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Transplant Dual Organ By Tejas Desai
 

Transplant Dual Organ By Tejas Desai

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    Transplant Dual Organ By Tejas Desai Transplant Dual Organ By Tejas Desai Presentation Transcript

    • Dual Organ Transplantation Tejas Desai, MD
    • Agenda
      • Our Case
      • Epidemiologic Data
      • Liver-Kidney Transplantation
      • Heart-Kidney Transplantation
      • Unanswered Questions
      • Our Case -- Revisited
    • Our Case A 58 year old male with significant CAD, multiple myocardial infarctions, resulting in an ischemic cardiomyopathy & ejection fraction of 15%. The patient’s baseline creatinine was 1.3 mg/dl, but had been persistently elevated between 2.5-3.0 mg/dl. This had been attributed to decompensated heart failure. Past Medical History: Type II diabetes mellitus Essential hypertension
    • Our Case (cont’d) Urine protein/Cr ratio: 122 mg/G CrCl: 31 ml/min (at a Cr of 3.0 mg/dl) Urine microscopy: bland urinary sediment Renal Ultrasonagraphy: R kidney 11.3 cm L kidney 9.8 cm Normal Echogenicity Cortical atrophy (L > R)
    • Our Case (cont’d) The patient was considered an appropriate candidate for a heart transplantation. Is the patient a candidate for a kidney transplantation as well? What are the criteria for a dual heart-kidney transplantation? Does our patient meet the criteria for a dual organ transplantation? + versus
    • By the Numbers… (The Organ Procurement and Transplantation Network; http://www.optn.org) (Living & Cadaveric) Nationwide 2007 2006 2005 # of KTx 8,304 17,090 16,481 # of LTx 3,260 6,650 6,443 # of HTx 1,140 2,192 2,125 # of LKTx 244 399 337 # of HKTx 23 39 57
    • By the Numbers… (The Organ Procurement & Transplantation Network: http://www.optn.org) (Living & Cadaveric) Emory 2007 2006 2005 # of KTx 77 141 117 # of LTx 36 77 86 # of HTx 10 21 21 # of LKTx 10 7 4 # of HKTx 0 0 0
    • Two Schools of Thought Purists Physicians who believe that each organ should have it’s own set of criteria regarding transplantation, & that dual-organ transplant candidates should be evaluated for each organ independently of the other. Liberalists Physicians who believe that in dual-organ transplant candidates, one organ is primary & the other is secondary. All steps should be taken to ensure graft survival of the primary organ, including, if needed, transplantation of the secondary organ.
    • + + Click Here Click Here
    • +
    • ( Combined Liver-Kidney Transplantation: What are the Indications? Transplantation . 1997: 64(8); pp. 1091-1096.)
    • ( Identification of Patients Best Suited for Combined Liver-Kidney Transplantation: Part II . Liver Transplantation . 2002: 8(3); pp. 193-211.)
    • ( Identification of Patients Best Suited for Combined Liver-Kidney Transplantation: Part II . Liver Transplantation . 2002: 8(3); pp. 193-211.) <= 67 ml/min GFR (pre-Tx) 67 - 95 ml/min 96 - 120 ml/min >=121 ml/min
    • 8 ( Clinical Transplantation . 1998; 12:123-129) 19 ( Clinical Nephrology . 1997; 48:159-164) 24 ( Clinical Transplantation . 1997; 11:354-360) 57 ( Transplantation . 1997; 64:1091-1096) Table Acquired from: Identification of Patients Best Suited for Combined Liver-Kidney Transplantation: Part II . Liver Transplantation . 2002: 8(3); pp. 193-211.
    • Why Dual Organ Transplantation?
      • Graft survival (liver) decreases if renal impairment is present
      • Renal dysfunction is inevitable with the current immunosuppressive agents used (specifically calcineurin inhibitors)
      • Single donor dual organ transplantation is complicated with less immunologic rejection of either organ than multiple donor dual organ transplantation
    • ( Combined Liver-Kidney Transplantation: What are the Indications? Transplantation . 1997: 64(8); pp. 1091-1096)
    • Why Not Dual Organ Transplantation?
      • Donor kidneys are rare
      • Renal dysfunction, if reversible, should not be an indication for dual-organ transplantation
      • Renal dysfunction, whose reversibility is unknown, should be quantified and followed over time to determine if permanent renal failure is likely
    • ( Identification of Patients Best Suited for Combined Liver-Kidney Transplantation: Part II . Liver Transplantation . 2002: 8(3); pp. 193-211.) Critical Care Medicine 1991; 19:8-11 Nephrology Dialysis Transplantation 2000; 15:224-230 Am J Kidney Dis 1998; 32:432-443
    • +
    • ( Outcomes in Recipients of Combined Heart-Kidney Transplantation: Multiorgan, Same Donor Transplant Study of the International Society of Heart and Lung Transplantation/United Network for Organ Sharing Scientific Registry . Transplantation . 1997: 63(6): 861-867)
    • ( Outcomes in Recipients of Combined Heart-Kidney Transplantation: Multiorgan, Same Donor Transplant Study of the International Society of Heart and Lung Transplantation/United Network for Organ Sharing Scientific Registry . Transplantation . 1997: 63(6): 861-867) Heart & Kidney (59 patients) Heart (911 patients) Transplant Cardiologists Research Database
    • Why Dual Organ Transplantation?
      • Rates of rejection increase in heart-only transplanted patients
      • Renal dysfunction is inevitable with the current immunosuppressive agents used (specifically calcineurin inhibitors)
      • Single donor dual organ transplantation is fraught with less immunologic rejection of either organ than multiple donor dual organ transplantation
      • Better post-transplantation survival rates
    • ( Outcomes in Recipients of Combined Heart-Kidney Transplantation: Multiorgan, Same Donor Transplant Study of the International Society of Heart and Lung Transplantation/United Network for Organ Sharing Scientific Registry . Transplantation . 1997: 63(6): 861-867) UNOS Scientific Registry Heart & Kidney (82 patients) Heart (14,340 patients)
    • ( Simultaneous Heart and Kidney Transplantation as Treatment for End-Stage Heart and Kidney Failure . Transplantation . 1997: 64(8): 1129-1134) p 0.21 University of Vienna
    • ( Simultaneous Heart and Kidney Transplantation as Treatment for End-Stage Heart and Kidney Failure . Transplantation . 1997: 64(8): 1129-1134) Not statistically significant At 36 months University of Vienna
    • ( Simultaneous Heart and Kidney Transplantation as Treatment for End-Stage Heart and Kidney Failure . Transplantation . 1997: 64(8): 1129-1134) Not statistically significant University of Vienna
    • ( Simultaneous Heart and Kidney Transplantation as Treatment for End-Stage Heart and Kidney Failure . Transplantation . 1997: 64(8): 1129-1134) Not statistically significant University of Vienna
    • Why Not Dual Organ Transplantation?
      • Donor kidneys are rare
      • Patient survival may not be any better with dual organ transplantation
      • Intermediate outcomes, such as rejection and infection rates, may not be better in dual organ recipients
    • Unanswered Questions
      • Will a patient with renal failure recover function?
      • If renal failure is not absolute, is there a way to predict who will recover?
      • If renal recovery is possible, to what degree must the kidneys regain function in order to negate the need for a dual transplantation?
      4) Do patients with dual organ transplants have improvements in any measurable outcome than single organ transplant patients with concomitant renal disease?
    • Our Case -- Revisited A lengthy discussion between the Transplant Nephrologist, the primary Cardiologist, the patient and his wife was conducted. The Cardiologist explained that the literature supported a dual heart-kidney transplant to improve patient outcomes. He/She suggested a CrCl of 50 ml/min or less as the threshold for dual transplantation.
    • Our Case -- Revisited The Transplant Nephrologist felt the patient had acute renal failure in the context of chronic kidney disease. However, neither the degree of acute renal failure nor the underlying chronic kidney disease was of sufficient irreversibility or severity (respectively) to warrant a kidney transplant.
    • The patient was discharged with aggressive medical management.
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