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THE OPTION OF TRANSPLANTATION LILLY BARBA, M.D. MEDICAL DIRECTOR RENAL TRANSPLANT PROGRAM HARBOR-UCLA MEDICAL CENTER.

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Presentation on theme: "THE OPTION OF TRANSPLANTATION LILLY BARBA, M.D. MEDICAL DIRECTOR RENAL TRANSPLANT PROGRAM HARBOR-UCLA MEDICAL CENTER."— Presentation transcript:

1 THE OPTION OF TRANSPLANTATION LILLY BARBA, M.D. MEDICAL DIRECTOR RENAL TRANSPLANT PROGRAM HARBOR-UCLA MEDICAL CENTER

2 OPTIONS FOR TREATMENT OF END STAGE RENAL DISEASE HEMODIALYSISHEMODIALYSIS PERITONEAL DIALYSISPERITONEAL DIALYSIS TRANSPLANTATIONTRANSPLANTATION

3 THE OPTION OF TRANSPLANTATION BEST OPTION TO RESTORE FEELING OF WELL BEINGBEST OPTION TO RESTORE FEELING OF WELL BEING LIBERALIZATION OF FLUID AND DIETARY RESTRICTIONLIBERALIZATION OF FLUID AND DIETARY RESTRICTION ABILITY TO TRAVELABILITY TO TRAVEL INCREASE IN LIFE SPAN AS COMPARED TO REMAINING ON DIALYSISINCREASE IN LIFE SPAN AS COMPARED TO REMAINING ON DIALYSIS

4 RISKS OF TRANSPLANTATION MAJOR SURGICAL PROCEDURE WITH POSSIBLE COMPLICATIONS INCLUDING:MAJOR SURGICAL PROCEDURE WITH POSSIBLE COMPLICATIONS INCLUDING: BLEEDINGBLEEDING INFECTIONINFECTION REJECTIONREJECTION ANESTHESIA RISKANESTHESIA RISK DEATHDEATH

5 OPTION OF TRANSPLANTATION CHOSING THE OPTION OF TRANSPLANTATION SHOULD BE TAKEN WITH CAUTIONCHOSING THE OPTION OF TRANSPLANTATION SHOULD BE TAKEN WITH CAUTION IN GENERAL, HOWEVER, TRANSPLANTATION IS THE BEST OPTION FOR TREATING PEOPLE WITH KIDNEY DISEASEIN GENERAL, HOWEVER, TRANSPLANTATION IS THE BEST OPTION FOR TREATING PEOPLE WITH KIDNEY DISEASE

6 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/MINPATIENTS 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 TRANSPLANTTHE REASON FOR EARLY REFERRAL IS TO ESTABLISH WAITING TIME OR READY FOR A PRE EMPTIVE TRANSPLANT

7 WAITING TIME UNOS (UNITED NETWORK FOR ORGAN SHARING) IS THE ORGANIZATION THAT OVERSEES ALL TRANSPLANT PROGRAMS IN THE UNITED STATESUNOS (UNITED NETWORK FOR ORGAN SHARING) IS THE ORGANIZATION THAT OVERSEES ALL TRANSPLANT PROGRAMS IN THE UNITED STATES TOLL FREE NUMBER INFORMATION LINE FOR TRANSPLANT CANDIDATES, RECIPIENTS AND FAMILY MEMBERSTOLL FREE NUMBER INFORMATION LINE FOR TRANSPLANT CANDIDATES, RECIPIENTS AND FAMILY MEMBERS

8 UNOS UNOS ALSO MAINTAINS A WEB SITE, TRANSPLANT LIVING, WHICH CONTAINS INFORMATION FOR TRANSPLANT CANDIDATES AND RECIPIENTS AND FAMILY MEMBERSUNOS ALSO MAINTAINS A WEB SITE, TRANSPLANT LIVING, WHICH CONTAINS INFORMATION FOR TRANSPLANT CANDIDATES AND RECIPIENTS AND FAMILY MEMBERS ADDRESS:

9 BENEFITS OF PRE EMPTIVE TRANSPLANTATION NO NEED TO START DIALYSIS: NO COMORBITIDIES ASSOCIATED WITH DIALYSISNO NEED TO START DIALYSIS: NO COMORBITIDIES ASSOCIATED WITH DIALYSIS BETTER QUALITY OF LIFEBETTER QUALITY OF LIFE HIGHER EMPLOYMENT RATES POST TRANSPLANTHIGHER EMPLOYMENT RATES POST TRANSPLANT NO NEED FOR AV GRAFT OR FISTULA PLACEMENTNO NEED FOR AV GRAFT OR FISTULA PLACEMENT

10 BENEFITS OF PRE EMPTIVE TRANSPLANTATION DO NOT HAVE TO WAIT YEARS FOR A DECEASED DONORDO NOT HAVE TO WAIT YEARS FOR A DECEASED DONOR PATIENTS WHO RECEIVE PRE- EMPTIVE TRANSPLANTS HAVE BETTER OUTCOMESPATIENTS WHO RECEIVE PRE- EMPTIVE TRANSPLANTS HAVE BETTER OUTCOMES COSTS FOR MAINTAINING A TRANSPLANT PATIENT ARE LESSCOSTS FOR MAINTAINING A TRANSPLANT PATIENT ARE LESS

11 BARRIERS TO PRE EMPTIVE TRANSPLANTATION 2005 USRDS : INCIDENCE OF PRE EMPTIVE TRANSPLANTATION WAS 2.5%2005 USRDS : INCIDENCE OF PRE EMPTIVE TRANSPLANTATION WAS 2.5% NKF CONSENSUS CITED REASONS: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

12 CANDIDATES FOR TRANSPLANTATION THOSE PATIENTS WITH: PATIENTS WITH IRREVERSIBLE LOSS OF RENAL FUNCTIONPATIENTS WITH IRREVERSIBLE LOSS OF RENAL FUNCTION THOSE WITH CREATININE > 3.5 MG/DLTHOSE WITH CREATININE > 3.5 MG/DL AGE IS A RELATIVE FACTOR IN DETERMINING CANDIDACYAGE IS A RELATIVE FACTOR IN DETERMINING CANDIDACY

13 WHO IS NOT A POTENTIAL CANDIDATE ? THOSE PATIENTS WITH: ACTIVE INFECTIONACTIVE INFECTION CANCER OR CANCER RECENTLY TREATEDCANCER OR CANCER RECENTLY TREATED UNCORRECTABLE HEART PROBLEMSUNCORRECTABLE HEART PROBLEMS ADVANCED LUNG DISEASEADVANCED LUNG DISEASE

14 WHO IS NOT A POTENTIAL CANDIDATE ? THOSE PATIENTS WITH: ACTIVE STOMACH ULCERSACTIVE STOMACH ULCERS CIRRHOSIS OF THE LIVERCIRRHOSIS OF THE LIVER NO ELIGIBILITY FOR INSURANCE OR NO MEDICAL INSURANCENO ELIGIBILITY FOR INSURANCE OR NO MEDICAL INSURANCE LACK OF A FAMILY/SOCIAL SUPPORT SYSTEMLACK OF A FAMILY/SOCIAL SUPPORT SYSTEM ONGOING KIDNEY DISEASE: VASCULITISONGOING KIDNEY DISEASE: VASCULITIS

15 WHO IS NOT A POTENTIAL CANDIDATE ? THOSE PATIENTS WITH: MORBID OBESITYMORBID OBESITY SEVERE PSYCHIATRIC PROBLEMS NOT WELL CONTROLLEDSEVERE PSYCHIATRIC PROBLEMS NOT WELL CONTROLLED CONTINUED ALCOHOL, TOBACCO OR ILLICIT DRUG ABUSECONTINUED ALCOHOL, TOBACCO OR ILLICIT DRUG ABUSE AGE GREATER THAN 70 WITHOUT THE POTENTIAL FOR A LIVING DONORAGE GREATER THAN 70 WITHOUT THE POTENTIAL FOR A LIVING DONOR

16 THOSE PATIENTS WITH PCKD OVERALL, PATIENTS WITH PCKD DO WELLOVERALL, PATIENTS WITH PCKD DO WELL PRE TRANSPLANT CLEARANCE MAY INCLUDE: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

17 THE TRANSPLANT SURGICAL PROCEDURE

18 WHAT YOU SHOULD EXPECT FOLLOWING TRANSPLANT SURGERY SURGERY IS 3 – 5 HOURS UNDER GENERAL ANESTHESIASURGERY IS 3 – 5 HOURS UNDER GENERAL ANESTHESIA HOSPITAL STAY 5 – 7 DAYSHOSPITAL STAY 5 – 7 DAYS AFTER SURGERY: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

19 IMMUNOSUPPRESSIVE MEDICATIONS CNI (TACROLIMUS OR CYCLOSPORINE)CNI (TACROLIMUS OR CYCLOSPORINE) STEROID (PREDNISONE)STEROID (PREDNISONE) ANTI-METABOLITE (CELLCEPT OR AZATHIOPRINE)ANTI-METABOLITE (CELLCEPT OR AZATHIOPRINE)

20 MEDICATIONS CAN HAVE SIDE EFFECTS: COMMON SIDE EFFECTS TACROLIMUS/CYCLOSPORINE : TREMORS, HIGH BLOOD PRESSURE, HAIR GROWTH WITH CYCLOSPORINE, POSSIBLE DIABETESTACROLIMUS/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 SUNPREDNISONE: GASTRITIS, WEIGHT GAIN SECONDARY TO INCREASE APPETITE, DIFFICULT TO CONTROL DIABETES, ACNE, EASY BRUISING, INCREASE SENSITIVITY TO THE SUN

21 MEDICATIONS CAN HAVE SIDE EFFECTS: COMMON SIDE EFFECTS CELLCEPT: GAS, DIARRHEA, LOW WHITE BLOOD CELL COUNT CELLCEPT: GAS, DIARRHEA, LOW WHITE BLOOD CELL COUNT

22 TRANSPLANTATION OPTIONS PRE-EMPTIVE TRANSPLANTATIONPRE-EMPTIVE TRANSPLANTATION LIVING DONOR TRANSPLANTATIONLIVING DONOR TRANSPLANTATION DECEASED DONOR TRANSPLANTATION:DECEASED DONOR TRANSPLANTATION: 1.STANDARD CRITERIA 2.EXTENDED CRITERIA 3.DONOR AFTER CARDIAC DEATH

23 LIVING DONORS ANY PERSON WHO IS HEALTHY CAN BE EVALUATED FOR A TRANSPLANTANY PERSON WHO IS HEALTHY CAN BE EVALUATED FOR A TRANSPLANT CANNOT HAVE DIABETES, HYPERTENSION, KIDNEY DISEASE OR ACTIVE DRUG USECANNOT HAVE DIABETES, HYPERTENSION, KIDNEY DISEASE OR ACTIVE DRUG USE EACH TRANSPLANT PROGRAM SETS CRITERIA FOR DONOREACH TRANSPLANT PROGRAM SETS CRITERIA FOR DONOR

24 LIVING DONORS DO WELL SURGERY IS USUALLY DONE LAPARASCOPICALLYSURGERY IS USUALLY DONE LAPARASCOPICALLY HOSPITAL STAY IS 3 DAYS MAXIMUMHOSPITAL STAY IS 3 DAYS MAXIMUM PAIN CONTROLLED WITH NARCOTICSPAIN CONTROLLED WITH NARCOTICS RESUMPTION OF DAILY ACTIVITES IN 4 TO 8 WEEKSRESUMPTION OF DAILY ACTIVITES IN 4 TO 8 WEEKS

25 LIVING DONORS DO WELL RESUMPTION OF NORMAL DAILY ACTIVITIES WITH 4 TO 8 WEEKSRESUMPTION OF NORMAL DAILY ACTIVITIES WITH 4 TO 8 WEEKS

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27 LIVING DONORS DO WELL RISKS LOW: MORTALITY 0.03 %, SURGICAL RISKS ABOUT 3 %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 AMERICANSLONG 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

28 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 TRANSPLANTSOWING TO THE DIFFICULTIES ENCOUNTERED IN EXCLUDING PKD IN RELATED POTENTIAL DONORS, PATIENTS WITH PKD RECEIVE FEWER LIVING RELATED KIDNEY TRANSPLANTS

29 LIVING RELATED DONATION IN PKD FAMILIES ULTRASOUND IS INSUFFICIENTLY INSENSITIVE TO EXCLUDE DISEASE BEFORE THE AGE OF 30 YEARSULTRASOUND 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 ANALYSISGENETIC TESTING CAN BE USED THROUGH ANALYSIS OF LINKED FLANKING POLYMORPHIC GENETIC MARKERS OR THE USE OF DIRECT MUTATION ANALYSIS

30 DECEASED DONORS DIFFERENCE IN ALLOGRAFT SURVIVALDIFFERENCE IN ALLOGRAFT SURVIVAL DECEASED DONOR HALF-LIFE 7 TO 12 YEARSDECEASED DONOR HALF-LIFE 7 TO 12 YEARS LIVING DONOR HALF-LIFE IS 20 YEARSLIVING DONOR HALF-LIFE IS 20 YEARS RISK OF REJECTION MAY BE HIGHER ESPECIALLY IS DONOR IS NOT RELATED TO RECIPIENTRISK OF REJECTION MAY BE HIGHER ESPECIALLY IS DONOR IS NOT RELATED TO RECIPIENT

31 WAITING TIME FOR A DECEASED DONOR BLOOD GROUPS ARE O, A, AB, BBLOOD GROUPS ARE O, A, AB, B AVERAGE WAITING TIME FOR AN O KIDNEY IS THE GREATER LA AREA IS 7 TO 10 YEARSAVERAGE WAITING TIME FOR AN O KIDNEY IS THE GREATER LA AREA IS 7 TO 10 YEARS B PATIENTS WAIT GREATER THAN 5 YEARSB PATIENTS WAIT GREATER THAN 5 YEARS

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33 DISCUSSION WITH TRANSPLANT CENTER WHICH IS THE BEST OPTION FOR ME?WHICH IS THE BEST OPTION FOR ME? EVALUATION OF POTENTIAL DONORSEVALUATION OF POTENTIAL DONORS COMPLETION OF WORK-UP IN A TIMELY BASISCOMPLETION OF WORK-UP IN A TIMELY BASIS HEAR ALL THE OPTIONSHEAR ALL THE OPTIONS

34 CONCLUDING REMARKS TRANSPLANTATION IS THE BEST OPTION FOR PATIENTS WITH KIDNEY DISEASETRANSPLANTATION IS THE BEST OPTION FOR PATIENTS WITH KIDNEY DISEASE COMPLICATIONS ARE POSSIBLECOMPLICATIONS ARE POSSIBLE LIVING DONATION IS ENCOURAGED ESPECIALLY TO EXPEDITE TRANSPLANTATION, FOR LONG TERM SUCCESSLIVING DONATION IS ENCOURAGED ESPECIALLY TO EXPEDITE TRANSPLANTATION, FOR LONG TERM SUCCESS


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