moderator: ervin ruzics, md, st. joseph transplant presenters: cynthia herrington, md, children’s...
Post on 23-Dec-2015
214 Views
Preview:
TRANSCRIPT
Moderator:• Ervin Ruzics, MD, St. Joseph Transplant Presenters:• Cynthia Herrington, MD, Children’s Hospital Los Angeles• Mudit Mathur, MD, Loma Linda University MC• Steven Colquhoun, MD, Cedars-Sinai Transplant Center• Clarence Foster, MD, UC Irvine Medical Center
Breakout Session B:
Decoding Transplant Center
Acceptance Criteria
Question to Run On
What practices have you learned today that you will
implement to increase organ acceptance and improve
long-term outcomes?
Objectives
By the end of this presentation, the attendee will be able to:• Understand the key considerations in determining
organ acceptance versus decline• Know which elements of donor management are
most impactful in organ placement and improved outcomes
Children’s Hospital Los Angeles
Cynthia Herrington, M.D.
Associate Professor of Clinical Cardiothoracic Surgery, Keck School of Medicine
Surgical Director of Pediatric Thoracic Transplantation & Ryan Winston Family Chair in Transplant Cardiology at Children’s Hospital Los Angeles
Surgical Director of Lung Transplant Program at USC.
Loma Linda University Children’s Hospital
Mudit Mathur, M.D.
Associate Professor of
Pediatrics
Expanding Transplant Center Acceptance Criteria-Hearts
Mudit Mathur, MDAssociate Professor of Pediatrics/Critical
CareLoma Linda University Children’s
Hospital
Donor quality Recipients July 2000- Dec 2008 84 trasnplants from 86 primary offers
vs. 29 from donors refused by other centers (quality UNOS code 830)
Pediatric Transplantation Using Hearts Refused on the Basis of Donor Quality. Bailey LL, Razzouk A, Hasaniya N et al. Ann Thoracic Surg 2009; 87(6): 1902-8
Recipient outcomes Despite….
Longer recovery distance (p < .002) Longer graft cold ischemic time (p <
0.001) Operative survival 93± 5% 7 year actuarial survival 74
±10.5% NO DIFFERENCE vs. PRIMARY OFFERSPediatric Hearts should seldom be refused on the basis of donor quality
Background Waitlist mortality for infants awaiting heart
transplantation 2465 deaths/1000 patient-years
(10-fold higher than 1-5, 6-10 or 11-17 year groups)
Risks-weight< 3kg, Status 1A, ECMO/VAD, mechanical ventilation, dialysis, race/ethnicity
PICU-potential 40% increase in total donors by including DCD donors
1995-2005 (USA): 683 Pediatric DCD transplants Kidney: 486, liver: 144, Pancreas: 38, Intestine: 1, Heart: 2, Lung: 12
NICU potential?
Methods Review of prospective NICU electronic
database All in-hospital deaths (6/2003-6/2008)
included Potential organ donors (weight > 2.5 kg)
categorized by mode of death Died despite cardiopulmonary resuscitation (CPR) Do not resuscitate (DNR) status Brain death (BD) Withdrawal of life-support (W)
Patients undergoing planned withdrawal evaluated further for suitability as DCD donors
Results 5446 NICU discharges
over 5 years 266 deaths, 117 (44%)
weighed > 2.5 kg 19 died despite CPR, 33
were DNR, 0 brain deaths Withdrawal of life support
in 69(59%)
Withdrawal (n=69) Age 1 d- 225 days Weight 2500-7495 grams 53 excluded-active infection/
significant cardiac dysfunction/ CHD/ MSOF.
16 evaluated further
Results 16 Potential DCD candidates
Median time (Withdrawal to death): 31 minutes (<1 to 310 min)
Withdrawal: Ventilator support (all), Dopa 4-8 mcg (3)
Reason for Withdrawal: Futility, neurodev outcome
Five patients (4.3% of all eligible donors) died in < 30 minutes
Results: 5 suitable DCD donors
Diagnosis Wt (kg) Bld type Echo ALT Creat
HIE 2.58 O+ normal 25 0.4
Midbrain bleed
2.72 O+ normal 29 0.3
BPD 2.99 A+ normal 23 0.4
Axonal dystrophy
5.57 A+ not done 31 0.1
Ribcage abn. 6.64 B+ normal 19 0.7
• No NICU Brain deaths during study period (6/2003-6/2008)
• Loma Linda PICU: 81 BD, 51 Donors, 158 organs transplanted
Potential impact of newborn DCD donors Local-Loma Linda
15/51 listed for heart transplant during the 5-year period studied died/taken off list
(2 NICU donors would have been blood type and size matches)
National 814 infants listed 3-month waitlist mortality 18.2% +
162 waitlist removals
Our approach IRB approval Unmodified DCD donor protocol (5
min) High risk waitlisted infants
consented Waitlisted for > 1 month Milrinone Mechanical Ventilation Dialysis ECMO/VAD
Conclusions Potential DCD donors can be readily
identified among NICU patients undergoing withdrawal of life support (5 infants, 4.3% of all deaths)
Potential is similar to PICU data (5.5-8.7%) Identifying NICU donors may
Markedly expand the infant donor pool Reduce short-term wait-list mortality rates for
infants
References Mathur M, Castleberry D, Job L, J Heart Lung Transpl
2011 ;30(4):389-94. Epub 2010 Dec 24 Koogler T, Costarino A. Pediatrics. 1998;101:1049–1052 Durall AL, Laussen PC, Randolph AG. Pediatrics.
2007;119:e219–e224 Naim MY, Hoehn KS, Hasz RD, White LS, Helfaer MA, Nelson RM.
Crit Care Med. 2008;36:1729–1733 Kolovos NS, Webster P, Bratton SL. Pediatr Crit Care Med.
2007;8:47–49 Pleacher KM, Roach ES, Van der Werf W, Antommaria AH,
Bratton SL. Pediatr Crit Care Med. 2009;10:166–170 Almond CS et al. Waiting list mortality among children listed for
heart transplantation in the United States. Circulation 2009, 119:717-727
Cedars-Sinai Medical Center
Steven Colquhoun, M.D.
Director, Liver Transplantation and
Surgical Oncology
Center for Liver Disease &
Transplantation
Deceased Donor Selection:
Liver
Steven Colquhoun, M.D., FACSDirector, Liver Transplantation
Cedars-Sinai Medical Center
Donor v. Recipient
Donor Quality
Recipient Condition
Balancing Act!
Distance/Cold Time/Expense
CA
NVUT
AZ NM
SF
LA
Rank Order: First Pass
Age Size Hemodynamics Numbers Co-morbidities Time hospitalized
Labs
Enzymes: – Current & Trend v. Mechanism
Sodium– Current & Peak
Serologies– HCV, HBV, HBVc
Bilirubin (?)
Fat Likelihood
– Height/Weight & Age– Diabetes Steroids/co-morbidities
Ultrasound / other imaging Biopsy (problems) Weighed against all other concerns Goal: ≤ 30%
Formulas
Donor Risk Indexes
Absolute cutoffs
– Age, Sodium, Enzymes
Unhelpful
Appearance
ColorTextureExperience
Surprising how often we’re surprised
How it Really Works:
SportsORTantrums
cars
MumblingNew gadgets
SewingCautery
U.C. Irvine Healthcare
Clarence E. Foster III, M.D.
FACS
Chief, Kidney & Pancreas
Transplantation
Associate Clinical Professor,
Department of Surgery, University
of California, Irvine
KIDNEY AND PANCREAS TRANSPLANT CENTER
ACCEPTANCE CRITERIA
Clarence E. Foster, III MD FACS
Chief, Transplantation
Department of Surgery,
School of Medicine
University of California, Irvine
Basic Framework of Donor Acceptance Criteria:AgeDonor Chronic DiseasesDonor Acute DiseasesDonor TypeCold Ischemia Times
Donor AgeKidney Pancreas
Most liberal of all transplanted organs
Infants Age-days to months Sharma A (2011)
○ mean 19 month ○ outcome equivalent to living
donor
Elderly- 70’s and above Boesmueller C (2011)
Age 10 y/o to 50 y/o
© 2011 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 3
.Long-Term Outcome in Kidney Transplant Recipients Over 70 Years in the Eurotransplant Senior Kidney Transplant Program: A Single Center Experience.Boesmueller, Claudia; Biebl, Matthias; Scheidl, Stefan; Oellinger, Robert; Margreiter, Christian; Pratschke, Johann; Margreiter, Raimund; Schneeberger, Stefan
Transplantation. 92(2):210-216, July 27, 2011.DOI: 10.1097/TP.0b013e318222ca2f
FIGURE 2. Death censored graft survival at year 1/5 was 100%/82% in 70+ group and 98.1%/92.7% in 70-group, respectively.
Kidney Donor Diseases Chronic Diseases
DiabetesHypertensionStrokeHepatitis C
Acute Disease
Donor Type
Expanded Criteria Kidney Donors (ECKD)
Donation after Circulatory Death (DCD)
Expanded Criteria Donors (ECD) Definition
Based on significant medical risk factors○ > 60 y/o○ 50-59 y/o with 2 of following:
History of hypertensionCerebrovascular accident as cause of deathFinal pre-procurement creatinine >1.5
RR >1.7 when compared to ideal 10-39 y/o donor
New Allocation for ECD
OPTN/UNOS Board of Directors, November 2001
ECD Kidneys allocated to predetermined patients to be recipients
Purpose is to stimulate use and decrease discard of organs
n
Acceptable Cold Ischemia
Kidney Pancreas
48 to 56 hours 12 to 24 hours
Conclusion
Potential kidney donors are the broadest group of donors when considering age and donor type
Excellent outcomes are achieved in kidney and pancreas transplantation
Question to Run On
What practices have you learned today that you will
implement to increase organ acceptance and improve
long-term outcomes?
top related