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Challenges in
PediatricTransplantation
Cavallieri, Silvana (Chile)WCA 2012
Buenos Aires
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1. Review figures and data regardingchildrens donation and heart
transplant throughout the world2. Emphasize challenges surrounding
pediatric donation and transplant
a. Discuss definitions and conditions for diagnosisof brain death in children
b. Discuss the management of pediatric donors
c. Discuss special issues in pediatric cardiac
donors
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Aspect that are milestone in organ harvesting forpediatric transplant
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Without donors there are no
transplants Every country should have an
organization COMITTED TO
Alleviating the organ and tissueshortage
Organ allocation
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Possible
donor
Medically
suitable FulfillBrainDeath
Criteria
Organprocurement
Transplant
Consent
ElegibledonorActualdonor
PotentialdonorUtilized
donor
Transplant Int 2011, 24:373-378
Devastating Brain
injury
BrainDeathconfirmed
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40-50 x millioninhbts/year die ofencephalic death
Taking into account
15% deceased in ICU
2% deceased in a hospital
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What is required to obtaina donor?
Pediatric heart
1. An adequate legislation
2. An organized system ofprocurement
3. A well educated and sensitivepopulation
4. Financial and medical resources
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Opting in Opting out
The person
and relatives
decide
All citizens are
donors
ExpressedConsent
Presumedconsent
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The Madrid Resolution on Organ Donation and
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Adapted from Organs Tissues & Cells.ul 2011
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The philosophy of the Spanishapproach is that improving the
organization of the wholeprocess will result in increasedorgan donation
The Donts
Do not place too much energy in changing thelegal system
Do not place much effort in public campaigns
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Actual Donor Rates:Comparison between countries (2011))
Adapted from Organs Tissues & Cells.
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Weak organ & procurementsystem We DETECT ONLY half of the possible
donors in our population
Possible donors are not a priority
Financial and logistic problems
We do not have a sensitive andwell educated population High rate ofFAMILY REFUSAL
Wh t h ith FAMILY
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What happens with FAMILYREFUSAL in different
countries?
From ONT (Spain), Corporacin del Trasplante(Chile)
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ILHTS. J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
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ILHTS. J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
#of
CentersReporting
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DISTRIBUTION OF TRANSPLANTSby Donor/Recipient Weight Ratio
(International Heart and Lung Transplant Registry.2003-june 2010)
%o
f
transplan
t
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Which are the figuresregarding pediatric donors?
ONT, Spain,
Years
Years
Years
Years
Years
Years
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3 kg:
AB: 0.16 A: 0.14
B. 0.10
O: 0.09
60 kg:
AB: 0.66 A: 0.61
B. 0.047
O: 0.44
J Paediatr Child Health, 2007. 43(1-2):
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J Pediatr.2011;158:31-6
10% organpool
increase
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1. Obtaining an adequate
donor ??1. Carrying out the explant and
transplant
2. Perioperative handling of therecipient
3. Immunosuppression/rejection
4. Follow up
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General:
Infectious disease (HIV or viralhepatitis),
Over 65
Disseminated malignancies
IV drug abuse
Specific for cardiac
transplant
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Congenital
Cardiomyophaty
Retransplant :
Dr. L. Bailey performed the first infant hearttransplant in in 1985
Numbers of pediatric heart
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Numbers of pediatric hearttrasplant and age of recipient per
year
J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132
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0
2550
75
100Myopathy Congenital
o
f
0
25
50
75100
0
25
50
75
100
%
o
C
a
Age
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1-year survival rate: 80-90%
2-year survival rate: 80-85%
5-year survival rate: 70-80%inexperienced
centers
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The most critical step is obtaining a
(cardiac) donor, and problems areusually related to...
Special difficulties indiagnosis of brain death
in pediatric donors
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Pediatrics, 2011;128: e720e740
Known structural disease or
irreversible systemic metabolic causethat can explain the clinical picture
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Exclusion and correction of
conditions that confound diagnosis ofbrain death (electrolyte abnormalities,intoxication, hypothermia or drugs)
Absence of recent doses of sedatives,
hypnotics or neuromuscular blockingagents
Absence of significant hypotension for
that age Pediatrics, 2011;128: e720e740
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Observation period
12 hours: for infants and children (30
d to 18 y)24 hours: from 37 weeks gestational
age to 30 d
2 neurological examinations Assessment of neurologic function following CPR
should be deferred for 24 hoursPediatrics. 2011;128:e720e740
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Harvard criteria
Set in 1968Reviewed 1987
Dead Donor Rule requirespatients to be declared dead before the removal oflife-sustaining organs for transplantation
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1. Coma
2. Absence of brainstemreflexes
3. Apnea
Formal neurologicalexamination
It is a requisite to have a known structural
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I: Coma (Absence of BrainFunctions)
unreactive coma is acondition where responsesto painful stimuli in cranialnerves territory are notpresent
b f
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II. Absence ofBrainstem Reflexes
certify the absence of brainstem
reflexes
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Pupillary response Mid-position or fully dilated pupils that do not respond to
light.
Vestibulo-ocular reflex (Cold caloric test)
Oculo-cephalic reflex Doll's eye movement)
Absence of bulbar functionincluding facial and
oropharyngeal muscles
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III. Apnea test
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Assesment of electrical
activity- EEG Assesment of Cerebral Blood
Flow- Radionuclide cerebral blood flow
These ancillary testsPediatrics. 2011;128:
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Programs for organ transplantationfrom anencephalic infants have beenapproved in Germany, Japan andHolland.
Is this ethical?
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Hypotension 81 %
Diabetes Insipidus 65-90%
IDC 28%
Arrhythmias 27%
Cardiac Arrest 25%
Hypothermia 23%
Oliguria 17%
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Full monitoring should be set upbecause of the unstable condition of
a patient in brain death
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Vasopressin
Thyroid
hormonereplacement
CorticoidsCanadian Medical Association Journal 2006,174(6)
THT
Improved organ-quality
UNOS evidence for THT in heart
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UNOS evidence for THT in hearttransplant
Use of T4 or T3/ Vasopressin/methylprednisolone :
retrospective studies
Hearts procured from donors
receiving THT: Improved one-month survival rate ascompared to those donors not receiving
THT.
Reduced early cardiac graftdysfunction
1. Rosendale JD, et al. Hormonal resuscitation associated with more transplanted organs with
no sacrifice in survival.Transplantation 2004;78(2) suppl 1:171. Canadian recommendations for donor management . Canadian
Medical Association Journal . 2006, 174(6)
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Limited supply ofcadaveric organ donors
Societal concerns about
the definition of BDCultural and family
concerns
The difficulties ofmedical managementBD organ donor
Legal & logistical
concerns
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Figures regarding donation andtransplants worldwide
Figures concerning the number oftransplants and results of cardiactransplant in children
Issues for Brain Death diagnosisand BD management in children.
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