Moderator:• Ervin Ruzics, MD, St. Joseph Transplant Presenters:• Cynthia Herrington, MD, Children’s Hospital Los Angeles• Mudit Mathur, MD, Loma Linda University MC• Steven Colquhoun, MD, Cedars-Sinai Transplant Center• Clarence Foster, MD, UC Irvine Medical Center

Breakout Session B:

Decoding Transplant Center

Acceptance Criteria

Question to Run On

What practices have you learned today that you will

implement to increase organ acceptance and improve

long-term outcomes?

Objectives

By the end of this presentation, the attendee will be able to:• Understand the key considerations in determining

organ acceptance versus decline• Know which elements of donor management are

most impactful in organ placement and improved outcomes

Children’s Hospital Los Angeles

Cynthia Herrington, M.D.

Associate Professor of Clinical Cardiothoracic Surgery, Keck School of Medicine

Surgical Director of Pediatric Thoracic Transplantation & Ryan Winston Family Chair in Transplant Cardiology at Children’s Hospital Los Angeles

Surgical Director of Lung Transplant Program at USC.

Loma Linda University Children’s Hospital

Mudit Mathur, M.D.

Associate Professor of

Pediatrics

Expanding Transplant Center Acceptance Criteria-Hearts

Mudit Mathur, MDAssociate Professor of Pediatrics/Critical

CareLoma Linda University Children’s

Hospital

Donor quality Recipients July 2000- Dec 2008 84 trasnplants from 86 primary offers

vs. 29 from donors refused by other centers (quality UNOS code 830)

Pediatric Transplantation Using Hearts Refused on the Basis of Donor Quality. Bailey LL, Razzouk A, Hasaniya N et al. Ann Thoracic Surg 2009; 87(6): 1902-8

Recipient outcomes Despite….

Longer recovery distance (p < .002) Longer graft cold ischemic time (p <

0.001) Operative survival 93± 5% 7 year actuarial survival 74

±10.5% NO DIFFERENCE vs. PRIMARY OFFERSPediatric Hearts should seldom be refused on the basis of donor quality

Background Waitlist mortality for infants awaiting heart

transplantation 2465 deaths/1000 patient-years

(10-fold higher than 1-5, 6-10 or 11-17 year groups)

Risks-weight< 3kg, Status 1A, ECMO/VAD, mechanical ventilation, dialysis, race/ethnicity

PICU-potential 40% increase in total donors by including DCD donors

1995-2005 (USA): 683 Pediatric DCD transplants Kidney: 486, liver: 144, Pancreas: 38, Intestine: 1, Heart: 2, Lung: 12

NICU potential?

Methods Review of prospective NICU electronic

database All in-hospital deaths (6/2003-6/2008)

included Potential organ donors (weight > 2.5 kg)

categorized by mode of death Died despite cardiopulmonary resuscitation (CPR) Do not resuscitate (DNR) status Brain death (BD) Withdrawal of life-support (W)

Patients undergoing planned withdrawal evaluated further for suitability as DCD donors

Results 5446 NICU discharges

over 5 years 266 deaths, 117 (44%)

weighed > 2.5 kg 19 died despite CPR, 33

were DNR, 0 brain deaths Withdrawal of life support

in 69(59%)

Withdrawal (n=69) Age 1 d- 225 days Weight 2500-7495 grams 53 excluded-active infection/

significant cardiac dysfunction/ CHD/ MSOF.

16 evaluated further

Results 16 Potential DCD candidates

Median time (Withdrawal to death): 31 minutes (<1 to 310 min)

Withdrawal: Ventilator support (all), Dopa 4-8 mcg (3)

Reason for Withdrawal: Futility, neurodev outcome

Five patients (4.3% of all eligible donors) died in < 30 minutes

Results: 5 suitable DCD donors

Diagnosis Wt (kg) Bld type Echo ALT Creat

HIE 2.58 O+ normal 25 0.4

Midbrain bleed

2.72 O+ normal 29 0.3

BPD 2.99 A+ normal 23 0.4

Axonal dystrophy

5.57 A+ not done 31 0.1

Ribcage abn. 6.64 B+ normal 19 0.7

• No NICU Brain deaths during study period (6/2003-6/2008)

• Loma Linda PICU: 81 BD, 51 Donors, 158 organs transplanted

Potential impact of newborn DCD donors Local-Loma Linda

15/51 listed for heart transplant during the 5-year period studied died/taken off list

(2 NICU donors would have been blood type and size matches)

National 814 infants listed 3-month waitlist mortality 18.2% +

162 waitlist removals

Our approach IRB approval Unmodified DCD donor protocol (5

min) High risk waitlisted infants

consented Waitlisted for > 1 month Milrinone Mechanical Ventilation Dialysis ECMO/VAD

Conclusions Potential DCD donors can be readily

identified among NICU patients undergoing withdrawal of life support (5 infants, 4.3% of all deaths)

Potential is similar to PICU data (5.5-8.7%) Identifying NICU donors may

Markedly expand the infant donor pool Reduce short-term wait-list mortality rates for

infants

References Mathur M, Castleberry D, Job L, J Heart Lung Transpl

2011 ;30(4):389-94. Epub 2010 Dec 24 Koogler T, Costarino A. Pediatrics. 1998;101:1049–1052 Durall AL, Laussen PC, Randolph AG. Pediatrics.

2007;119:e219–e224 Naim MY, Hoehn KS, Hasz RD, White LS, Helfaer MA, Nelson RM.

Crit Care Med. 2008;36:1729–1733 Kolovos NS, Webster P, Bratton SL. Pediatr Crit Care Med.

2007;8:47–49 Pleacher KM, Roach ES, Van der Werf W, Antommaria AH,

Bratton SL. Pediatr Crit Care Med. 2009;10:166–170 Almond CS et al. Waiting list mortality among children listed for

heart transplantation in the United States. Circulation 2009, 119:717-727

Cedars-Sinai Medical Center

Steven Colquhoun, M.D.

Director, Liver Transplantation and

Surgical Oncology

Center for Liver Disease &

Transplantation

Deceased Donor Selection:

Liver

Steven Colquhoun, M.D., FACSDirector, Liver Transplantation

Cedars-Sinai Medical Center

Donor v. Recipient

Donor Quality

Recipient Condition

Balancing Act!

Distance/Cold Time/Expense

CA

NVUT

AZ NM

SF

LA

Rank Order: First Pass

Age Size Hemodynamics Numbers Co-morbidities Time hospitalized

Labs

Enzymes: – Current & Trend v. Mechanism

Sodium– Current & Peak

Serologies– HCV, HBV, HBVc

Bilirubin (?)

Fat Likelihood

– Height/Weight & Age– Diabetes Steroids/co-morbidities

Ultrasound / other imaging Biopsy (problems) Weighed against all other concerns Goal: ≤ 30%

Formulas

Donor Risk Indexes

Absolute cutoffs

– Age, Sodium, Enzymes

Unhelpful

Appearance

ColorTextureExperience

Surprising how often we’re surprised

How it Really Works:

SportsORTantrums

cars

MumblingNew gadgets

SewingCautery

U.C. Irvine Healthcare

Clarence E. Foster III, M.D.

FACS

Chief, Kidney & Pancreas

Transplantation

Associate Clinical Professor,

Department of Surgery, University

of California, Irvine

KIDNEY AND PANCREAS TRANSPLANT CENTER

ACCEPTANCE CRITERIA

Clarence E. Foster, III MD FACS

Chief, Transplantation

Department of Surgery,

School of Medicine

University of California, Irvine

Basic Framework of Donor Acceptance Criteria:AgeDonor Chronic DiseasesDonor Acute DiseasesDonor TypeCold Ischemia Times

Donor AgeKidney Pancreas

Most liberal of all transplanted organs

Infants Age-days to months Sharma A (2011)

○ mean 19 month ○ outcome equivalent to living

donor

Elderly- 70’s and above Boesmueller C (2011)

Age 10 y/o to 50 y/o

© 2011 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 3

.Long-Term Outcome in Kidney Transplant Recipients Over 70 Years in the Eurotransplant Senior Kidney Transplant Program: A Single Center Experience.Boesmueller, Claudia; Biebl, Matthias; Scheidl, Stefan; Oellinger, Robert; Margreiter, Christian; Pratschke, Johann; Margreiter, Raimund; Schneeberger, Stefan

Transplantation. 92(2):210-216, July 27, 2011.DOI: 10.1097/TP.0b013e318222ca2f

FIGURE 2. Death censored graft survival at year 1/5 was 100%/82% in 70+ group and 98.1%/92.7% in 70-group, respectively.

Kidney Donor Diseases Chronic Diseases

DiabetesHypertensionStrokeHepatitis C

Acute Disease

Donor Type

Expanded Criteria Kidney Donors (ECKD)

Donation after Circulatory Death (DCD)

Expanded Criteria Donors (ECD) Definition

Based on significant medical risk factors○ > 60 y/o○ 50-59 y/o with 2 of following:

History of hypertensionCerebrovascular accident as cause of deathFinal pre-procurement creatinine >1.5

RR >1.7 when compared to ideal 10-39 y/o donor

New Allocation for ECD

OPTN/UNOS Board of Directors, November 2001

ECD Kidneys allocated to predetermined patients to be recipients

Purpose is to stimulate use and decrease discard of organs

n

Acceptable Cold Ischemia

Kidney Pancreas

48 to 56 hours 12 to 24 hours

Conclusion

Potential kidney donors are the broadest group of donors when considering age and donor type

Excellent outcomes are achieved in kidney and pancreas transplantation

Question to Run On

What practices have you learned today that you will

implement to increase organ acceptance and improve

long-term outcomes?