renal transplant evaluation process

7/28/2019 Renal Transplant Evaluation Process

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Renal Transplant

Evaluation ProcessShobha Ratnam M.D.,Ph.D.

Assistant Professor of MedicineUniversity of Toledo-College of Medicine


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Introduction

1954First successful kidney transplant performed.

1966 First simultaneous kidney/pancreas transplantperformed.

1967First successful liver transplant performed.

1968First successful isolated pancreas transplantperformed.

First successful heart transplant performed.


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Introduction (contd.)

1977 Implementation of the first computer-based organmatching system, dubbed the "United Network for OrganSharing.

1984The National Organ Transplant Act, passed by Congress inoutlawed the sale of human organs and began the developmentof a national system for

organ sharing and a scientific registry to collect and reporttransplant data

1986 UNOS receives the initial federal contract to operate theOrgan Procurement and Transplantation Network(OPTN).

1992UNOS helps found Donate Life America to build publicsupport for organ donation.
http://www.unos.org/core/redirector.php?dom=optn.transplant.hrsa.gov&page=http://optn.transplant.hrsa.gov/http://www.donatelife.net/http://www.donatelife.net/http://www.unos.org/core/redirector.php?dom=optn.transplant.hrsa.gov&page=http://optn.transplant.hrsa.gov/


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1995 UNOS launches its first Web site for all users withan interest in transplantation.

2001 For the first time, the total of living organ donors

for the year (6,528) exceeds the number of deceasedorgan donors (6,081).

2006 UNOS launches DonorNetsm, a secure, Internet-based system in which organ procurement coordinators

send out offers of newly donated organs to transplanthospitals with compatible candidates.


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UNOS Patient Services Department provides

transplantation and donation information to patients,family members, friends, potential donors and medical

professionals. Information can be requested on topicssuch as:

The transplantation and donation process

Living donation

Various national, regional, state and center-specific datareports


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Transplant Statistics

Waiting list candidates as of Nov,2010 109,300

Active waiting list candidates 72,137 Transplants JanuaryJuly 2010, 16,779

Donors January - July 2010, 8,477
http://optn.transplant.hrsa.gov/resources/glossary.asphttp://optn.transplant.hrsa.gov/resources/glossary.asp


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ORGAN SHARING SYSTEM


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The F.M. Kirby Foundation Organ Center

The primary functions of the Organ Center are to: assist in placing donated organs for transplantation assist in gathering donor information and running the

donor/recipient computer matching process assist with transportation of organs and tissues for the

purposes of transplantation act as a resource to the transplant community regarding

organ-sharing policies


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The Donation Process

When organs are donated, a complex process begins.UNOS maintains a centralized computer network,UNetSM, which links all organ procurement

organizations (OPOs) and transplant centers.Transplant professionals can access this computernetwork 24 hours a day, seven days a week.

UNet electronically links all transplant hospitals and

OPOs in a secure, real-time environment using theInternet.


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The Five Steps

In Organ Matching1. An organ is donated

OPO managing the donor enters medical information about the donorincluding organ size and condition, blood type and tissue type into theUNOS computer system.

2. A list of potential recipients is generatedThe UNOS computer system generates a list of candidates who havemedical and biologic profiles compatible with the donors. The computerranks candidates based upon how closely their medicalCharacteristics match the donors, medical urgency, time spent waiting

and proximity of candidates to the donor.


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The Five Steps

In Organ Matching (contd.)3. The transplant center is

notified of an available organOrgan placement specialists at the OPO or the

UNOS Organ Center contact the transplant centers

whose patients appear on the ranked list.

4. The transplant team considersthe organ for the patientWhen the team is offered an organ, it bases its acceptance or refusalof the organ upon established medical criteria, organ condition, candidatecondition, staff and patient availability and organ transportation.By policy, the transplant team has only one hour to make its

decision.5. The organ is accepted or declinedIf the organ is not accepted, the OPO continues to offer it for patientsat other centers until it is placed.


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The importance of time

The length of time donated organs and tissuescan be kept outside the body vary:

Heart: 4-6 hoursLiver: 12-24 hoursKidney: 48-72 hoursHeart-Lung: 4-6 hours

Lung: 4-6 hours


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Expanded Criteria Donors

Less traditional donors who are 60

or older or who are between 50-59

with at least two of the following

conditions: 1. history of high blood

pressure; 2. creatinine level of greater

than 1.5 (a creatinine test measures

how well a kidney is functioning with

a normal range of 0.8-1.4); 3. cause

of death was from a cerebrovascular

accident (stroke or aneurysm).


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Organ Allocation POL ICY DEVELOPMENT


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Challenges are

what make lifeinteresting;

overcoming them

is what makes lifemeaningful.

JOSHUA J. MARINE


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Conditions for coverage for ESRD

facilities

CMS mandates that accredited dialysis centersprovide

-evidence of transplant education

-track patients transplant referrals

-track patients transplant status on waiting

listcommunicate with transplant facilities


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Healthy People 2010 goal

Increase the proportion of dialysis

patients waitlisted and/or receiving a

deceased donor kidney transplantwithin one year of ESRD start


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Concept of WHOLE

Informed decision making by patients re: transplant

Without disability payments

social security benefits end 12 months after transplant

High cost of medications

$3000-$5000 a year

Out of pocket expenses for doctors, specialists, exams

Medicare pays 80% of costs and 20% paid by American KidneyFund while on dialysis


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Concept of WHOLE (contd.)

Loss of Medicare in many situations

Ends 3 years after transplant if patient not disabled or

has not initiated a work incentive through social security

Effects of medications

Short term and long term side effects of

immunosuppresion


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The Cost of Transplantation

Medical costs Pre-transplant evaluation and testing Hospital stay and surgery Additional hospital stays for complications

Follow-up care and testing Anti-rejection and other drugs, which can cost more than

$10,000 per year Fees for surgeons, physicians, radiologist and anesthesiologist Fees for the surgical recovery (procurement) of the organ from

the donor Physical, occupational and vocational rehabilitation Insurance deductibles and co-payments


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The Cost of Transplantation

Nonmedical costs Transportation to and from your transplant center,

before and after your transplant Food, lodging, long distance phone calls for you and

your family Child care Lost wages if your employer does not pay for the time

you or a family member spends

away from work If your transplant center is not near your home, you

may need to live near the transplant center


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FINANCING TRANSPLANTATION

The most common funding sources are:

Insurance

Extending Insurance Coverage through COBRA

Medicare Coverage TRICARE (formerly CHAMPUS)

Charitable Organizations

Advocacy Organizations

Fund Raising Campaigns


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Did you know?

About 78 people receive organ transplantsevery day in the United States, however . . .

About 18 people die each day waiting for atransplant


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Stages of Decision Making

PrecontemplationNot considering or not ready

Contemplation

Considering transplantation PreparationPlanning to pursue transplantation

Action

Contacted the transplant center Maintenance

Listed or found a living donor


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Pre-transplant labs

The first step to get on the waiting list is havingpre-transplant labs drawn.

Labs that we draw at your evaluation include:

ABO blood typing;

Tissue typing; and

Serologies.


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Compatibility of Blood Types

Recipient Compatible Donor

A O, A

B O, BAB O, A, B, AB

O O


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HLA System

There are three major genetically

controlled groups: HLA-A, HLA-B and

HLA-DR. In transplantation, the HLA tissue types of the donor and recipient

are important in deciding whether the

transplant will be accepted or rejected.

Genetic matching is generally performed

on kidneys and pancreas only.


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Tissue Typing

This test looks for the six histocompatibility antigens.There are three major genetically controlled groups:HLA-A, HLA-B and HLA-DR.

In transplantation that will define the amount of

matching between a recipient and donor. Although this test (and ABO blood typing) is necessary

for placement on the transplant waiting list, itsimportance has diminished.

This is because we now know that even transplantswith minimal matching (say, only one of six antigens)can have excellent outcomes, thanks to new advances inimmunosuppressive medications.


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Serologies

These tests look for a patients past exposure to

infections such as hepatitis, HIV, other virusesand syphilis.


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Panel Reactive

Antibodies (PRAs) Panel reactive antibodies show a patients level of sensitization to donor

antigens. Patients with high PRA levels tend to have more rejection episodes. In

addition, it is more difficult to identify a compatible kidney for patients with a high

PRA level. PRA tests are performed when a patient is put on the waiting list and every one to three months while waiting. Because of the information this test provides, it can be used to counsel patients regarding how long they may wait for a transplant. It also helps the transplant team choose the appropriate

antirejection

medications.


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Cross Match

This test establishes compatibility between a particular donor-recipient pair

and, for patients with a living donor, is performed during thetransplant work-up.

A negative cross-match suggests that a donor and recipient arecompatible

and the transplant can proceed. If the cross-match is positive,the pair can

participate in the Paired Donation Program. For patients with adeceased donor,

this test occurs prior to transplant surgery, once a donorbecomes available.


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Cardiac evaluation

EKG

Echocardiogram

Stress testexercise treadmill, stress echo and persantinethallium

Cardiac catherization Coronary artery bypass surgery


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Pulmonary evaluation

Stop smoking

Chest X-Ray

Pulmonary Function Tests CT chest


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Routine Health

Screenings

Female recipients-PAP smears, mammograms if> 40 y

Male recipients-Prostate exam, prostate specificantigen if >50 y

Colonoscopy if >50 y

Dental check up


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Types of Kidney Transplants from a

Deceased Donor

Brain Dead Donor: Kidney donor with an irreversible head injurywho was declared brain dead based on specific criteria. Braindead donors remain on life support during organ recoverysurgery.

Donation after Cardiac Death Donor (DCD Donor): Kidneydonor with a severe brain injury who does not meet the criteriafor brain death but has no chance of survival. Donation aftercardiac death donors are removed from life support prior toorgan recovery surgery.

Expanded Criteria Donor (ECD Donor):Any brain dead donorover age 60, or over age 50 with concurrent health problems.


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Types of Kidney Transplants from a

Living Donor

Living Related Donor:A living donor who is a healthy blood relative ofthe person awaiting transplant. This includes a sibling, parent, child, aunt,uncle, cousin, etc.Living Unrelated Donor: A living-unrelated donor is a healthy person

who is emotionally close to, but not blood-related to the person awaitingtransplant. This includes ones spouse, in-law relatives and close friends.A living-unrelated donor can also include a compatible, anonymous donormatched by the Paired Donation program.

Living donor transplantation is the most successful kidney transplantprocedure. Typically, living donor transplants last longer than deceaseddonor transplants.


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Contraindications

Untreated current infection

Active malignancy with short life expectancy

Chronic illness with life expectancy of less thanone year

Poorly controlled psychosis

Active substance abuse


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Relative Contraindications

Active infection

Coronary heart disease

Active hepatitis Active peptic ulcer disease

Cerebrovascular disease

Proven habitual medical noncompliance HIV infection.


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The Waiting Period

Keep your Transplant Team updated whileyoure on the waiting list. Call your transplant

coordinator on his/her direct line to notify

about any changes to your:

contact information (address, phone numbers)

insurance

doctor or dialysis unit

medical condition


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After Transplantation

Time After Transplant Frequency of Lab

Tests

0-6 weeks 2 times a week

6 weeks to 3-4 months 1 time a week

3-4 months to 6-9 months Every other week

9-12 months Every 1-3 months


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renal transplant evaluation process

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