Advanced Donor Management Strategies   Pre recovery Liver Biopsies Hormonal Resuscitation Breakout F6  National Learning C...
Presenters <ul><li>Pre Recovery Liver Biopsies   </li></ul><ul><ul><li>Megan Shaughnessy, CTDN </li></ul></ul><ul><ul><li>...
Advanced Management Strategies <ul><li>Questions to run on: </li></ul><ul><ul><li>How can pre-recovery biopsies improve li...
Advanced Donor Management Strategy:  Pre-recovery liver biopsies Megan Shaughnessy Placement Coordinator/Quality Specialis...
The story <ul><li>We had a 13% liver discard rate.  </li></ul><ul><li>All were related to fat or fibrosis on visualization...
 
Who <ul><li>Selection Criteria </li></ul><ul><li>BMI > 32 </li></ul><ul><li>Anti HCV+ </li></ul><ul><li>U/S or CT suggesti...
What <ul><li>Tissue sample </li></ul><ul><li>At least one 2cm core biopsy. Multiple cores preferred. </li></ul><ul><li>Pre...
More W’s <ul><li>When </li></ul><ul><li>Biopsies will be performed at the earliest opportunity after brain death in order ...
How to: <ul><li>Obtain biopsy </li></ul><ul><li>U/S guided at bedside  </li></ul><ul><li>Radiology guided (CT or U/S) in I...
Can it be done? <ul><li>2005:  67  pre-recovery liver biopsies performed </li></ul><ul><li>1/1/06 thru 6/30/06:  58  pre-r...
What the numbers look like CTDN began our pre-recovery liver biopsy protocol on 1/1/05.  129 282 254 Total Donors 114 249 ...
What we wish we’d known <ul><li>Get feedback/buy-in from local path labs on the front end </li></ul><ul><li>Set realistic ...
Looking toward the future <ul><li>Conduct double-read study to compare donor hospital reads against transplant center read...
Questions to run on <ul><li>How can pre recovery liver biopsies improve outcomes in my DSA? </li></ul><ul><li>What practic...
Hormonal Resuscitation  Improving Organ Use & Quality <ul><li>H. Myron Kauffman, M.D. </li></ul><ul><li>John D. Rosendale ...
The Challenge: Kidney Registrations at Year End vs. Kidneys Transplanted: 1988 - 2004
The Challenge: Liver Registrations at Year End vs.  Livers Transplanted: 1988 - 2004
The Challenge: Heart Registrations at Year End vs.  Hearts Transplanted: 1988 - 2004
Wait List Removals for Death:  1995-2004
Conventional Management <ul><li>Volume – Target CVP = 6 – 10 mm Hg </li></ul><ul><li>Acidosis – Target pH = 7.40 – 7.45 </...
Conventional Management Initial ECHO LVEF >= 45% Organ Recovery
Conventional Management Initial ECHO LVEF < 45% Hormonal Resuscitation
Increased Use of Hormonal Resuscitation 2000 - 2004
Hormonal Resuscitation <ul><li>Methylprednisilone – 15 mg/kg bolus </li></ul><ul><li>Vasopressin – 1 unit bolus – then 0.5...
Hemodynamic Management  (PA Catheter) <ul><li>MAP > 60 mm Hg </li></ul><ul><li>CVP  4 – 12 mm Hg </li></ul><ul><li>PCWP  8...
Aggressive Pharmacological Donor Management Results in More Transplanted Organs (2003) John D. Rosendale, H. Myron Kauffma...
Methods <ul><li>Retrospective study </li></ul><ul><li>Brain dead donors recovered between January 1, 2000, and June 30, 20...
Univariate Analyses 3.8 3.1 p < 0.001
Multivariate Logistic Regression Analyses Kidney Model (Odds of kidney transplant) Odds Ratios > 1 = Higher Odds of Transp...
Multivariate Logistic Regression Analyses Hormonal Resuscitation Odds Ratios > 1 = Higher Odds of Transplant
Extrapolation Based on Adjusted Probabilities <ul><li>Additional Transplantable Organs with the use of Hormonal Resuscitat...
Kidneys from Heart Donors <ul><li>Heart Donors </li></ul><ul><li>N = 6,893 </li></ul><ul><li>Non-Heart Donors </li></ul><u...
Hormonal Resuscitation Yields More Transplanted Hearts With Improved Early Function (2003) John D. Rosendale, H. Myron Kau...
Multivariate Analyses <ul><li>Logistic Regression </li></ul><ul><ul><li>Patient mortality within 1-month post-transplant <...
Multivariate Logistic Regression Prolonged Graft Dysfunction Odds Ratios < 1 = Lower Odds of Dysfunction NS p<0.01 p<0.01 ...
Multivariate Logistic Regression Odds of Mortality at 1-Month Posttransplant Odds Ratios < 1 = Lower Odds of Mortality NS ...
Hormonal Resuscitation Yields More Transplanted Kidneys With No Sacrifice In Quality  John D. Rosendale, H. Myron Kauffman...
EXPANDED CRITERIA DONORS   <ul><li>Any Donor Age  >  60  </li></ul><ul><li>Donor Age 50-59 + any two: </li></ul><ul><li>  ...
Probability of Kidney Being Transplanted
All Deceased Donors   11/1/99-12/31/02 *  p<0.01
Non-Expanded Criteria Donors   11/11/99-12/31/02 *  p<0.01
Expanded Criteria Donors   11/11/99-12/31/02 *  p<0.01
Kidney Graft Survival
Heart Patient Survival
Liver Patient Survival
Summary <ul><li>HR is associated with more Tx. kidneys, livers, and hearts </li></ul><ul><ul><li>Which based on the 6,001 ...
Questions to run on: <ul><li>What opportunities do you see for spreading this best practice? </li></ul><ul><li>How can we ...
 
PART Goals <ul><li>Increase the number of deceased donor organs transplanted </li></ul><ul><li>Increase the number of non-...
Increase Avg.   No. Organs Transplanted per Non-DCD Donor by 0.08/Year  <ul><li>FY 03: 3.20 (baseline) </li></ul><ul><li>F...
Organs Recovered Per Donor by Donor Type 1995 – June, 2005
Organs Transplanted Per Donor by Donor Type 1995 –   June, 2005
Organs Transplanted Per Donor 11/11/99-12/31/02 *  p<0.01
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  • The waiting list has increased at year end from nearly 14,000 in 1988 to nearly 60,000 in 2003, while the number of deceased donor transplants has only increased from 7,062 in 1988 to 8,666 in 2003.
  • Presentation 1

    1. 1. Advanced Donor Management Strategies Pre recovery Liver Biopsies Hormonal Resuscitation Breakout F6 National Learning Congress New Orleans October 19, 2006 Faculty: Susan Gunderson Producer: Franki Chabelewski
    2. 2. Presenters <ul><li>Pre Recovery Liver Biopsies </li></ul><ul><ul><li>Megan Shaughnessy, CTDN </li></ul></ul><ul><ul><li>Robert Osorio, MD, California Pacific Medical Center </li></ul></ul><ul><li>Hormonal Resuscitation </li></ul><ul><ul><li>Myron Kauffman, MD, UNOS </li></ul></ul>
    3. 3. Advanced Management Strategies <ul><li>Questions to run on: </li></ul><ul><ul><li>How can pre-recovery biopsies improve liver placement in my DSA? </li></ul></ul><ul><ul><li>How can the results of hormonal resuscitation improve organ utilization in our DSA? </li></ul></ul><ul><ul><li>What steps can we take by next Tuesday to introduce these advanced management strategies? </li></ul></ul>
    4. 4. Advanced Donor Management Strategy: Pre-recovery liver biopsies Megan Shaughnessy Placement Coordinator/Quality Specialist California Transplant Donor Network Robert Osorio, MD Chairman The Barry S. Levin MD Department of Transplantation California Pacific Medical Center
    5. 5. The story <ul><li>We had a 13% liver discard rate. </li></ul><ul><li>All were related to fat or fibrosis on visualization or biopsy. </li></ul><ul><li>Re-allocation attempts with biopsy results plus CIT were unsuccessful. </li></ul><ul><li>So we asked ourselves: </li></ul><ul><li>“ Can we improve transplantation rates if we have a better assessment of the liver parenchyma during the liver offer?” </li></ul>
    6. 7. Who <ul><li>Selection Criteria </li></ul><ul><li>BMI > 32 </li></ul><ul><li>Anti HCV+ </li></ul><ul><li>U/S or CT suggestive of fatty infiltrate </li></ul><ul><li>PMH and/or clinical indications suggestive of liver disease </li></ul><ul><li>At surgeon’s request </li></ul><ul><li>Significant ETOH use </li></ul><ul><li>Age > 70 </li></ul><ul><li>Age 65-70 with hx of DM </li></ul>
    7. 8. What <ul><li>Tissue sample </li></ul><ul><li>At least one 2cm core biopsy. Multiple cores preferred. </li></ul><ul><li>Preservation </li></ul><ul><li>Saline or RPMI dampened telfa gauze folded over to cover the biopsied tissue. </li></ul><ul><li>Interpretation </li></ul><ul><li>Permanent sections preferred, especially when evaluating HCV+ donors. </li></ul><ul><li>Stat frozen sections used most frequently. Follow-up permanent sections available the next day. </li></ul>
    8. 9. More W’s <ul><li>When </li></ul><ul><li>Biopsies will be performed at the earliest opportunity after brain death in order to provide biopsy results during the organ offer process. </li></ul><ul><li>Where </li></ul><ul><li>Our goal is to have all pre-recovery liver biopsies read at a local transplant center. </li></ul>
    9. 10. How to: <ul><li>Obtain biopsy </li></ul><ul><li>U/S guided at bedside </li></ul><ul><li>Radiology guided (CT or U/S) in Interventional Radiology </li></ul><ul><li>Care for donor </li></ul><ul><li>Ensure CBC, PT, PTT and INR are WNL </li></ul><ul><li>If platelet count is <70,000 administer platelet cells prior to the procedure. </li></ul><ul><li>If INR >1.4, transfuse FFP prior to the procedure. </li></ul><ul><li>Consult with medical director on donors with coagulopathy issues </li></ul><ul><li>(consider transjugular bx) </li></ul>
    10. 11. Can it be done? <ul><li>2005: 67 pre-recovery liver biopsies performed </li></ul><ul><li>1/1/06 thru 6/30/06: 58 pre-recovery liver biopsies performed </li></ul><ul><li>Complication rate of 2% </li></ul><ul><li>1 donor experienced a significant drop in hemoglobin after biopsy </li></ul><ul><li>1 donor had 1.5 liters of blood in his abdominal cavity at recovery 1 donor’s kidney was nicked during the liver biopsy </li></ul><ul><li>No transplantable organs were lost in any of the above instances. </li></ul><ul><li>**Of note, there have been at least three cases where we’ve chosen not to perform a biopsy due to irresolvable coagulopathy issues. </li></ul>
    11. 12. What the numbers look like CTDN began our pre-recovery liver biopsy protocol on 1/1/05. 129 282 254 Total Donors 114 249 211 Livers Tx’d 5% 7% 4% Not allocated 3.95 3.76 3.81 OPTD 7% 8% 13% Discarded 88% 85% 83% Transplanted 1 st Half 2006 2005 2004
    12. 13. What we wish we’d known <ul><li>Get feedback/buy-in from local path labs on the front end </li></ul><ul><li>Set realistic expectations of volume and timelines </li></ul><ul><li>Provide biopsy kits with necessary materials to onsite staff </li></ul>BIOPSIES
    13. 14. Looking toward the future <ul><li>Conduct double-read study to compare donor hospital reads against transplant center reads </li></ul><ul><li>Work with pathologists to develop a “How-To Interpret Liver Bx for Transplant” guide </li></ul>
    14. 15. Questions to run on <ul><li>How can pre recovery liver biopsies improve outcomes in my DSA? </li></ul><ul><li>What practices & actions did you hear that you’d like to test? </li></ul>
    15. 16. Hormonal Resuscitation Improving Organ Use & Quality <ul><li>H. Myron Kauffman, M.D. </li></ul><ul><li>John D. Rosendale MS </li></ul><ul><li>Franki Chabalewski RN, MS </li></ul><ul><li>Maureen A. McBride, PhD </li></ul>
    16. 17. The Challenge: Kidney Registrations at Year End vs. Kidneys Transplanted: 1988 - 2004
    17. 18. The Challenge: Liver Registrations at Year End vs. Livers Transplanted: 1988 - 2004
    18. 19. The Challenge: Heart Registrations at Year End vs. Hearts Transplanted: 1988 - 2004
    19. 20. Wait List Removals for Death: 1995-2004
    20. 21. Conventional Management <ul><li>Volume – Target CVP = 6 – 10 mm Hg </li></ul><ul><li>Acidosis – Target pH = 7.40 – 7.45 </li></ul><ul><li>Hypoxemia – Target pO 2 > 80 mm Hg </li></ul><ul><li>Anemia – Target Hct >= 30% </li></ul><ul><li>B.P. – Target MAP >= 60 mm Hg </li></ul><ul><li>Ionotropes – Target Dopamine dose < 10 u g/kg/min </li></ul>
    21. 22. Conventional Management Initial ECHO LVEF >= 45% Organ Recovery
    22. 23. Conventional Management Initial ECHO LVEF < 45% Hormonal Resuscitation
    23. 24. Increased Use of Hormonal Resuscitation 2000 - 2004
    24. 25. Hormonal Resuscitation <ul><li>Methylprednisilone – 15 mg/kg bolus </li></ul><ul><li>Vasopressin – 1 unit bolus – then 0.5 – 4.0 u/hr. </li></ul><ul><li>T 3 – 4 u g bolus – then 3 u g/hr. </li></ul><ul><li>T 4 – 20 u g bolus – then 10 u g/hr. </li></ul><ul><li>Insulin – 1u/hr (minimum) </li></ul>
    25. 26. Hemodynamic Management (PA Catheter) <ul><li>MAP > 60 mm Hg </li></ul><ul><li>CVP 4 – 12 mm Hg </li></ul><ul><li>PCWP 8 – 12 mm Hg </li></ul><ul><li>Cardiac Index > 2.4 L/min/m 2 </li></ul><ul><li>SVR 800 – 1200 dyne/sec/cm5 </li></ul><ul><li>Dopamine/Dobutamine < 10 u g/kg/min </li></ul>
    26. 27. Aggressive Pharmacological Donor Management Results in More Transplanted Organs (2003) John D. Rosendale, H. Myron Kauffman, Maureen A. McBride, Franki L. Chabalewski, John G. Zaroff, Edward R. Garrity, Francis L. Delmonico, and Bruce R. Rosengard United Network for Organ Sharing, University of California-San Francisco, Loyola University, Massachusetts General Hospital, and University of Pennsylvania
    27. 28. Methods <ul><li>Retrospective study </li></ul><ul><li>Brain dead donors recovered between January 1, 2000, and June 30, 2001 (8,769 donors) </li></ul><ul><li>Hormonal resuscitation donors (584) vs. non-hormonal resuscitation donors (8,185) </li></ul><ul><li>Univariate analyses: chi-square, t-test </li></ul><ul><li>Multivariate analyses: logistic regression </li></ul>
    28. 29. Univariate Analyses 3.8 3.1 p < 0.001
    29. 30. Multivariate Logistic Regression Analyses Kidney Model (Odds of kidney transplant) Odds Ratios > 1 = Higher Odds of Transplant
    30. 31. Multivariate Logistic Regression Analyses Hormonal Resuscitation Odds Ratios > 1 = Higher Odds of Transplant
    31. 32. Extrapolation Based on Adjusted Probabilities <ul><li>Additional Transplantable Organs with the use of Hormonal Resuscitation </li></ul><ul><li>Based on the 5,921 brain dead donors recovered in 2001 </li></ul><ul><ul><li>924 Kidneys </li></ul></ul><ul><ul><li>278 Hearts </li></ul></ul><ul><ul><li>290 Livers </li></ul></ul><ul><ul><li>414 Lungs </li></ul></ul><ul><ul><li>456 Pancreata </li></ul></ul><ul><ul><li>2,362 Total Organs </li></ul></ul>
    32. 33. Kidneys from Heart Donors <ul><li>Heart Donors </li></ul><ul><li>N = 6,893 </li></ul><ul><li>Non-Heart Donors </li></ul><ul><li>N = 26,885 </li></ul>20% more kidneys from Heart Donors DGF – 18.0% vs. 24.8%; p<0.001 Graft Survival – 90.9% vs. 87.3%; p<0.001
    33. 34. Hormonal Resuscitation Yields More Transplanted Hearts With Improved Early Function (2003) John D. Rosendale, H. Myron Kauffman, Maureen A. McBride, Franki L. Chabalewski, Jonathan G. Zaroff, Edward R. Garrity, Francis L. Delmonico, and Bruce R. Rosengard United Network for Organ Sharing, University of California-San Francisco, Loyola University, Massachusetts General Hospital, and University of Pennsylvania
    34. 35. Multivariate Analyses <ul><li>Logistic Regression </li></ul><ul><ul><li>Patient mortality within 1-month post-transplant </li></ul></ul><ul><ul><li>Early graft dysfunction (defined as graft failure within 14 days or prolonged graft dysfunction prior to discharge) </li></ul></ul><ul><ul><li>Models adjusted for recipient/donor factors: </li></ul></ul><ul><ul><ul><li>recipient and donor age, race/ethnicity, and gender mismatch, donor cause of death, history of hypertension, history of diabetes, history of alcohol dependence, history of cigarette use, creatinine > 1.5, hormonal resuscitation (yes, no), recipient medical status, life support, ABO, etc. </li></ul></ul></ul>
    35. 36. Multivariate Logistic Regression Prolonged Graft Dysfunction Odds Ratios < 1 = Lower Odds of Dysfunction NS p<0.01 p<0.01 p<0.02 NS NS NS
    36. 37. Multivariate Logistic Regression Odds of Mortality at 1-Month Posttransplant Odds Ratios < 1 = Lower Odds of Mortality NS p<0.01 NS NS NS NS NS
    37. 38. Hormonal Resuscitation Yields More Transplanted Kidneys With No Sacrifice In Quality John D. Rosendale, H. Myron Kauffman, Maureen A. McBride, Franki L. Chabalewski, Jonathan G. Zaroff, Edward R. Garrity, Francis L. Delmonico, and Bruce R. Rosengard United Network for Organ Sharing, University of California-San Francisco, Loyola University, Massachusetts General Hospital, and University of Pennsylvania
    38. 39. EXPANDED CRITERIA DONORS <ul><li>Any Donor Age > 60 </li></ul><ul><li>Donor Age 50-59 + any two: </li></ul><ul><li> CVA cause of death </li></ul><ul><li>Creatinine > 1.5 mg/dl </li></ul><ul><li> History of Hypertension </li></ul>
    39. 40. Probability of Kidney Being Transplanted
    40. 41. All Deceased Donors 11/1/99-12/31/02 * p<0.01
    41. 42. Non-Expanded Criteria Donors 11/11/99-12/31/02 * p<0.01
    42. 43. Expanded Criteria Donors 11/11/99-12/31/02 * p<0.01
    43. 44. Kidney Graft Survival
    44. 45. Heart Patient Survival
    45. 46. Liver Patient Survival
    46. 47. Summary <ul><li>HR is associated with more Tx. kidneys, livers, and hearts </li></ul><ul><ul><li>Which based on the 6,001 brain dead donors in 2002 could have resulted in an additional: </li></ul></ul><ul><ul><ul><li>400 kidney transplants </li></ul></ul></ul><ul><ul><ul><li>150 liver transplants </li></ul></ul></ul><ul><ul><ul><li>210 heart transplants </li></ul></ul></ul><ul><li>HR is not associated with any difference in 1-year liver patient survival (p=0.82), but is associated with improved 1-year kidney graft survival (p<0.02) and 1-year heart patient survival (p<0.01) </li></ul>
    47. 48. Questions to run on: <ul><li>What opportunities do you see for spreading this best practice? </li></ul><ul><li>How can we use hormonal resuscitation more effectively? </li></ul>
    48. 50. PART Goals <ul><li>Increase the number of deceased donor organs transplanted </li></ul><ul><li>Increase the number of non-DCD donors </li></ul><ul><li>Increase the number of DCD donors </li></ul><ul><li>Increase the average number of organs transplanted per non-DCD donor </li></ul><ul><li>Increase the average number of organs transplanted per DCD donors </li></ul>
    49. 51. Increase Avg. No. Organs Transplanted per Non-DCD Donor by 0.08/Year <ul><li>FY 03: 3.20 (baseline) </li></ul><ul><li>FY 04: 3.28 </li></ul><ul><li>FY 05: 3.36 </li></ul><ul><li>FY 06: 3.44 </li></ul><ul><li>FY 13: 4.00 </li></ul>
    50. 52. Organs Recovered Per Donor by Donor Type 1995 – June, 2005
    51. 53. Organs Transplanted Per Donor by Donor Type 1995 – June, 2005
    52. 54. Organs Transplanted Per Donor 11/11/99-12/31/02 * p<0.01
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