Comparison of HTK and UW in Abdominal Transplantation Dr. Richard S. Mangus, MD MS Indiana University, School of Medicine.

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Presentation transcript:

Comparison of HTK and UW in Abdominal Transplantation Dr. Richard S. Mangus, MD MS Indiana University, School of Medicine

OUTLINE Conversion from UW to HTK Indiana Organ Procurement Organization Indiana University Transplant outcomes: UW vs HTK Kidney transplantation Pancreas transplantation Liver transplantation Intestinal transplantation Future research

Indiana Organ Procurement Organization (IOPO) Service area:Indiana Population:5.1 million Hospitals:130 Transplant centers:7

Indiana Organ Procurement Organization (IOPO) Potential advantages to HTK: Decreased cost Decrease contamination risk No mixing No filter Longer shelf life Can store at cool room temperature Faster preparation time for coordinator - “hang it, spike it, infuse it”

Indiana Organ Procurement Organization (IOPO) Potential advantages to HTK: Improved organ flushing Lower viscosity Faster organ cooling No organ flushing before reperfusion Lower K+ load decreases risks of hyperkalemia and bradycardia Easier to work with on back bench ? Improved outcomes

Indiana Organ Procurement Organization (IOPO) Cost analysis: HTK vs UW UW flush volume / donor:3.5 liters UW cost / liter$ Total cost per donor$1071 HTK flush volume / donor3.5 liters HTK cost / liter$ Total cost per donor$525 Cost savings per donor$546

Indiana Organ Procurement Organization (IOPO) Center cost savings Cost savings / donor$546 Annual cost savings for average OPO (200 donors)$109,200

Indiana University Medical Center Abdominal Organ Transplants Liver Pancreas Kidney Islets Small intestine / Multivisceral

Indiana University Medical Center Abdominal Organ Transplants 2007Rank * Liver155Top 5 Pancreas841 st Kidney255Top 10 Small intestine22Top 5 OVERALL (+ thoracic) 562 Top 5 * data reportwww.unos.org

Transplant Volume YearOrgans *

Transplant Volume YearOrgans * Conversion to HTK

Natural Experiment A naturally occurring instance which approaches or duplicates a scientific experiment. In contrast to laboratory experiments, these events aren't created by scientists, but yield scientific data. Natural experiments are a common research tool in fields where artificial experimentation is difficult, such as epidemiology.

Renal Transplantation

Transplants: 1990 to 1992 DGF: Need for dialysis 2 or more times during first 7-days post-transplant Flush volume:HTK 5 – 6 L UW1 – 2 L EC4 L Renal Transplantation

de Boer, et al, Transpl Proc, 1999; 31: 2065

Renal Transplantation de Boer, et al, Transpl Proc, 1999; 31: 2065

HTK vs UW: KIDNEY Transplantation N=91 renal transplantsHTK 50UW 41 No differences in:Delayed graft function Graft survival Patient survival

Creatinine Clearance Post Transplantation time (days) ml/min UW HTK

Serum Creatinine Post Transplantation time (days) mg/dL UW HTK

HTK vs UW: Kidney Transplantation N=149 renal transplants > 16 hrsHTK 62, UW 87 No difference patient / graft survival HTK lower DGF (24% vs 56%, p<0.01) > 24 hrsHTK 31, UW 38 No difference in patient / graft survival HTK lower DGF (16% vs 56%, p<0.05)

PANCREAS TRANSPLANTATION

Pancreas Transplantation N= 20 pancreas transplantsHTK 10UW 10 No differences in:Graft survival Patient survival Serum fasting blood glucose Peak serum amylase Serial amylase levels

Pancreas Transplantation

N= 87pancreas transplantsHTK 78UW 9 No differences in:Graft survival Patient survival Serum fasting blood glucose Peak serum amylase Serial amylase levels

Pancreas Transplantation

Primary preservation solution: HTK, 2003 to 2007:

Pancreas Islet Transplantation

LIVER TRANSPLANTATION

Liver Transplantation N=378 liver transplantsHTK 174UW 204

Liver Transplantation: ECD N=698 liver transplantsHTK 371UW 327 Groups:Standard209 (30%) ECD (old age)70 (10%) ECD (physiologic stress)435 (62%)

Liver Transplantation: ECD

N=698HTK 371UW 327

Liver Transplantation: ECD Standard donors, n=209Extended criteria donors, n=489

Liver Transplantation: ECD Donor < 60 years, n=628 Donor ≥ 60 years, n=70

Liver Transplantation: ECD No physiologic stress, n=263 Physiologic ECD, n=435

Liver Transplantation: ECD

Liver Transplantation Biliary complications Elevated liver enzymes post- transplant Liver U/S with doppler Biliary imaging Liver biopsy

Liver Transplantation Biliary complications

Liver Transplantation Donation after cardiac death, n=43 HTK 35UW 7

Liver Transplantation: Recent

Intestinal / Multivisceral Transplantation

“Comparison of HTK and UW in Intestinal and Multivisceral Transplantation” - Mangus, et al. Transplantation, 2008; In Press Intestinal Transplantation N=57 intestinal transplantsHTK 35UW 22

Intestinal Transplantation

N=57 intestinal transplantsHTK 35UW 22

Intestinal Transplantation No difference between HTK and UW in graft and patient survival at 30- and 90- days, and 1-year post-transplant No differences noted in: * Initial function * Appearance on early magnification endoscopy * Rejection episodes * Transplant pancreatitis

CONCLUSIONS Cost savings associated with HTK use No demonstrated difference in outcomes for: kidney pancreas pancreatic islets liver intestine Possible decrease in biliary complications for HTK in liver transplantation Possible long-term improvement in survival with HTK in liver transplantation

HTK vs UW: FUTURE RESEARCH HTK vs UW Prolonged cold ischemia time Transplant pancreatitis DCD allografts Biliary complications / Flush of microcirculation Multicenter data – large volume data analysis