1. Organ Transplantation
Dr. Nelson L. Rhodus
Director of Oral Medicine
University of Minnesota

2. Organ Transplantation
Bone Marrow ( stem cell)
Solid organs
Heart
Lung
Liver
Kidney
Pancreas
Small intestine

3. Organ Transplantation
Heart transplants
First performed in 1967; first year only 1:5 survived
2000= 3500 performed
Total= 53,000
Present survival rate >70%

4. Organ Transplantation
Kidney
First solid organ transplant ( 1954) performed
Since then >490,000 kidney transplants
Presently 581 centers perform >10,000 kidney transplants per year: 1-year survival rate >90%( cadaver~80%) ( 5 yr. ~70%)

5. Organ Transplantation
Liver transplants
First liver transplant in 1967
>90,000 liver transplants
> 8,000 liver transplants per year 1-year survival rate >90% ( 5 yr. ~70%)

6. Organ Transplantation
Pancreas transplants
first pancreas transplant was performed in 1966, by Kelly and Lillehei at the University of Minnesota
2000 >3500 transplants performed
>2000 at the U of M !
1 year survival rate >85% ( 5 yr. ~70%)
survival rate w/o pancreas transplant = about the same ! ( JAMA- Dec. ‘03)

7. Organ Transplantation
Heart - lung transplants
~ 800 performed as of 2000
1 year survival ~ 60 %

8. Organ Transplantation
Small intestine transplants
less than 50 performed (some combined with liver transplants)
four transplant centers (Cambridge; London, Ontario; Pittsburgh, and Omaha).
current 1-year survival rate at 70%.1

9. Bone marrow transplantation
First performed in 1958
Early = very poor prognosis
Immunosuppression, GVHD, rejection
2000 > 100,000
Today = successful ( 50-80% survival rate-1 year)

10. Organ Transplantation
HEART TRANSPLANTS
Reasons; cardiomyopathy, congenital heart disease, atherosclerotic coronary artery disease
Terminal heart disease (6-12 months)
Age <50-55 years

11. Organ Transplantation
HEART TRANSPLANTS
Good renal and hepatic function
No infections
No diabetes
Family support

12. Organ Transplantation
HEART TRANSPLANTS
Causes of death:
Infection 40%
Acute graft rejection 25%
Chronic graft rejection 10 %
Cardiac disease 25%

13. Organ Transplantation
HEART TRANSPLANTS
Endocarditis prevention
Pacemakers-arrhythmias
Medications- drugs
Avoid epinephrine
Anticoagulation

14. Organ Transplantation
HEART TRANSPLANTS
Immunosuppression
Adrenal suppression
Bleeding
Infection (IE)

15. Organ Transplantation
HEART TRANSPLANTS
ACCELERATED GRAFT ATHEROSCLEROSIS(AGAS)
~ 50 % of post-transplant patients have AGAS ( same degree as pre-transplant)

16. Organ Transplantation
HEART TRANSPLANTS
Transplanted heart has no nerve supply
Therefore with AGAS there is NO ANGINA. MI will cause sudden death.

17. Heart - lung transplants
first 1981 ( now~800 performed)
per year

18. Organ Transplantation
LIVER TRANSPLANTATION
Indications:
Chronic active hepatitis
Extrahepatic biliary atresia
Primary biliary cirrhosis
Budd-Chiari syndrome(hepatic vein thrombosis)
Sclerosing cholangitis
Hepatocellular carcinoma

19. Organ Transplantation
LIVER TRANSPLANTATION
Primary organ disease problems
Excessive bleeding
Infection
Altered drug metabolism
Hypertension

20. Liver-
small bowel
transplant

21. Organ Transplantation
RENAL TRANSPLANTATION
ESRD management
Endocarditis, endarteritis
Same as other organ transplants
Aggessive prevention-treatment of infections
Viral infections( CMV, HBV,HCV, HIV)

23. Organ Transplantation
RENAL TRANSPLANTATION
Avoid certain drugs( acetaminophen, phenacetin, tetracycline, aminoglycosides, ASA, K+, PCN, Magnesium-antacids, etc.)
Laboratory tests: urinalysis( BUN, creatinine, protein, electrolytes)

24. Bone marrow transplantation
condition success rate
ALL %
AML %
CML 60%
Aplastic anemia %
Lymphoma %
Neuroblastoma %

25. Bone marrow transplantation
HISTOCOMPATABILITY
Autologous self %
Allogeneic sibling %
Syngeneic ident. twin < 5%
Haploidentical parent < 5%
Unrelated any donor %

26. Bone marrow transplantation
Stages:
Medical evaluation 1 week
Histocompatibility matching 1 day
BM procurement (iliac crest) 1-2 weeks
Immunosuppressive Tx (TBI)1-2 weeks
Pancytopenic phase 4-6 weeks
Immune recovery phase 1 year
Long-term recovery 1-4 years

27. Bone marrow transplantation
Three phases of immunosuppressive Tx
1.) pre-transplant
Cyclophosphimide or methotrexate ± TBI ( single or fractionated)
2.) transplant( pancytopenic phase)
3.) cyclosporine, methotrexate, IFN-a to prevent GVHD

28. Bone marrow transplantation
Phases 2-3 pancytopenic phase
ANC<500: severe susceptibility to infection : 4-6 weeks post-transplant
Immunosuppression ( long-term)
Recurrence of leukemia
GVHD
encephalitis

30. Bone marrow transplantation
ORAL COMPLICATIONS
Peak 2-3 weeks post BMT
( pancytopenic phase: ANC<500)
Mucositis, xerostomia, GVHD, viral infections(HSV,HIV), ELP-like, erythema, Candidiasis

34. Dental management of the Organ Transplant patient
Dr. Nelson L. Rhodus
Director of Oral Medicine
University of Minnesota

35. Organ Transplantation
Before transplant
MEDICAL CONSULTATION
Establish patient status
primary organ failure-complications
Current treatment-drugs, etc.
Antibiotic prophylaxis

36. Organ Transplantation
LABORATORY TESTS
CBC
differential white count
platelets
PT, PTT, BT

37. Organ Transplantation
COMPLICATIONS
Over-immunosuppression
Side-effects of drugs
Rejection of transplant
Acute
Chronic

38. Organ Transplantation
DENTAL EVALUATION
Aggressive treatment prior to immunosuppression
Extract teeth with poor prognosis
Advanced perio, endo, questionable
Aggressive oral hygiene: maintenance

39. Organ Transplantation
IMMUNOSUPPRESSION
Prednisone
Aziothioprine(Immuran) 33%*
Cyclosporine %*
Antilymphocyte globulin (ALG) 84%*
* 1 year survival rate

40. Organ Transplantation
IMMUNOSUPPRESSION
Infection
Delayed wound healing
Bleeding
Hypertension
Heart failure
Diabetes mellitus

41. Organ Transplantation
IMMUNOSUPPRESSION
Tumors ( lip cancer, lymphoma)
Adrenal crisis
Anemia
Osteoporosis
GI problems

42. Organ Transplantation
DENTAL MANAGEMENT
MEDICAL CONSULTATION
Minimize stress, short appointments
Monitor vitals ( HTN)
Infections( endocarditis, endarteritis)
Pneumonia, encephalitis
Aggessive prevention & Tx of infection

43. Organ Transplantation
DENTAL MANAGEMENT
Bleeding
GI problems
IMMUNOSUPPRESSION
Consider steroid supplementation
Personal Oral hygiene

44. Transplantation ORAL COMPLICATIONS
Bleeding, infections, poor wound healing
Pain
Mucositis, ulcers, xerostomia, dysguesia, dysphagia

45. Organ Transplantation
Tumors
Lip carcinoma 8-10%
Kaposi’s 6-7 %
Lymphoma 20 %
Kidney Ca 5 %

51. Organ Transplantation
IMMUNOSUPPRESSION
Minor complications
Gingival hyperplasia
Hirsutism
Gynecomastia
Depression

52. Organ Transplantation
Graft rejection
Heart- death, retransplant( unlikely)
Kidney- death, Hemodialysis, re-Tx
Pancreas- death, insulin, re-Tx

53. Organ Transplantation
IMMEDIATE POST-TRANSPLANT
No routine dental treatment ~ 6 mos.
POH
Emergency( conservative) treatment
MEDICAL CONSULTATION

54. Organ Transplantation
Stable graft period ( >6 months)
Most dental treatment can be performed with adequate management
OVER-IMMUNOSUPPRESSION
GVHD
HTN, BLEEDING, DRUGS, etc.
OTHER INFECTIONS

55. Organ Transplantation
CHRONIC REJECTION PERIOD
No routine dental treatment
POH
Emergency( conservative) treatment
MEDICAL CONSULTATION

56. Organ Transplantation
Salivary gland dysfunction
Very aggressive oral hygiene program
POH: plaque control : toothbrushing, flossing, fluorides
Dietary counseling
Perio treatment
Chlorohexidine gluconate