wca cavallieri final challenges in pediatric transplantation

7/31/2019 WCA Cavallieri FINAL Challenges in Pediatric Transplantation

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Challenges in

PediatricTransplantation

Cavallieri, Silvana (Chile)WCA 2012

Buenos Aires


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1. Review figures and data regardingchildrens donation and heart

transplant throughout the world2. Emphasize challenges surrounding

pediatric donation and transplant

a. Discuss definitions and conditions for diagnosisof brain death in children

b. Discuss the management of pediatric donors

c. Discuss special issues in pediatric cardiac

donors


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Aspect that are milestone in organ harvesting forpediatric transplant


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Without donors there are no

transplants Every country should have an

organization COMITTED TO

Alleviating the organ and tissueshortage

Organ allocation


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Possible

donor

Medically

suitable FulfillBrainDeath

Criteria

Organprocurement

Transplant

Consent

ElegibledonorActualdonor

PotentialdonorUtilized

donor

Transplant Int 2011, 24:373-378

Devastating Brain

injury

BrainDeathconfirmed


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40-50 x millioninhbts/year die ofencephalic death

Taking into account

15% deceased in ICU

2% deceased in a hospital


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What is required to obtaina donor?

Pediatric heart

1. An adequate legislation

2. An organized system ofprocurement

3. A well educated and sensitivepopulation

4. Financial and medical resources


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Opting in Opting out

The person

and relatives

decide

All citizens are

donors

ExpressedConsent

Presumedconsent


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The Madrid Resolution on Organ Donation and


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Adapted from Organs Tissues & Cells.ul 2011


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The philosophy of the Spanishapproach is that improving the

organization of the wholeprocess will result in increasedorgan donation

The Donts

Do not place too much energy in changing thelegal system

Do not place much effort in public campaigns


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Actual Donor Rates:Comparison between countries (2011))

Adapted from Organs Tissues & Cells.


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Weak organ & procurementsystem We DETECT ONLY half of the possible

donors in our population

Possible donors are not a priority

Financial and logistic problems

We do not have a sensitive andwell educated population High rate ofFAMILY REFUSAL

Wh t h ith FAMILY


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What happens with FAMILYREFUSAL in different

countries?

From ONT (Spain), Corporacin del Trasplante(Chile)


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ILHTS. J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132


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ILHTS. J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132

#of

CentersReporting


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DISTRIBUTION OF TRANSPLANTSby Donor/Recipient Weight Ratio

(International Heart and Lung Transplant Registry.2003-june 2010)

%o

f

transplan

t


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Which are the figuresregarding pediatric donors?

ONT, Spain,

Years

Years

Years

Years

Years

Years


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3 kg:

AB: 0.16 A: 0.14

B. 0.10

O: 0.09

60 kg:

AB: 0.66 A: 0.61

B. 0.047

O: 0.44

J Paediatr Child Health, 2007. 43(1-2):


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J Pediatr.2011;158:31-6

10% organpool

increase


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1. Obtaining an adequate

donor ??1. Carrying out the explant and

transplant

2. Perioperative handling of therecipient

3. Immunosuppression/rejection

4. Follow up


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General:

Infectious disease (HIV or viralhepatitis),

Over 65

Disseminated malignancies

IV drug abuse

Specific for cardiac

transplant


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Congenital

Cardiomyophaty

Retransplant :

Dr. L. Bailey performed the first infant hearttransplant in in 1985

Numbers of pediatric heart


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Numbers of pediatric hearttrasplant and age of recipient per

year

J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132


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0

2550

75

100Myopathy Congenital

o

f

0

25

50

75100

0

25

50

75

100

%

o

C

a

Age


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1-year survival rate: 80-90%

2-year survival rate: 80-85%

5-year survival rate: 70-80%inexperienced

centers


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The most critical step is obtaining a

(cardiac) donor, and problems areusually related to...

Special difficulties indiagnosis of brain death

in pediatric donors


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Pediatrics, 2011;128: e720e740

Known structural disease or

irreversible systemic metabolic causethat can explain the clinical picture


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Exclusion and correction of

conditions that confound diagnosis ofbrain death (electrolyte abnormalities,intoxication, hypothermia or drugs)

Absence of recent doses of sedatives,

hypnotics or neuromuscular blockingagents

Absence of significant hypotension for

that age Pediatrics, 2011;128: e720e740


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Observation period

12 hours: for infants and children (30

d to 18 y)24 hours: from 37 weeks gestational

age to 30 d

2 neurological examinations Assessment of neurologic function following CPR

should be deferred for 24 hoursPediatrics. 2011;128:e720e740


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Harvard criteria

Set in 1968Reviewed 1987

Dead Donor Rule requirespatients to be declared dead before the removal oflife-sustaining organs for transplantation


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1. Coma

2. Absence of brainstemreflexes

3. Apnea

Formal neurologicalexamination

It is a requisite to have a known structural


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I: Coma (Absence of BrainFunctions)

unreactive coma is acondition where responsesto painful stimuli in cranialnerves territory are notpresent

b f


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II. Absence ofBrainstem Reflexes

certify the absence of brainstem

reflexes


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Pupillary response Mid-position or fully dilated pupils that do not respond to

light.

Vestibulo-ocular reflex (Cold caloric test)

Oculo-cephalic reflex Doll's eye movement)

Absence of bulbar functionincluding facial and

oropharyngeal muscles


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III. Apnea test


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Assesment of electrical

activity- EEG Assesment of Cerebral Blood

Flow- Radionuclide cerebral blood flow

These ancillary testsPediatrics. 2011;128:

-


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Programs for organ transplantationfrom anencephalic infants have beenapproved in Germany, Japan andHolland.

Is this ethical?


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Hypotension 81 %

Diabetes Insipidus 65-90%

IDC 28%

Arrhythmias 27%

Cardiac Arrest 25%

Hypothermia 23%

Oliguria 17%


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Full monitoring should be set upbecause of the unstable condition of

a patient in brain death


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Vasopressin

Thyroid

hormonereplacement

CorticoidsCanadian Medical Association Journal 2006,174(6)

THT

Improved organ-quality

UNOS evidence for THT in heart


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UNOS evidence for THT in hearttransplant

Use of T4 or T3/ Vasopressin/methylprednisolone :

retrospective studies

Hearts procured from donors

receiving THT: Improved one-month survival rate ascompared to those donors not receiving

THT.

Reduced early cardiac graftdysfunction

1. Rosendale JD, et al. Hormonal resuscitation associated with more transplanted organs with

no sacrifice in survival.Transplantation 2004;78(2) suppl 1:171. Canadian recommendations for donor management . Canadian

Medical Association Journal . 2006, 174(6)


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Limited supply ofcadaveric organ donors

Societal concerns about

the definition of BDCultural and family

concerns

The difficulties ofmedical managementBD organ donor

Legal & logistical

concerns


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Figures regarding donation andtransplants worldwide

Figures concerning the number oftransplants and results of cardiactransplant in children

Issues for Brain Death diagnosisand BD management in children.


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wca cavallieri final challenges in pediatric transplantation

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