Northwestern University Feinberg School of Medicine

New Trends in organ donation and

TransplantationJuan Carlos Caicedo, MD FACS

Director, Hispanic Transplant Program

Adult transplant Surgeon (NMH)

Pediatric Transplant Surgeon (LCH)

Overview

Introduction

Kidney ( Living / deceased/ combined stem cell)

Liver: whole, split, reduce size, living donor

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Who Needs a Transplant?

Transplantation is offered to patients who:

are in end-stage organ failure

have no other surgical or medical option available to them

have a limited life expectancy without a transplant

have undergone a rigorous and thorough assessment process and meet all necessary criteria

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Type of donorsDeceased (dead) donors-Brain dead donors: intact heartbeat & circulation, on ventilator

less than 3% of all deaths

-Donors after cardiac death: occurs in hopeless cases in the hospital where the decision to withdraw life-support is made (decision is independent of the decision to donate). Organ donation occurs immediately once the heart has stopped and the patient is declared dead

Living donor-Patient chooses to donate one or part of an organ to someone on a transplant waiting list

•can only occur with organs when removal will NOT cause grave harm to the donor-

Northwestern University Feinberg School of Medicine

United States Organ Transplantation

OPTN & SRTR Annual Data Report, 2011

Patients on the waiting list on December 31

of the year (active listings only)

Transplants performed during the year (adult & pediatric combined)

First-year all-cause graft survival

Northwestern University Feinberg School of Medicine

Adult Kidney Transplantation

End Stage Renal DiseaseDimension of the problem

>500.000 people in US

Options: Dialysis and kidney transplantation

US kidney waiting list: 105.124 people / 2013

Kidney Failure: Treatment

Kidney Transplantation

“ Best option”

- Replace all functions of the kidney

- Increase survival and quality of life

- Decrease complications

- Cost effective

Incident ESRD Rate and Transplant Rate

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USRDS 2010 ADR

Northwestern University Feinberg School of Medicine

2013: 105124 Waiting list2012: 16485 Transplanted 758 ( 4.5%) Pediatric pts

Whites :38%AA: 34%Hispanics: 19%Asian: 8%

Distribution of adult patients waiting for a kidney transplant

Deceased donor kidney donation rates

Cause of death among deceased kidney donors

Organs recovered per donor (ORPD), by SCD, DCD, & ECD status

Delayed graft function among adult kidney transplant recipients

Kidney donations from living donors

Living kidney donation

Laparoscopic vs Open

- Safe

- Less pain

- Fast recovery

- POD 1: Home

- Smaller Incisions

Intended kidney transplant procedure type, & percent of intended laparoscopic procedures converted to open

Number of transplants from living donors, by donor relation

All patients receiving a living donor kidney transplant.

USRDS 2010 ADR

Kidney Transplantation

Kidney Transplantation

Sensitized Patients

PRA Levels of Wait-Listed Patients

64%

21%

15%

0-9% 10-79% >80%

Sensitized

Very Highly Sensitized 36% Sensitized

Total = 17,814 pts

2010: 25% Sensitized

Options for Sensitized and ABO incompatible Patients

Wait and hope

Desensitization•Live Donor

•Deceased Donor

Live Donor Paired Exchange•List Exchange

Wait and hopeDesensitization

Live DonorDeceased Donor

Live Donor Paired ExchangeList Exchange

Paired kidney donations

Basic Kidney Paired Donation (KPD)

Northwestern University Feinberg School of Medicine

Desensitization

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N Engl J Med 365;4 July 28, 2011

Trends in Transplant Medications

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Immunosuppression use in adult kidney transplant recipients

Initial immunosuppression regimen in adult kidney transplant recipients, 2011

Acute rejections within the first year post-transplant

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First-time, kidney-only transplant recipients, age 18 & older, with functioning graft at discharge.

Source: USRDS 2010 ADR

Trends in Transplant Research

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The co-existence of two genetically different components in one organism

Chimerism induces tolerance

Mixed Chimeras

How can we make it safe?

Northwestern Clinical Tolerance Protocols

Sequential kidney/HSC in HLA matched related

Simultaneous kidney/HSC in HLA mismatched

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HLA-Matched Protocol

Current Enrollment – 20/20

First patient enrolled January 2008

HLA identical siblings

Excluded if high risk of recurrent disease in the allograft (role of immunosuppression in preventing disease recurrence)

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PI: Joshua Miller

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HSCT mobilized, collected, processed, & cryopreserved (> 2 wks before Tx)

ConditioningFludarabine, cytoxan, 200 cGy

TBI Perform Transplant

Processed donor leukopheresis product/marrow enriched for

HSC, FC and progenitors (FCRx)

Simultaneous FCRx +Kidney Transplant

d0 d +1

Adult kidney transplants

Outcomes among adult kidney transplant recipients: deceased donor

Outcomes among adult kidney transplant recipients: living donor

Half-lives for adult kidney transplant recipients

Liver Transplantation

Type of donor: Living vs deceased donor

Type of graft: Partial vs whole organ

Whole Organ Orthotopic Liver Transplant

Standard technique. This figure illustrates a completed liver transplant with vascular and biliary anastomoses.

Partial Grafts / Liver transplantation (LTX)

-Reduce Size Ltx

-Split LTx

-Living Donor Ltx

Partial Liver Transplantation

The split through midplane with right and left lobe graftsReference: Humar A, et al. Amer J Transpl 2001;1:366-72

Schematic drawing of the right lobe after transplantation into the recipient. The major vascular anastomosis and drainage of the bile duct into a Roux loop of bowel is illustrated

Northwestern University Feinberg School of Medicine

Adult Liver Transplantation

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Distribution of adult patients waiting for a liver transplant

Liver donors who are DCD

Liver transplants from living donors, by donor relation

Living donor liver transplant graft type

Total adult liver transplants

Adult liver transplants

Graft failure among adult liver transplant recipients: deceased donor

Immunosuppression use in adult liver transplant recipients

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ConclusionTransplantation offers a second chance at life to thousands of people. It has been proven over and over again to be very successful. However, transplantation can only occur if someone consents to the ultimate gift – organ and tissue donation.

liver transplant recipient

Kidney donor and recipient

Northwestern University Feinberg School of Medicine

Thank you

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