NURSING CARE OF

PATIENTS WITH INFECTION

LEARNING OUTCOMES
1. Explain the components and functions of the immune
system and the immune response
2. Compare antibody-mediated and cell-mediated
immune responses
3. Describe the pathophysiology of wound healing,
inflammation, and infection
4. Identify factors responsible for nosocomial infections
5. 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 antiinfectives 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.
2.
3.
4.
5.

Acquired immunity
Active immunity
Adaptive immune response
Anergy
Antibodies

6. Antibody-mediated (humoral)
immune response
7. Antigens
8. B lymphocytes (B cells)
9. Cell-mediated (cellular) immune
response
10.cytokines

11.Endotoxins
12.Exotoxins
13.Immunity
14.Immunocompetent
15.Immunoglobulin (Ig)

16.Infection
17.Innate adaptive immunity
18.Lymphocyte
19.Macrophages
20.Natural killer cells (NK cells, null
cells)

16.Nosocomial infections
17.Passive immunity
18.Pathogens
19.Phagocytosis
20.T lymphocytes (T cells)
21.Vaccines

Foreign Substances That Threatened

the Human Body
Immune system is the bodys major defense
mechanism against infectious organisms and
abnormal or damaged cells
Emergence of resistant microorganisms
1. Methicillin-resistant Staphylococcus aureus
(MRSA)
2. Altered strains of familiar diseases like MultipleDrug-Resistant Tuberculosis
3. Lyme Disease
4. Clostridium difficile
5. Human Immunodeficiency Virus (HIV)

UNDERSTANDING THE FOLLOWING:

1. Local and systemic inflammatory
response
2. Resistance to infectious disease
3. 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. Bacteria
2. Viruses
3. 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 as
1. Lacerations
2. Bruises
. the immune system is also activated by
major injuries such as
1. Burns
2. Surgeries
3. 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. Molecules
2. Cells
3. 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 OUTCOMES
1. Review the normal anatomy and physiology
of the immune system
2. Compare and contrast the four types of
hypersensitivity reactions
3. Explain the pathophysiology of autoimmune
disorders and tissue transplant rejection
4. 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. ALLERGIES
B. AUTOIMMUNE DISORDERS
C. REACTIONS TO ORGAN OR TISSUE
TRANSPLANTS
D. 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 cells
2. Tissues
3. Fluids
.ANTIGENIC 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 microorganisms
2. Cells and tissues from other humans or
animals
3. 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 persons 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. Gender
3. Race
4. 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 ASSESSMENT
The techniques of INSPECTION and PALPATION
are used to assess a patients immune sytem
1. 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 response
2. 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
Kaposis 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 antigenantibody 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 ANTIGENLYMPHOCYTE 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 systems ability to
recognize and destroy foreign tissues
and other antigens, but also on the
immune systems ability to

 Autoimmune disorders can affect any tissue in

the body
Some are tissue or organ specific, affecting a
particular tissue or a particular organ
HASHIMOTOS 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 selfantigens 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 patients
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 patients 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 SJORENS
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 antigenantibody 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

MEDICATIONS
A. 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 antiinflammatory 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 liverkidney, 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: Kidney
.Graft type: allograft; maybe Isograft
.Indications for Transplant: ESRD
.Success Rate: 88.1% at 5 years
2. Organ: Heart
.Graft type: Allograft
.Indication: End stage cardiac disease ,
refractory to medical management
.Success rate: 74.4% at 5 years

3. Organ: Lung
.Graft type: Allograft
.Indications: pulmonary hypertension , cystic/pulmonary
fibrosis, COPD
.RATE: 52.6% at 5 years
4. Organ: Liver
.Graft type: Allograft
.Indications: severe liver dysfunction due to chronic active
hepatitis, primary biliary cirrhosis. Sclerosing cholangitis
.RATE: 73.6% 5-year survival
5. Organ: Bone marrow
.Graft type: Autograft or allograft
.Indications: leukemia, aplastic anemia, congenital
immunologic deffects
.Rate: 30-70% cure

6. Organ: Skin
.Graft type: Autograft, allograft, or
xenograft
.Indications: severe burns, plastic
surgery
.Rate: > 95% at 5 years
7. Organ: Cornea
.Graft type: Allograft
.Indication: corneal ulceration and
opacification
.Rate: >95% at 5 years

8. Organ: Pancreas
.Graft type: Allograft
.Indication: Pancreatic Insufficiency,
diabetes
.Rate: 88.1% at 5 years
9. Organ: Islet cells
.Graft type: Allograft (multiple donor)
.Indication: Type 1 Diabetes Mellitus
.Rate: 100% > 2 years

PATHOPHYSIOLOGY
AUTOGRAFT = a transplant of the patients 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
Examples
1. Bone marrow
2. Blood
3. Kidney
.Most often, organs for transplantation are obtained from a
CADAVER
.Donors are people who meet the criteria for
1. Brain death
2. Less than 65 years old
3. Free of systemic disease
4. Free from malignancy
5. 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 donors
HLA
.Both antibody-mediated and cell-mediated immune
responses are involved in the complex process of hostversus-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. Fever
2. Redness
3. Swelling
4. Tenderness over the graft site
.Sites of impaired function of the transplanted organ may
be noted:
1. Elevated blood urea nitrogen (BUN) and Creatinine
2. Liver enzyme and bilirubin elevations
3. 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 complication
1. Of bone marrow transplant
2. Some liver transplants
3. 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 patients
3. 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 pain
2. Nausea
3. 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 recipients blood type and histocompatibility
Potential donors are identified through diagnostic studies,
and the recipients 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 TEST
1. Blood type of both the donor and recipient are
determined and they must match
2. 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 organs
3. Crossmatchinhg of the patients serum against the
donors 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