Transcript Pre Transplant Educational Session

Pre Transplant
Kidney/Pancreas
Educational Session
Miami Transplant Institute
About the Transplant Program
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Started in 1979
Have performed over 4,000 kidney transplants
200+ kidney transplants per year (279 in 2009)
25-30 kidney/pancreas transplants per year
Only center in FL performing all transplant types
One of the top 10 busiest centers in the US (4th in
nation 2007 behind UCLA, UPMC, UCSF)
Success rates for transplant and patient survival are
some of the best in the country
Contact Information for the
United Network for Organ Sharing
(UNOS)
www.unos.org
 Patient Services
Hotline for Concerns
or Grievances
1-888-894-6361
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Who is on Your Transplant Team?
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Transplant Surgeon
Transplant Nephrologist
Transplant Nurse
Coordinator
Social Worker
Pre Transplant Secretary
Donor Team
Patient Financial Services
Dietician
Transplant
Psychologist/Addiction
Team
Transplant Team-Surgeons
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George Burke, MD-Director K/P Program
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Gaetano Ciancio, MD-Asst. Director
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Tyann Barnes, RN-305-355-5082
Linda Chen, MD. Director Donor Team
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Dianne Peers, RN-305-355-5156
Michelle Gascon, RN-305-355-5194
Junichiro Sageshima, MD
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Michelle Gascon, RN-305-355-5194
Transplant Team-Nephrologists
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David Roth, MD-Medical Director
Warren Kupin, MD, Asst Director
Giselle Guerra, MD, Medical Director Donor
Team
Adela Mattiazzi, MD, Transplant Nephrology
Facts about Kidney/SPK Transplant
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Kidney, SPK transplant is a “treatment” for
ESRD, diabetes, it is not a cure
Transplantation requires taking life-long antirejection medication, follow-up and compliance
Transplantation may prolong your life
expectancy
Selection Criteria for
Kidney/Pancreas Transplant
The following criteria are used by the
Transplant Committee to determine
candidacy
Inclusion Criteria for Kidney
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Initiation of dialysis therapy or kidney function
of 20% or less (calculated or measured)
Age-Infants (10kg) to adult (no limit)
Hepatitis B or C without cirrhosis (evaluated by
liver biopsy)
HIV infection on HAART therapy (may qualify
for current study protocol)
Exclusion Criteria
(Absolute and Relative)
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Malignancy within the past 2 years (other than skin
cancer)
Severe Cardiac Disease
Severe Pulmonary pathology
Hepatitis B or C with documented cirrhosis on liver
biopsy
HIV + and not on HAART therapy
Evidence of current alcohol or substance abuse
Morbid Obesity (BMI > 45, unless vascular access has
failed)
Current psychiatric or psychological pathology
Psychosocial Criteria
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Ability to follow a complex regime of
medication and post transplant follow-up
(compliance) by oneself or by an identified
support person
Identified support person available
Coverage for medications
Transportation
What is my next step to becoming a
Transplant Candidate?
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Class Session-attending today
1st Appointment with the Transplant
Team
 Physician, Nurse Coordinator,
Social Worker, Dietician, lab work
 Must bring additional medical
records and testing done by
Nephrologist and PCP, GYN and
Dietician
 copy of most recent labs for
Dietician
 Bring copies of driver’s license and
all insurance cards
 Bring a Sweater
 Bring a snack
 Appointment may last hours
What testing is required?
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Bladder ultrasound-if indicated
Gallbladder/Abdominal ultrasound (good
for 2 years)-not required for all
Cardiac evaluation (annual)
 One of most important aspects of
evaluation
 Includes EKG, echo, stress test
 Cardiac catheterization if indicated
Chest x-ray (annual)
TB test (annual)
Immunizations
 Pneumovax-good for 5 years
 Hepatitis B vaccine
 Varicella Titer-Zoster IGG
Gynecological evaluation (done by PCP,
good for 2 years, unless indicated otherwise)
Vascular studies
*any testing done in the 6 months is accepted
Optional testing…
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Pulmonary evaluation
CT of abdomen/pelvis
(PKD)
UGI/endoscopy
Colonoscopy (PCP)
Dental evaluation (outside)
Sustacal Challenge Test
(SPK)
Ophthalmology evaluation
Hepatology consult/liver
biopsy-hepatitis (PCP)
All other consults (outside)
*any other testing as directed
by your Past medical history
When and Where Will
My Testing be Done?
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Diagnostic testing is required to be arranged by the
Transplant Center to be performed at UM/JMH or one
of the outlying clinics
 Biscayne Imaging
 MICC
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Does not include “standard of care” or preexisting conditions testing
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GYN, oncology, surgical intervention,
hepatology/liver biopsy
Meeting with the Transplant Social
Worker-Psychosocial Requirements
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Funding for transplant medications
$4,500-$5,000 per month
 Must check insurance coverage and co-pays
 If transplant is covered by Medicare primary, anti rejection medications
will be covered by Medicare B at 80%-not
Medicare D
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Must have a Primary Caregiver
Housing if not a local resident-Transplant House
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Some insurance plans offer travel and lodging benefit
Transportation to clinic (no driving 4-6 weeks)
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Transplant Center/Pompano Satellite
Lab visits 3 x/ week (month 1)
2 x/ week (month 2 )
1 x / week (month 3)
Every other week (4-6 months)
Eventually once a month or every other month depending on status
Psychosocial-Advanced Directives
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If you are unable to make medical decisions an Advanced
Directive:
 Lets your doctor know the type of medical care you want
 Allows you to choose someone you trust (health care
surrogate) to carry out your wishes regarding your medical
treatment
Your Transplant Social Worker can provide you with an
Advanced Directive. If you have one already, bring a copy to the
hospital when you are admitted for transplant
When will I be listed?
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Meet criteria established at this center for listing
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Complete required diagnostic testing and have F/U
appt. for initial medical approval
Majority approval by Transplant Team (Listing
Conference-every Monday
Will blood testing be done?
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Yes, required in our Lab
at the Transplant Center
(Miami)
Non-Fasting
Several tubes
Blood Type
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Type
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50% “O”-universal donor
30% ”A”
>10% “B”
>5% “AB”-universal
recipient
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Donor
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“O” only
“A” or “O”
“B” or “O”
“AB”, “A”, “B”, or “O”
*Deceased Donor-”O” only
to type “O”
Genetic Typing
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You inherit 3 Genes from Mother and
3 from Father=6 Total
Siblings
50%-3 Gene Match
 25%-6 Gene Match-Identical
 25%-0 Gene Match
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*Minimum “1” gene match for Deceased List
Cross match
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Mixing of blood between
Donor and Recipient
Can be performed may
times during evaluation
Will be final test
performed prior to
transplant
PRA has bearing on
results of cross match
What is PRA?
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“Panel Reactive
Antibody”
What causes antibodies
Previous Transplants
 Transfusions
 Pregnancy
 Infection
*can have the greatest
bearing on your waiting
time and will be sent
monthly when listed
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What are my Transplant Options?
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Living Related Donor
(LRD)
Living Unrelated Donor
(LURD)
Deceased DonorWaiting List
Living Donation
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Donors an be identified any time (3 at a time
only)
To Referral Team
 To Nurse Coordinator
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Donor must make contact
All donors living here or elsewhere will be phonescreened and provided information and instructions
Goal of Living Donation…
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To make sure that the living donor
is not only “willing” to donate but
also “able” to donate a kidney
safely
Risks of the surgical procedure are
minimal if medically cleared by the
Donor Team
Potential donor needs to contact
Nurse Coordinator directly for
referral to Donor Team
Donor can be blood tested any
time after recipients blood is
drawn
How do I qualify to be a Kidney Donor?
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18-65 years old
No diabetes
No hypertension
Healthy with no physical
problems with kidney
Family member-blood
relative
Extended family memberNon-blood relative
Only 3 donors will be blood
tested at a time
Only 1 donor in active
workup at a time
Who is on the Donor Team?
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Transplant Surgeon
Transplant Nephrologist
Donor Nurse Coordinator
Donor Advocate
Laboratory personnel
Secretarial staff
Transplant Psychologist
*team will manage all aspects of Donor testing
Kidney Donation facts…
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All testing is done as an outpatient –preferably at the
Transplant Center
There are no costs to the donor for evaluation, surgery
or immediate post-operative care
Recovery time is 2-6 weeks
No heavy lifting for 6 weeks
Women can become pregnant after kidney donation
Surgery is 3-4 hours
Hospitalization is 3-4 days
The donor can be ruled out for medical/psychological
reasons at any point in donation process
How Do I Begin the Donor Process?
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Blood testing
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Local donors
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Blood Type
Genetic Typing
Cross-match
Tested at Transplant Center
Out-of Area Donors
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Will FedEx blood for testing
against recipient
What is the Next Step?
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Blood testing
Urine testing
Chest x-ray
EKG
TB test
GTT (if diabetes in
family)
Gynecological evaluation
Final Donor Testing…
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Spiral CT Scan of
Kidneys
Psychological Evaluation
History and Physical
Surgical Consult
Anesthesia Consult
Dietician Consult
Surgical Options…
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Laparoscopic Nephrectomy
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Done for left sided kidney
removals, beginning to do right
lap cases (individual basis)
Recovery is quicker
Less pain
Improved cosmetic results
Higher rate of organ donation
Decision is based on spiral CT
results
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Open Nephrectomy
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For right sided removal
(individual basis)
Longer hospitalization
(additional day in the
hospital
Laparoscopic Nephrectomy
Benefits of having Living Donor vs.
Deceased Transplant
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Usually a better genetic
match
Kidney usually functions
right away
Transplant can be planned
Do not have to wait on
waiting list for donor
Transplant may last longersometimes twice as long as
deceased transplant
Deceased Transplant (DD)
How long am I going to wait?
 Kidney
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2 to 3 years in Miami
 Can happen at any time from listing
Who receives the kidney?
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Based on a point system UNOS-new list is run
for each kidney
Seniority (days on the list)
 Genetic match (better match, more points)
 Antibody level (PRA)-higher lever, more points
 Up to age 18-”Kid points”
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Highest point with negative cross match receives
kidney
Are there other options for listing?
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Expanded Criteria Donor (ECD) list
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Discussed at listing with transplant physician
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Signed consent is required
Separate from standard list
 Donor age 60 or older
 Donor 50-59 with two of the following
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Donor medical history of hypertension
 Creatinine above 1.5 (normal 0.8-1.4)
 Cause of death from stroke
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Other options…
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Multiple listing
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Allowed by OPTN policy
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Up to individual center to accept as candidate
May increase chances of local offer
May shorten waiting time-no guarantee
Wait Time Transfer
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Coordinated by transferring center
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UNOS Form required to be signed by patient/Coordinator/Physician
Must be approved by transferring center or you may risk
losing all previous wait time
How are organs distributed?
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Local (UM/JMH list)
Regional – UNOS region 3 (south east states)
National- over 80,000 on waiting list
Mandatory share
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Perfect match, highest priority
What are my responsibilities to
maintain my active listed status?
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Keep testing updated annually
Cardiac
 Chest x-ray
 TB
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Every other year (unless otherwise indicated)
Gallbladder US
 Gynecological
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Listed Patient responsibilities (con’t)
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Visit transplant center every 6 months
Notify transplant team of any changes in
address, phone, insurance or travel
Must send monthly PRA
Notify transplant team of any changes in health
or medical urgency issues
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Out of vascular access
Transplant Team’s Responsibility to
our patient
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Listing letter
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Patient
Nephrologist
Dialysis center
Annual Listed letter
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Listed status continues, testing required, hold status issues
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Patient
Nephrologist
Dialysis center
Insurance company
Transplant Informed Consent
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Signed by patient/Coordinator/Transplant Physician
Copy to you and your patient file
Listed Status
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Active (1)-can be called at any time
Hold (7)-will not be called for transplant but
time continues to accrue. Can be placed on hold
at any time due to medical, psychological or
social issues
Medically Urgent (5)- highest priority, medical
condition requires transplant ASAP
What happens if you are called?
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Can be called 24/7
If on dialysis, finish
treatment-not first come, first
served
Can call in 5-10 people for
kidney transplant, unless
mandatory share
Call in 2 people for SPK/PA
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Must remain on stand-by
for up to 24 hours
May have multiple “dryruns”
Instructions for Admission prior to
Surgery
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Map with directions will be provided
Have “goodie bag” ready
List of meds/meds
 Essential toiletries
 PD supplies
 If you need financial assistance, bring a copy of
income tax papers
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Don’t bring…
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Valuables
Plants or flowers
Visitors under the age of 14
OR Time/Hospital Stay
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Surgery time
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Kidney 4-6 hours
SPK 6-12 hours
Pancreas 4-6
Time in hospital
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Discharge teaching will begin from time of admission for transplant-have
support system available
Discharge when medically stable-even if you may not feel ready
Kidney 5-6 days, may go home with Foley catheter or other new devices
(glucometer)
SPK 7 days
Donors
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3 Days Laparoscopic Nephrectomy
4 days Open Nephrectomy
Where is the kidney placed?
Will your new kidney work right
away?
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Most kidneys work immediately
Some take a period of time to begin functioning
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Might require dialysis session(s)
Rarely, the kidney never functions
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If within 90 days of transplant can be reactivated on
the list with no time lost
Post Transplant Medication and
After Care Video…
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Anti- rejection
medications
Diet
Follow-up visits and labs
Patient responsibilities
Your kidney transplant operation is
not the end of this process… it is the
beginning
Completion of Medical Lecture
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Certificate of
Completion distribution
Q&A
Thank you for you
attention …Good Luck!