New Trends in organ donation and Transplantation

1. New Trends in organ donation and Transplantation Juan Carlos Caicedo, MD FACS Director, Hispanic Transplant Program Adult transplant Surgeon (NMH) Pediatric Transplant Surgeon (LCH)

2. Overview • Introduction • Kidney ( Living / deceased/ combined stem cell) • Liver: whole, split, reduce size, living donor

3. 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 Who Needs a Transplant?

4. Type of donors Deceased (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-

5. United States Organ TransplantationOPTN & SRTR Annual Data Report, 2011

6. Patients on the waiting list on December 31 of the year (active listings only)

7. Transplants performed during the year (adult & pediatric combined)

8. First-year all-cause graft survival

9. AdultKidneyTransplantation

10. 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

11. Kidney Failure: Treatment • Kidney Transplantation “ Best option” • Replace all functions of the kidney • Increase survival and quality of life • Decrease complications • Cost effective

12. Incident ESRD Rate and Transplant Rate USRDS 2010 ADR

13. Whites :38% AA: 34% Hispanics: 19% Asian: 8% 2013: 105124 Waiting list 2012: 16485 Transplanted 758 ( 4.5%) Pediatric pts

14. Distribution of adult patients waiting for a kidney transplant

15. Deceased donor kidney donation rates

16. Cause of death among deceased kidney donors

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

18. Delayed graft function among adult kidney transplant recipients

19. Kidney donations from living donors

20. Living kidney donation • Laparoscopic vs Open - Safe - Less pain - Fast recovery - POD 1: Home - Smaller Incisions

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

22. Number of transplants from living donors, by donor relation All patients receiving a living donor kidney transplant. USRDS 2010 ADR

23. Kidney Transplantation

24. Kidney Transplantation

25. Sensitized Patients Very Highly Sensitized 36% Sensitized Total = 17,814 pts Sensitized 2010: 25%Sensitized

26. Options for Sensitized and ABO incompatible Patients • Wait and hope • Desensitization • Live Donor • Deceased Donor • Live Donor Paired Exchange • List Exchange • Wait and hope • Desensitization • Live Donor • Deceased Donor • Live Donor Paired Exchange • List Exchange

27. Paired kidney donations

28. Basic Kidney Paired Donation (KPD)

30. Desensitization N Engl J Med 365;4 July 28, 2011

31. Trends in Transplant Medications

32. Immunosuppression use in adult kidney transplant recipients

33. Initial immunosuppression regimen in adult kidney transplant recipients, 2011

34. Acute rejections within the first year post-transplant First-time, kidney-only transplant recipients, age 18 & older, with functioning graft at discharge. Source: USRDS 2010 ADR

35. Trends in Transplant Research

36. The co-existence of two genetically different components in one organism Mixed Chimeras Chimerism induces tolerance How can we make it safe?

37. Sequential kidney/HSC in HLA matched related • Simultaneous kidney/HSC in HLA mismatched Northwestern Clinical Tolerance Protocols

38. 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) HLA-Matched Protocol PI: Joshua Miller

39. Simultaneous FCRx +Kidney Transplant Processed donor leukopheresis product/marrow enriched for HSC, FC and progenitors (FCRx) HSCT mobilized, collected, processed, & cryopreserved (> 2 wks before Tx) Conditioning Fludarabine, cytoxan, 200 cGy TBI d0 d +1 Perform Transplant

40. Adult kidney transplants

41. Outcomes among adult kidney transplant recipients: deceased donor

42. Outcomes among adult kidney transplant recipients: living donor

43. Half-lives for adult kidney transplant recipients

44. Liver Transplantation • Type of donor: Living vs deceased donor • Type of graft: Partial vs whole organ

45. Whole Organ Orthotopic Liver Transplant Standard technique. This figure illustrates a completed liver transplant with vascular and biliaryanastomoses.

46. Partial Grafts / Liver transplantation (LTX) • -Reduce Size Ltx • -Split LTx • -Living Donor Ltx

47. Partial Liver Transplantation 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 The split through midplane with right and left lobe grafts Reference: Humar A, et al. Amer J Transpl 2001;1:366-72

48. AdultLiverTransplantation