Download THE OPTION OF TRANSPLANTATION

THE OPTION OF
TRANSPLANTATION
LILLY BARBA, M.D.
MEDICAL DIRECTOR RENAL
TRANSPLANT PROGRAM
HARBOR-UCLA MEDICAL CENTER
OPTIONS FOR TREATMENT OF
END STAGE RENAL DISEASE
• HEMODIALYSIS
• PERITONEAL DIALYSIS
• TRANSPLANTATION
THE OPTION OF
TRANSPLANTATION
• BEST OPTION TO RESTORE FEELING
OF WELL BEING
• LIBERALIZATION OF FLUID AND
DIETARY RESTRICTION
• ABILITY TO TRAVEL
• INCREASE IN LIFE SPAN AS
COMPARED TO REMAINING ON
DIALYSIS
RISKS OF TRANSPLANTATION
• MAJOR SURGICAL PROCEDURE WITH
POSSIBLE COMPLICATIONS
INCLUDING:
• BLEEDING
• INFECTION
• REJECTION
• ANESTHESIA RISK
• DEATH
OPTION OF
TRANSPLANTATION
• CHOSING THE OPTION OF
TRANSPLANTATION SHOULD BE
TAKEN WITH CAUTION
• IN GENERAL, HOWEVER,
TRANSPLANTATION IS THE BEST
OPTION FOR TREATING PEOPLE
WITH KIDNEY DISEASE
PURSUING THE OPTION OF
TRANSPLANTATION
• PATIENTS MAY BE REFERRED BY
THEIR NEPHROLOGIST WHEN THE
SERUM CREATININE IS 3.5 MG/DL OR
ESTIMATED GFR < 20 CC/MIN
• THE REASON FOR EARLY REFERRAL
IS TO ESTABLISH WAITING TIME OR
READY FOR A PRE EMPTIVE
TRANSPLANT
WAITING TIME
• UNOS (UNITED NETWORK FOR
ORGAN SHARING) IS THE
ORGANIZATION THAT OVERSEES
ALL TRANSPLANT PROGRAMS IN THE
UNITED STATES
• TOLL FREE NUMBER 1-888-894-6361
INFORMATION LINE FOR
TRANSPLANT CANDIDATES,
RECIPIENTS AND FAMILY MEMBERS
UNOS
• UNOS ALSO MAINTAINS A WEB SITE,
TRANSPLANT LIVING, WHICH
CONTAINS INFORMATION FOR
TRANSPLANT CANDIDATES AND
RECIPIENTS AND FAMILY MEMBERS
• ADDRESS:
WWW.TRANSPLANTLIVING.ORG
BENEFITS OF PRE EMPTIVE
TRANSPLANTATION
• NO NEED TO START DIALYSIS: NO
COMORBITIDIES ASSOCIATED WITH
DIALYSIS
• BETTER QUALITY OF LIFE
• HIGHER EMPLOYMENT RATES POST
TRANSPLANT
• NO NEED FOR AV GRAFT OR FISTULA
PLACEMENT
BENEFITS OF PRE EMPTIVE
TRANSPLANTATION
• DO NOT HAVE TO WAIT YEARS FOR A
DECEASED DONOR
• PATIENTS WHO RECEIVE PREEMPTIVE TRANSPLANTS HAVE
BETTER OUTCOMES
• COSTS FOR MAINTAINING A
TRANSPLANT PATIENT ARE LESS
BARRIERS TO PRE EMPTIVE
TRANSPLANTATION
•
2005 USRDS : INCIDENCE OF PRE
EMPTIVE TRANSPLANTATION WAS 2.5%
• NKF CONSENSUS CITED REASONS:
1. EARLY EDUCATION NEEDED
2. TIMELY TRANSPLANT REFERRAL
NEEDED
3. IDENTIFICATION OF POTENTIAL LIVING
DONOR
4. REFERRAL WHEN PATIENT IS REFERRED
FOR AV ACCESS
CANDIDATES FOR
TRANSPLANTATION
THOSE PATIENTS WITH:
• PATIENTS WITH IRREVERSIBLE LOSS
OF RENAL FUNCTION
• THOSE WITH CREATININE > 3.5
MG/DL
• AGE IS A RELATIVE FACTOR IN
DETERMINING CANDIDACY
WHO IS NOT A POTENTIAL
CANDIDATE ?
THOSE PATIENTS WITH:
• ACTIVE INFECTION
• CANCER OR CANCER RECENTLY
TREATED
• UNCORRECTABLE HEART PROBLEMS
• ADVANCED LUNG DISEASE
WHO IS NOT A POTENTIAL
CANDIDATE ?
THOSE PATIENTS WITH:
• ACTIVE STOMACH ULCERS
• CIRRHOSIS OF THE LIVER
• NO ELIGIBILITY FOR INSURANCE OR NO
MEDICAL INSURANCE
• LACK OF A FAMILY/SOCIAL SUPPORT
SYSTEM
• ONGOING KIDNEY DISEASE: VASCULITIS
WHO IS NOT A POTENTIAL
CANDIDATE ?
THOSE PATIENTS WITH:
• MORBID OBESITY
• SEVERE PSYCHIATRIC PROBLEMS
NOT WELL CONTROLLED
• CONTINUED ALCOHOL, TOBACCO
OR ILLICIT DRUG ABUSE
• AGE GREATER THAN 70 WITHOUT
THE POTENTIAL FOR A LIVING
DONOR
THOSE PATIENTS WITH PCKD
•
OVERALL, PATIENTS WITH PCKD DO
WELL
• PRE TRANSPLANT CLEARANCE MAY
INCLUDE:
1. CT SCAN OF THE ABDOMEN
2. CT SCAN OF THE BRAIN
3. ECHOCARDIOGRAM
4. SURGICAL REMOVAL OF NATIVE
KIDNEYS
THE TRANSPLANT SURGICAL
PROCEDURE
WHAT YOU SHOULD EXPECT
FOLLOWING TRANSPLANT
SURGERY
• SURGERY IS 3 – 5 HOURS UNDER GENERAL
ANESTHESIA
• HOSPITAL STAY 5 – 7 DAYS
• AFTER SURGERY:
–
–
–
–
–
–
FOLEY CATHETER
JACKSON PRATT DRAINAGE BULB (JP)
CENTRAL VENOUS PRESSURE LINE (CVP)
STAPLES HOLDING WOUND TOGETHER
POD # 1 : BEDREST
POD # 2: START EATING
POD # 3: WALKING AS TOLERATED
IMMUNOSUPPRESSIVE
MEDICATIONS
• CNI (TACROLIMUS OR
CYCLOSPORINE)
• STEROID (PREDNISONE)
• ANTI-METABOLITE (CELLCEPT OR
AZATHIOPRINE)
MEDICATIONS CAN HAVE SIDE
EFFECTS: COMMON SIDE
EFFECTS
• TACROLIMUS/CYCLOSPORINE :
TREMORS, HIGH BLOOD PRESSURE,
HAIR GROWTH WITH
CYCLOSPORINE, POSSIBLE DIABETES
• PREDNISONE: GASTRITIS, WEIGHT
GAIN SECONDARY TO INCREASE
APPETITE, DIFFICULT TO CONTROL
DIABETES, ACNE, EASY BRUISING,
INCREASE SENSITIVITY TO THE SUN
MEDICATIONS CAN HAVE SIDE
EFFECTS: COMMON SIDE
EFFECTS
• CELLCEPT: GAS, DIARRHEA, LOW
WHITE BLOOD CELL COUNT
TRANSPLANTATION OPTIONS
•
•
•
PRE-EMPTIVE TRANSPLANTATION
LIVING DONOR TRANSPLANTATION
DECEASED DONOR
TRANSPLANTATION:
1. STANDARD CRITERIA
2. EXTENDED CRITERIA
3. DONOR AFTER CARDIAC DEATH
LIVING DONORS
• ANY PERSON WHO IS HEALTHY CAN
BE EVALUATED FOR A TRANSPLANT
• CANNOT HAVE DIABETES,
HYPERTENSION, KIDNEY DISEASE
OR ACTIVE DRUG USE
• EACH TRANSPLANT PROGRAM SETS
CRITERIA FOR DONOR
LIVING DONORS DO WELL
• SURGERY IS USUALLY DONE
LAPARASCOPICALLY
• HOSPITAL STAY IS 3 DAYS MAXIMUM
• PAIN CONTROLLED WITH
NARCOTICS
• RESUMPTION OF DAILY ACTIVITES
IN 4 TO 8 WEEKS
LIVING DONORS DO WELL
• RESUMPTION OF NORMAL DAILY
ACTIVITIES WITH 4 TO 8 WEEKS
LIVING DONORS DO WELL
• RISKS LOW: MORTALITY 0.03 %, SURGICAL
RISKS ABOUT 3 %
• LONG TERM RISKS: HAVE TO BE
EVALUATED IN CONTEXT OF PRE
EXISITING PROBLEMS, DEVELOPMENT OF
MEDICAL PROBLEMS AFTER DONATION
AND GENERAL POPULATION RISKS OF
DEVELOPING KIDNEY DISEASE WHICH IS
APPROXIMATELY 2 % FOR CAUCASIANS
AND 7.5 % FOR AFRICAN AMERICANS
LIVING RELATED DONATION
IN PKD FAMILIES
• OWING TO THE DIFFICULTIES
ENCOUNTERED IN EXCLUDING PKD
IN RELATED POTENTIAL DONORS,
PATIENTS WITH PKD RECEIVE
FEWER LIVING RELATED KIDNEY
TRANSPLANTS
LIVING RELATED DONATION
IN PKD FAMILIES
• ULTRASOUND IS INSUFFICIENTLY
INSENSITIVE TO EXCLUDE DISEASE
BEFORE THE AGE OF 30 YEARS
• GENETIC TESTING CAN BE USED
THROUGH ANALYSIS OF LINKED
FLANKING POLYMORPHIC GENETIC
MARKERS OR THE USE OF DIRECT
MUTATION ANALYSIS
DECEASED DONORS
• DIFFERENCE IN ALLOGRAFT
SURVIVAL
• DECEASED DONOR HALF-LIFE 7 TO 12
YEARS
• LIVING DONOR HALF-LIFE IS 20
YEARS
• RISK OF REJECTION MAY BE HIGHER
ESPECIALLY IS DONOR IS NOT
RELATED TO RECIPIENT
WAITING TIME FOR A
DECEASED DONOR
• BLOOD GROUPS ARE O, A, AB, B
• AVERAGE WAITING TIME FOR AN O
KIDNEY IS THE GREATER LA AREA IS
7 TO 10 YEARS
• B PATIENTS WAIT GREATER THAN 5
YEARS
DISCUSSION WITH
TRANSPLANT CENTER
• WHICH IS THE BEST OPTION FOR
ME?
• EVALUATION OF POTENTIAL
DONORS
• COMPLETION OF WORK-UP IN A
TIMELY BASIS
• HEAR ALL THE OPTIONS
CONCLUDING REMARKS
• TRANSPLANTATION IS THE BEST
OPTION FOR PATIENTS WITH
KIDNEY DISEASE
• COMPLICATIONS ARE POSSIBLE
• LIVING DONATION IS ENCOURAGED
ESPECIALLY TO EXPEDITE
TRANSPLANTATION, FOR LONG
TERM SUCCESS