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Michael E. DeBakey Department of Surgery Baylor College of Medicine Houston, Texas Liver Transplantation at SLEH/BCM John A. Goss, MD Professor of Surgery.

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Presentation on theme: "Michael E. DeBakey Department of Surgery Baylor College of Medicine Houston, Texas Liver Transplantation at SLEH/BCM John A. Goss, MD Professor of Surgery."— Presentation transcript:

1 Michael E. DeBakey Department of Surgery Baylor College of Medicine Houston, Texas Liver Transplantation at SLEH/BCM John A. Goss, MD Professor of Surgery

2 History of Transplantation First attempt at kidney transplant First attempt at kidney transplant with human kidney First pediatric living donor liver transplant Cyclosporine FDA approved First liver transplant First successful kidney transplant First US adult living donor liver transplant Tacrolimus FDA approved MELD implemented

3 Initial Kidney Transplant Attempts: YearLocationSurgeonProcedure 1902LyonAlex Carrel Dog kidney tx into dog neck 1902ViennaEmerich Ulmann Dog kidney tx into goat 1906LyonMathieu Jaboulay Pig kidney tx into antecubital fossa 1909BerlinErnest Unger Monkey kidney tx into thigh 1936KhersonYu Voronoy First kidney tx using cadaveric human donor 1954BostonJoseph Murray First successful kidney tx 1956BostonJoseph Murray First tx using immunosuppression

4 First Successful Kidney Transplant

5 Experimental Liver Transplantation

6 Initial Liver Transplant Attempts: No.LocationAgeDiseaseSurvivalDeath 1Denver3BA 0 days hemorrhage 2Denver48HCC 22 days sepsis, PE 3Denver68HCC 7 days sepsis, PE 4Denver52HCC 6 days liver failure 5Boston58mets. 11 days sepsis 6Denver29HCC 23 days sepsis 7Paris75mets. 0 days hemorrhage

7 Initial Liver Transplant Attempts:

8 First Liver Transplant  March 1, 1963: First attempted human liver transplant  July 23, 1967: First successful human liver transplant

9 Post-Moratorium Successes Starzl TE. J Am Coll Surg 2002; 195:587.  anti-lymphocyte globulin (ALG) & the “triple cocktail”  improved organ preservation  definition of “brain death”

10 1968 Ad Hoc Committee of Harvard Medical School Published Criteria for Brain Death1968 Ad Hoc Committee of Harvard Medical School Published Criteria for Brain Death 1968 Uniform Anatomical Gift Act1968 Uniform Anatomical Gift Act 1978 Uniform Brain Death Act1978 Uniform Brain Death Act 1983 NIH Consensus Development Conference:1983 NIH Consensus Development Conference: “…Liver Transplantation is a therapeutic modality for end stage liver disease that deserves broader application.” “…Liver Transplantation is a therapeutic modality for end stage liver disease that deserves broader application.” 1984 National Organ Transplant Act:1984 National Organ Transplant Act: Sale of organs prohibitedSale of organs prohibited Development of UNOSDevelopment of UNOS

11 Indications for Liver Transplant 1. Life-threatening and progressive irreversible liver disease 2. Fulminant hepatic failure 3. Hepatopulmonary or hepatorenal syndrome 4. Worsening synthetic function 5. Ascites resistant to medical therapy 6. Hepatic encephalopathy 7. Variceal hemorrhage 8. Progressive malnutrition 9. Increasing fatigue that interferes with daily activities 10. Recurrent cholangitis 11. Development of hepatocellular carcinoma

12 Etiology of Liver Disease

13 Indication for Liver Transplantation Evaluation Process Hepatologist Transplant Surgeon Cardiologist Nurse Coordinator Social Worker Laboratory Studies Imaging (CT or MRI) Relative Contraindications Portal vein thrombosis Pulmonary hypertension Cholangiocarcinoma HIV Absolute Contraindications Uncontrolled systemic infection Extra-hepatic malignancies Ongoing drug or alcohol use Inability to comply with post-transplant therapy List for Transplant Medical Management

14 Liver Waitlist

15 Timing of Transplant MELD (Model of End Stage Liver Disease) Originally developed to evaluate mortality in patients undergoing elective TIPS proceduresOriginally developed to evaluate mortality in patients undergoing elective TIPS procedures Subsequently validated as predictive of survival in patients with end stage liver diseaseSubsequently validated as predictive of survival in patients with end stage liver disease 85% of time accurately predicts individuals survival85% of time accurately predicts individuals survival Only objective data used in calculationOnly objective data used in calculation Organ Allocation 2002-present

16 MELDMELD 3 Month Mortality <102-8% % % % >40100% R= (0.957 x Log e (creatinine mg/dl) x Log e (total bilirubin mg/dl) x Log e (INR) )) x 10

17 Liver Allocation Status IA Status IA Status IB Status IB Local MELD/PELD Local MELD/PELD Regional MELD/PELD Regional MELD/PELD National IA/IB National IA/IB National MELD/PELD National MELD/PELD

18

19 Deceased Donor Technique

20 Recipient Technique: Liver

21

22 Immunosuppression

23 Improvement in Patient Survival Patient Survival % Time After Transplantation (years)

24 Improvement in Allograft Survival Survival % Time After Transplantation (years)

25 US Survival: Adult Liver

26 US Survival: Pediatric Liver

27 BCM initiated Recruitment in 1998 BCM initiated Recruitment in Hepatologist, 2 Surgeons, 1 Nurse Coordinator 1 Hepatologist, 2 Surgeons, 1 Nurse Coordinator 1 Social Worker, 1 Financial Coordinator, HLA Blood Bank, etc. 1 Social Worker, 1 Financial Coordinator, HLA Blood Bank, etc. Development of Patient Care Protocols – ICU, Anesthesia, OR Nurse Development of Patient Care Protocols – ICU, Anesthesia, OR Nurse Obtainment of UNOS Certification 6/98 Obtainment of UNOS Certification 6/98 Liver Transplantation -

28 Opened program 7/1/98 – combined with pediatric program at Texas Children’s Hospital Opened program 7/1/98 – combined with pediatric program at Texas Children’s Hospital 1 st resection 7/5/98 1 st resection 7/5/98 1 st liver transplant 9/2/98 1 st liver transplant 9/2/98 9 liver transplants in All patients survived with 14 day length of stay 9 liver transplants in All patients survived with 14 day length of stay

29 17 Physicians - 9 Adult Hepatologists 17 Physicians - 9 Adult Hepatologists 6 Pediatric Hepatologists 6 Pediatric Hepatologists 2 Surgeons 2 Surgeons 14 Nurse Coordinators 14 Nurse Coordinators 5 Hepatology Nurses 5 Hepatology Nurses 5 Medical Assistants 5 Medical Assistants 2 Administrative Staff 2 Administrative Staff 3 Transplant programs 3 Transplant programs Liver Transplantation-

30 SLEH Liver Transplant Team SLEH/BCM Administration Margaret Van Bree, MHA, DrPH Paul Klotman, MD Todd Rosengart, MD Rachel Goldsmith, MPA Diesa Samp, BSN, RN, CCTC Physicians John Goss – BCM Blaine Hollinger-BCM Khozema Hussein-BCM Prasun Jalal-BCM Saira Khaderi-BCM Charles Phan-BCM Christine O’Mahony- BCM Gagan Sood, BCM Rise Stribling- BCM Norman Sussman-BCM John Vierling- BCM THI Anesthesiology C. David Collard, MD Cardiology Sayeed Feghali, MD THI Pathology/Blood Bank/ Lab Med Rhonda Shannon, MD Psychiatry Jennifer Pate, M.D. Pulmonary, Nephrology, Infectious Diseases, GI THI Nurse Coordinators Claudette Campbell, RN Jeanette Cleveland, RN Shannon Cook, RN Norma Flores, RN Felicia Franco, RN Diana Gonzalez, RN Demetrice Gray, RN Yolanda Murray, RN Wanda Samuels, RN Tamara Stephens, RN Pharmacy Raymond Yau, PharmD Social Work Ann Holder, LCSW Robin Kremer, LCSW Dietary Amy Cook, RD Financial Deidra Lester Exercise Physiologist Fabian Nursing Staff: CVOR, CV Recovery, 8CB 12 & 7 Tower

31 Diagnosis

32 Primary Payor 33% 15% 48% 3%

33 Transplant Totals

34 2010: One Thousand Liver Transplants 2010 Adult Liver Transplant Team

35 Patient Survival

36 * *Statistically higher than expected Graft Survival * *

37 2012 Summary Unadjusted patient and graft survival: 98%Unadjusted patient and graft survival: 98% Median length of stay: 9 daysMedian length of stay: 9 days Operative time: 3 hours and 20 minutesOperative time: 3 hours and 20 minutes Number of blood transfusions: 1.7 units of PRBCsNumber of blood transfusions: 1.7 units of PRBCs

38 Future Directions Asian Liver CenterAsian Liver Center Outreach clinicsOutreach clinics Improvement in length of stayImprovement in length of stay Improvement in survivalImprovement in survival Telemedicine/ECHOTelemedicine/ECHO

39

40 Liver Transplantation – Education/Research Provide Clinical Environment for BCM 3 rd Year Medical Student and BCM General Surgery Residents Provide Clinical Environment for BCM 3 rd Year Medical Student and BCM General Surgery Residents TSMBE and ASTS Approved Liver Transplant Fellowship TSMBE and ASTS Approved Liver Transplant Fellowship AASLD Funded NP Fellowship AASLD Funded NP Fellowship Trained Murat Kilic, MD – Chief of Liver Transplantation Izmir, Turkey Trained Murat Kilic, MD – Chief of Liver Transplantation Izmir, Turkey 108 Peer-reviewed publications 108 Peer-reviewed publications 102 National oral presentations 102 National oral presentations TSMBE/ACGME Hepatology Fellowship TSMBE/ACGME Hepatology Fellowship

41 Liver Transplant Division: Ongoing Research Projects Research Division Post-transplant Lymphoma Hepatocellular carcinoma Clinical Research

42 Status of Tissue Bank > 1400 tissue samples from 146 patients> 1400 tissue samples from 146 patients Sanger Sequencing of HCC SamplesSanger Sequencing of HCC Samples 300 amplicons over 30 genes300 amplicons over 30 genes 89 HCC samples with matched non tumor tissue or blood89 HCC samples with matched non tumor tissue or blood 33 HCV, 3 EtOH, 1 BA, 49 HBV, 3 with no underlying liver disease33 HCV, 3 EtOH, 1 BA, 49 HBV, 3 with no underlying liver disease 16 Hepatoblastoma with non tumor tissue16 Hepatoblastoma with non tumor tissue 4 Hepatic adenoma with non tumor tissue4 Hepatic adenoma with non tumor tissue

43 Ongoing Projects Epigenetics of HCCEpigenetics of HCC Investigating differential methylation patterns in tumor and non tumor tissueInvestigating differential methylation patterns in tumor and non tumor tissue Gene expression profilingGene expression profiling Developing cDNA libraries from mRNADeveloping cDNA libraries from mRNA Whole genome sequencingWhole genome sequencing Select patients to have entire genome sequencedSelect patients to have entire genome sequenced Testing new platformsTesting new platforms New Next Generation sequencers to be tested on HCC samplesNew Next Generation sequencers to be tested on HCC samples Development of collaborative tissue exchange programsDevelopment of collaborative tissue exchange programs Vanderbilt, Baylor Dallas, Harvard, and Mayo Clinic participating in the early stages of the development of an HCC consortiumVanderbilt, Baylor Dallas, Harvard, and Mayo Clinic participating in the early stages of the development of an HCC consortium

44 Future Reduce Donor/Recipient Discrepancy Donor awareness campaigns Donor awareness campaigns Extended criteria/ asystolic donors Extended criteria/ asystolic donors Split liver transplantation Split liver transplantation Living-donor liver transplantation Living-donor liver transplantation Xenotransplantation Xenotransplantation

45 Future Bioartificial Liver Stem Cells

46 Future Tolerance

47 Future Increase selectivity, decrease toxicity/side effects Increase selectivity, decrease toxicity/side effects Pediatric transplantationPediatric transplantation Hepatitis CHepatitis C CoinfectionCoinfection Personalized Immunosuppression

48 Future Pharmacogenetics and Pharmacogenomics

49 Future Hepatocellular carcinoma that exceeds Milan Criteria Hepatocellular carcinoma that exceeds Milan Criteria Down-staging Down-staging Presence of vascular invasion Presence of vascular invasion Genetics Genetics Choangiocarcinoma Choangiocarcinoma Previously considered a contraindication to OLT Previously considered a contraindication to OLT Mayo Protocol: multimodality neoadjuvant therapy Mayo Protocol: multimodality neoadjuvant therapy Genetics Genetics Primary Liver Tumors

50 Conclusion Liver transplantation has produced a positive impact on patients with advanced liver disease Liver transplantation has produced a positive impact on patients with advanced liver disease Spectacular improvement have occurred since the preliminary work of Dr. Starzl Spectacular improvement have occurred since the preliminary work of Dr. Starzl The advances in liver transplantation have occurred in a short 45 years and provide a base for future advances The advances in liver transplantation have occurred in a short 45 years and provide a base for future advances


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