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Pulsatile Perfusion Overview Ralph Aguilar, SRPPT

© OneLegacy OneLegacy Federally designated OPO Education Family/Patient Advocate Donor Identification Donor Management Procurement coordination Organ preservation

© OneLegacy Transplant Process Patient Identification Pre-tx work-up, psycho-social work, dental activity, bloodwork maintenance, LRD?, Cad?, etc Peri-transplant activity Post-transplant follow up ……….Organ Procurement

© OneLegacy What is kidney pumping? Another method of organ storage during transport Active preservation of kidneys allowing benefits not provided by static storage.

© OneLegacy When will my kidneys get on the pump? after biopsy is read after delivered from OR / UCLA / NIT

© OneLegacy is going on in the pumping world? Two FDA approved pumps Waters Instruments Organ Recovery Systems What

© OneLegacy Where OneLegacy Corporate Office 221 South Figueroa Street

© OneLegacy Organ Preservation “The goal of optimal organ preservation is to maintain viability for transplant.” Robert Hoffman, BS, CPTC, James Southard, Ph.D., Folkert O. Belzer, MD Organ Preservation, UNOS, ORGAN PROCUREMENT, PRESERVATION AND DISTRIBUTION IN TRANSPLANTATION

© OneLegacy Perfusion of Isolated Organs Loebel 1849; 1st attempt Langendorf 1895; siphon tube/gravity Carrel 1905; “Anastomosis and Transplantation of Blood Vessels” Lindbergh 1930s; sister-in- law, introduced to Carrel, mechanical pump for cardiac surgery; sterilizable, pulsating Carrel/Lindbergh 1937; hypothermia; War USSR 1960s; limbs/kidneys

© OneLegacy Organ Preservation The ideal preservation method for [organs] during any ischemia – both warm or cold, MUST Maximize the quality of the organ Minimize the chance for delayed graft function (DGF)

© OneLegacy What can we do with Renal Preservation? Normo-thermic Cold Static Storage (CSS) Pulsatile Perfusion Combination CADAVERIC KIDNEY TRANSPLANTS UNOS 1998 SR & OPN Annual Reports

© OneLegacy Preservation is Critical Patients who required dialysis within the first week postransplant had lower graft survival and patient survival rates at all time points than those who did not require dialysis soon after transplant. Graft survival for the dialysis group was 83% at one year and 53% at five years postransplant compared to 93% at one year and 68% at five years for the nondialysis group.”

© OneLegacy What is Renal Pulsatile Perfusion? Kidneys are connected to a machine that allows a solution to actively maintain organs for transplant preservation, and provide additional information to aid in determination of organ viability.

© OneLegacy The RM3 Renal Perfusion System “The Ultimate Pumping Machine…” Tom Mone, CEO OneLegacy

© OneLegacy Observations Objective Flow Pressure Resistance (MAP/flow=rr) Labs (pH, O2, CO2, Osmo) Chemotherapy (mannitol, verapamil, papavarine, etc.) Subjective Visualization assessment Bounce Gestalt

© OneLegacy Early Function Prediction The best predictor of early function based on a linear regression analysis of these five variables: 1. Renal Blood Flow 2. Final Resistance (mean pressure/flow) 3. Patient age 4. Cold perfusion time 5.Warm ischemia time was determined to be: Final Resistance. Renal Blood Flow and Intrarenal Resistance Predict Immediate Renal Allograft Function ML Henry, BG Sommer and RM Ferguson 1986 Grune & Stratton /86/

© OneLegacy Cold Static Storage vs Machine Perfusion MPCSMP-Extended CS-Extended Donor age40+/-837+/-1654+/-9 51+/-9 LOS9.8+/ / / /-3 DGF YR “Renal allograft preservation by continuous hypothermic preservation conferred an advantage in both immediate graft function and LT graft survival when compared to cold storage in UW solution.” THE INFLUENCE OF PULSATILE PRESERVATION ON RENAL TRANSPLANTATION IN THE 1990’S TRANSPLATATION Vol No2Jan MMR Polyak, etal. Organ Preservation Unit, Division of Transplantation, The New York Presbyterian Hospital-Weil, NY.

© OneLegacy Pulsatile Perfusion Benefits Two kidneys singly or enbloc Continuous evaluation for predictable results Lower Delayed Graft Function (DGF) within 7 days postop Lower costs and shorter LOS Stimulates ATP synthesis (with Belzer MPS) Expansion to include marginal donors (older & hypertensive) as well as DACD Elective surgery Improves long term graft survival Kidneys pumped 30 plus hrs equal to kidneys iced less than 12 hours

© OneLegacy How much does PP save? Cadaveric Transplants n = 170 DGF(34)No DGF(136) Room11,700 +/- 9,8504,860 +/- 1,500 Pharmacy11,400 +/- 8,9006,085 +/- 3,400 Radiology2,470 +/- 1, /- 440 Laboratory 11,900 +/-11,3004,750 +/- 1,650 Dialysis9,300 +/- 8, /- 75 Surgery/Supplies4,430 +/- 1,5006,007 +/- 1,200 Total$51,200 +/- 41,250$22,700 +/- 8,265 The High Cost of Delayed Graft Function in Cadaveric Renal Transplantation. T.Rosenthal, MD et. al. TRANSPLANTATION VOL , No.5 May 1991.

© OneLegacy SVMC Experience 41 consecutive cases utilizing RPP, 2002, 6 month data: 28 had Cr ≤2.0 4 had Cr deceased 1 being followed at another center 4 relisted

© OneLegacy Th-th-that’s all, folks! Thank you

© OneLegacy