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Moderator: Ervin Ruzics, MD, St. Joseph Transplant Presenters: Cynthia Herrington, MD, Children’s Hospital Los Angeles Mudit Mathur, MD, Loma Linda University.

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Presentation on theme: "Moderator: Ervin Ruzics, MD, St. Joseph Transplant Presenters: Cynthia Herrington, MD, Children’s Hospital Los Angeles Mudit Mathur, MD, Loma Linda University."— Presentation transcript:

1 Moderator: Ervin Ruzics, MD, St. Joseph Transplant Presenters: Cynthia Herrington, MD, Children’s Hospital Los Angeles Mudit Mathur, MD, Loma Linda University MC Steven Colquhoun, MD, Cedars-Sinai Transplant Center Clarence Foster, MD, UC Irvine Medical Center Breakout Session B: Decoding Transplant Center Acceptance Criteria

2 Question to Run On What practices have you learned today that you will implement to increase organ acceptance and improve long-term outcomes?

3 Objectives By the end of this presentation, the attendee will be able to: Understand the key considerations in determining organ acceptance versus decline Know which elements of donor management are most impactful in organ placement and improved outcomes

4 Children’s Hospital Los Angeles Cynthia Herrington, M.D. Associate Professor of Clinical Cardiothoracic Surgery, Keck School of Medicine Surgical Director of Pediatric Thoracic Transplantation & Ryan Winston Family Chair in Transplant Cardiology at Children’s Hospital Los Angeles Surgical Director of Lung Transplant Program at USC.

5 Loma Linda University Children’s Hospital Mudit Mathur, M.D. Associate Professor of Pediatrics

6 Expanding Transplant Center Acceptance Criteria-Hearts Mudit Mathur, MD Associate Professor of Pediatrics/Critical Care Loma Linda University Children’s Hospital

7 Donor quality Recipients July 2000- Dec 2008 84 trasnplants from 86 primary offers vs. 29 from donors refused by other centers (quality UNOS code 830) Pediatric Transplantation Using Hearts Refused on the Basis of Donor Quality. Bailey LL, Razzouk A, Hasaniya N et al. Ann Thoracic Surg 2009; 87(6): 1902-8

8 Recipient outcomes Despite…. Longer recovery distance (p <.002) Longer graft cold ischemic time (p < 0.001) Operative survival 93± 5% 7 year actuarial survival 74 ±10.5% NO DIFFERENCE vs. PRIMARY OFFERS Pediatric Hearts should seldom be refused on the basis of donor quality

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10 Background Waitlist mortality for infants awaiting heart transplantation 2465 deaths/1000 patient-years (10-fold higher than 1-5, 6-10 or 11-17 year groups) Risks-weight< 3kg, Status 1A, ECMO/VAD, mechanical ventilation, dialysis, race/ethnicity PICU-potential 40% increase in total donors by including DCD donors 1995-2005 (USA): 683 Pediatric DCD transplants Kidney: 486, liver: 144, Pancreas: 38, Intestine: 1, Heart: 2, Lung: 12 NICU potential?

11 Methods Review of prospective NICU electronic database All in-hospital deaths (6/2003-6/2008) included Potential organ donors (weight > 2.5 kg) categorized by mode of death Died despite cardiopulmonary resuscitation (CPR) Do not resuscitate (DNR) status Brain death (BD) Withdrawal of life-support (W) Patients undergoing planned withdrawal evaluated further for suitability as DCD donors

12 Results 5446 NICU discharges over 5 years 266 deaths, 117 (44%) weighed > 2.5 kg 19 died despite CPR, 33 were DNR, 0 brain deaths Withdrawal of life support in 69(59%)

13 Withdrawal (n=69) Age 1 d- 225 days Weight 2500-7495 grams 53 excluded-active infection/ significant cardiac dysfunction/ CHD/ MSOF. 16 evaluated further

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15 Results 16 Potential DCD candidates Median time (Withdrawal to death): 31 minutes (<1 to 310 min) Withdrawal: Ventilator support (all), Dopa 4-8 mcg (3) Reason for Withdrawal: Futility, neurodev outcome Five patients (4.3% of all eligible donors) died in < 30 minutes

16 Results: 5 suitable DCD donors DiagnosisWt (kg)Bld typeEchoALTCreat HIE2.58O+normal250.4 Midbrain bleed2.72O+normal290.3 BPD2.99A+normal230.4 Axonal dystrophy 5.57A+not done310.1 Ribcage abn.6.64B+normal190.7 No NICU Brain deaths during study period (6/2003-6/2008) Loma Linda PICU: 81 BD, 51 Donors, 158 organs transplanted

17 Potential impact of newborn DCD donors Local-Loma Linda 15/51 listed for heart transplant during the 5-year period studied died/taken off list (2 NICU donors would have been blood type and size matches) National 814 infants listed 3-month waitlist mortality 18.2% + 162 waitlist removals

18 Our approach IRB approval Unmodified DCD donor protocol (5 min) High risk waitlisted infants consented Waitlisted for > 1 month Milrinone Mechanical Ventilation Dialysis ECMO/VAD

19 Conclusions Potential DCD donors can be readily identified among NICU patients undergoing withdrawal of life support (5 infants, 4.3% of all deaths) Potential is similar to PICU data (5.5-8.7%) Identifying NICU donors may Markedly expand the infant donor pool Reduce short-term wait-list mortality rates for infants

20 References Mathur M, Castleberry D, Job L, J Heart Lung Transpl 2011 ;30(4):389- 94. Epub 2010 Dec 24 Koogler T, Costarino A. Pediatrics. 1998;101:1049–1052 Durall AL, Laussen PC, Randolph AG. Pediatrics. 2007;119:e219–e224 Naim MY, Hoehn KS, Hasz RD, White LS, Helfaer MA, Nelson RM. Crit Care Med. 2008;36:1729–1733 Kolovos NS, Webster P, Bratton SL. Pediatr Crit Care Med. 2007;8:47–49 Pleacher KM, Roach ES, Van der Werf W, Antommaria AH, Bratton SL. Pediatr Crit Care Med. 2009;10:166–170 Almond CS et al. Waiting list mortality among children listed for heart transplantation in the United States. Circulation 2009, 119:717-727

21 Cedars-Sinai Medical Center Steven Colquhoun, M.D. Director, Liver Transplantation and Surgical Oncology Center for Liver Disease & Transplantation

22 Deceased Donor Selection: Liver Steven Colquhoun, M.D., FACS Director, Liver Transplantation Cedars-Sinai Medical Center

23 Donor v. Recipient Donor Quality Recipient Condition Balancing Act!

24 Distance/Cold Time/Expense CA NV UT AZ NM SF LA

25 Rank Order: First Pass  Age  Size  Hemodynamics  Numbers  Co-morbidities  Time hospitalized

26 Labs  Enzymes: –Current & Trend v. Mechanism  Sodium –Current & Peak  Serologies –HCV, HBV, HBVc  Bilirubin (?)

27 Fat  Likelihood –Height/Weight & Age –Diabetes Steroids/co-morbidities  Ultrasound / other imaging  Biopsy (problems)  Weighed against all other concerns  Goal: ≤ 30%

28 Formulas  Donor Risk Indexes  Absolute cutoffs –Age, Sodium, Enzymes  Unhelpful

29 Appearance Color Texture Experience Surprising how often we’re surprised

30 How it Really Works: Sports OR Tantrums cars Mumbling New gadgets Sewing Cautery

31 U.C. Irvine Healthcare Clarence E. Foster III, M.D. FACS Chief, Kidney & Pancreas Transplantation Associate Clinical Professor, Department of Surgery, University of California, Irvine

32 Clarence E. Foster, III MD FACS Chief, Transplantation Department of Surgery, School of Medicine University of California, Irvine

33  Basic Framework of Donor Acceptance Criteria: Age Donor Chronic Diseases Donor Acute Diseases Donor Type Cold Ischemia Times

34 Donor Age Kidney Pancreas  Most liberal of all transplanted organs  Infants Age-days to months Sharma A (2011) ○ mean 19 month ○ outcome equivalent to living donor  Elderly- 70’s and above Boesmueller C (2011)  Age 10 y/o to 50 y/o

35 © 2011 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.3. Long-Term Outcome in Kidney Transplant Recipients Over 70 Years in the Eurotransplant Senior Kidney Transplant Program: A Single Center Experience. Boesmueller, Claudia; Biebl, Matthias; Scheidl, Stefan; Oellinger, Robert; Margreiter, Christian; Pratschke, Johann; Margreiter, Raimund; Schneeberger, Stefan Transplantation. 92(2):210-216, July 27, 2011. DOI: 10.1097/TP.0b013e318222ca2f FIGURE 2. Death censored graft survival at year 1/5 was 100%/82% in 70+ group and 98.1%/92.7% in 70- group, respectively.

36 Kidney Donor Diseases  Chronic Diseases Diabetes Hypertension Stroke Hepatitis C  Acute Disease

37 Donor Type  Expanded Criteria Kidney Donors (ECKD)  Donation after Circulatory Death (DCD)

38 Expanded Criteria Donors (ECD)  Definition Based on significant medical risk factors ○ > 60 y/o ○ 50-59 y/o with 2 of following: History of hypertension Cerebrovascular accident as cause of death Final pre-procurement creatinine >1.5  RR >1.7 when compared to ideal 10-39 y/o donor

39 New Allocation for ECD  OPTN/UNOS Board of Directors, November 2001  ECD Kidneys allocated to predetermined patients to be recipients  Purpose is to stimulate use and decrease discard of organs

40 n

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42 Acceptable Cold Ischemia Kidney Pancreas  48 to 56 hours  12 to 24 hours

43 Conclusion  Potential kidney donors are the broadest group of donors when considering age and donor type  Excellent outcomes are achieved in kidney and pancreas transplantation

44 Question to Run On What practices have you learned today that you will implement to increase organ acceptance and improve long-term outcomes?

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