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Pulsatile Perfusion
Overview
Ralph Aguilar, SRPPT
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OneLegacy
• Federally designated OPO
• Education
• Family/Patient Advocate
• Donor Identification
• Donor Management
• Procurement coordination
• Organ preservation
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Transplant Process
• Patient Identification
• Pre-tx work-up, psycho-social work, dental
activity, bloodwork maintenance, LRD?,
Cad?, etc
• Peri-transplant activity
• Post-transplant follow up
• ……….Organ Procurement
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What
• is kidney pumping?
Another method of organ storage during
transport
Active preservation of kidneys allowing benefits
not provided by static storage.
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When
will my kidneys get on the pump?
after biopsy is read
after delivered from OR/UCLA/NIT
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What
is going on in the pumping world?
Two FDA approved pumps
Waters Instruments
Systems
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Organ Recovery
Where
OneLegacy Corporate Office
221 South Figueroa Street
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Organ Preservation
“The goal of optimal organ preservation is to
maintain viability for transplant.”
Robert Hoffman, BS, CPTC, James Southard, Ph.D.,
Folkert O. Belzer, MD
Organ Preservation, UNOS,
ORGAN PROCUREMENT, PRESERVATION AND
DISTRIBUTION IN TRANSPLANTATION
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Perfusion of Isolated Organs
Loebel 1849; 1st attempt
Langendorf 1895; siphon
tube/gravity
Carrel 1905; “Anastomosis
and Transplantation of
Blood Vessels”
Lindbergh 1930s; sister-inlaw, introduced to Carrel,
mechanical pump for
cardiac surgery;
sterilizable, pulsating
Carrel/Lindbergh 1937;
hypothermia; War
USSR 1960s; limbs/kidneys
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Organ Preservation
The ideal preservation method for [organs] during
any ischemia – both warm or cold, MUST
• Maximize the quality of the organ
• Minimize the chance for delayed graft function (DGF)
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What can we do with Renal Preservation?
Normo-thermic
Cold Static Storage (CSS)
Pulsatile Perfusion
Combination
CADAVERIC KIDNEY TRANSPLANTS
UNOS 1998 SR & OPN Annual Reports
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Preservation is Critical
Patients who required dialysis within the first week
postransplant had lower graft survival and patient
survival rates at all time points than those who
did not require dialysis soon after transplant.
Graft survival for the dialysis group was 83% at
one year and 53% at five years postransplant
compared to 93% at one year and 68% at five
years for the nondialysis group.”
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What is Renal Pulsatile Perfusion?
Kidneys are connected to a machine that allows
a solution to actively maintain organs for
transplant preservation, and provide
additional information to aid in determination
of organ viability.
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The RM3 Renal Perfusion System
“The Ultimate Pumping
Machine…”
Tom Mone, CEO OneLegacy
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Observations
Objective
• Flow
• Pressure
• Resistance (MAP/flow=rr)
• Labs (pH, O2, CO2, Osmo)
• Chemotherapy (mannitol, verapamil, papavarine, etc.)
Subjective
• Visualization assessment
• Bounce
• Gestalt
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Early Function Prediction
The best predictor of early function based on a linear regression analysis of
these five variables:
1. Renal Blood Flow
2.
Final Resistance (mean pressure/flow)
3.
Patient age
4.
Cold perfusion time
5.
Warm ischemia time
was determined to be:
Final Resistance.
Renal Blood Flow and Intrarenal Resistance Predict Immediate Renal Allograft Function ML Henry, BG Sommer and RM
Ferguson 1986 Grune & Stratton 0041-1345/86/1803005.
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Cold Static Storage vs Machine Perfusion
MP
CS
MP-Extended CS-Extended
Donor age
40+/-8
37+/-16
54+/-9
51+/-9
LOS
9.8+/-5
11.9+/-4
11.1+/-3
17.9+/-3
DGF
9
24
14
37
1 YR
95
90
88
79
“Renal allograft preservation by continuous hypothermic preservation
conferred an advantage in both immediate graft function and LT graft
survival when compared to cold storage in UW solution.”
THE INFLUENCE OF PULSATILE PRESERVATION ON RENAL TRANSPLANTATION IN THE 1990’S TRANSPLATATION Vol. 69 249-258
No2Jan 2000. MMR Polyak, etal. Organ Preservation Unit, Division of Transplantation, The New York Presbyterian Hospital-Weil, NY.
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Pulsatile Perfusion Benefits
•
Two kidneys singly or enbloc
•
Continuous evaluation for predictable results
•
Lower Delayed Graft Function (DGF) within 7 days postop
•
Lower costs and shorter LOS
•
Stimulates ATP synthesis (with Belzer MPS)
•
Expansion to include marginal donors (older & hypertensive) as well
as DACD
•
Elective surgery
•
Improves long term graft survival
•
Kidneys pumped 30 plus hrs equal to kidneys iced less than 12 hours
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How much does PP save?
Cadaveric Transplants n = 170
DGF(34)
No DGF(136)
Room
11,700 +/- 9,850
4,860 +/- 1,500
Pharmacy
11,400 +/- 8,900
6,085 +/- 3,400
Radiology
2,470 +/- 1,700
668 +/- 440
Laboratory
11,900 +/-11,300
4,750 +/- 1,650
Dialysis
9,300 +/- 8,000
330 +/- 75
Surgery/Supplies
4,430 +/- 1,500
6,007 +/- 1,200
Total
$51,200 +/- 41,250
$22,700 +/- 8,265
The High Cost of Delayed Graft Function in Cadaveric Renal Transplantation. T.Rosenthal, MD et. al.
TRANSPLANTATION VOL. 51 1115-1139, No.5 May 1991.
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SVMC Experience
41 consecutive cases utilizing RPP, 2002, 6
month data:
• 28 had Cr ≤2.0
• 4 had Cr 2.1-2.9
• 3 deceased
• 1 being followed at another center
• 4 relisted
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Th-th-that’s
all, folks!
Thank you
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