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THE OPTION OF TRANSPLANTATION. LILLY BARBA, M.D. MEDICAL DIRECTOR RENAL TRANSPLANT PROGRAM HARBOR-UCLA MEDICAL CENTER. OPTIONS FOR TREATMENT OF END STAGE RENAL DISEASE. HEMODIALYSIS PERITONEAL DIALYSIS TRANSPLANTATION. THE OPTION OF TRANSPLANTATION.

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The option of transplantation

THE OPTION OF TRANSPLANTATION

LILLY BARBA, M.D.

MEDICAL DIRECTOR RENAL TRANSPLANT PROGRAM

HARBOR-UCLA MEDICAL CENTER


Options for treatment of end stage renal disease
OPTIONS FOR TREATMENT OF END STAGE RENAL DISEASE

  • HEMODIALYSIS

  • PERITONEAL DIALYSIS

  • TRANSPLANTATION


The option of transplantation1
THE OPTION OF TRANSPLANTATION

  • BEST OPTION TO RESTORE FEELING OF WELL BEING

  • LIBERALIZATION OF FLUID AND DIETARY RESTRICTION

  • ABILITY TO TRAVEL

  • INCREASE IN LIFE SPAN AS COMPARED TO REMAINING ON DIALYSIS


Risks of transplantation
RISKS OF TRANSPLANTATION

  • MAJOR SURGICAL PROCEDURE WITH POSSIBLE COMPLICATIONS INCLUDING:

  • BLEEDING

  • INFECTION

  • REJECTION

  • ANESTHESIA RISK

  • DEATH


Option of transplantation
OPTION OF TRANSPLANTATION

  • CHOSING THE OPTION OF TRANSPLANTATION SHOULD BE TAKEN WITH CAUTION

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


Pursuing the option of transplantation
PURSUING THE OPTION OF TRANSPLANTATION

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

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


Waiting time
WAITING TIME

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

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


The option of transplantation
UNOS

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

  • ADDRESS: WWW.TRANSPLANTLIVING.ORG


Benefits of pre emptive transplantation
BENEFITS OF PRE EMPTIVE TRANSPLANTATION

  • NO NEED TO START DIALYSIS: NO COMORBITIDIES ASSOCIATED WITH DIALYSIS

  • BETTER QUALITY OF LIFE

  • HIGHER EMPLOYMENT RATES POST TRANSPLANT

  • NO NEED FOR AV GRAFT OR FISTULA PLACEMENT


Benefits of pre emptive transplantation1
BENEFITS OF PRE EMPTIVE TRANSPLANTATION

  • DO NOT HAVE TO WAIT YEARS FOR A DECEASED DONOR

  • PATIENTS WHO RECEIVE PRE-EMPTIVE TRANSPLANTS HAVE BETTER OUTCOMES

  • COSTS FOR MAINTAINING A TRANSPLANT PATIENT ARE LESS


Barriers to pre emptive transplantation
BARRIERS TO PRE EMPTIVE TRANSPLANTATION

  • 2005 USRDS : INCIDENCE OF PRE EMPTIVE TRANSPLANTATION WAS 2.5%

  • NKF CONSENSUS CITED REASONS:

  • EARLY EDUCATION NEEDED

  • TIMELY TRANSPLANT REFERRAL NEEDED

  • IDENTIFICATION OF POTENTIAL LIVING DONOR

  • REFERRAL WHEN PATIENT IS REFERRED FOR AV ACCESS


Candidates for transplantation
CANDIDATES FOR TRANSPLANTATION

THOSE PATIENTS WITH:

  • PATIENTS WITH IRREVERSIBLE LOSS OF RENAL FUNCTION

  • THOSE WITH CREATININE > 3.5 MG/DL

  • AGE IS A RELATIVE FACTOR IN DETERMINING CANDIDACY


Who is not a potential candidate
WHO IS NOT A POTENTIAL CANDIDATE ?

THOSE PATIENTS WITH:

  • ACTIVE INFECTION

  • CANCER OR CANCER RECENTLY TREATED

  • UNCORRECTABLE HEART PROBLEMS

  • ADVANCED LUNG DISEASE


Who is not a potential candidate1
WHO IS NOT A POTENTIAL CANDIDATE ?

THOSE PATIENTS WITH:

  • ACTIVE STOMACH ULCERS

  • CIRRHOSIS OF THE LIVER

  • NO ELIGIBILITY FOR INSURANCE OR NO MEDICAL INSURANCE

  • LACK OF A FAMILY/SOCIAL SUPPORT SYSTEM

  • ONGOING KIDNEY DISEASE: VASCULITIS


Who is not a potential candidate2
WHO IS NOT A POTENTIAL CANDIDATE ?

THOSE PATIENTS WITH:

  • MORBID OBESITY

  • SEVERE PSYCHIATRIC PROBLEMS NOT WELL CONTROLLED

  • CONTINUED ALCOHOL, TOBACCO OR ILLICIT DRUG ABUSE

  • AGE GREATER THAN 70 WITHOUT THE POTENTIAL FOR A LIVING DONOR


Those patients with pckd
THOSE PATIENTS WITH PCKD

  • OVERALL, PATIENTS WITH PCKD DO WELL

  • PRE TRANSPLANT CLEARANCE MAY INCLUDE:

  • CT SCAN OF THE ABDOMEN

  • CT SCAN OF THE BRAIN

  • ECHOCARDIOGRAM

  • SURGICAL REMOVAL OF NATIVE KIDNEYS



What you should expect following transplant surgery
WHAT YOU SHOULD EXPECT FOLLOWING TRANSPLANT SURGERY

  • SURGERY IS 3 – 5 HOURS UNDER GENERAL ANESTHESIA

  • HOSPITAL STAY 5 – 7 DAYS

  • AFTER SURGERY:

    • FOLEY CATHETER

    • JACKSON PRATT DRAINAGE BULB (JP)

    • CENTRAL VENOUS PRESSURE LINE (CVP)

    • STAPLES HOLDING WOUND TOGETHER

    • POD # 1 : BEDREST POD # 2: START EATING

    • POD # 3: WALKING AS TOLERATED


Immunosuppressive medications
IMMUNOSUPPRESSIVE MEDICATIONS

  • CNI (TACROLIMUS OR CYCLOSPORINE)

  • STEROID (PREDNISONE)

  • ANTI-METABOLITE (CELLCEPT OR AZATHIOPRINE)


Medications can have side effects common side effects
MEDICATIONS CAN HAVE SIDE EFFECTS: COMMON SIDE EFFECTS

  • TACROLIMUS/CYCLOSPORINE : TREMORS, HIGH BLOOD PRESSURE, HAIR GROWTH WITH CYCLOSPORINE, POSSIBLE DIABETES

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


Medications can have side effects common side effects1
MEDICATIONS CAN HAVE SIDE EFFECTS: COMMON SIDE EFFECTS

  • CELLCEPT: GAS, DIARRHEA, LOW WHITE BLOOD CELL COUNT


Transplantation options
TRANSPLANTATION OPTIONS

  • PRE-EMPTIVE TRANSPLANTATION

  • LIVING DONOR TRANSPLANTATION

  • DECEASED DONOR TRANSPLANTATION:

  • STANDARD CRITERIA

  • EXTENDED CRITERIA

  • DONOR AFTER CARDIAC DEATH


Living donors
LIVING DONORS

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

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

  • EACH TRANSPLANT PROGRAM SETS CRITERIA FOR DONOR


Living donors do well
LIVING DONORS DO WELL

  • SURGERY IS USUALLY DONE LAPARASCOPICALLY

  • HOSPITAL STAY IS 3 DAYS MAXIMUM

  • PAIN CONTROLLED WITH NARCOTICS

  • RESUMPTION OF DAILY ACTIVITES IN 4 TO 8 WEEKS


Living donors do well1
LIVING DONORS DO WELL

  • RESUMPTION OF NORMAL DAILY ACTIVITIES WITH 4 TO 8 WEEKS


Living donors do well2
LIVING DONORS DO WELL

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

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


Living related donation in pkd families
LIVING RELATED DONATION IN PKD FAMILIES

  • OWING TO THE DIFFICULTIES ENCOUNTERED IN EXCLUDING PKD IN RELATED POTENTIAL DONORS, PATIENTS WITH PKD RECEIVE FEWER LIVING RELATED KIDNEY TRANSPLANTS


Living related donation in pkd families1
LIVING RELATED DONATION IN PKD FAMILIES

  • ULTRASOUND IS INSUFFICIENTLY INSENSITIVE TO EXCLUDE DISEASE BEFORE THE AGE OF 30 YEARS

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


Deceased donors
DECEASED DONORS

  • DIFFERENCE IN ALLOGRAFT SURVIVAL

  • DECEASED DONOR HALF-LIFE 7 TO 12 YEARS

  • LIVING DONOR HALF-LIFE IS 20 YEARS

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


Waiting time for a deceased donor
WAITING TIME FOR A DECEASED DONOR

  • BLOOD GROUPS ARE O, A, AB, B

  • AVERAGE WAITING TIME FOR AN O KIDNEY IS THE GREATER LA AREA IS 7 TO 10 YEARS

  • B PATIENTS WAIT GREATER THAN 5 YEARS


Discussion with transplant center
DISCUSSION WITH TRANSPLANT CENTER

  • WHICH IS THE BEST OPTION FOR ME?

  • EVALUATION OF POTENTIAL DONORS

  • COMPLETION OF WORK-UP IN A TIMELY BASIS

  • HEAR ALL THE OPTIONS


Concluding remarks
CONCLUDING REMARKS

  • TRANSPLANTATION IS THE BEST OPTION FOR PATIENTS WITH KIDNEY DISEASE

  • COMPLICATIONS ARE POSSIBLE

  • LIVING DONATION IS ENCOURAGED ESPECIALLY TO EXPEDITE TRANSPLANTATION, FOR LONG TERM SUCCESS