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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. HEMODIALYSIS PERITONEAL DIALYSIS TRANSPLANTATION. THE OPTION OF TRANSPLANTATION.

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THE OPTION OF TRANSPLANTATION

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  1. THE OPTION OF TRANSPLANTATION LILLY BARBA, M.D. MEDICAL DIRECTOR RENAL TRANSPLANT PROGRAM HARBOR-UCLA MEDICAL CENTER

  2. OPTIONS FOR TREATMENT OF END STAGE RENAL DISEASE • HEMODIALYSIS • PERITONEAL DIALYSIS • TRANSPLANTATION

  3. 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

  4. RISKS OF TRANSPLANTATION • MAJOR SURGICAL PROCEDURE WITH POSSIBLE COMPLICATIONS INCLUDING: • BLEEDING • INFECTION • REJECTION • ANESTHESIA RISK • DEATH

  5. 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

  6. 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

  7. 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

  8. UNOS • UNOS ALSO MAINTAINS A WEB SITE, TRANSPLANT LIVING, WHICH CONTAINS INFORMATION FOR TRANSPLANT CANDIDATES AND RECIPIENTS AND FAMILY MEMBERS • ADDRESS: WWW.TRANSPLANTLIVING.ORG

  9. 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

  10. 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

  11. 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

  12. 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

  13. WHO IS NOT A POTENTIAL CANDIDATE ? THOSE PATIENTS WITH: • ACTIVE INFECTION • CANCER OR CANCER RECENTLY TREATED • UNCORRECTABLE HEART PROBLEMS • ADVANCED LUNG DISEASE

  14. 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

  15. 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

  16. 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

  17. THE TRANSPLANT SURGICAL PROCEDURE

  18. 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

  19. IMMUNOSUPPRESSIVE MEDICATIONS • CNI (TACROLIMUS OR CYCLOSPORINE) • STEROID (PREDNISONE) • ANTI-METABOLITE (CELLCEPT OR AZATHIOPRINE)

  20. 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

  21. MEDICATIONS CAN HAVE SIDE EFFECTS: COMMON SIDE EFFECTS • CELLCEPT: GAS, DIARRHEA, LOW WHITE BLOOD CELL COUNT

  22. TRANSPLANTATION OPTIONS • PRE-EMPTIVE TRANSPLANTATION • LIVING DONOR TRANSPLANTATION • DECEASED DONOR TRANSPLANTATION: • STANDARD CRITERIA • EXTENDED CRITERIA • DONOR AFTER CARDIAC DEATH

  23. 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

  24. 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

  25. LIVING DONORS DO WELL • RESUMPTION OF NORMAL DAILY ACTIVITIES WITH 4 TO 8 WEEKS

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

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