the option of transplantation lilly barba, m.d. medical director renal transplant program...
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THE OPTION OF THE OPTION OF TRANSPLANTATIOTRANSPLANTATIO
NNLILLY BARBA, M.D.LILLY BARBA, M.D.
MEDICAL DIRECTOR RENAL MEDICAL DIRECTOR RENAL TRANSPLANT PROGRAMTRANSPLANT PROGRAMHARBOR-UCLA MEDICAL HARBOR-UCLA MEDICAL
CENTERCENTER
OPTIONS FOR TREATMENT OPTIONS FOR TREATMENT OF END STAGE RENAL OF END STAGE RENAL
DISEASEDISEASE• HEMODIALYSISHEMODIALYSIS• PERITONEAL DIALYSISPERITONEAL DIALYSIS• TRANSPLANTATIONTRANSPLANTATION
THE OPTION OF THE OPTION OF TRANSPLANTATIONTRANSPLANTATION
• BEST OPTION TO RESTORE BEST OPTION TO RESTORE FEELING OF WELL BEINGFEELING OF WELL BEING
• LIBERALIZATION OF FLUID AND LIBERALIZATION OF FLUID AND DIETARY RESTRICTIONDIETARY RESTRICTION
• ABILITY TO TRAVELABILITY TO TRAVEL• INCREASE IN LIFE SPAN AS INCREASE IN LIFE SPAN AS
COMPARED TO REMAINING ON COMPARED TO REMAINING ON DIALYSISDIALYSIS
RISKS OF RISKS OF TRANSPLANTATIONTRANSPLANTATION
• MAJOR SURGICAL PROCEDURE MAJOR SURGICAL PROCEDURE WITH POSSIBLE WITH POSSIBLE COMPLICATIONS INCLUDING:COMPLICATIONS INCLUDING:
• BLEEDING BLEEDING • INFECTIONINFECTION• REJECTIONREJECTION• ANESTHESIA RISKANESTHESIA RISK• DEATHDEATH
OPTION OF OPTION OF TRANSPLANTATIONTRANSPLANTATION
• CHOSING THE OPTION OF CHOSING THE OPTION OF TRANSPLANTATION SHOULD TRANSPLANTATION SHOULD BE TAKEN WITH CAUTIONBE TAKEN WITH CAUTION
• IN GENERAL, HOWEVER, IN GENERAL, HOWEVER, TRANSPLANTATION IS THE TRANSPLANTATION IS THE BEST OPTION FOR TREATING BEST OPTION FOR TREATING PEOPLE WITH KIDNEY DISEASEPEOPLE WITH KIDNEY DISEASE
PURSUING THE OPTION PURSUING THE OPTION OF TRANSPLANTATIONOF TRANSPLANTATION
• PATIENTS MAY BE REFERRED PATIENTS MAY BE REFERRED BY THEIR NEPHROLOGIST BY THEIR NEPHROLOGIST WHEN THE SERUM WHEN THE SERUM CREATININE IS 3.5 MG/DL OR CREATININE IS 3.5 MG/DL OR ESTIMATED GFR < 20 CC/MINESTIMATED GFR < 20 CC/MIN
• THE REASON FOR EARLY THE REASON FOR EARLY REFERRAL IS TO ESTABLISH REFERRAL IS TO ESTABLISH WAITING TIME OR READY FOR WAITING TIME OR READY FOR A PRE EMPTIVE TRANSPLANTA PRE EMPTIVE TRANSPLANT
WAITING TIMEWAITING TIME
• UNOS (UNITED NETWORK FOR UNOS (UNITED NETWORK FOR ORGAN SHARING) IS THE ORGAN SHARING) IS THE ORGANIZATION THAT OVERSEES ORGANIZATION THAT OVERSEES ALL TRANSPLANT PROGRAMS IN ALL TRANSPLANT PROGRAMS IN THE UNITED STATESTHE UNITED STATES
• TOLL FREE NUMBER 1-888-894-TOLL FREE NUMBER 1-888-894-6361 INFORMATION LINE FOR 6361 INFORMATION LINE FOR TRANSPLANT CANDIDATES, TRANSPLANT CANDIDATES, RECIPIENTS AND FAMILY RECIPIENTS AND FAMILY MEMBERSMEMBERS
UNOSUNOS
• UNOS ALSO MAINTAINS A WEB UNOS ALSO MAINTAINS A WEB SITE,SITE, TRANSPLANT LIVING, TRANSPLANT LIVING, WHICH CONTAINS WHICH CONTAINS INFORMATION FOR INFORMATION FOR TRANSPLANT CANDIDATES AND TRANSPLANT CANDIDATES AND RECIPIENTS AND FAMILY RECIPIENTS AND FAMILY MEMBERSMEMBERS
• ADDRESS: ADDRESS: WWW.TRANSPLANTLIVING.ORGWWW.TRANSPLANTLIVING.ORG
BENEFITS OF PRE BENEFITS OF PRE EMPTIVE EMPTIVE
TRANSPLANTATION TRANSPLANTATION • NO NEED TO START DIALYSIS: NO NEED TO START DIALYSIS:
NO COMORBITIDIES NO COMORBITIDIES ASSOCIATED WITH DIALYSISASSOCIATED WITH DIALYSIS
• BETTER QUALITY OF LIFEBETTER QUALITY OF LIFE• HIGHER EMPLOYMENT RATES HIGHER EMPLOYMENT RATES
POST TRANSPLANTPOST TRANSPLANT• NO NEED FOR AV GRAFT OR NO NEED FOR AV GRAFT OR
FISTULA PLACEMENTFISTULA PLACEMENT
BENEFITS OF PRE BENEFITS OF PRE EMPTIVE EMPTIVE
TRANSPLANTATION TRANSPLANTATION • DO NOT HAVE TO WAIT YEARS DO NOT HAVE TO WAIT YEARS
FOR A DECEASED DONORFOR A DECEASED DONOR• PATIENTS WHO RECEIVE PRE-PATIENTS WHO RECEIVE PRE-
EMPTIVE TRANSPLANTS HAVE EMPTIVE TRANSPLANTS HAVE BETTER OUTCOMESBETTER OUTCOMES
• COSTS FOR MAINTAINING A COSTS FOR MAINTAINING A TRANSPLANT PATIENT ARE TRANSPLANT PATIENT ARE LESSLESS
BARRIERS TO PRE BARRIERS TO PRE EMPTIVE EMPTIVE
TRANSPLANTATIONTRANSPLANTATION• 2005 USRDS : INCIDENCE OF PRE 2005 USRDS : INCIDENCE OF PRE
EMPTIVE TRANSPLANTATION WAS EMPTIVE TRANSPLANTATION WAS 2.5%2.5%
• NKF CONSENSUS CITED REASONS:NKF CONSENSUS CITED REASONS:1.1. EARLY EDUCATION NEEDEDEARLY EDUCATION NEEDED2.2. TIMELY TRANSPLANT REFERRAL TIMELY TRANSPLANT REFERRAL
NEEDEDNEEDED3.3. IDENTIFICATION OF POTENTIAL IDENTIFICATION OF POTENTIAL
LIVING DONORLIVING DONOR4.4. REFERRAL WHEN PATIENT IS REFERRAL WHEN PATIENT IS
REFERRED FOR AV ACCESSREFERRED FOR AV ACCESS
CANDIDATES FOR CANDIDATES FOR TRANSPLANTATIONTRANSPLANTATION
THOSE PATIENTS WITH:THOSE PATIENTS WITH:• PATIENTS WITH IRREVERSIBLE PATIENTS WITH IRREVERSIBLE
LOSS OF RENAL FUNCTIONLOSS OF RENAL FUNCTION• THOSE WITH CREATININE > 3.5 THOSE WITH CREATININE > 3.5
MG/DLMG/DL• AGE IS A RELATIVE FACTOR IN AGE IS A RELATIVE FACTOR IN
DETERMINING CANDIDACYDETERMINING CANDIDACY
WHO IS WHO IS NOT A POTENTIAL NOT A POTENTIAL CANDIDATE CANDIDATE ??
THOSE PATIENTS WITH:THOSE PATIENTS WITH:• ACTIVE INFECTIONACTIVE INFECTION• CANCER OR CANCER RECENTLY CANCER OR CANCER RECENTLY
TREATEDTREATED• UNCORRECTABLE HEART UNCORRECTABLE HEART
PROBLEMSPROBLEMS• ADVANCED LUNG DISEASEADVANCED LUNG DISEASE
WHO IS WHO IS NOT A POTENTIAL NOT A POTENTIAL CANDIDATE CANDIDATE ??
THOSE PATIENTS WITH:THOSE PATIENTS WITH:• ACTIVE STOMACH ULCERSACTIVE STOMACH ULCERS• CIRRHOSIS OF THE LIVERCIRRHOSIS OF THE LIVER• NO ELIGIBILITY FOR INSURANCE OR NO ELIGIBILITY FOR INSURANCE OR
NO MEDICAL INSURANCENO MEDICAL INSURANCE• LACK OF A FAMILY/SOCIAL SUPPORT LACK OF A FAMILY/SOCIAL SUPPORT
SYSTEMSYSTEM• ONGOING KIDNEY DISEASE: ONGOING KIDNEY DISEASE:
VASCULITISVASCULITIS
WHO IS WHO IS NOT A POTENTIAL NOT A POTENTIAL CANDIDATE CANDIDATE ??
THOSE PATIENTS WITH:THOSE PATIENTS WITH:• MORBID OBESITYMORBID OBESITY• SEVERE PSYCHIATRIC PROBLEMS SEVERE PSYCHIATRIC PROBLEMS
NOT WELL CONTROLLEDNOT WELL CONTROLLED• CONTINUED ALCOHOL, TOBACCO CONTINUED ALCOHOL, TOBACCO
OR ILLICIT DRUG ABUSEOR ILLICIT DRUG ABUSE• AGE GREATER THAN 70 WITHOUT AGE GREATER THAN 70 WITHOUT
THE POTENTIAL FOR A LIVING THE POTENTIAL FOR A LIVING DONORDONOR
THOSE PATIENTS WITH THOSE PATIENTS WITH PCKDPCKD
• OVERALL, PATIENTS WITH PCKD OVERALL, PATIENTS WITH PCKD DO WELLDO WELL
• PRE TRANSPLANT CLEARANCE PRE TRANSPLANT CLEARANCE MAY INCLUDE:MAY INCLUDE:
1.1. CT SCAN OF THE ABDOMENCT SCAN OF THE ABDOMEN
2.2. CT SCAN OF THE BRAINCT SCAN OF THE BRAIN
3.3. ECHOCARDIOGRAMECHOCARDIOGRAM
4.4. SURGICAL REMOVAL OF NATIVE SURGICAL REMOVAL OF NATIVE KIDNEYSKIDNEYS
THE TRANSPLANT THE TRANSPLANT SURGICAL PROCEDURESURGICAL PROCEDURE
WHAT YOU SHOULD WHAT YOU SHOULD EXPECT FOLLOWING EXPECT FOLLOWING
TRANSPLANT SURGERYTRANSPLANT SURGERY• SURGERY IS 3 – 5 HOURS UNDER SURGERY IS 3 – 5 HOURS UNDER
GENERAL ANESTHESIAGENERAL ANESTHESIA• HOSPITAL STAY 5 – 7 DAYSHOSPITAL STAY 5 – 7 DAYS• AFTER SURGERY:AFTER SURGERY:
– FOLEY CATHETERFOLEY CATHETER– JACKSON PRATT DRAINAGE BULB (JP)JACKSON PRATT DRAINAGE BULB (JP)– CENTRAL VENOUS PRESSURE LINE (CVP)CENTRAL VENOUS PRESSURE LINE (CVP)– STAPLES HOLDING WOUND TOGETHERSTAPLES HOLDING WOUND TOGETHER– POD # 1 : BEDREST POD # 2: START POD # 1 : BEDREST POD # 2: START
EATINGEATING– POD # 3: WALKING AS TOLERATEDPOD # 3: WALKING AS TOLERATED
IMMUNOSUPPRESSIVE IMMUNOSUPPRESSIVE MEDICATIONSMEDICATIONS
• CNI (TACROLIMUS OR CNI (TACROLIMUS OR CYCLOSPORINE)CYCLOSPORINE)
• STEROID (PREDNISONE)STEROID (PREDNISONE)• ANTI-METABOLITE (CELLCEPT ANTI-METABOLITE (CELLCEPT
OR AZATHIOPRINE)OR AZATHIOPRINE)
MEDICATIONS CAN HAVE MEDICATIONS CAN HAVE SIDE EFFECTS: COMMON SIDE EFFECTS: COMMON
SIDE EFFECTSSIDE EFFECTS• TACROLIMUS/CYCLOSPORINETACROLIMUS/CYCLOSPORINE : :
TREMORS, HIGH BLOOD TREMORS, HIGH BLOOD PRESSURE, HAIR GROWTH WITH PRESSURE, HAIR GROWTH WITH CYCLOSPORINE, POSSIBLE CYCLOSPORINE, POSSIBLE DIABETESDIABETES
• PREDNISONE:PREDNISONE: GASTRITIS, WEIGHT GASTRITIS, WEIGHT GAIN SECONDARY TO INCREASE GAIN SECONDARY TO INCREASE APPETITE, DIFFICULT TO CONTROL APPETITE, DIFFICULT TO CONTROL DIABETES, ACNE, EASY BRUISING, DIABETES, ACNE, EASY BRUISING, INCREASE SENSITIVITY TO THE INCREASE SENSITIVITY TO THE SUNSUN
MEDICATIONS CAN HAVE MEDICATIONS CAN HAVE SIDE EFFECTS: COMMON SIDE EFFECTS: COMMON
SIDE EFFECTSSIDE EFFECTS
• CELLCEPTCELLCEPT: GAS, DIARRHEA, : GAS, DIARRHEA, LOW WHITE BLOOD CELL LOW WHITE BLOOD CELL COUNTCOUNT
TRANSPLANTATION TRANSPLANTATION OPTIONSOPTIONS
• PRE-EMPTIVE TRANSPLANTATIONPRE-EMPTIVE TRANSPLANTATION• LIVING DONOR LIVING DONOR
TRANSPLANTATIONTRANSPLANTATION• DECEASED DONOR DECEASED DONOR
TRANSPLANTATION:TRANSPLANTATION:
1.1. STANDARD CRITERIASTANDARD CRITERIA
2.2. EXTENDED CRITERIAEXTENDED CRITERIA
3.3. DONOR AFTER CARDIAC DEATH DONOR AFTER CARDIAC DEATH
LIVING DONORSLIVING DONORS
• ANY PERSON WHO IS HEALTHY ANY PERSON WHO IS HEALTHY CAN BE EVALUATED FOR A CAN BE EVALUATED FOR A TRANSPLANTTRANSPLANT
• CANNOT HAVE DIABETES, CANNOT HAVE DIABETES, HYPERTENSION, KIDNEY HYPERTENSION, KIDNEY DISEASE OR ACTIVE DRUG USEDISEASE OR ACTIVE DRUG USE
• EACH TRANSPLANT PROGRAM EACH TRANSPLANT PROGRAM SETS CRITERIA FOR DONORSETS CRITERIA FOR DONOR
LIVING DONORS DO LIVING DONORS DO WELLWELL
• SURGERY IS USUALLY DONE SURGERY IS USUALLY DONE LAPARASCOPICALLYLAPARASCOPICALLY
• HOSPITAL STAY IS 3 DAYS HOSPITAL STAY IS 3 DAYS MAXIMUMMAXIMUM
• PAIN CONTROLLED WITH PAIN CONTROLLED WITH NARCOTICSNARCOTICS
• RESUMPTION OF DAILY RESUMPTION OF DAILY ACTIVITES IN 4 TO 8 WEEKSACTIVITES IN 4 TO 8 WEEKS
LIVING DONORS DO LIVING DONORS DO WELLWELL
• RESUMPTION OF NORMAL RESUMPTION OF NORMAL DAILY ACTIVITIES WITH 4 TO 8 DAILY ACTIVITIES WITH 4 TO 8 WEEKSWEEKS
LIVING DONORS DO LIVING DONORS DO WELLWELL
• RISKS LOW: MORTALITY 0.03 %, RISKS LOW: MORTALITY 0.03 %, SURGICAL RISKS ABOUT 3 %SURGICAL RISKS ABOUT 3 %
• LONG TERM RISKS: HAVE TO BE LONG TERM RISKS: HAVE TO BE EVALUATED IN CONTEXT OF PRE EVALUATED IN CONTEXT OF PRE EXISITING PROBLEMS, DEVELOPMENT EXISITING PROBLEMS, DEVELOPMENT OF MEDICAL PROBLEMS AFTER OF MEDICAL PROBLEMS AFTER DONATION AND GENERAL POPULATION DONATION AND GENERAL POPULATION RISKS OF DEVELOPING KIDNEY RISKS OF DEVELOPING KIDNEY DISEASE WHICH IS APPROXIMATELY 2 DISEASE WHICH IS APPROXIMATELY 2 % FOR CAUCASIANS AND 7.5 % FOR % FOR CAUCASIANS AND 7.5 % FOR AFRICAN AMERICANSAFRICAN AMERICANS
LIVING RELATED LIVING RELATED DONATION IN PKD DONATION IN PKD
FAMILIESFAMILIES• OWING TO THE DIFFICULTIES OWING TO THE DIFFICULTIES
ENCOUNTERED IN EXCLUDING ENCOUNTERED IN EXCLUDING PKD IN RELATED POTENTIAL PKD IN RELATED POTENTIAL DONORS, PATIENTS WITH PKD DONORS, PATIENTS WITH PKD RECEIVE FEWER LIVING RECEIVE FEWER LIVING RELATED KIDNEY RELATED KIDNEY TRANSPLANTSTRANSPLANTS
LIVING RELATED LIVING RELATED DONATION IN PKD DONATION IN PKD
FAMILIESFAMILIES• ULTRASOUND IS ULTRASOUND IS
INSUFFICIENTLY INSENSITIVE INSUFFICIENTLY INSENSITIVE TO EXCLUDE DISEASE BEFORE TO EXCLUDE DISEASE BEFORE THE AGE OF 30 YEARSTHE AGE OF 30 YEARS
• GENETIC TESTING CAN BE USED GENETIC TESTING CAN BE USED THROUGH ANALYSIS OF LINKED THROUGH ANALYSIS OF LINKED FLANKING POLYMORPHIC FLANKING POLYMORPHIC GENETIC MARKERS OR THE USE GENETIC MARKERS OR THE USE OF DIRECT MUTATION ANALYSISOF DIRECT MUTATION ANALYSIS
DECEASED DONORSDECEASED DONORS
• DIFFERENCE IN ALLOGRAFT DIFFERENCE IN ALLOGRAFT SURVIVALSURVIVAL
• DECEASED DONOR HALF-LIFE 7 DECEASED DONOR HALF-LIFE 7 TO 12 YEARSTO 12 YEARS
• LIVING DONOR HALF-LIFE IS 20 LIVING DONOR HALF-LIFE IS 20 YEARSYEARS
• RISK OF REJECTION MAY BE RISK OF REJECTION MAY BE HIGHER ESPECIALLY IS DONOR HIGHER ESPECIALLY IS DONOR IS NOT RELATED TO RECIPIENTIS NOT RELATED TO RECIPIENT
WAITING TIME FOR A WAITING TIME FOR A DECEASED DONORDECEASED DONOR
• BLOOD GROUPS ARE O, A, AB, BBLOOD GROUPS ARE O, A, AB, B• AVERAGE WAITING TIME FOR AVERAGE WAITING TIME FOR
AN O KIDNEY IS THE GREATER AN O KIDNEY IS THE GREATER LA AREA IS 7 TO 10 YEARSLA AREA IS 7 TO 10 YEARS
• B PATIENTS WAIT GREATER B PATIENTS WAIT GREATER THAN 5 YEARSTHAN 5 YEARS
DISCUSSION WITH DISCUSSION WITH TRANSPLANT CENTER TRANSPLANT CENTER
• WHICH IS THE BEST OPTION WHICH IS THE BEST OPTION FOR ME?FOR ME?
• EVALUATION OF POTENTIAL EVALUATION OF POTENTIAL DONORSDONORS
• COMPLETION OF WORK-UP IN A COMPLETION OF WORK-UP IN A TIMELY BASISTIMELY BASIS
• HEAR ALL THE OPTIONSHEAR ALL THE OPTIONS
CONCLUDING REMARKSCONCLUDING REMARKS
• TRANSPLANTATION IS THE TRANSPLANTATION IS THE BEST OPTION FOR PATIENTS BEST OPTION FOR PATIENTS WITH KIDNEY DISEASEWITH KIDNEY DISEASE
• COMPLICATIONS ARE POSSIBLECOMPLICATIONS ARE POSSIBLE• LIVING DONATION IS LIVING DONATION IS
ENCOURAGED ESPECIALLY TO ENCOURAGED ESPECIALLY TO EXPEDITE TRANSPLANTATION, EXPEDITE TRANSPLANTATION, FOR LONG TERM SUCCESSFOR LONG TERM SUCCESS