Northwestern University Feinberg School of Medicine New Trends in organ donation and Transplantation Juan Carlos Caicedo, MD FACS Director, Hispanic Transplant Program Adult transplant Surgeon (NMH) Pediatric Transplant Surgeon (LCH) Overview Introduction Kidney ( Living / deceased/ combined stem cell) Liver: whole, split, reduce size, living donor 2 Who Needs a Transplant? Transplantation is offered to patients who: are in end-stage organ failure have no other surgical or medical option available to them have a limited life expectancy without a transplant have undergone a rigorous and thorough assessment process and meet all necessary criteria Type of donors Deceased (dead) donors -Brain dead donors: intact heartbeat & circulation, on ventilator less than 3% of all deaths -Donors after cardiac death: occurs in hopeless cases in the hospital where the decision to withdraw life-support is made (decision is independent of the decision to donate). Organ donation occurs immediately once the heart has stopped and the patient is declared dead Living donor -Patient chooses to donate one or part of an organ to someone on a transplant waiting list • can only occur with organs when removal will NOT cause grave harm to the donor4 United States Organ Transplantation Northwestern University Feinberg School of Medicine OPTN & SRTR Annual Data Report, 2011 Patients on the waiting list on December 31 of the year (active listings only) Transplants performed during the year (adult & pediatric combined) First-year all-cause graft survival Northwestern University Feinberg School of Medicine Adult Kidney Transplantation End Stage Renal Disease Dimension of the problem >500.000 people in US Options: Dialysis and kidney transplantation US kidney waiting list: 105.124 people / 2013 Kidney Failure: Treatment Kidney Transplantation “ Best option” - Replace all functions of the kidney - Increase survival and quality of life - Decrease complications - Cost effective Incident ESRD Rate and Transplant Rate 12 USRDS 2010 ADR Northwestern University Feinberg School of Medicine 2013: 105124 Waiting list 2012: 16485 Transplanted 758 ( 4.5%) Pediatric pts Whites :38% AA: 34% Hispanics: 19% Asian: 8% Distribution of adult patients waiting for a kidney transplant Deceased donor kidney donation rates Cause of death among deceased kidney donors Organs recovered per donor (ORPD), by SCD, DCD, & ECD status Delayed graft function among adult kidney transplant recipients Kidney donations from living donors Living kidney donation Laparoscopic vs Open - Safe - Less pain - Fast recovery - POD 1: Home - Smaller Incisions Intended kidney transplant procedure type, & percent of intended laparoscopic procedures converted to open Number of transplants from living donors, by donor relation All patients receiving a living donor kidney transplant. USRDS 2010 ADR Kidney Transplantation Kidney Transplantation Sensitized Patients PRA Levels of Wait-Listed Patients Very Highly Sensitized 36% Sensitized 15% Total = 17,814 pts 21% Sensitized 64% 2010: 25% Sensitized 0-9% 10-79% >80% Options for Sensitized and ABO incompatible Patients Wait and hope Desensitization Live Donor Deceased Donor Live Donor Paired Exchange List Exchange Paired kidney donations Basic Kidney Paired Donation (KPD) Northwestern University Feinberg School of Medicine Desensitization 30 N Engl J Med 365;4 July 28, 2011 Trends in Transplant Medications 31 Immunosuppression use in adult kidney transplant recipients Initial immunosuppression regimen in adult kidney transplant recipients, 2011 Acute rejections within the first year post-transplant First-time, kidney-only transplant recipients, age 18 & older, with functioning graft at discharge. Source: USRDS 2010 ADR 34 Trends in Transplant Research 35 Mixed Chimeras The co-existence of two genetically different components in one organism Chimerism induces tolerance How can we make it safe? Northwestern Clinical Tolerance Protocols Sequential kidney/HSC in HLA matched related Simultaneous kidney/HSC in HLA mismatched 37 HLA-Matched Protocol PI: Joshua Miller Current Enrollment – 20/20 First patient enrolled January 2008 HLA identical siblings Excluded if high risk of recurrent disease in the allograft (role of immunosuppression in preventing disease recurrence) 38 Simultaneous FCRx +Kidney Transplant Processed donor leukopheresis product/marrow enriched for HSC, FC and progenitors (FCRx) HSCT mobilized, collected, processed, & cryopreserved (> 2 wks before Tx) Conditioning Fludarabine, cytoxan, 200 cGy TBI Perform Transplant 39 d0 d +1 Adult kidney transplants Outcomes among adult kidney transplant recipients: deceased donor Outcomes among adult kidney transplant recipients: living donor Half-lives for adult kidney transplant recipients Liver Transplantation Type of donor: Living vs deceased donor Type of graft: Partial vs whole organ Whole Organ Orthotopic Liver Transplant Standard technique. This figure illustrates a completed liver transplant with vascular and biliary anastomoses. Partial Grafts / Liver transplantation (LTX) -Reduce Size Ltx -Split LTx -Living Donor Ltx Partial Liver Transplantation The split through midplane with right and left lobe grafts Reference: Humar A, et al. Amer J Transpl 2001;1:366-72 Schematic drawing of the right lobe after transplantation into the recipient. The major vascular anastomosis and drainage of the bile duct into a Roux loop of bowel is illustrated 48 Northwestern University Feinberg School of Medicine Adult Liver Transplantation Distribution of adult patients waiting for a liver transplant Liver donors who are DCD Liver transplants from living donors, by donor relation Living donor liver transplant graft type Total adult liver transplants Adult liver transplants Graft failure among adult liver transplant recipients: deceased donor Immunosuppression use in adult liver transplant recipients Conclusion Transplantation offers a second chance at life to thousands of people. It has been proven over and over again to be very successful. However, transplantation can only occur if someone consents to the ultimate gift – organ and tissue donation. liver transplant recipient Kidney donor and recipient 59 60 Northwestern University Feinberg School of Medicine Thank you