2. transplantasyon 8. sunum

8/14/2019 2. TRANSPLANTASYON 8. SUNUM

http://slidepdf.com/reader/full/2-transplantasyon-8-sunum 1/50

Use of Extended Criteria Donor OrganUse of Extended Criteria Donor Organsfor Liver Transplantationfor Liver Transplantation

Antalya, Turkey

September 4, 2007

Charles B. Rosen, MD

Surgical Director, Liver Transplantation

Mayo Clinic Rochester Mayo Clinic College of Medicine



Use of Extended Criteria Donor Organs forUse of Extended Criteria Donor Organs forLiver TransplantationLiver Transplantation

Liver Transplantation Strategy

Results with Liver Transplantation

Millenium Challenges(Performance, Allocation, ECD and DCD)

Organ Transplantation Breakthrough

Collaborative



Liver TransplantationLiver TransplantationAims

• Prolong life

• Improve quality of life

For patients with acuteor chronic end-stage

liver disease



Liver TransplantationLiver TransplantationIndications

• Ascites, SBP

• Variceal hemorrhage

• Encephalopathy

• Pruritus

• Hepatorenal syndrome

• Muscle wasting

• Growth failure

• Fatigue and weakness

• Hepatocellular carcinom

• Hilar cholangiocarcinom

• Metabolic disease

• Acute liver failure



Liver TransplantationLiver TransplantationPatient Selection - Predictors of Success

• Technical difficulty – Prior abdominal operations

– Portal vein thrombosis

•

Severity of liver disease• Other medical issues

– Heart, lung, and kidney problems,diabetes

• Psychosocial status – Compliance

– Chemical dependency



Mayo Clinic Rochester Mayo Clinic Rochester Liver Transplant ProgramLiver Transplant Program

1985 - 2007

*1773 transplants

* 1591 primary transplants

*70 living donor transplants

*1138 living patientsWaiting list 389 patients

80-109 transplants per year since mid 1990’s

**91% patient and 88% graft survival at 1 year

**84% patient and 79% graft survival at 3 years*August 30, 2007

**www.ustransplant.org (Tables 10 and 11)



Mayo Clinic Rochester Liver Transplant ProgramMayo Clinic Rochester Liver Transplant ProgramAdult Patient Survival - Primary Transplantation

n = 1442

010

20

30

40

50

60

70

80

90100

0 1 2 3 4 5

1985 - 2006



Mayo Clinic Rochester Liver Transplant ProgramMayo Clinic Rochester Liver Transplant ProgramAdult Patient Survival - Primary Transplantation

010

20

30

40

50

60

70

80

90100

0 1 2 3 4 5

1985-1990, n=227

1991-1995, n=335

1996-2000, n=408

2001-2005, n=407

92% 83%



SUCCESS AT THE MAYO CLINIC

– A BIRD’S EYE VIEW



Liver Transplant ProgramLiver Transplant ProgramAdult Patient Survival

010

20

30

40

5060

70

80

90

100

1 Year 3 Year

1985-1990

1991-1995

1996-2000

2001-2005



Liver Transplant ProgramLiver Transplant ProgramMillennium Challenges

• Increase in waiting list – Deaths

– Morbidity

• MELD/PELD liver allocation

• Changes in organ donation – Increase in donor age

– Increase in medical vs trauma deaths

• Increasing competition – Patients

– Donor organs



Liver Transplant ProgramLiver Transplant ProgramMillennium Strategy

• Increase use of extended criteriadonor organs –Marginal organs

–Higher risk donors• Living donor liver transplantation

• Waiting list management

• Accommodate the “cluster effect”



Liver Transplant ProgramLiver Transplant ProgramOlder Donors

• Mayo Clinic Rochester 1998 - 2002

• 25 donors age 70-80 years

•95% one-year patient survival

• 1 retransplant for “small-for-size” graft – Avoid small grafts in large patients

• High risk for recurrent HCV

– Avoid older donor livers for HCV patients

Transpl Int 2005; 18:73



Liver Transplant ProgramLiver Transplant ProgramOlder Donors

• Result of aim to use all transplantablelivers from older donors:

–Donors > 65 years: 15% of activity –Donors > 70 years: 10% of activity

–Actual patient survival remains high

–Decrease in expected patient survival



Liver Transplant ProgramLiver Transplant ProgramWaiting List Management

• Maximize each and every patient’sopportunity to receive a deceased donor liver

• Donor organ acceptance decisions guidedonly by each patient’s best interest inorder on the waiting list

• Identify “disadvantaged” patients whom

would benefit from transplantation with anextended criteria donor liver



Deceased Donor Liver AllocationDeceased Donor Liver AllocationFebruary 2002 Changes

OLD UNOS POLICY

• Local, regional, national

•Medical status

→ →

• Waiting time → →

• Regional sharing for status 1

• Status 2A for ICU → → patients

NEW UNOS POLICY

• Local, regional, national

•Probability of death

• No waiting time

• Regional sharing for status 1

• No preference for ICUpatients



Deceased Donor Liver AllocationDeceased Donor Liver Allocation February 2002 Changes

OLD UNOS POLICY

Medical Status

Waiting Time

Child-Turcotte-Pugh Score

• Ascites

• Encephalopathy

• Bilirubin

• Protime INR

• Albumin

NEW UNOS POLICY

Probability of Death

No Waiting Time

→ → MELD Score

• Creatinine

• Protime INR

• Bilirubin



Deceased Donor Liver AllocationDeceased Donor Liver AllocationPatients Awaiting Transplantation

ADVANTAGED

• High MELD score

• Renal failure,anticoagulation

• Hepatocellular carcinoma

• Special diseases:amyloidosis, oxalosis

• Special conditions: HPS

• ABO: AB

DISADVANTAGED

• Debilitating illness withlow MELD score: ascites,encephalopathy, pruritus

• Cholestatic liver diseases,chronic graft failure

• Special conditions: PPH,logistics, foreign nationalpatients

• Emerging indications:CCA, NET



Deceased Donor Liver AllocationDeceased Donor Liver Allocation Patient Waiting List Management

• Coordinator responsibilities: – Arrange tests for score renewal and updates

– Notification for patients nearing time of transplantation

– Ongoing clinical care coordination • Identification of disadvantaged patients

– Living donor transplantation

– Expanded criteria donor organs

• Weekly list review

• Database



Liver TransplantationLiver TransplantationExpanded Donor Criteria

High Risk Donors

• HCV Ab+

• HBcAb+

• Intracranial malignancies

• Remote malignancies• High risk behavior/exposure

• Infectious cause of death(HSV, meningitis)

• Older donors (malignancies)

•Familial amyloidosis

Marginal Organs

• Steatosis

• Ischemia

• Elevated enzymes

• High serum sodium• High pressor requirement

• Active infection, sepsis

• Prolonged preservation time

• Split liver grafts

• Donation after Cardiac Death(DCD)



Liver Transplant ProgramLiver Transplant ProgramAccommodating the Cluster Effect

• Cluster effect: two or more transplantsoccurring during the same day

• 43% of transplants for a program

performing 100 deceased donor transplantsper year

• Opportunity cost of limited staffing:

–2 transplants per day limit: 10-15 –1 transplant per day limit: 20-25



Liver Transplant ProgramLiver Transplant Program2001 - 2005 Strategy Summary

• Use of extended criteria donor organs

• Living donor liver transplantation

• Waiting list management

•Accommodate the “cluster effect”



Liver Transplant ProgramLiver Transplant Program2001 – 2005 Results Summary

• Maintained high level of activity

• Maintained high patient survival

• Achieved statistically higher thanexpected patient and graft survival

Li T l t P



Liver Transplant ProgramLiver Transplant ProgramTransplant Activity

0

20

40

60

80

100

120

1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005



US Center-Specific DataUS Center-Specific DataAdult Patient Survival – July 2007

0

10

20

30

40

50

60

70

80

90

100

1 Year 3 Year

Observed

Expected

* Statistically higher than expected patient survival at 1 year

www.ustransplant.org

90.886.3 83.5

79.0

US C t S ifi D t



US Center-Specific DataUS Center-Specific DataAdult Patient Graft Survival – July 2007

0

10

20

30

40

50

60

70

80

90

100

1 Year 3 Year

Observed

Expected

* Statistically higher than expected graft survival at both 1and 3 years


88.583.6

79.373.5

Li T l t PLi T l t P



Liver Transplant ProgramLiver Transplant ProgramStrategic Results

• Mayo Clinic identification as a“center of excellence”

• Attracts patients

• Lower cost of transplantation

• More transplants with higher

survival benefit helps more patients



Organ Donation AwarenessOrgan Donation Awareness

• Hospital development• Donor designation legislation

• National priority

• HRSA National Collaboratives

–Organ Donation: 75% donation rate

–Organ Transplantation : 3.75 organs

per donor

HRSA O d D ti T l t tiHRSA O d D ti T l t ti



HRSA Organ and Donation TransplantationHRSA Organ and Donation TransplantationCollaborativesCollaboratives

Government at its bestGovernment at its best

• HRSA – study best practices – Donor hospitals

– Organ procurement organizations

– Transplant centers

• Faculty – develop “change package”

• Learning congresses – widespread sharing andcollaboration

• Result – rapid implementation, breakthroughchanges, dramatic results

The Possibility – to Double Annual



50% 6,000

3/D 18,000

75% 9,000

4/D 36,000

Donors/year

Recipients/year

The Possibility to Double Annual

Transplants

N b f O D b M th



Number of Organ Donors by Month

400

450

500

550

600

650

700

750

1 4 7 1 0 1 4 7 1 0 1 4 7 1 0 1 4 7 1 0 1 4 7 1 0 1 4 7 1 0 1 4 7 1 0 1 4

Month

N u m b e r o

f o r g a n d o n o r s

1999 2000 2001 2002 2003 2004 2005 2006

1st Donation Collaborative

2nd Donation Collaborative

Transplant Collaborative

Old System

New System



We have a lot more donorsand organs than we used tohave…



…and a lot less sleep as well!

-notorious transplant surgeon



Donation After Cardiac DeathDonation After Cardiac Death

• The norm for organ procurement during the early yearsof transplantation

• Nearly abandoned during the 1970’s and 1980’s – adoption of brain death criteria

– better organ function with heart-beating donors

– poor organ function:

» hypoxia and hypotension during process of death

» warm ischemia time

• Worsening donor organ crisis as a result of superbresults with transplantation and an increase in patientsawaiting transplantation

• Organ procurement from DCD donors regainingacceptance during late 1990’s




DCD has emerged as a “standard of care”

• Institute of Medicine and DHHS endorsements

• HRSA OTBC – Increase DCD to 10% of all donation• JCAHO – Hospital protocol standard in 2007

• UNOS/OPTN – Membership requirement in 2007

Donation after Cardiac DeathDonation after Cardiac Death



Donation after Cardiac DeathDonation after Cardiac DeathConsent

• Decision to withdraw support – No different than is current practice

– Decision made by patient, family, and medical team inaccord with hospital policy and procedure

– Decision is independent of decision to donate

• Decision to donate – Family discussion with procurement coordinator

» Education and Counseling

– Assessment for donation

» Suitability of organs

» Likelihood of cardiac death within one hour of withdrawal of support

Donation After Cardiac Death



0

100

200

300

400

500

600

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

7.4%

Donation After Cardiac Death1993 - 2005

WWW.USTRANSPLANT.ORG




Liver Transplantation

UNOS• Inferior graft survival with DCD donors

– 70% versus 80% at 1 year

• Inferior patient survival with DCD donors

– 80% versus 85% at 1 year

• Association between preservation time and graft failure

– 30% at 8 hours, 58% at 12 hours and 17% increase eachadditional hour

• Poor results with older (age > 60 years) DCD donors

– 25% graft failure

Annals of Surgery 2004; 239:87

Donation after Cardiac DeathDonation after Cardiac Death



Donation after Cardiac DeathDonation after Cardiac DeathMayo Clinic Experience

• 12 DCD multiorgan procurement procedures

• 7 Mayo Clinic liver recipients

– includes 1 pediatric recipient of pediatric DCD donor – no cholangiopathy

• 1 liver recipient at another transplant center

Li i D Ri ht H t tLi i D Ri ht H t t



Living Donor Right HepatectomyLiving Donor Right Hepatectomy

Ex vivo Split Liver AllograftEx-vivo Split Liver Allograft



Ex-vivo Split Liver AllograftEx-vivo Split Liver Allograft

Jason and Stephanie



Jason and Stephanie

Jason and Stephanie



Jason and Stephanie

Domino Liver TransplantationDomino Liver Transplantation



Domino Liver TransplantationDomino Liver TransplantationAutosomal Dominant AmyloidosisAutosomal Dominant Amyloidosis

• Liver histologically normal

• Liver produces amyloid

• Problems from amyloid after 20 – 40 years

• Amyloid liver recipient selection – Disadvantaged patients > 60 years

• Donor / recipient interaction

• Several dozen cases world-wide

Amyloid and Domino Transplant Recipient



Amyloid and Domino Transplant RecipientDecember 25-26, 2002

Focus on the FutureFocus on the Future



Strategic Initiatives

• Expanded criteria donor organ utilization• Obesity – weight loss management protocol

• Hepatitis C – prevention and treatment of recurrent disease

• Chemical dependency – programmaticapproach to evaluation and treatment

• Transplant Center quality initiative

• Commitment to excellence – outcome,satisfaction

US Center-Specific DataUS Center-Specific Data



ppAdult Patient Survival – July 2007

0

10

20

30

4050

60

70

80

90

100

1 Year 3 Year

Observed

Expected

* Statistically higher than expected patient survival at 1 year


90.886.3 83.5

79.0




Deaths 1 year 3 year Observed 17 31

Expected 29 42Obs/Exp 60% 75%

US Center-Specific DataUS Center Specific DataAdult Patient Survival – July 2007




Deaths 1 year 3 year Observed 17 31

Expected 29 42Obs/Exp 60% 75%

• 25 to 40% decrease in likelihood of

dying after liver transplantation at theMayo Clinic Rochester

US Center-Specific DataUS Center Specific DataAdult Patient Survival – July 2007

2. transplantasyon 8. sunum

Documents