THE OPTION OF THE OPTION OF TRANSPLANTATIOTRANSPLANTATIO

NNLILLY BARBA, M.D.LILLY BARBA, M.D.

MEDICAL DIRECTOR RENAL MEDICAL DIRECTOR RENAL TRANSPLANT PROGRAMTRANSPLANT PROGRAMHARBOR-UCLA MEDICAL HARBOR-UCLA MEDICAL

CENTERCENTER

OPTIONS FOR TREATMENT OPTIONS FOR TREATMENT OF END STAGE RENAL OF END STAGE RENAL

DISEASEDISEASE• HEMODIALYSISHEMODIALYSIS• PERITONEAL DIALYSISPERITONEAL DIALYSIS• TRANSPLANTATIONTRANSPLANTATION

THE OPTION OF THE OPTION OF TRANSPLANTATIONTRANSPLANTATION

• BEST OPTION TO RESTORE BEST OPTION TO RESTORE FEELING OF WELL BEINGFEELING OF WELL BEING

• LIBERALIZATION OF FLUID AND LIBERALIZATION OF FLUID AND DIETARY RESTRICTIONDIETARY RESTRICTION

• ABILITY TO TRAVELABILITY TO TRAVEL• INCREASE IN LIFE SPAN AS INCREASE IN LIFE SPAN AS

COMPARED TO REMAINING ON COMPARED TO REMAINING ON DIALYSISDIALYSIS

RISKS OF RISKS OF TRANSPLANTATIONTRANSPLANTATION

• MAJOR SURGICAL PROCEDURE MAJOR SURGICAL PROCEDURE WITH POSSIBLE WITH POSSIBLE COMPLICATIONS INCLUDING:COMPLICATIONS INCLUDING:

• BLEEDING BLEEDING • INFECTIONINFECTION• REJECTIONREJECTION• ANESTHESIA RISKANESTHESIA RISK• DEATHDEATH

OPTION OF OPTION OF TRANSPLANTATIONTRANSPLANTATION

• CHOSING THE OPTION OF CHOSING THE OPTION OF TRANSPLANTATION SHOULD TRANSPLANTATION SHOULD BE TAKEN WITH CAUTIONBE TAKEN WITH CAUTION

• IN GENERAL, HOWEVER, IN GENERAL, HOWEVER, TRANSPLANTATION IS THE TRANSPLANTATION IS THE BEST OPTION FOR TREATING BEST OPTION FOR TREATING PEOPLE WITH KIDNEY DISEASEPEOPLE WITH KIDNEY DISEASE

PURSUING THE OPTION PURSUING THE OPTION OF TRANSPLANTATIONOF TRANSPLANTATION

• PATIENTS MAY BE REFERRED PATIENTS MAY BE REFERRED BY THEIR NEPHROLOGIST BY THEIR NEPHROLOGIST WHEN THE SERUM WHEN THE SERUM CREATININE IS 3.5 MG/DL OR CREATININE IS 3.5 MG/DL OR ESTIMATED GFR < 20 CC/MINESTIMATED GFR < 20 CC/MIN

• THE REASON FOR EARLY THE REASON FOR EARLY REFERRAL IS TO ESTABLISH REFERRAL IS TO ESTABLISH WAITING TIME OR READY FOR WAITING TIME OR READY FOR A PRE EMPTIVE TRANSPLANTA PRE EMPTIVE TRANSPLANT

WAITING TIMEWAITING TIME

• UNOS (UNITED NETWORK FOR UNOS (UNITED NETWORK FOR ORGAN SHARING) IS THE ORGAN SHARING) IS THE ORGANIZATION THAT OVERSEES ORGANIZATION THAT OVERSEES ALL TRANSPLANT PROGRAMS IN ALL TRANSPLANT PROGRAMS IN THE UNITED STATESTHE UNITED STATES

• TOLL FREE NUMBER 1-888-894-TOLL FREE NUMBER 1-888-894-6361 INFORMATION LINE FOR 6361 INFORMATION LINE FOR TRANSPLANT CANDIDATES, TRANSPLANT CANDIDATES, RECIPIENTS AND FAMILY RECIPIENTS AND FAMILY MEMBERSMEMBERS

UNOSUNOS

• UNOS ALSO MAINTAINS A WEB UNOS ALSO MAINTAINS A WEB SITE,SITE, TRANSPLANT LIVING, TRANSPLANT LIVING, WHICH CONTAINS WHICH CONTAINS INFORMATION FOR INFORMATION FOR TRANSPLANT CANDIDATES AND TRANSPLANT CANDIDATES AND RECIPIENTS AND FAMILY RECIPIENTS AND FAMILY MEMBERSMEMBERS

• ADDRESS: ADDRESS: WWW.TRANSPLANTLIVING.ORGWWW.TRANSPLANTLIVING.ORG

BENEFITS OF PRE BENEFITS OF PRE EMPTIVE EMPTIVE

TRANSPLANTATION TRANSPLANTATION • NO NEED TO START DIALYSIS: NO NEED TO START DIALYSIS:

NO COMORBITIDIES NO COMORBITIDIES ASSOCIATED WITH DIALYSISASSOCIATED WITH DIALYSIS

• BETTER QUALITY OF LIFEBETTER QUALITY OF LIFE• HIGHER EMPLOYMENT RATES HIGHER EMPLOYMENT RATES

POST TRANSPLANTPOST TRANSPLANT• NO NEED FOR AV GRAFT OR NO NEED FOR AV GRAFT OR

FISTULA PLACEMENTFISTULA PLACEMENT

BENEFITS OF PRE BENEFITS OF PRE EMPTIVE EMPTIVE

TRANSPLANTATION TRANSPLANTATION • DO NOT HAVE TO WAIT YEARS DO NOT HAVE TO WAIT YEARS

FOR A DECEASED DONORFOR A DECEASED DONOR• PATIENTS WHO RECEIVE PRE-PATIENTS WHO RECEIVE PRE-

EMPTIVE TRANSPLANTS HAVE EMPTIVE TRANSPLANTS HAVE BETTER OUTCOMESBETTER OUTCOMES

• COSTS FOR MAINTAINING A COSTS FOR MAINTAINING A TRANSPLANT PATIENT ARE TRANSPLANT PATIENT ARE LESSLESS

BARRIERS TO PRE BARRIERS TO PRE EMPTIVE EMPTIVE

TRANSPLANTATIONTRANSPLANTATION• 2005 USRDS : INCIDENCE OF PRE 2005 USRDS : INCIDENCE OF PRE

EMPTIVE TRANSPLANTATION WAS EMPTIVE TRANSPLANTATION WAS 2.5%2.5%

• NKF CONSENSUS CITED REASONS:NKF CONSENSUS CITED REASONS:1.1. EARLY EDUCATION NEEDEDEARLY EDUCATION NEEDED2.2. TIMELY TRANSPLANT REFERRAL TIMELY TRANSPLANT REFERRAL

NEEDEDNEEDED3.3. IDENTIFICATION OF POTENTIAL IDENTIFICATION OF POTENTIAL

LIVING DONORLIVING DONOR4.4. REFERRAL WHEN PATIENT IS REFERRAL WHEN PATIENT IS

REFERRED FOR AV ACCESSREFERRED FOR AV ACCESS

CANDIDATES FOR CANDIDATES FOR TRANSPLANTATIONTRANSPLANTATION

THOSE PATIENTS WITH:THOSE PATIENTS WITH:• PATIENTS WITH IRREVERSIBLE PATIENTS WITH IRREVERSIBLE

LOSS OF RENAL FUNCTIONLOSS OF RENAL FUNCTION• THOSE WITH CREATININE > 3.5 THOSE WITH CREATININE > 3.5

MG/DLMG/DL• AGE IS A RELATIVE FACTOR IN AGE IS A RELATIVE FACTOR IN

DETERMINING CANDIDACYDETERMINING CANDIDACY

WHO IS WHO IS NOT A POTENTIAL NOT A POTENTIAL CANDIDATE CANDIDATE ??

THOSE PATIENTS WITH:THOSE PATIENTS WITH:• ACTIVE INFECTIONACTIVE INFECTION• CANCER OR CANCER RECENTLY CANCER OR CANCER RECENTLY

TREATEDTREATED• UNCORRECTABLE HEART UNCORRECTABLE HEART

PROBLEMSPROBLEMS• ADVANCED LUNG DISEASEADVANCED LUNG DISEASE

WHO IS WHO IS NOT A POTENTIAL NOT A POTENTIAL CANDIDATE CANDIDATE ??

THOSE PATIENTS WITH:THOSE PATIENTS WITH:• ACTIVE STOMACH ULCERSACTIVE STOMACH ULCERS• CIRRHOSIS OF THE LIVERCIRRHOSIS OF THE LIVER• NO ELIGIBILITY FOR INSURANCE OR NO ELIGIBILITY FOR INSURANCE OR

NO MEDICAL INSURANCENO MEDICAL INSURANCE• LACK OF A FAMILY/SOCIAL SUPPORT LACK OF A FAMILY/SOCIAL SUPPORT

SYSTEMSYSTEM• ONGOING KIDNEY DISEASE: ONGOING KIDNEY DISEASE:

VASCULITISVASCULITIS

WHO IS WHO IS NOT A POTENTIAL NOT A POTENTIAL CANDIDATE CANDIDATE ??

THOSE PATIENTS WITH:THOSE PATIENTS WITH:• MORBID OBESITYMORBID OBESITY• SEVERE PSYCHIATRIC PROBLEMS SEVERE PSYCHIATRIC PROBLEMS

NOT WELL CONTROLLEDNOT WELL CONTROLLED• CONTINUED ALCOHOL, TOBACCO CONTINUED ALCOHOL, TOBACCO

OR ILLICIT DRUG ABUSEOR ILLICIT DRUG ABUSE• AGE GREATER THAN 70 WITHOUT AGE GREATER THAN 70 WITHOUT

THE POTENTIAL FOR A LIVING THE POTENTIAL FOR A LIVING DONORDONOR

THOSE PATIENTS WITH THOSE PATIENTS WITH PCKDPCKD

• OVERALL, PATIENTS WITH PCKD OVERALL, PATIENTS WITH PCKD DO WELLDO WELL

• PRE TRANSPLANT CLEARANCE PRE TRANSPLANT CLEARANCE MAY INCLUDE:MAY INCLUDE:

1.1. CT SCAN OF THE ABDOMENCT SCAN OF THE ABDOMEN

2.2. CT SCAN OF THE BRAINCT SCAN OF THE BRAIN

3.3. ECHOCARDIOGRAMECHOCARDIOGRAM

4.4. SURGICAL REMOVAL OF NATIVE SURGICAL REMOVAL OF NATIVE KIDNEYSKIDNEYS

THE TRANSPLANT THE TRANSPLANT SURGICAL PROCEDURESURGICAL PROCEDURE

WHAT YOU SHOULD WHAT YOU SHOULD EXPECT FOLLOWING EXPECT FOLLOWING

TRANSPLANT SURGERYTRANSPLANT SURGERY• SURGERY IS 3 – 5 HOURS UNDER SURGERY IS 3 – 5 HOURS UNDER

GENERAL ANESTHESIAGENERAL ANESTHESIA• HOSPITAL STAY 5 – 7 DAYSHOSPITAL STAY 5 – 7 DAYS• AFTER SURGERY:AFTER SURGERY:

– FOLEY CATHETERFOLEY CATHETER– JACKSON PRATT DRAINAGE BULB (JP)JACKSON PRATT DRAINAGE BULB (JP)– CENTRAL VENOUS PRESSURE LINE (CVP)CENTRAL VENOUS PRESSURE LINE (CVP)– STAPLES HOLDING WOUND TOGETHERSTAPLES HOLDING WOUND TOGETHER– POD # 1 : BEDREST POD # 2: START POD # 1 : BEDREST POD # 2: START

EATINGEATING– POD # 3: WALKING AS TOLERATEDPOD # 3: WALKING AS TOLERATED

IMMUNOSUPPRESSIVE IMMUNOSUPPRESSIVE MEDICATIONSMEDICATIONS

• CNI (TACROLIMUS OR CNI (TACROLIMUS OR CYCLOSPORINE)CYCLOSPORINE)

• STEROID (PREDNISONE)STEROID (PREDNISONE)• ANTI-METABOLITE (CELLCEPT ANTI-METABOLITE (CELLCEPT

OR AZATHIOPRINE)OR AZATHIOPRINE)

MEDICATIONS CAN HAVE MEDICATIONS CAN HAVE SIDE EFFECTS: COMMON SIDE EFFECTS: COMMON

SIDE EFFECTSSIDE EFFECTS• TACROLIMUS/CYCLOSPORINETACROLIMUS/CYCLOSPORINE : :

TREMORS, HIGH BLOOD TREMORS, HIGH BLOOD PRESSURE, HAIR GROWTH WITH PRESSURE, HAIR GROWTH WITH CYCLOSPORINE, POSSIBLE CYCLOSPORINE, POSSIBLE DIABETESDIABETES

• PREDNISONE:PREDNISONE: GASTRITIS, WEIGHT GASTRITIS, WEIGHT GAIN SECONDARY TO INCREASE GAIN SECONDARY TO INCREASE APPETITE, DIFFICULT TO CONTROL APPETITE, DIFFICULT TO CONTROL DIABETES, ACNE, EASY BRUISING, DIABETES, ACNE, EASY BRUISING, INCREASE SENSITIVITY TO THE INCREASE SENSITIVITY TO THE SUNSUN

MEDICATIONS CAN HAVE MEDICATIONS CAN HAVE SIDE EFFECTS: COMMON SIDE EFFECTS: COMMON

SIDE EFFECTSSIDE EFFECTS

• CELLCEPTCELLCEPT: GAS, DIARRHEA, : GAS, DIARRHEA, LOW WHITE BLOOD CELL LOW WHITE BLOOD CELL COUNTCOUNT

TRANSPLANTATION TRANSPLANTATION OPTIONSOPTIONS

• PRE-EMPTIVE TRANSPLANTATIONPRE-EMPTIVE TRANSPLANTATION• LIVING DONOR LIVING DONOR

TRANSPLANTATIONTRANSPLANTATION• DECEASED DONOR DECEASED DONOR

TRANSPLANTATION:TRANSPLANTATION:

1.1. STANDARD CRITERIASTANDARD CRITERIA

2.2. EXTENDED CRITERIAEXTENDED CRITERIA

3.3. DONOR AFTER CARDIAC DEATH DONOR AFTER CARDIAC DEATH

LIVING DONORSLIVING DONORS

• ANY PERSON WHO IS HEALTHY ANY PERSON WHO IS HEALTHY CAN BE EVALUATED FOR A CAN BE EVALUATED FOR A TRANSPLANTTRANSPLANT

• CANNOT HAVE DIABETES, CANNOT HAVE DIABETES, HYPERTENSION, KIDNEY HYPERTENSION, KIDNEY DISEASE OR ACTIVE DRUG USEDISEASE OR ACTIVE DRUG USE

• EACH TRANSPLANT PROGRAM EACH TRANSPLANT PROGRAM SETS CRITERIA FOR DONORSETS CRITERIA FOR DONOR

LIVING DONORS DO LIVING DONORS DO WELLWELL

• SURGERY IS USUALLY DONE SURGERY IS USUALLY DONE LAPARASCOPICALLYLAPARASCOPICALLY

• HOSPITAL STAY IS 3 DAYS HOSPITAL STAY IS 3 DAYS MAXIMUMMAXIMUM

• PAIN CONTROLLED WITH PAIN CONTROLLED WITH NARCOTICSNARCOTICS

• RESUMPTION OF DAILY RESUMPTION OF DAILY ACTIVITES IN 4 TO 8 WEEKSACTIVITES IN 4 TO 8 WEEKS

LIVING DONORS DO LIVING DONORS DO WELLWELL

• RESUMPTION OF NORMAL RESUMPTION OF NORMAL DAILY ACTIVITIES WITH 4 TO 8 DAILY ACTIVITIES WITH 4 TO 8 WEEKSWEEKS

LIVING DONORS DO LIVING DONORS DO WELLWELL

• RISKS LOW: MORTALITY 0.03 %, RISKS LOW: MORTALITY 0.03 %, SURGICAL RISKS ABOUT 3 %SURGICAL RISKS ABOUT 3 %

• LONG TERM RISKS: HAVE TO BE LONG TERM RISKS: HAVE TO BE EVALUATED IN CONTEXT OF PRE EVALUATED IN CONTEXT OF PRE EXISITING PROBLEMS, DEVELOPMENT EXISITING PROBLEMS, DEVELOPMENT OF MEDICAL PROBLEMS AFTER OF MEDICAL PROBLEMS AFTER DONATION AND GENERAL POPULATION DONATION AND GENERAL POPULATION RISKS OF DEVELOPING KIDNEY RISKS OF DEVELOPING KIDNEY DISEASE WHICH IS APPROXIMATELY 2 DISEASE WHICH IS APPROXIMATELY 2 % FOR CAUCASIANS AND 7.5 % FOR % FOR CAUCASIANS AND 7.5 % FOR AFRICAN AMERICANSAFRICAN AMERICANS

LIVING RELATED LIVING RELATED DONATION IN PKD DONATION IN PKD

FAMILIESFAMILIES• OWING TO THE DIFFICULTIES OWING TO THE DIFFICULTIES

ENCOUNTERED IN EXCLUDING ENCOUNTERED IN EXCLUDING PKD IN RELATED POTENTIAL PKD IN RELATED POTENTIAL DONORS, PATIENTS WITH PKD DONORS, PATIENTS WITH PKD RECEIVE FEWER LIVING RECEIVE FEWER LIVING RELATED KIDNEY RELATED KIDNEY TRANSPLANTSTRANSPLANTS

LIVING RELATED LIVING RELATED DONATION IN PKD DONATION IN PKD

FAMILIESFAMILIES• ULTRASOUND IS ULTRASOUND IS

INSUFFICIENTLY INSENSITIVE INSUFFICIENTLY INSENSITIVE TO EXCLUDE DISEASE BEFORE TO EXCLUDE DISEASE BEFORE THE AGE OF 30 YEARSTHE AGE OF 30 YEARS

• GENETIC TESTING CAN BE USED GENETIC TESTING CAN BE USED THROUGH ANALYSIS OF LINKED THROUGH ANALYSIS OF LINKED FLANKING POLYMORPHIC FLANKING POLYMORPHIC GENETIC MARKERS OR THE USE GENETIC MARKERS OR THE USE OF DIRECT MUTATION ANALYSISOF DIRECT MUTATION ANALYSIS

DECEASED DONORSDECEASED DONORS

• DIFFERENCE IN ALLOGRAFT DIFFERENCE IN ALLOGRAFT SURVIVALSURVIVAL

• DECEASED DONOR HALF-LIFE 7 DECEASED DONOR HALF-LIFE 7 TO 12 YEARSTO 12 YEARS

• LIVING DONOR HALF-LIFE IS 20 LIVING DONOR HALF-LIFE IS 20 YEARSYEARS

• RISK OF REJECTION MAY BE RISK OF REJECTION MAY BE HIGHER ESPECIALLY IS DONOR HIGHER ESPECIALLY IS DONOR IS NOT RELATED TO RECIPIENTIS NOT RELATED TO RECIPIENT

WAITING TIME FOR A WAITING TIME FOR A DECEASED DONORDECEASED DONOR

• BLOOD GROUPS ARE O, A, AB, BBLOOD GROUPS ARE O, A, AB, B• AVERAGE WAITING TIME FOR AVERAGE WAITING TIME FOR

AN O KIDNEY IS THE GREATER AN O KIDNEY IS THE GREATER LA AREA IS 7 TO 10 YEARSLA AREA IS 7 TO 10 YEARS

• B PATIENTS WAIT GREATER B PATIENTS WAIT GREATER THAN 5 YEARSTHAN 5 YEARS

DISCUSSION WITH DISCUSSION WITH TRANSPLANT CENTER TRANSPLANT CENTER

• WHICH IS THE BEST OPTION WHICH IS THE BEST OPTION FOR ME?FOR ME?

• EVALUATION OF POTENTIAL EVALUATION OF POTENTIAL DONORSDONORS

• COMPLETION OF WORK-UP IN A COMPLETION OF WORK-UP IN A TIMELY BASISTIMELY BASIS

• HEAR ALL THE OPTIONSHEAR ALL THE OPTIONS

CONCLUDING REMARKSCONCLUDING REMARKS

• TRANSPLANTATION IS THE TRANSPLANTATION IS THE BEST OPTION FOR PATIENTS BEST OPTION FOR PATIENTS WITH KIDNEY DISEASEWITH KIDNEY DISEASE

• COMPLICATIONS ARE POSSIBLECOMPLICATIONS ARE POSSIBLE• LIVING DONATION IS LIVING DONATION IS

ENCOURAGED ESPECIALLY TO ENCOURAGED ESPECIALLY TO EXPEDITE TRANSPLANTATION, EXPEDITE TRANSPLANTATION, FOR LONG TERM SUCCESSFOR LONG TERM SUCCESS