Renal Transplant Renal Transplant Evaluation Process Evaluation Process

Shobha Ratnam M.D.,Ph.D.Shobha Ratnam M.D.,Ph.D.

Assistant Professor of MedicineAssistant Professor of Medicine

University of Toledo-College of University of Toledo-College of MedicineMedicine

IntroductionIntroduction

• 19541954First successful kidney transplant First successful kidney transplant performed.performed.

• 19661966 First simultaneous kidney/pancreas First simultaneous kidney/pancreas transplant performed.transplant performed.

• 19671967First successful liver transplant First successful liver transplant performed.performed.

• 19681968First successful isolated pancreas First successful isolated pancreas transplant performed. transplant performed. First successful heart transplant First successful heart transplant performed. performed.

Introduction (contd.)Introduction (contd.)• 19771977 Implementation of the first computer-based Implementation of the first computer-based

organ matching system, dubbed the "United organ matching system, dubbed the "United Network for Organ Sharing.“Network for Organ Sharing.“

• 19841984The National Organ Transplant Act, passed The National Organ Transplant Act, passed by Congress in outlawed the sale of human organs by Congress in outlawed the sale of human organs and began the development of a national system and began the development of a national system forfor

• organ sharing and a scientific registry to collect organ sharing and a scientific registry to collect and report transplant dataand report transplant data

• 19861986 UNOS receives the initial federal contract to UNOS receives the initial federal contract to operate the operate the Organ Procurement and Transplantation Network (OPTN).(OPTN).

• 19921992UNOS helps found UNOS helps found Donate Life America to to build public support for organ donation. build public support for organ donation.

Introduction (contd.)Introduction (contd.)

• 1995 1995 UNOS launches its first Web site for all UNOS launches its first Web site for all users with an interest in transplantation.users with an interest in transplantation.

• 2001 2001 For the first time, the total of living For the first time, the total of living organ donors for the year (6,528) exceeds the organ donors for the year (6,528) exceeds the number of deceased organ donors (6,081).number of deceased organ donors (6,081).

• 2006 2006 UNOS launches DonorNetsm, a secure, UNOS launches DonorNetsm, a secure, Internet-based system in which organ Internet-based system in which organ procurement coordinators send out offers of procurement coordinators send out offers of newly donated organs to transplant hospitals newly donated organs to transplant hospitals with compatible candidates.with compatible candidates.

Introduction (contd.)Introduction (contd.)

• UNOS’ Patient Services Department UNOS’ Patient Services Department provides transplantation and donation provides transplantation and donation information to patients, family members, information to patients, family members, friends, potential donors and medical friends, potential donors and medical professionals. Information can be professionals. Information can be requested on topics such as:requested on topics such as:

• The transplantation and donation process The transplantation and donation process • Living donation Living donation • Various national, regional, state and Various national, regional, state and

center-specific data reports center-specific data reports

Transplant StatisticsTransplant Statistics

  • Waiting list candidates as of Waiting list candidates as of

Nov,2010 109,300Nov,2010 109,300• Active waiting list candidates 72,137 waiting list candidates 72,137• Transplants January – July 2010, Transplants January – July 2010,

16,77916,779• Donors January - July 2010, 8,477Donors January - July 2010, 8,477

ORGAN SHARING ORGAN SHARING SYSTEMSYSTEM

The F.M. Kirby Foundation Organ The F.M. Kirby Foundation Organ Center Center

• The primary functions of the Organ The primary functions of the Organ Center are to: Center are to:

• assist in placing donated organs for assist in placing donated organs for transplantation transplantation

• assist in gathering donor information and assist in gathering donor information and running the donor/recipient computer running the donor/recipient computer matching process matching process

• assist with transportation of organs and assist with transportation of organs and tissues for the purposes of transplantation tissues for the purposes of transplantation

• act as a resource to the transplant act as a resource to the transplant community regarding organ-sharing community regarding organ-sharing policies policies

The Donation ProcessThe Donation Process

• When organs are donated, a complex When organs are donated, a complex process begins. UNOS maintains a process begins. UNOS maintains a centralized computer network, UNetSM, centralized computer network, UNetSM, which links all organ procurement which links all organ procurement organizations (OPOs) and transplant organizations (OPOs) and transplant centers. Transplant professionals can centers. Transplant professionals can access this computer network 24 hours a access this computer network 24 hours a day, seven days a week. day, seven days a week.

• UNet electronically links all transplant UNet electronically links all transplant hospitals and OPOs in a secure, real-time hospitals and OPOs in a secure, real-time environment using the Internet.environment using the Internet.

The Five StepsThe Five StepsIn Organ MatchingIn Organ Matching

1.1. An organ is donatedAn organ is donatedOPO managing the donor enters medical information about OPO managing the donor enters medical information about

the donorthe donorincluding organ size and condition, blood type and tissue type including organ size and condition, blood type and tissue type

into the into the UNOS computer system.UNOS computer system.

2. A list of potential recipients is generated2. A list of potential recipients is generatedThe UNOS computer system generates a list of candidates The UNOS computer system generates a list of candidates

who havewho havemedical and biologic profiles compatible with the donor’s. medical and biologic profiles compatible with the donor’s.

The computerThe computerranks candidates based upon how closely their medical ranks candidates based upon how closely their medical Characteristics match the donor’s, medical urgency, time Characteristics match the donor’s, medical urgency, time

spent waitingspent waitingand proximity of candidates to the donor.and proximity of candidates to the donor.

The Five StepsThe Five StepsIn Organ Matching (contd.)In Organ Matching (contd.)

3. The transplant center is3. The transplant center isnotified of an available organnotified of an available organOrgan placement specialists at the OPO or theOrgan placement specialists at the OPO or theUNOS Organ Center contact the transplant centersUNOS Organ Center contact the transplant centerswhose patients appear on the ranked list.whose patients appear on the ranked list.

4. The transplant team considers4. The transplant team considersthe organ for the patientthe organ for the patientWhen the team is offered an organ, it bases its acceptance or refusalWhen the team is offered an organ, it bases its acceptance or refusalof the organ upon established medical criteria, organ condition, of the organ upon established medical criteria, organ condition,

candidate candidate condition, staff and patient availability and organ transportation.condition, staff and patient availability and organ transportation.By policy, the transplant team has only one hour to make itsBy policy, the transplant team has only one hour to make itsdecision.decision.5. The organ is accepted or declined5. The organ is accepted or declinedIf the organ is not accepted, the OPO continues to offer it for If the organ is not accepted, the OPO continues to offer it for

patientspatientsat other centers until it is placed.at other centers until it is placed.

The importance of timeThe importance of time

• The length of time donated organs The length of time donated organs and tissues can be kept outside the and tissues can be kept outside the body vary: body vary:

• Heart: 4-6 hoursHeart: 4-6 hoursLiver: 12-24 hoursLiver: 12-24 hoursKidney: 48-72 hoursKidney: 48-72 hoursHeart-Lung: 4-6 hoursHeart-Lung: 4-6 hoursLung: 4-6 hoursLung: 4-6 hours

Expanded Criteria DonorsExpanded Criteria Donors

• ““Less traditional” donors who are 60Less traditional” donors who are 60• or older or who are between 50-59or older or who are between 50-59• with at least two of the followingwith at least two of the following• conditions: 1. history of high bloodconditions: 1. history of high blood• pressure; 2. creatinine level of greaterpressure; 2. creatinine level of greater• than 1.5 (a creatinine test measuresthan 1.5 (a creatinine test measures• how well a kidney is functioning withhow well a kidney is functioning with• a normal range of 0.8-1.4); 3. causea normal range of 0.8-1.4); 3. cause• of death was from a cerebrovascularof death was from a cerebrovascular• accident (stroke or aneurysm).accident (stroke or aneurysm).

Organ Allocation POL ICY DEVELOPMENTOrgan Allocation POL ICY DEVELOPMENT

Challenges are what make life interesting;overcoming them is what makes life meaningful.

JOSHUA J. MARINE

Conditions for coverage for Conditions for coverage for ESRD facilitiesESRD facilities

• CMS mandates that accredited dialysis CMS mandates that accredited dialysis centers providecenters provide

-evidence of transplant education-evidence of transplant education

-track patient’s transplant referrals-track patient’s transplant referrals

-track patient’s transplant status -track patient’s transplant status on waiting on waiting

listlist

communicate with transplant communicate with transplant facilitiesfacilities

Healthy People 2010 goalHealthy People 2010 goal

““Increase the proportion of Increase the proportion of dialysis patients waitlisted dialysis patients waitlisted and/or receiving a deceased and/or receiving a deceased donor kidney transplant donor kidney transplant within one year of ESRD within one year of ESRD start”start”

Concept of “WHOLE”Concept of “WHOLE”

Informed decision making by patients re: Informed decision making by patients re: transplanttransplant

• WWithout disability paymentsithout disability payments

social security benefits end 12 months after social security benefits end 12 months after transplanttransplant

• HHigh cost of medicationsigh cost of medications

$3000-$5000 a year$3000-$5000 a year• OOut of pocket expenses for doctors, specialists, ut of pocket expenses for doctors, specialists,

examsexams

Medicare pays 80% of costs and 20% paid by Medicare pays 80% of costs and 20% paid by American Kidney Fund while on dialysisAmerican Kidney Fund while on dialysis

Concept of “WHOLE” Concept of “WHOLE” (contd.)(contd.)

• LLoss of Medicare in many situationsoss of Medicare in many situations

Ends 3 years after transplant if Ends 3 years after transplant if patient not disabled or has not patient not disabled or has not initiated a work incentive through initiated a work incentive through social securitysocial security

• EEffects of medicationsffects of medications

Short term and long term side Short term and long term side effects of immunosuppresioneffects of immunosuppresion

The Cost of The Cost of TransplantationTransplantation

• Medical costsMedical costs• • • Pre-transplant evaluation and testingPre-transplant evaluation and testing• • • Hospital stay and surgeryHospital stay and surgery• • • Additional hospital stays for complicationsAdditional hospital stays for complications• • • Follow-up care and testingFollow-up care and testing• • • Anti-rejection and other drugs, which can cost Anti-rejection and other drugs, which can cost

more than $10,000 per yearmore than $10,000 per year• • • Fees for surgeons, physicians, radiologist and Fees for surgeons, physicians, radiologist and

anesthesiologistanesthesiologist• • • Fees for the surgical recovery (procurement) of Fees for the surgical recovery (procurement) of

the organ from the donorthe organ from the donor• • • Physical, occupational and vocational Physical, occupational and vocational

rehabilitationrehabilitation• • • Insurance deductibles and co-paymentsInsurance deductibles and co-payments

The Cost of The Cost of TransplantationTransplantation

• Nonmedical costsNonmedical costs• • • Transportation to and from your transplant Transportation to and from your transplant

center, before and after your transplantcenter, before and after your transplant• • • Food, lodging, long distance phone calls Food, lodging, long distance phone calls

for you and your familyfor you and your family• • • Child careChild care• • • Lost wages if your employer does not pay Lost wages if your employer does not pay

for the time you or a family member spendsfor the time you or a family member spends• away from workaway from work• If your transplant center is not near your If your transplant center is not near your

home, you may need to live near the home, you may need to live near the transplant centertransplant center

FINANCING FINANCING TRANSPLANTATIONTRANSPLANTATION

• The most common funding sources The most common funding sources are:are:

• ■ ■ InsuranceInsurance• ■ ■ Extending Insurance Coverage through Extending Insurance Coverage through

COBRACOBRA• ■ ■ Medicare CoverageMedicare Coverage• ■ ■ TRICARE (formerly CHAMPUS)TRICARE (formerly CHAMPUS)• ■ ■ Charitable OrganizationsCharitable Organizations• ■ ■ Advocacy OrganizationsAdvocacy Organizations• ■ ■ Fund Raising CampaignsFund Raising Campaigns

Did you know?

About 78 people receive organ transplants every day in the United States, however . . .

About 18 people die each day waiting for a transplant

Stages of Decision Stages of Decision MakingMaking

• PrecontemplationPrecontemplation Not considering or not readyNot considering or not ready• ContemplationContemplation Considering transplantationConsidering transplantation• PreparationPreparation Planning to pursue transplantationPlanning to pursue transplantation• ActionAction Contacted the transplant centerContacted the transplant center• MaintenanceMaintenance Listed or found a living donorListed or found a living donor

Pre-transplant labsPre-transplant labs

• The first step to get on the waiting list is having pre-transplant labs drawn.

• Labs that we draw at your evaluation include:

• ● ABO blood typing;• ● Tissue typing; and• ● Serologies.

Compatibility of Blood Compatibility of Blood TypesTypes

Recipient Compatible DonorA O, AB O, BAB O, A, B, ABO O

HLA SystemHLA System

• There are three major geneticallyThere are three major genetically• controlled groups: HLA-A, HLA-B andcontrolled groups: HLA-A, HLA-B and• HLA-DR. In transplantation, the HLAHLA-DR. In transplantation, the HLA• tissue types of the donor and recipienttissue types of the donor and recipient• are important in deciding whether theare important in deciding whether the• transplant will be accepted or rejected.transplant will be accepted or rejected.• Genetic matching is generally performedGenetic matching is generally performed• on kidneys and pancreas only.on kidneys and pancreas only.

Tissue TypingTissue Typing• This test looks for the six histocompatibility

antigens. There are three major genetically There are three major genetically controlled groups: HLA-A, HLA-B and HLA-DR. controlled groups: HLA-A, HLA-B and HLA-DR.

• In transplantationIn transplantation that will define the amount of “matching” between a recipient and donor.

• Although this test (and ABO blood typing) is necessary for placement on the transplant waiting list, its importance has diminished.

• This is because we now know that even transplants with minimal matching (say, only one of six antigens) can have excellent outcomes, thanks to new advances in immunosuppressive medications.

SerologiesSerologies

These tests look for a patient’s past exposure to infections such as hepatitis, HIV, other viruses and syphilis.

Panel ReactiveAntibodies (PRAs)

• Panel reactive antibodies show a patient’s level of sensitization to donor antigens.

• Patients with high PRA levels tend to have more rejection episodes. In addition,

• it is more difficult to identify a compatible kidney for patients with a high PRA

• level. PRA tests are performed when a patient is put on the waiting list and

• every one to three months while waiting. Because of the information this test

• provides, it can be used to counsel patients regarding how long they may wait

• for a transplant. It also helps the transplant team choose the appropriate antirejection

• medications.

Cross MatchCross Match

• This test establishes compatibility between a particular donor-recipient pair

• and, for patients with a living donor, is performed during the transplant work-up.

• A “negative” cross-match suggests that a donor and recipient are compatible

• and the transplant can proceed. If the cross-match is “positive,” the pair can

• participate in the Paired Donation Program. For patients with a deceased donor,

• this test occurs prior to transplant surgery, once a donor becomes available.

Cardiac evaluation

• EKGEKG• EchocardiogramEchocardiogram• Stress testStress test

exercise treadmill, stress echo and persantine thallium

• Cardiac catherization• Coronary artery bypass surgery

Pulmonary evaluationPulmonary evaluation

• Stop smoking• Chest X-Ray• Pulmonary Function Tests• CT chest

Routine HealthScreenings

• Female recipients-PAP smears, mammograms if > 40 y

• Male recipients-Prostate exam, prostate specific antigen if >50 y

• Colonoscopy if >50 y• Dental check up

Types of Kidney Transplants from a

Deceased DonorBrain Dead Donor: Kidney donor with an

irreversible head injury who was declared brain dead based on specific criteria. Brain dead donors remain on life support during organ recovery surgery.

Donation after Cardiac Death Donor (DCD Donor): Kidney donor with a severe brain injury who does not meet the criteria for brain death but has no chance of survival. Donation after cardiac death donors are removed from life support prior to organ recovery surgery.

Expanded Criteria Donor (ECD Donor): Any brain dead donor over age 60, or over age 50 with concurrent health problems.

Types of Kidney Transplants from a Living

DonorLiving Related Donor: A living donor who is a healthy blood relative

ofthe person awaiting transplant. This includes a sibling, parent, child,

aunt,uncle, cousin, etc.Living Unrelated Donor: A living-unrelated donor is a healthy personwho is emotionally close to, but not blood-related to the person

awaitingtransplant. This includes one’s spouse, in-law relatives and close

friends.A living-unrelated donor can also include a compatible, anonymous

donormatched by the Paired Donation program.

Living donor transplantation is the most successful kidney transplantprocedure. Typically, living donor transplants last longer than deceaseddonor transplants.

ContraindicationsContraindications

• Untreated current infectionUntreated current infection• Active malignancy with short life Active malignancy with short life

expectancyexpectancy• Chronic illness with life expectancy Chronic illness with life expectancy

of less than one yearof less than one year• Poorly controlled psychosisPoorly controlled psychosis• Active substance abuseActive substance abuse

Relative Relative ContraindicationsContraindications

• Active infectionActive infection• Coronary heart diseaseCoronary heart disease• Active hepatitisActive hepatitis• Active peptic ulcer diseaseActive peptic ulcer disease• Cerebrovascular diseaseCerebrovascular disease• Proven habitual medical Proven habitual medical

noncompliancenoncompliance• HIV infection. HIV infection.

The Waiting Period

• Keep your Transplant Team updated while you’re on the waiting list. Call your transplant coordinator on his/her direct line to notify about any changes to your:

● contact information (address, phone numbers)

● insurance● doctor or dialysis unit● medical condition

After TransplantationAfter Transplantation

• Time After Transplant Frequency of Lab Tests

• 0-6 weeks 2 times a week• 6 weeks to 3-4 months 1 time a week• 3-4 months to 6-9 months Every

other week• 9-12 months Every 1-3 months