Abdominal Organ Transplant Program
Mayo Clinic Arizona
2006 Review
Annual Report to CPC / Board of Governors
David D. Douglas, MD
Raymond L. Heilman, MD
David C. Mulligan, MD
Pamela L. Gillette, MPH, RN
Todd E. Wilkening / Duffy Suba / Susanne M. Gauthier
1
Presentation Outline
• Overview and History
• Academic/Research Activity
• Liver Transplant Program
• Kidney/Pancreas Transplant Program
• DSS Financial Analysis for 2005
• Strategic Plan and Targets for 2007
2
Mayo Clinic
Largest Transplant Entity in U.S.
1469 Total Transplants in 2006
717
800
700
446
600
306
500
400
300
200
100
0
MCR
Heart
Lung
MCJ
Liver
Kidney
MCA
Pancreas
BMT
3
MCA Abdominal Organ Transplant History
Then and Now
• Liver Transplant Program
• Deceased Donor Liver Transplantation (1999)
• Living Donor Liver Program (2001) – 1st in AZ
• 2006 – 7th largest in the US
• Kidney Transplant Program
• Living Donor Kidney Program (1999)
• 2006 – 15th largest in the US
• Laparoscopic Donor Procedure (1999)
• First in the Foundation & Arizona
• Pancreas Transplant Program
• November 2002 UNOS Certified
• First K/P Transplant in July 2003
• 2006 – 7th largest in the US
4
2006 Overview Summary
• Total Annual Transplants Decreased by 6%*
• 2005 – 238, 2006 - 224
• Transplant Annual Evaluations - 15% Increase*
• 2005 – 548, 2006 - 630
• Waitlist Growth Increased in Kidney, Pancreas and Liver
Transplant
• Program Quality Maintained
• Graft and Patient Survival Rates Exceed Expected
• Patient Satisfaction in PRC Survey
• 80.2% in Overall “Top Box” Score in 2006, up from
2005 73.9%
• Market Distinction
• Leader in Living Donor Liver Transplant
•Heart Transplant data removed for
separate presentation
5
MCA Abdominal Transplant
Program
National & Regional Presence
Academic & Research Activity
6
MCA Abdominal Transplant Program
National / Regional Leadership
• AASLD and ILTS Journal “Liver Transplantation”
• Co-Editor: Dr. Rakela
• Associate Editor: Dr. Vargas, Dr. Kusne, Dr. Mulligan
• AASLD
• Chair, Education Committee
• Dr. Vargas
• ASTS
• Chair, Standards on Organ Transplantation Committee
• Dr. Mulligan
• AST
• Liver and Intestinal Committee member
• Dr. Douglas
• Kidney Pancreas Committee member
• Dr. Heilman
7
MCA Abdominal Transplant Program
National / Regional Leadership
• United Network for Organ Sharing (UNOS)
• Councilor Region 5, Board of Directors
• Chair, MPSC Workgroup for Organ Allocation
• Dr. Mulligan
• Region 5 Liver Transplant Regional Review Board
• Dr. Douglas
• Region 5 Transplant Administrator / TAC
• Kevin Paige
• Region 5 Finance
• Pam Gillette
• Donor Network Arizona
• Board of Directors
• Dr. Mulligan
8
MCA Abdominal Transplant Program
National / Regional Leadership
• Intermountain End-Stage-Renal-Disease Network
• Board of Directors
• Dr. Heilman
• American Liver Foundation, AZ Chapter
• Board of Directors
• Pam Gillette
• Arizona Coalition for Transplantation
• Board of Directors
• Kevin Paige
• Pam Gillette
• Arizona Transplant House Board of Directors
• Victoria Miller-Cage, Todd Wilkening, Tom Byrne, Paul
Hottenstein, Mandy Impson, Susan Misztal, Kevin Paige
9
MCA Abdominal Transplant Program
Publications, Presentations and Research
• Publications By Transplant Program*
• 2006 Unique Peer Reviewed Journal Articles - 36
• 2006 Authored Book Chapters - 3
• Presentations at National Meetings 2006
•
•
•
•
ATC - 4 Oral and 6 Poster Presentations
ILTS – 3 Oral and 2 Poster Presentations
AASLD - 3 Oral and 9 Poster Presentations
UNOS Administrator's Forum 2006: 1 Oral and 3 Poster
Presentations
• AGA - 6 Poster Presentations
• Research Activity
• 30 Ongoing Protocols
* MCA Librarian Database
10
MCA Abdominal Transplant
Program
Education Programs
• Hepatology MD Fellowship Program (1999-Present)*
• Hepatology PA Fellowship Program (2003-2007)
• Both Programs AASLD Funded
• Hepatobiliary & Liver Transplant Rotation
• General Surgery Residents, Internal Medicine Residents,
Gastroenterology Fellows
• Social Worker Internship Program
• ASU Collaboration
• Liver Transplant CME Course: 1995, 1997, 1999, 2001, 2003, 2005,
2006 and 2007
*Pending initial ACGME accreditation 2007
11
Liver Transplant
Program
2006
12
MCA Liver Transplantation Program
• 1999 to 2006 Volume Data
• Liver Transplants - 345
• Living Donor Transplants - 64 (18%)
• 2006 Volume Data
• Liver Transplants - 43 (Target 73)
• 8 of 43 Transplants - Living Donor
• 2006 Outcome Data*
• 1 Year Patient Survival
• 91.85% Actual vs. 88.18% National Avg (Combined)
• 1 Year Graft Survival
• 89.41% Actual vs. 84.43% National Avg (Combined)
* SRTR National Data Base - January 2007 Release
13
Mayo System and National Comparison
% 1 Year Patient and Graft Survival
95
90
85
90.78
91.85
86.49
89.86
88.47
89.41
81.96
83.19
80
75
70
65
60
55
50
1 Yr Graft Surv
1 Yr Pt Surv
MCR
MCJ
MCA
National Mean
SRTR National Data Base - January 2007 Release
Deceased Donor Only for Appropriate Comparison
14
Mayo System and National Comparison
Median Length of Stay Post Transplant
14
12
10
8
6
10
9
7
4
6
2
0
LOS Post Transplant
MCR
MCJ
MCA
National Mean
SRTR National Data Base - January 2007 Release
Median LOS for Deceased Donor
15
Liver Waitlist & Transplants
2001 - 2006
151
158
140
146
120
129
100
101
80
70
60
40
20
52
38
42
48
53
2001
2002
2003
2004
43
0
Waitlist
2005
2006
Transplants
Wait List Size as of Last Day of Year
16
Etiology of Liver Disease
Hepatitis C*
HCC*
PSC*
Hemochromatosis
Autoimmune Hepatitis*
Graft Failure*
Familial Amyloidosis
A-1-A Deficiency
Sec. Biliary Cirrhosis
Primary Oxaluria
Neuroendrocrine Tumor
0
10
20
30
* Liver disease transplanted Q1 2007
40
50
60
70
80
Number of Transplants
90
100
110
120
Q1 2007
130
17
Cold Ischemia Time (hours)
Cumulative
• Average CIT 6.02 hrs
13%
17%
• Median CIT 5.75 hrs
18%
15%
13%
• Range 1.5 -23 hrs
7%
1.5-2.9
6-6.9
10%
3-3.9
7-7.9
4-4.9
8-8.9
7%
5-5.9
9+
Q1 2007
18
Benchmarking: National Centers of Excellence
UNOS Patient Survival Data
(7/01/03 - 12/31/05 w/ 1 Mo. & 1 Yr. Cohorts; 01/01/01 - 6/30/03 w/ 3 Yr. Cohort)
Program
1 Month
(Actual)
Mayo
Arizona
95.65% 96.55% 91.85% 88.18% 83.33% 81.01%
Pittsburgh
Omaha
Nebraska
UCLA
Mayo
Rochester
1 Month
1 Year
(Expected) (Actual)
1 Year
3 Year
(Expected) (Actual)
3 Year
(Expected)
95.48% 95.32% 82.22% 84.73% 74.30% 77.01
97.48% 96.28% 88.93% 87.63% 81.60% 79.47
95.74% 94.49% 85.32% 82.57% 75.00% 73.68
98.07% 95.92% 90.78% 86.38% 84.97% 78.50%
^
^
* Significantly below expected rate (p < 0.05)
^ Significantly above expected rate (p < 0.05)
Q1 2007
19
Benchmarking: National Centers of Excellence
UNOS Graft Survival Data
(7/01/03 - 12/31/05 w/ 1 Mo. & 1 Yr. Cohorts; 01/01/01 - 6/30/03 w/ 3 Yr. Cohort)
Program
Mayo
Arizona
Pittsburgh
Omaha
Nebraska
UCLA
Mayo
Rochester
1 Month
(Actual)
1 Month
(Expected)
1 Year
(Actual)
1 Year
(Expected)
3 Year
(Actual)
3 Year
(Expected)
93.84% 94.14% 89.41% 84.43% 81.25% 76.11%
91.64% 91.37% 75.54% 78.16% 66.75% 69.96%
92.57% 92.94% 81.82% 81.69% 75.69% 73.73%
90.71% 90.93% 78.63% 77.24% 67.82% 67.77%
96.02% 93.76% 88.47% 83.60% 79.26% 72.64%
^
^
* Significantly below expected rate (p < 0.05)
^ Significantly above expected rate (p < 0.05)
Q1 2007
20
The Impact of Gender
Mismatch on Living Donor
Liver Transplantation
Kristin L. Mekeel, Adyr A. Moss, David D. Douglas, M.E. Harrison,
Hugo E. Vargas, Thomas J. Byrne, Vijay Balan, Elizabeth J. Carey,
Jorge Rakela, Kunam S. Reddy and David C. Mulligan
Divisions of Transplant Surgery and Hepatology
Mayo Clinic Arizona
21
Background
• In liver transplantation
• Gender mismatch has been associated
with decreased graft survival, especially
female to male transplantation.
• In adult living donor liver transplantation
• The ratio between graft size and recipient
weight (GRWR) has been shown to be
essential to graft function, preventing small
graft for size syndrome.
22
Purpose
• The combination of smaller graft size and
gender mismatch could lead to inferior results
for female to male LDLT.
• The purpose of this study is to compare the
outcomes of female to male LDLT with male
to female and gender matched transplants.
23
Methods
• This is a retrospective
study 70 living donor
liver transplants
completed at our
institution between
January 2001 and April
2007.
• All grafts were right
lobes, preserved with
custodial HTK after the
15th transplant.
24
Methods
• GRWR was estimated
pre-operatively with CT
volumetry and the graft
was weighed after
resection to determine
actual GRWR, which is
used for this
presentation.
• The right paramedian
sectoral vein was
routinely preserved
starting after the 26th
transplant.
25
Methods
• Analyses of variance were carried out to
assess differences between groups on
the continuous variables.
• Kruskal-Wallis tests were used for nonparametric continuous variables.
• Chi-square analyses were used to
assess differences between groups on
the categorical variables.
26
Patient Demographics
Demographic
GM (32)
MF (16)
FM (22)
P-value
Age
17–68 (49)
30–66 (49)
30–67 (55)
0.27
GRWR
0.8–1.5 (1.19)
0.8–1.9 (1.42)
0.7–1.2 (0.94)
0.0001
Donor age
19–46 (33.3)
21–54 (36.8)
18–56 (41.7)
0.02
MELD
8–22 (14.3)
6–20 (11.7)
7–22 (14.1)
0.11
% HCV
48%
37.5%
50%
0.89
Operative time
3:25–10:17 (5:13) 2:52–6:59 (4:40) 3:26–8:09 (5:10) 0.3732
CIT (min)
150–285 (214)
150–270 (196)
150–285 (208)
0.35
27
Results
Outcomes
GM (32)
MF (16)
FM(22)
P-value
LOS (days)
5–17 (7.84)
4–22 (9.88)
2–23 (8.9)
0.47
FU (months)
0.7–64.2 (24) 0.3–62 (19.9) 0.3–63.5 (20.4) 0.16
Acute rejection 3 (9.6%)
2 (12.5%)
1(4.5%)
0.59
HAT
4 (12.9%)
3 (18.75%)
6 (27.3%)
0.42
Bile Leak or
Stricture
18 (58%)
10 (56.3%)
12 (54.5%)
0.95
Re-transplant
2 (6.5%)
2 (12.5%)
1 (4.5%)
0.63
Pt Survival
(actual)
27 (87%)
12 (75%)
20 (91%)
0.37
28
Results
Causes of Death
GM (4)
Recurrent hepatocellular carcinoma (2)
Fungal sepsis after biliary leak (1)
Hepatic artery thrombosis and graft failure (1)
MF (4)
Recurrent hepatitis C virus (2)
Systemic aspergillosis (1)
Hepatic artery thrombosis, re-transplantation and graft failure (1)
FM (2)
Intra-operative cardiac arrest after re-perfusion (1)
Fungal pneumonia and sepsis (1)
29
30
31
Conclusions
• Despite a lower graft to recipient weight ratio,
female to male LDLT recipients do not have
an increased risk of complications or
diminished graft or patient survival compared
to gender matched or male to female cohorts
• Gender should not be a factor in determining
suitability for living donation.
32
Kidney / Pancreas
Transplant Program
2006
33
MCA Kidney Transplantation Program
• 1999 to 2006 Volume Data
• Kidney Transplants - 705
• Living Donor Kidney Transplants - 367 (53%)
• Pancreas Transplants - 65
• 2006 Volume Data
• Kidney Transplants - 152
• Living Donor Kidney Transplants - 81 (53%)
• Pancreas Transplants - 27
• 2006 Outcome Data Kidney Transplant*
• 1 Year Patient Survival
• 96.13% Actual vs. 96.47% Expected
• 1 Year Graft Survival
• 92.83% Actual vs. 93.34% Expected
* SRTR National Data Base - January 2007 Release
Combined Living and Deceased Donor Transplants
34
Mayo System and National Comparison
% 1 Year Patient and Graft Survival
100
95
95.25 96.48
96.13 95.94
93.95
91.86
92.83
89.46
90
85
80
75
70
65
60
1 Yr Pt Surv
MCR
MCJ
1 Yr Graft Surv
MCA
National Mean
* SRTR National Data Base - January 2007 Release
Combined Living and Deceased Donor Transplants
35
Mayo System and National Comparison
Length of Stay - Time on Wait List
38.3
40
35
30
25
20
15
10
5
0
11.1
6
5
4
MCJ
10.4
6
Median LOS Post
Transplant (Days)
MCR
12.5
Median Wait List Time
(Months)
MCA
National Mean
SRTR National Data Base - January 2007 Release
LOS for Deceased Donor, Wait Times Includes Both Living
and Deceased Donor Transplants
36
Kidney Waitlist & Transplants
2001 - 2006
296
300
250
209
200
191
150
100
152
137
109
50
0
140
37 46
2001
59 66
72
2002
2003
Waitlist
2004
2005
2006
Transplants
Wait List Size as of Last Day of Year
37
Donor Source (N=654)
Cumulative
Living Related Donor
238
Living Unrelated Donor
154
Deceased Donor
262
Q1 2007
38
Pancreas Transplantation at MCA
30
Number
25
20
KP and solitary
pancreas Txs
15
10
5
0
2003
2004
2005
2006
2007
Year
39
Pancreas Transplants at MCA by type
of transplant
25
Number
20
15
Kidney-Pancreas
Solitary Pancreas
10
5
0
2003
2004
2005
2006
2007
Year
40
Type of Surgical Procedure
60
50
Portal Enteric
40
30
20
SystemicEnteric
Portal Enteric
SystemicEnteric
10
0
KP Tx
Solitary PTX
41
MCH Patient/Graft Survival for KP Txs
(Kaplan-Meier)
100
95
90
85
80
75
70
65
60
55
50
Pt. Survival
%
Kidney Graft
Survival
Pancreas
Graft
Survival
0
30
90
150 260 365 700
Days
42
MCH Patient/Graft Survival
for PAK & PTA
(Kaplan-Meier)
100
95
90
85
80
75
70
65
60
55
50
%
Pt. Survival
Graft
Survival
0
30
90
150 280 365 580 700
Days
43
Immunosuppression
•
•
•
•
Thymoglobulin
Prograf
MMF
Long-term steroids
•
•
•
•
Campath
Prograf
MMF
Rapid steroid taper
44
Acute Rejection during the first year
• Kidney-Pancreas : 17%
• Solitary Pancreas: 32%
45
Kidney-Pancreas : Steroid
Avoidance
• 37 patients
• Patient survival 100%
• Graft Survival
• Kidney 97%
• Pancreas 95%
• Acute Rejection 11%
46
Historical Total Transplant Volumes
2001 to present
250
2
28
200
16
27
0
8
150
140
2
100
50
152
109
66
70
38
42
48
53
2001
2002
2003
2004
46
1
19
86
70
43
37
0
Liver
Kidney
2005
Pancreas
2006 5/15/2007
Heart
47
Support for Organ Donation in AZ
• Active Mayo Participation in Multiple
Organizations
• AKF, ALF, ACT, DNA
• DNA, ACT and Mayo Collaborations
• AZ Medal Ceremony for Donors
• Active Participation in National Donor
•
Week
Continue Participation in National
Collaborative
• Bronze Level Sponsor of Team AZ at
Transplant Games
48
Program Summary
• High Quality Transplant Program
• Distinguished by
• Mayo Model of Care
• Living Donor Liver Transplant
• Controlled Growth
•
•
•
•
Strong Education Focus
Strong Research Focus
National and Regional Presence
Financial Enhancement to MCA
49
Conclusions
• Strong clinical academic solid organ
transplant practice with complete
conversion from UW to Custodial HTK in
2003 without any negative effect
• Improved outcomes using Custodial for
Living Donor Liver Transplantation
• Recommendation for HTK for DCD
donors to improve outcomes
50