Transcript Northwestern University Feinberg School of Medicine

Northwestern University Feinberg School of Medicine
New Trends in organ donation and
Transplantation
Juan Carlos Caicedo, MD FACS
Director, Hispanic Transplant Program
Adult transplant Surgeon (NMH)
Pediatric Transplant Surgeon (LCH)
Overview
Introduction
Kidney ( Living / deceased/ combined stem cell)
Liver: whole, split, reduce size, living donor
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Who Needs a Transplant?
Transplantation is offered to patients
who:
are in end-stage organ failure
have no other surgical or medical
option available to them
have a limited life expectancy without a
transplant
have undergone a rigorous and
thorough assessment process and
meet all necessary criteria
Type of donors
Deceased (dead) donors
-Brain dead donors: intact heartbeat & circulation, on ventilator
less than 3% of all deaths
-Donors after cardiac death: occurs in hopeless cases in the hospital
where the decision to withdraw life-support is made (decision is
independent of the decision to donate). Organ donation occurs
immediately once the heart has stopped and the patient is
declared dead
Living donor
-Patient chooses to donate one or part of an organ to someone on a
transplant waiting list
• can only occur with organs when removal will NOT cause grave
harm to the donor4
United States
Organ Transplantation
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OPTN & SRTR Annual
Data Report, 2011
Patients on the waiting list on December 31
of the year (active listings only)
Transplants performed during the
year (adult & pediatric combined)
First-year all-cause graft survival
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Adult Kidney
Transplantation
End Stage Renal Disease
Dimension of the problem
>500.000 people in US
Options: Dialysis and kidney transplantation
US kidney waiting list: 105.124 people / 2013
Kidney Failure: Treatment
Kidney Transplantation
“ Best option”
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Replace all functions of the kidney
-
Increase survival and quality of life
-
Decrease complications
-
Cost effective
Incident ESRD Rate and Transplant Rate
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USRDS 2010 ADR
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2013: 105124 Waiting list
2012: 16485 Transplanted
758 ( 4.5%) Pediatric pts
Whites :38%
AA: 34%
Hispanics: 19%
Asian: 8%
Distribution of adult patients waiting for a
kidney transplant
Deceased donor kidney donation rates
Cause of death among deceased kidney
donors
Organs recovered per donor (ORPD), by SCD,
DCD, & ECD status
Delayed graft function among
adult kidney transplant recipients
Kidney donations from living donors
Living kidney donation
Laparoscopic vs Open
- Safe
- Less pain
- Fast recovery
- POD 1: Home
- Smaller Incisions
Intended kidney transplant procedure type, &
percent of intended laparoscopic procedures
converted to open
Number of transplants from
living donors, by donor relation
All patients receiving a
living donor kidney
transplant.
USRDS 2010 ADR
Kidney Transplantation
Kidney Transplantation
Sensitized Patients
PRA Levels of Wait-Listed Patients
Very Highly Sensitized
36% Sensitized
15%
Total = 17,814
pts
21%
Sensitized
64%
2010: 25% Sensitized
0-9%
10-79%
>80%
Options for Sensitized and
ABO incompatible Patients
Wait and hope
Desensitization
Live Donor
Deceased Donor
Live Donor Paired Exchange
List Exchange
Paired kidney donations
Basic Kidney Paired Donation (KPD)
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Desensitization
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N Engl J Med 365;4 July 28, 2011
Trends in Transplant
Medications
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Immunosuppression use
in adult kidney transplant recipients
Initial immunosuppression regimen
in adult kidney transplant recipients, 2011
Acute rejections within
the first year post-transplant
First-time, kidney-only
transplant recipients,
age 18 & older, with
functioning graft at
discharge.
Source: USRDS 2010 ADR
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Trends in Transplant
Research
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Mixed Chimeras
The co-existence of two genetically different
components in one organism
Chimerism induces
tolerance
How can we make it safe?
Northwestern Clinical
Tolerance Protocols
Sequential kidney/HSC in HLA matched related
Simultaneous kidney/HSC in HLA mismatched
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HLA-Matched Protocol
PI: Joshua Miller
Current Enrollment – 20/20
First patient enrolled January 2008
HLA identical siblings
Excluded if high risk of recurrent disease in the
allograft (role of immunosuppression in
preventing disease recurrence)
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Simultaneous FCRx +Kidney Transplant
Processed donor leukopheresis
product/marrow enriched for HSC, FC
and progenitors (FCRx)
HSCT mobilized, collected,
processed, & cryopreserved (> 2
wks before Tx)
Conditioning
Fludarabine, cytoxan,
200 cGy TBI
Perform
Transplant
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d0
d +1
Adult kidney transplants
Outcomes among adult kidney
transplant recipients: deceased donor
Outcomes among adult kidney
transplant recipients: living donor
Half-lives for adult kidney transplant
recipients
Liver Transplantation
Type of donor: Living vs deceased donor
Type of graft: Partial vs whole organ
Whole Organ
Orthotopic Liver Transplant
Standard technique. This figure illustrates a completed liver transplant with
vascular and biliary anastomoses.
Partial Grafts / Liver
transplantation (LTX)
-Reduce Size Ltx
-Split LTx
-Living Donor Ltx
Partial Liver
Transplantation
The split through midplane with right and left
lobe grafts
Reference: Humar A, et al. Amer J Transpl
2001;1:366-72
Schematic drawing of the right lobe after
transplantation into the recipient. The
major vascular anastomosis and drainage
of the bile duct into a Roux loop of bowel
is illustrated
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Adult Liver
Transplantation
Distribution of adult patients
waiting for a liver transplant
Liver donors who are DCD
Liver transplants from living donors, by
donor relation
Living donor liver transplant graft type
Total adult liver transplants
Adult liver transplants
Graft failure among adult liver
transplant recipients: deceased donor
Immunosuppression use in adult
liver transplant recipients
Conclusion
Transplantation offers a second chance at life to thousands of people.
It has been proven over and over again to be very successful.
However, transplantation can only occur if someone consents to the
ultimate gift – organ and tissue donation.
liver transplant
recipient
Kidney donor and
recipient
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Thank you