and note any evident

stiffness or difficulty moving

Check vital signs An elevated temperature may indicate an

infection or inflammatory response2. Inspect the mucous membranes of the nose

and mouth for color and condition Pale, boggy (edematous) nasal mucosa is often

associated with chronic allergies Note petechiae, white patches, or lacy white

plaques in the oral mucosa; they may indicate hemolysis or immunodeficiency

3. Assess skin color, temperature, and moisture Pale or jaundiced skin may indicate a hemolytic

reaction Pallor may also indicate bone marrow suppression

with accompanying immunodeficiency Inspect the skin for evidence of rashes or lesions,

such as petechiae; numerous bruises; purple or blue patches or lesions indicative of Kaposi’s sarcoma; and wounds that are infected, inflamed, or unhealed

Note the location and distribution of any rashes or lesions

Inspect and palpate the cervical, axillae, and groin lymph nodes for evidence of lymphadenopathy (swelling) or tenderness

4. Inspect and palpate the joints for redness, swelling, tenderness, or deformity, which may indicate an autoimmune disorder such as rheumatoid arthritis or systemic lupus erythematosus

Assess joint range of motion, including the spine

THE PATIENT WITH A HYPERSENSITIVITY REACTION

HYPERSENSITIVITY = is an altered immune response to an antigen that results in harm to the patient

When the antigen is environmental or exogenous, it is called an ALLERGY, and the antigen is referred to as an ALLERGEN

The tissue response to a hypersensitivity reaction may be bothersome, causing a runny nose or itchy eyes, or it may be life threatening, leading to blood cell hemolysis or laryngospasm, an involuntary tightening of the muscles of larynx that causes difficulty inhaling

Hypersensitivity reactions are primarily classified by the type of immune response that occurs on contact with the allergen

They may also be classified as immediate or delayed hypersensitivity responses

Anaphylaxis and transfusion reactions are examples of immediate hypersensitivity reactions; contact dermatitis is a typical delayed response

Allergies are sometimes referred to by the affected organ system (e.g., allergic rhinitis) or the allergen involved, as in hay fever

More than one type of reaction may occur simultaneously

PATHOPHYSIOLOGY

In a hypersensitivity reaction, an antigen-antibody or antigen-lymphocyte interaction causes a response that is damaging to body tissues

Antigen-antibody responses characterize types I, II, and III, also known as IMMEDIATE HYPERSENSITIVITY RESPONSES

Type IV hypersensitivity is an ANTIGEN-LYMPHOCYTE REACTION, resulting in a DELAYED HYPERSENSITIVITY RESPONSE

TYPE I IgE – MEDIATED

THE PATIENT WITH AN AUTOIMMUNE DISORDER

AUTOIMMUNE DISORDER = when self-recognition is impaired and immune defenses are directed against normal host tissue

Maintaining optimal health and preventing disease depend not only on the immune system’s ability to recognize and destroy foreign tissues and other antigens, but also on the immune system’s ability to recognize self

Autoimmune disorders can affect any tissue in the body Some are tissue or organ specific, affecting a particular

tissue or a particular organ HASHIMOTO”S THYROIDITIS is an example of an organ-

specific autoimmune disorder Circulating antibodies are formed to certain thyroid

components, resulting ultimately in destruction of the gland

In other disorders, autoantibodies are formed that are not tissue specific, but tend to accumulate and cause an inflammatory response in certain tissue, for example, the renal glomeruli or the hepatic small bile ductules

Autoimmune disorders may also be systemic, with neither antibodies nor the resulting inflammatory lesions confined to any one organ

Rheumatologic disorders, such as rheumatoid arthritis and systemic lupus erythematosus (SLE), arte characteristic of systemic autoimmune disorders

PATHOPHYSIOLOGY The mechanism that causes the immune system

to recognize host tissue as a foreign antigen is not clear

FOLLOWING FACTORS UNDER STUDY SERVE AS THE POSSIBLE CONTRIBUTORS TO THE DEVELOPMENT OF AUTOIMMUNE DISORDER

1. The release of previously “HIDDEN” antigens into the circulation, such as DNA or other components of the cell nucleus, which elicits an immune response

2. Chemical, physical, or biologic changes in host tissue that cause self-antigens to stimulate the production of autoantibodies

3. The introduction of an antigen, such as bacteria or virus, whose antigenic properties closely resemble those of host tissue, resulting in the production of antibodies that target not only the foreign antigen but also normal tissue

This is termed MOLECULAR MIMICRY

Heart damage in rheumatic fever and acute glomerulonephritis following beta-hemolytic streptococcal infections are examples of the development of antibodies against normal tissue

4. A defect in normal cellular immune function that allows B cells to produce autoantibodies unchecked

5. Initiation of the autoimmune response by very slow-growing mycobacteria

Although the exact mechanism producing autoimmunity is unclear, several characteristics of autoimmune diseases are known

It is apparent that genetics plays a role because a higher incidence is seen in family members of people with autoimmune disorders

More than one genetic change is likely occurring to cause development of these disorders

Autoimmune disorders are far more prevalent in females than in males

There is evidence that ESTROGEN STIMULATES THE IMMUNE RESPONSE while ANDROGENS SUPPRESS THE IMMUNE RESPONSE

The disorders tend to overlap, so that the patient with one autoimmune disorder may develop another or some manifestations of another

The onset of an autoimmune disorder is frequently associated with a physical or psychologic stressor

Autoimmune disorders are frequently characterized by periods of exacerbation and remission

INTERDISCIPLINARY CARE

Diagnosis of an autoimmune disorder is based on the patient’s manifestations

Although the manifestations of this disorders can often be managed, a cure typically is not possible unless the affected target tissue is removed. (e.g., colectomy for the patient with ulcerative colitis)

DIAGNOSIS Serologic assays are used to identify and measure antibodies

directed toward host tissue antigens or normal cellular components

1. ANTINUCLEAR ANTIBODY (ANA) =detects antibodies produced to DNA and other nuclear material

These antibodies can cause tissue damage characteristic of autoimmune disorders such as SLE

The patient’s serum is combined with nuclear material and tagged antihuman antibody to detect ANA-antihuman antibody complexes

A negative, or normal, result is a titer <1:20 When complexes are detected at higher titer levels (>1:20),

the test is positive for ANA

2. LUPUS ERYTHEMATOSUS (LE) CELL TEST = is used to detect SLE and monitor its treatment

Neutrophils that contain large masses of phagocytized DNA from the nuclei of PMNs are called LE cells

Like the ANA, the LE cell test is nonspecific for SLE A positive result may also be seen in rheumatoid

arthritis (RA) or with medications such as isoniazid, clofibrate, penicillin, phenytoin, procainamide, streptomycin, tetracyline, trazodone, oral contraceptives, or sulfonamide drugs

3. RHEUMATOID FACTOR (RF) = is an immunoglobulin present in the serum of approximately 80% of patients with rheumatoid arthritis

A person with RA may not have detectable RF Low titer levels (<1:20) may normally be present in the

older adult RF titer 1:80 or higher indicates RA A titer between 1:20 and 1:80 could indicate SLE,

scleroderma, or liver cirrhosis Results are also reported as IU/ml Above 20 IU/ml is indicative of RA or SJOREN’S

SYNDROME, a disease in which autoantibodies attack the moisture-producing glands to cause dry eyes and dry mouth

4. COMPLEMENT ASSAY = may also be useful in identifying autoimmune disorders

In these disorders, complement may be consumed in the development of antigen-antibody complexes

Decreased levels are seen on examination Both total complement level and amounts of

individual components of the complement cascade can be determined

5. ANTI CCP ANTIBODY TEST = is a blood test for RA. It measures anti-cyclic citrullinated peptide antibody

in blood; the results are specific for RA These antibodies replace normal protein in the

joints of patients with RA

MEDICATIONSA. ANTI-INFLAMMATORY MEDICATIONS 1. Aspirin 2. Nonsteroidal anti-inflammatory drugs (NSAIDs)3. Corticosteroids This is to reduce the inflammatory response Minimize tissue damage When these agents are not effective or well tolerated

by the patient, disease-modifying antirheumatic drugs or slow-acting anti-inflammatory medications may be prescribed

4. Cytotoxic drugs may be used in combination with plasmapheresis in treating many autoimmune disorders

5. Disease-modifying antirheumatic drugs (DMARDs) = reduce manifestations, reduce or prevent joint damage, and preserve the structure and function of the joints in patients with RA

The most common DMARDs in current use are:1. Methotrexate (Rheumatrex)2. Sulfasalazine Azulfidine)3. Hydroxychloroquine (Plaquenil)4. Leflunomide (Arava)5. Cyclosporine (Sandimmune, Neoral)

6. Another class of Antirheumatic drugs, referred to as BIOLOGICALS OR BIOLOGICAL RESPONSE MODIFIERS consists of laboratory-produced proteins that decrease the inflammatory process

These antibodies bind tumor necrosis factor alpha (TNF-) and interleukin-1, both inflammatory elements

These medications include infliximab (Remicade) or adalimumab (Humira), etanercept (Enbrel), anakinra (Kineret), Rituxan, and abatacept (Orencia)

7. Slow-acting anti-inflammatory drugs, including gold salts, hydroxychloroquine (Plaquenil), and Penicillamine, may be used when other therapies are ineffective or not tolerated by the patient

These drugs, however, are relatively toxic and less frequently used

NURSING CARE

Nursing Interventions for the patient with an autoimmune disorder are individualized and tailored to needs dictated by manifestations of the disorder

NURSING DIAGNOSIS

1. Activity Intolerance related to inflammatory effects of autoimmune disorder

2. Ineffective Coping related to chronic disease process

3. Interrupted Family Processes related to lack of understanding about autoimmune disorder and its effects

4. Ineffective Protection related to disordered immune function

COMMUNITY-BASED CARE

1. Teaching the patient and family about the disorder and its management is a key nursing intervention

2. Effective teachings for patient taking drugs with multiple side effects or long-term effects

3. Provide psychologic support, listening and teachinh

THE PATIENT WITH A TISSUE TRANSPLANT

The first kidney transplant was performed to the identical twins in year 1954

The transplantation of avascular tissues, such as skin, cornea, bone, and heart valves, is considered routine, with little need for tissue matching and IMMUNOSUPPRESSION (the use of drugs to make the immune response less effective)

Transplants of organs (e.g., the kidney, heart, heart and lung, liver, and bone marrow)are increasingly common

Transplant success is closely tied to obtaining an organ with tissue antigens as close to those of the recipient as possible

Every body cell has cell surface antigens known as HUMAN LEUKOCYTE ANTIGENS (HLA) that are unique to the individual

Even though identical twins have the same HLA type, a few of their antigens may be dissimilar enough to cause a transplant between them to be rejected

Matching the HLA type of the donor and recipient as closely as possible decreases the potential for rejection of the transplanted organ or tissue but does not eliminate it

Combining multiple organs for transplant such as liver-kidney, heart-liver, or heart-lung seems to be protective from rejection

The multiplicity of antigens seems to increase tolerance or may produce an “Immune Paralysis”)

ORGAN TRANSPLANT INDICATIONS & SUCCESS RATE

1. Organ: KidneyGraft type: allograft; maybe Isograft Indications for Transplant: ESRDSuccess Rate: 88.1% at 5 years2. Organ: HeartGraft type: Allograft Indication: End stage cardiac disease , refractory to

medical managementSuccess rate: 74.4% at 5 years

3. Organ: Lung Graft type: Allograft Indications: pulmonary hypertension , cystic/pulmonary fibrosis,

COPD RATE: 52.6% at 5 years4. Organ: Liver Graft type: Allograft Indications: severe liver dysfunction due to chronic active

hepatitis, primary biliary cirrhosis. Sclerosing cholangitis RATE: 73.6% 5-year survival5. Organ: Bone marrow Graft type: Autograft or allograft Indications: leukemia, aplastic anemia, congenital immunologic

deffects Rate: 30-70% cure

6. Organ: SkinGraft type: Autograft, allograft, or xenograftIndications: severe burns, plastic surgeryRate: > 95% at 5 years7. Organ: CorneaGraft type: AllograftIndication: corneal ulceration and

opacificationRate: >95% at 5 years

8. Organ: PancreasGraft type: AllograftIndication: Pancreatic Insufficiency, diabetesRate: 88.1% at 5 years9. Organ: Islet cellsGraft type: Allograft (multiple donor)Indication: Type 1 Diabetes MellitusRate: 100% > 2 years

PATHOPHYSIOLOGY AUTOGRAFT = a transplant of the patient’s own tissue, is

the most successful type of tissue transplant Skin grafts are the most common example Autologous bone marrow transplants and blood

transfusions are being used to reduce immunologic responses

ISOGRAFT = when the donor and the recipient are identical twins

Because of the high likelihood of an HLA match, the success of these grafts is good and rejection of episodes are mild

Identical twins belongs to the few people that can provide tissue for donation, and when the need is for an organ such as heart, liver, or lungs, a living donor transplantation is not possible

ALLOGRAFTS = grafts between members of the same species that have different genotypes and HLA

Most often organ and tissue transplants Allografts may come from living donors Examples1. Bone marrow2. Blood3. Kidney Most often, organs for transplantation are obtained from a CADAVER Donors are people who meet the criteria for1. Brain death2. Less than 65 years old3. Free of systemic disease4. Free from malignancy5. Free from infection, including HIV, Hepatitis B or Hepatitis C

The organ is removed immediately before or after cardiac arrest and preserved until it is transplanted into the waiting recipient

XENOGRAFT = a transplant from an animal species to a human The least successful but may be used in selected instances :1. Use of pig skin = temporary covering from a massive burn HISTOCOMPATIBILITY = the ability of cells and tissues to survive

transplantation without immunologic interference by the recipient

Tissue typing is used to determine HC Tissue typing is performed in an attempt to match the donor

and recipient as closely as possible for HLA type and blood type and to identify performed antibodies to the donor’s HLA

Both antibody-mediated and cell-mediated immune responses are involved in the complex process of host-versus-graft transplant rejection

Host macrophages process donor antigen, presenting it to T and B lymphocytes

Activated lymphocytes (B & T cells) produce both antibody- and cell-mediated effects

Killer T cells bind with cells of the transplanted organ, resulting in cell lysis

Helper T cells the multiplication and differentiation of B cells, and antibodies are produced to graft endothelium

Complement activation or antibody-dependent cell mediated cytotoxicity leads to transplant cell destruction

Rejection typically begins after the first 24 HOURS of the transplant, although it may present immediately

Rejection episodes are characterized as HYPERACUTE, ACUTE, or CHRONIC

HYPERACUTE TISSUE REJECTION Occurs immediately to 2-3 days after the transplant of new tissue Rejection is due to performed antibodies and sensitized T cells to

antigens in the donor organ It is more likely to occur in patients who have had a previous

organ or tissue transplant Example:1. Blood transfusion = may be evident even before the transplant

procedure is completed The grafted organ appears initially pink and healthy, but soon

becomes soft and cyanotic as blood flow is impaired Organ function deteriorates rapidly, and manifestations of organ

failure develop

ACUTE TISSUE REJECTION The most common and treatable type of rejection episode It occurs between 4 days and 3 months after the transplant Acute rejection is mediated primarily by the cellular immune

response, resulting in transplant cell destruction The patient experiencing acute rejection demonstrates

manifestations of the inflammatory process:1. Fever2. Redness3. Swelling4. Tenderness over the graft site Sites of impaired function of the transplanted organ may be noted:1. Elevated blood urea nitrogen (BUN) and Creatinine2. Liver enzyme and bilirubin elevations3. Elevated cardiac enzymes 4. Signs of cardiac failure

CHRONIC TISSUE REJECTION

Occurs from 4 months to years after transplant of new tissue

Chronic rejection is most likely the result of antibody-mediated immune responses

Antibodies and complement are deposited in transplant vessel walls, causing narrowing and decreased function of the organ due to ischemia

The gradual deterioration of transplanted organ function is seen with chronic tissue rejection

GRAFT-VERSUS-HOST DISEASE (GVHD) • A frequent and potentially fatal complication1. Of bone marrow transplant2. Some liver transplants3. Transfusions with nonirradiated blood to

immunocompromised patients When there is no close match between donor and

recipient HLA, immunocompetent cells in the grafted tissue recognize host tissue as foreign and mounth a cell-mediated immune response

If the host is immunocompromised, as in the case of bone marrow transplant, host cells are unable to destroy the graft and instead become the targets of destruction

3 IMPORTANT STRATEGIES FOR PREVENTING OR DECREASING THE SEVERITY OF GVHD

1. Deleting donor T cells in the tissue or organ prior to infusion into the patient (however, this may increase the risk of graft failure and infection

2. Using umbilical cord stem cells in adult patients3. Closer HLA matching between donor and recipient 4. Acute GVHD occurs within the first 100 days

following a transplant and primarily affects the skin, liver, and gastrointestinal tract

The patient develops a maculopapular pruritic rash beginning on the palms of the hands and soles of the feet

The rash may spread to involve the the entire body and lead to desquamation

Gastrointestinal manifestations incude:1. Abdominal pain2. Nausea3. Bloody diarrhea GVHD that lasts longer than 100 days is said to be

chronic If it is limited to the skin and liver, the prognosis is POOR

INTERDISCIPLINARY CARE Pretransplant care and post-transplant care are directed toward

reducing the risk that transplanted tissue will be rejected or result in GVHD

Diagnostic studies are directed first at identifying the potential recipient’s blood type and histocompatibility

Potential donors are identified through diagnostic studies, and the recipient’s immune response to the transplant is monitored

Immunosuppressive therapy with medications is a vital part of post-transplant care

The development of effective immunosuppressive drugs as well as improved methods of tissue typing are responsible for the success of organ transplants using allografts

DIAGNOSTIC TEST1. Blood type of both the donor and recipient are determined

and they must match2. DNA Sequencing = is made on blood cells to determine

histocompatibility Sequencing can be completed quickly Quick response is important to minimize cold ischemia in

cadaverous organs3. Crossmatchinhg of the patient’s serum against the donor’s

lymphocytes is performed to identify any performed antibodies against antigens on donor tissues

4. If present, these antibodies would likely result in an immediate or hyperacute graft rejection with probable loss of the transplant

IMPAIRED IMMUNE RESPONSE

THE PATIENT WITH HIV INFECTION

ANTIRETROVIRAL DRUGS