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Organ Transplantation
Dr. Nelson L. Rhodus Director of Oral Medicine University of Minnesota
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Organ Transplantation
Bone Marrow ( stem cell) Solid organs Heart Lung Liver Kidney Pancreas Small intestine
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Organ Transplantation
Heart transplants First performed in 1967; first year only 1:5 survived 2000= 3500 performed Total= 53,000 Present survival rate >70%
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Organ Transplantation
Kidney First solid organ transplant ( 1954) performed Since then >490,000 kidney transplants Presently 581 centers perform >10,000 kidney transplants per year: 1-year survival rate >90%( cadaver~80%) ( 5 yr. ~70%)
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Organ Transplantation
Liver transplants First liver transplant in 1967 >90,000 liver transplants > 8,000 liver transplants per year 1-year survival rate >90% ( 5 yr. ~70%)
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Organ Transplantation
Pancreas transplants first pancreas transplant was performed in 1966, by Kelly and Lillehei at the University of Minnesota 2000 >3500 transplants performed >2000 at the U of M ! 1 year survival rate >85% ( 5 yr. ~70%) survival rate w/o pancreas transplant = about the same ! ( JAMA- Dec. ‘03)
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Organ Transplantation
Heart - lung transplants ~ 800 performed as of 2000 1 year survival ~ 60 %
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Organ Transplantation
Small intestine transplants less than 50 performed (some combined with liver transplants) four transplant centers (Cambridge; London, Ontario; Pittsburgh, and Omaha). current 1-year survival rate at 70%.1
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Bone marrow transplantation
First performed in 1958 Early = very poor prognosis Immunosuppression, GVHD, rejection 2000 > 100,000 Today = successful ( 50-80% survival rate-1 year)
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Organ Transplantation
HEART TRANSPLANTS Reasons; cardiomyopathy, congenital heart disease, atherosclerotic coronary artery disease Terminal heart disease (6-12 months) Age <50-55 years
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Organ Transplantation
HEART TRANSPLANTS Good renal and hepatic function No infections No diabetes Family support
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Organ Transplantation
HEART TRANSPLANTS Causes of death: Infection 40% Acute graft rejection 25% Chronic graft rejection 10 % Cardiac disease 25%
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Organ Transplantation
HEART TRANSPLANTS Endocarditis prevention Pacemakers-arrhythmias Medications- drugs Avoid epinephrine Anticoagulation
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Organ Transplantation
HEART TRANSPLANTS Immunosuppression Adrenal suppression Bleeding Infection (IE)
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Organ Transplantation
HEART TRANSPLANTS ACCELERATED GRAFT ATHEROSCLEROSIS(AGAS) ~ 50 % of post-transplant patients have AGAS ( same degree as pre-transplant)
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Organ Transplantation
HEART TRANSPLANTS Transplanted heart has no nerve supply Therefore with AGAS there is NO ANGINA. MI will cause sudden death.
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Heart - lung transplants
first 1981 ( now~800 performed) per year
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Organ Transplantation
LIVER TRANSPLANTATION Indications: Chronic active hepatitis Extrahepatic biliary atresia Primary biliary cirrhosis Budd-Chiari syndrome(hepatic vein thrombosis) Sclerosing cholangitis Hepatocellular carcinoma
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Organ Transplantation
LIVER TRANSPLANTATION Primary organ disease problems Excessive bleeding Infection Altered drug metabolism Hypertension
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Liver- small bowel transplant
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Organ Transplantation
RENAL TRANSPLANTATION ESRD management Endocarditis, endarteritis Same as other organ transplants Aggessive prevention-treatment of infections Viral infections( CMV, HBV,HCV, HIV)
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Organ Transplantation
RENAL TRANSPLANTATION Avoid certain drugs( acetaminophen, phenacetin, tetracycline, aminoglycosides, ASA, K+, PCN, Magnesium-antacids, etc.) Laboratory tests: urinalysis( BUN, creatinine, protein, electrolytes)
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Bone marrow transplantation
condition success rate ALL % AML % CML 60% Aplastic anemia % Lymphoma % Neuroblastoma %
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Bone marrow transplantation
HISTOCOMPATABILITY Autologous self % Allogeneic sibling % Syngeneic ident. twin < 5% Haploidentical parent < 5% Unrelated any donor %
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Bone marrow transplantation
Stages: Medical evaluation 1 week Histocompatibility matching 1 day BM procurement (iliac crest) 1-2 weeks Immunosuppressive Tx (TBI)1-2 weeks Pancytopenic phase 4-6 weeks Immune recovery phase 1 year Long-term recovery 1-4 years
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Bone marrow transplantation
Three phases of immunosuppressive Tx 1.) pre-transplant Cyclophosphimide or methotrexate ± TBI ( single or fractionated) 2.) transplant( pancytopenic phase) 3.) cyclosporine, methotrexate, IFN-a to prevent GVHD
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Bone marrow transplantation
Phases 2-3 pancytopenic phase ANC<500: severe susceptibility to infection : 4-6 weeks post-transplant Immunosuppression ( long-term) Recurrence of leukemia GVHD encephalitis
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Bone marrow transplantation
ORAL COMPLICATIONS Peak 2-3 weeks post BMT ( pancytopenic phase: ANC<500) Mucositis, xerostomia, GVHD, viral infections(HSV,HIV), ELP-like, erythema, Candidiasis
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Dental management of the Organ Transplant patient
Dr. Nelson L. Rhodus Director of Oral Medicine University of Minnesota
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Organ Transplantation
Before transplant MEDICAL CONSULTATION Establish patient status primary organ failure-complications Current treatment-drugs, etc. Antibiotic prophylaxis
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Organ Transplantation
LABORATORY TESTS CBC differential white count platelets PT, PTT, BT
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Organ Transplantation
COMPLICATIONS Over-immunosuppression Side-effects of drugs Rejection of transplant Acute Chronic
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Organ Transplantation
DENTAL EVALUATION Aggressive treatment prior to immunosuppression Extract teeth with poor prognosis Advanced perio, endo, questionable Aggressive oral hygiene: maintenance
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Organ Transplantation
IMMUNOSUPPRESSION Prednisone Aziothioprine(Immuran) 33%* Cyclosporine %* Antilymphocyte globulin (ALG) 84%* * 1 year survival rate
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Organ Transplantation
IMMUNOSUPPRESSION Infection Delayed wound healing Bleeding Hypertension Heart failure Diabetes mellitus
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Organ Transplantation
IMMUNOSUPPRESSION Tumors ( lip cancer, lymphoma) Adrenal crisis Anemia Osteoporosis GI problems
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Organ Transplantation
DENTAL MANAGEMENT MEDICAL CONSULTATION Minimize stress, short appointments Monitor vitals ( HTN) Infections( endocarditis, endarteritis) Pneumonia, encephalitis Aggessive prevention & Tx of infection
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Organ Transplantation
DENTAL MANAGEMENT Bleeding GI problems IMMUNOSUPPRESSION Consider steroid supplementation Personal Oral hygiene
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Transplantation ORAL COMPLICATIONS
Bleeding, infections, poor wound healing Pain Mucositis, ulcers, xerostomia, dysguesia, dysphagia
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Organ Transplantation
Tumors Lip carcinoma 8-10% Kaposi’s 6-7 % Lymphoma 20 % Kidney Ca 5 %
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Organ Transplantation
IMMUNOSUPPRESSION Minor complications Gingival hyperplasia Hirsutism Gynecomastia Depression
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Organ Transplantation
Graft rejection Heart- death, retransplant( unlikely) Kidney- death, Hemodialysis, re-Tx Pancreas- death, insulin, re-Tx
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Organ Transplantation
IMMEDIATE POST-TRANSPLANT No routine dental treatment ~ 6 mos. POH Emergency( conservative) treatment MEDICAL CONSULTATION
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Organ Transplantation
Stable graft period ( >6 months) Most dental treatment can be performed with adequate management OVER-IMMUNOSUPPRESSION GVHD HTN, BLEEDING, DRUGS, etc. OTHER INFECTIONS
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Organ Transplantation
CHRONIC REJECTION PERIOD No routine dental treatment POH Emergency( conservative) treatment MEDICAL CONSULTATION
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Organ Transplantation
Salivary gland dysfunction Very aggressive oral hygiene program POH: plaque control : toothbrushing, flossing, fluorides Dietary counseling Perio treatment Chlorohexidine gluconate
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