Renal Transplant Evaluation Process

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Renal Transplant
Evaluation Process
Shobha Ratnam M.D.,Ph.D.
Assistant Professor of Medicine
University of Toledo-College of Medicine
Introduction
• 1954First successful kidney transplant performed.
• 1966 First simultaneous kidney/pancreas transplant
performed.
• 1967First successful liver transplant performed.
• 1968First successful isolated pancreas transplant
performed.
First successful heart transplant performed.
Introduction (contd.)
• 1977 Implementation of the first computer-based organ
matching system, dubbed the "United Network for Organ
Sharing.“
• 1984The National Organ Transplant Act, passed by Congress in
outlawed the sale of human organs and began the development
of a national system for
• organ sharing and a scientific registry to collect and report
transplant data
• 1986 UNOS receives the initial federal contract to operate the
Organ Procurement and Transplantation Network (OPTN).
• 1992UNOS helps found Donate Life America to build public
support for organ donation.
Introduction (contd.)
• 1995 UNOS launches its first Web site for all users with
an interest in transplantation.
• 2001 For the first time, the total of living organ donors
for the year (6,528) exceeds the number of deceased
organ donors (6,081).
• 2006 UNOS launches DonorNetsm, a secure, Internetbased system in which organ procurement coordinators
send out offers of newly donated organs to transplant
hospitals with compatible candidates.
Introduction (contd.)
• UNOS’ Patient Services Department provides
transplantation and donation information to patients,
family members, friends, potential donors and medical
professionals. Information can be requested on topics
such as:
• The transplantation and donation process
• Living donation
• Various national, regional, state and center-specific data
reports
Transplant Statistics
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Waiting list candidates as of Nov,2010 109,300
Active waiting list candidates 72,137
Transplants January – July 2010, 16,779
Donors January - July 2010, 8,477
ORGAN SHARING SYSTEM
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
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 computer
network 24 hours a day, seven days a week.
• UNet electronically links all transplant hospitals and
OPOs in a secure, real-time environment using the
Internet.
The Five Steps
In Organ Matching
1.
An organ is donated
OPO managing the donor enters medical information about the donor
including organ size and condition, blood type and tissue type into the
UNOS computer system.
2. A list of potential recipients is generated
The UNOS computer system generates a list of candidates who have
medical and biologic profiles compatible with the donor’s. The computer
ranks candidates based upon how closely their medical
Characteristics match the donor’s, medical urgency, time spent waiting
and proximity of candidates to the donor.
The Five Steps
In Organ Matching (contd.)
3. The transplant center is
notified of an available organ
Organ 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 considers
the organ for the patient
When the team is offered an organ, it bases its acceptance or refusal
of the organ upon established medical criteria, organ condition, candidate
condition, 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 declined
If the organ is not accepted, the OPO continues to offer it for patients
at other centers until it is placed.
The importance of time
• The length of time donated organs and tissues
can be kept outside the body vary:
• Heart: 4-6 hours
Liver: 12-24 hours
Kidney: 48-72 hours
Heart-Lung: 4-6 hours
Lung: 4-6 hours
Expanded Criteria Donors
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“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).
Organ Allocation POL ICY DEVELOPMENT
Challenges are
what make life
interesting;
overcoming them
is what makes life
meaningful.
JOSHUA J. MARINE
Conditions for coverage for ESRD
facilities
• CMS mandates that accredited dialysis centers
provide
-evidence of transplant education
-track patient’s transplant referrals
-track patient’s transplant status on waiting
list
communicate with transplant facilities
Healthy People 2010 goal
“Increase the proportion of dialysis
patients waitlisted and/or receiving a
deceased donor kidney transplant
within one year of ESRD start”
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 Kidney
Fund while on dialysis
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
The Cost of Transplantation
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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
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
FINANCING TRANSPLANTATION
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The most common funding sources are:
■ Insurance
■ Extending Insurance Coverage through COBRA
■ Medicare Coverage
■ TRICARE (formerly CHAMPUS)
■ Charitable Organizations
■ Advocacy Organizations
■ Fund Raising Campaigns
Did you know?
About 78 people receive organ transplants
every day in the United States, however . . .
About 18 people die each day waiting for a
transplant
Stages of Decision Making
• Precontemplation
Not considering or not ready
• Contemplation
Considering transplantation
• Preparation
Planning to pursue transplantation
• Action
Contacted the transplant center
• Maintenance
Listed or found a living donor
Pre-transplant labs
• The first step to get on the waiting list is having
pre-transplant labs drawn.
• Labs that we draw at your evaluation include:
• ● ABO blood typing;
• ● Tissue typing; and
• ● Serologies.
Compatibility of Blood Types
Recipient
A
B
AB
O
Compatible Donor
O, A
O, B
O, A, B, AB
O
HLA System
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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.
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, its
importance has diminished.
• This is because we now know that even transplants
with minimal matching (say, only one of six antigens)
can have excellent outcomes, thanks to new advances in
immunosuppressive medications.
Serologies
These tests look for a patient’s past exposure to
infections such as hepatitis, HIV, other viruses
and syphilis.
Panel Reactive
Antibodies (PRAs)
• Panel reactive antibodies show a patient’s 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.
Cross Match
• This test establishes compatibility between a particular donorrecipient pair
• and, for patients with a living donor, is performed during the
transplant work-up.
• A “negative” cross-match suggests that a donor and recipient are
compatible
• and the transplant can proceed. If the cross-match is “positive,”
the pair can
• participate in the Paired Donation Program. For patients with a
deceased donor,
• this test occurs prior to transplant surgery, once a donor
becomes available.
Cardiac evaluation
• EKG
• Echocardiogram
• Stress test
exercise treadmill, stress echo and persantine
thallium
• Cardiac catherization
• Coronary artery bypass surgery
Pulmonary evaluation
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Stop smoking
Chest X-Ray
Pulmonary Function Tests
CT chest
Routine Health
Screenings
• Female recipients-PAP smears, mammograms if
> 40 y
• Male recipients-Prostate exam, prostate specific
antigen if >50 y
• Colonoscopy if >50 y
• Dental check up
Types of Kidney Transplants from a
Deceased Donor
Brain Dead Donor: Kidney donor with an irreversible head injury
who was declared brain dead based on specific criteria. Brain
dead donors remain on life support during organ recovery
surgery.
Donation after Cardiac Death Donor (DCD Donor): Kidney
donor with a severe brain injury who does not meet the criteria
for brain death but has no chance of survival. Donation after
cardiac death donors are removed from life support prior to
organ recovery surgery.
Expanded Criteria Donor (ECD Donor): Any brain dead donor
over age 60, or over age 50 with concurrent health problems.
Types of Kidney Transplants from a
Living Donor
Living Related Donor: A living donor who is a healthy blood relative of
the 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 awaiting
transplant. This includes one’s spouse, in-law relatives and close friends.
A living-unrelated donor can also include a compatible, anonymous donor
matched by the Paired Donation program.
Living donor transplantation is the most successful kidney transplant
procedure. Typically, living donor transplants last longer than deceased
donor transplants.
Contraindications
• Untreated current infection
• Active malignancy with short life expectancy
• Chronic illness with life expectancy of less than
one year
• Poorly controlled psychosis
• Active substance abuse
Relative Contraindications
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Active infection
Coronary heart disease
Active hepatitis
Active peptic ulcer disease
Cerebrovascular disease
Proven habitual medical noncompliance
HIV infection.
The Waiting Period
• Keep your Transplant Team updated while
you’re 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
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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