Renal Transplant Evaluation Process Shobha Ratnam M D

Renal Transplant Evaluation Process Shobha Ratnam M. D. , Ph. D. Assistant Professor of Medicine University of Toledo-College of Medicine

Introduction • • 1954 First successful kidney transplant performed. 1966 First simultaneous kidney/pancreas transplant performed. • 1967 First successful liver transplant performed. • 1968 First 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. “ • 1984 The 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). • 1992 UNOS 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 Donor. Netsm, 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 • • 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, UNet. SM, 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

Expanded Criteria Donors • • • “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 • • • 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 • • 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 • • 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 • • 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 • • 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