David Hull, MD ,  FACS Director of Transplantation Hartford Hospital Co-Medical Director LifeChoice Donor Services DONOR K...
KIDNEY COLD STORAGE (CS) – PUMP PRESERVATION (PP) <ul><li>Dr. Najarian 1964 LR Kidney Transplant San Francisco </li></ul><...
KIDNEY PRESERVATION  COLD STORAGE (CS) <ul><li>G.M. Collins, MD </li></ul><ul><ul><li>UCLA  </li></ul></ul><ul><ul><li>Lan...
WATERS RENAL PRESERVATION SYSTEM- RM3 <ul><li>Belzer 1967 Lab & Clinical </li></ul><ul><li>Belzer & Truman (Moffin Hosp) 1...
<ul><li>SRTR 1994-2003 </li></ul><ul><ul><li>98,736  Deceased Donor Kidneys </li></ul></ul><ul><li>Pump Preservative (PP) ...
LIFEPORT- ORGAN RECOVERY SYSTEM <ul><li>FDA Approved 2003 </li></ul><ul><li>Characteristics </li></ul><ul><ul><li>Solution...
Unadjusted and Adjusted Models DCD  Delayed Graft Function 7/1/04-5/1/06 <ul><li>Adjusted for donor age, sex, race, hypert...
THE AGING KIDNEY Prevalence of Moderate to Severe Renal Failure = 20.6%  Without Hypertension and Diabetes = 10.8% Brenner...
AGING AND GFR Brenner & Rector's The Kidney, 7th ed. , Copyright © 2004 Saunders, An Imprint of Elsevier                  ...
THE AGING  & EXTENDED CRITERIA DONOR KIDNEYS <ul><li>Decreased Renal Weight and Mass </li></ul><ul><li>Thickening Intra-Re...
Deceased Cardiac Donor (DCD) <ul><li>Profound Tissue Stresses –  </li></ul><ul><ul><li>Ischemia / Hypoxemia </li></ul></ul...
Kidney Selection Process <ul><li>Know Parameters Reflective of Outcomes </li></ul><ul><ul><li>SCD, DCD and ECD Characteris...
Pumped Kidneys: Unadjusted and Adjusted Models for Delayed Graft Function, 7/1/04-5/1/06 <ul><li>Adjusted for donor age, s...
High Risk of Discard (HRD) Kidneys <ul><li>Deceased Donor Kidneys with at Least Four of the Following: </li></ul><ul><ul><...
DONOR QUALITY AND DISCARD RATE SRTR 11-1-2003 to 10-31-2005 16.5% 21,366 25,590 Total 51.6% 2,104 4,343 Yes No 9.3% 19,262...
ECD Kidneys Recovered For Transplant And Discarded SRTR 2000-2004 P< 0.001 61.5 % 81.2 % > 20% P< 0.001 46.5 % 63.6 % 16-2...
LCDS SELECTIVE BX & PUMP PRESERVATION <ul><li>Pump Preservation 1971 – Present </li></ul><ul><li>Waters (RM3) 1971 – 2005 ...
LCDS SELECTIVE BX & PUMP PRESERVATION 2003*-06 NOT PUMPED PUMPED TOTAL * ECD Defined 10.8 8/74 16.7 39/233 15.2 47/309 TOT...
PUMP PRESERVATION <ul><li>Organ Procurement Organization </li></ul><ul><ul><li>COST ? </li></ul></ul><ul><ul><li>PERSONEL ...
COSTS RELATED TO PUMP PRESERVATION (LCDS) * Based on 2 kidneys WATERS RM3 LIFEPORT ORS ONE TIME COSTS COSTS FOR PUMPIMG 2 ...
ESTIMATED BENEFIT AND COSTS TO OPO WITH PUMP PRESERVATION AND BIOPSY <ul><li>Additional 6 Kidney Tx’s </li></ul><ul><ul><l...
ESTIMATED BENEFIT AND COSTS TO OPO WITH PUMP PRESERVATION AND BIOPSY METHODOLOGY <ul><li>Additional 499 Kidney Tx’s </li><...
CONCLUSIONS <ul><li>Cold Storage vs Pump Preservation </li></ul><ul><ul><li>OUTCOME / DEBATE GOES ON </li></ul></ul><ul><l...
ACKNOWLEDGEMENTS SURGEONS HARTFORD HOSPITAL  & BAYSTATE MEDICAL CENTER GEORGE LIPKOWITZ, MD LIFECHOICE DONOR SERVICES DEB ...
END
DATA FOR DCD AND DGF AND Ω Table 3.3: Sample Size and Number of Delayed Graft Function Events, 7/1/04-5/1/06 * According t...
 
1/2001 – 10/2005 16.5% 21,366 25,590 Total 8.7% 16,917 18,530 SCD 41.2% 3,149 5,358 ECD 23.6% 1300 1702 DCD Percent Discar...
Table 3.4: Unadjusted and Adjusted Models for Delayed Graft Function, 7/1/04-5/1/06 <ul><li>Adjusted for donor age, sex, r...
Table 3.3: Sample Size and Number of Delayed Graft Function Events, 7/1/04-5/1/06 * According to OPO 40.1 184 459 17.9 385...
Pumping and Outcomes of Deceased Donor Kidneys: Review of Recent SRTR Analyses <ul><li>Laura L. Christensen, M.S. </li></u...
Background <ul><li>OPTN Organ Availability Committee has long been interested in the benefits of pumping of kidneys </li><...
Ascertainment of Pumping Data <ul><li>Until recently, pumping of kidneys was only reported by the OPO </li></ul><ul><li>Be...
Analyses Based on OPO Pumping Only
Pulsatile Perfusion by OPO and Organ Type* Range: 0-85% Median: 8% Discard Rate: 16.5% Range: 0-84% Median: 2.3% Discard R...
Complications of Varying OPO Pumping Practice <ul><li>OPOs that never pump give us no information about pumping outcomes <...
SCD Kidneys: % DGF by OPO Pumping Practice n OPOs: n Kidneys: 24 8377 30 6 13565 20 151 1569 OR for 100% vs. 0% pumped by ...
DCD Kidneys: % DGF by OPO Pumping Practice n OPOs: n Kidneys: 15 187 8 20 287 139 77 521 OR for 100% vs. 0% pumped by OPO:...
ECD Kidneys: % DGF by OPO Pumping Practice n OPOs: n Kidneys: 27 1806 20 13 1425 514 302 662 OR for 100% vs. 0% pumped by ...
Adjusted Cox Regression for Graft Failure/Death   Among deceased donor transplants, January 1, 2001 to July 31, 2004
SCD Kidneys: % Discard by OPO Pumping Practice n OPOs: n Kidneys: 22 8941 32 6 17592 831 1091 2139 OR for 100% vs. 0% pump...
DCD Kidneys: % Discard by OPO Pumping Practice n OPOs: n Kidneys: 15 249 9 19 379 198 94 628 OR for 100% vs. 0% pumped by ...
ECD Kidneys: % Discard by OPO Pumping Practice n OPOs: n Kidneys: 22 2420 34 4 3728 1352 93 318 OR for 100% vs. 0% pumped ...
Analyses Based on OPO and Center Pumping
Pumping at the OPO and Center 7/1/04 – 5/1/06 Non-DCD Kidneys DCD Kidneys
Relationship between Pumping and Delayed Graft Function 7/1/04-5/1/06, n=16,889 Adjusted for donor age, sex, race, hyperte...
Among Pumped Kidneys: Resistance and Delayed Graft Function  7/1/04-5/1/06, n=4,226  Adjusted for donor age, sex, race, hy...
Conclusions <ul><li>Pumping practice varies widely by OPO for each type of kidney (SCD, DCD, ECD) </li></ul><ul><li>Varyin...
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  • This procedure is bulky and doesn’t lend it self to transport and CS has the same ability to provide for preservation
  • Blue:236 Lum:194 Green:135 Sat:246 Red:253 Hue:219 Blue:252 Lum:127 Green:252 Sat:251 Red:2 Hue:128 Blue:0 Lum:128 Green:255 Sat:255 Red:255 Hue:42 Blue:102 Lum:179 Green:255 Sat:255 Red:102 Hue:85
  • Blue:236 Lum:194 Green:135 Sat:246 Red:253 Hue:219 Blue:252 Lum:127 Green:252 Sat:251 Red:2 Hue:128 Blue:0 Lum:128 Green:255 Sat:255 Red:255 Hue:42 Blue:102 Lum:179 Green:255 Sat:255 Red:102 Hue:85
  • Blue:236 Lum:194 Green:135 Sat:246 Red:253 Hue:219 Blue:252 Lum:127 Green:252 Sat:251 Red:2 Hue:128 Blue:0 Lum:128 Green:255 Sat:255 Red:255 Hue:42 Blue:102 Lum:179 Green:255 Sat:255 Red:102 Hue:85
  • Blue:236 Lum:194 Green:135 Sat:246 Red:253 Hue:219 Blue:252 Lum:127 Green:252 Sat:251 Red:2 Hue:128 Blue:0 Lum:128 Green:255 Sat:255 Red:255 Hue:42 Blue:102 Lum:179 Green:255 Sat:255 Red:102 Hue:85
  • Blue:236 Lum:194 Green:135 Sat:246 Red:253 Hue:219 Blue:252 Lum:127 Green:252 Sat:251 Red:2 Hue:128 Blue:0 Lum:128 Green:255 Sat:255 Red:255 Hue:42 Blue:102 Lum:179 Green:255 Sat:255 Red:102 Hue:85
  • Blue:236 Lum:194 Green:135 Sat:246 Red:253 Hue:219 Blue:252 Lum:127 Green:252 Sat:251 Red:2 Hue:128 Blue:0 Lum:128 Green:255 Sat:255 Red:255 Hue:42 Blue:102 Lum:179 Green:255 Sat:255 Red:102 Hue:85
  • Presentation 2

    1. 1. David Hull, MD , FACS Director of Transplantation Hartford Hospital Co-Medical Director LifeChoice Donor Services DONOR KIDNEY PUMPING FROM OPO / TRANSPLANT CENTER PERSPECTIVE
    2. 2. KIDNEY COLD STORAGE (CS) – PUMP PRESERVATION (PP) <ul><li>Dr. Najarian 1964 LR Kidney Transplant San Francisco </li></ul><ul><li>Folkert Belzer, MD </li></ul><ul><ul><li>Pump Preservation </li></ul></ul><ul><ul><li>1967 ‘24 and 72 Canine Kidney Preservation’ </li></ul></ul><ul><ul><li>1967 Human Kidney Tx 17 Hr Storage </li></ul></ul>Lancet Sept, 1967 536-39
    3. 3. KIDNEY PRESERVATION COLD STORAGE (CS) <ul><li>G.M. Collins, MD </li></ul><ul><ul><li>UCLA </li></ul></ul><ul><ul><li>Lancet 1969 ‘Kidney Preservation 30 Hours Ice Storage’ Canine Model </li></ul></ul><ul><ul><li>Dog Kidneys From L.A. </li></ul></ul><ul><ul><ul><li>Tel Aviv </li></ul></ul></ul><ul><ul><ul><li>Sydney </li></ul></ul></ul><ul><ul><ul><li>London </li></ul></ul></ul>Lancet Dec. 1969 , 1219-22
    4. 4. WATERS RENAL PRESERVATION SYSTEM- RM3 <ul><li>Belzer 1967 Lab & Clinical </li></ul><ul><li>Belzer & Truman (Moffin Hosp) 1971 Waters Company – Membrane Oxygenator </li></ul><ul><li>1971 Storage of a Kidney Shipped to Holland Tx 37 Hr </li></ul><ul><li>UW Solution 1987 – Clinical </li></ul><ul><ul><li>1979 UW CS </li></ul></ul><ul><ul><li>1984 Gluconate UW PP </li></ul></ul><ul><li>Characteristics Past & Present </li></ul><ul><ul><li>PO2 & PCO2 Controlled </li></ul></ul><ul><ul><li>Ph Controlled at 4ºC </li></ul></ul><ul><ul><li>Microfiltration </li></ul></ul><ul><ul><li>Pulsatile Pump </li></ul></ul><ul><ul><li>Solution Gluconate UW 1984 </li></ul></ul>
    5. 5. <ul><li>SRTR 1994-2003 </li></ul><ul><ul><li>98,736 Deceased Donor Kidneys </li></ul></ul><ul><li>Pump Preservative (PP) </li></ul><ul><ul><li>Less ECD Discards p < 0.0001 </li></ul></ul><ul><ul><li>Less DGF </li></ul></ul><ul><ul><ul><li>Group - With High Risk Factors for DGF </li></ul></ul></ul><ul><ul><ul><li>Prolonged Ischemic Times </li></ul></ul></ul><ul><ul><li>10 % Overall Decrease in Discards With PP = +1500 Transplants / 10 year </li></ul></ul><ul><ul><li>Slight Improvement in Survival </li></ul></ul>AJT 2005;5: 1681-88
    6. 6. LIFEPORT- ORGAN RECOVERY SYSTEM <ul><li>FDA Approved 2003 </li></ul><ul><li>Characteristics </li></ul><ul><ul><li>Solution KPS-1 </li></ul></ul><ul><ul><ul><li>UW Gluconate </li></ul></ul></ul><ul><ul><li>Measurements </li></ul></ul><ul><ul><ul><li>Pressure Limit 30mm HG </li></ul></ul></ul><ul><ul><ul><li>30 Beats/Min </li></ul></ul></ul><ul><ul><ul><li>Averages Pressure over 30 Beats </li></ul></ul></ul><ul><ul><ul><li>Measures Volume of Flow </li></ul></ul></ul><ul><ul><ul><li>Ω = Average Press / Flow </li></ul></ul></ul><ul><ul><ul><li>Data Base Downloads </li></ul></ul></ul><ul><ul><li>Battery </li></ul></ul><ul><ul><ul><li>Charge 40-48 Hrs </li></ul></ul></ul><ul><ul><ul><li>Life 3 Years </li></ul></ul></ul><ul><ul><li>Back Up Cold Storage </li></ul></ul><ul><ul><ul><li>24 Hrs </li></ul></ul></ul>
    7. 7. Unadjusted and Adjusted Models DCD Delayed Graft Function 7/1/04-5/1/06 <ul><li>Adjusted for donor age, sex, race, hypertension status </li></ul><ul><li>diabetic status, cause of death, creatinine and ECD status </li></ul><ul><li>, recipient age, sex, race, cause of ESRD and PRA, </li></ul><ul><li>HLA matching, ABO compatibility, shared status and cold ischemia time. </li></ul>n=16,889 n=4,226 SRTR 0.3268 0.89 0.21 0.86 Pumped During Transfer Ref 1.00 Ref 1.00 Not Pumped During Transfer 0.0005 0.58 0.15 0.78 Pumped by OPO and Center 0.0605 0.80 0.94 0.99 Pumped by Center only 0.0003 0.70 0.94 0.99 Pumped by OPO only Ref 1.00 Ref 1.00 Not Pumped < 0.0001 3.11 < 0.0001 2.61 DCD Ref 1.00 Ref 1.00 Non-DCD p OR p OR Adjusted* Unadjusted 0.020 1.35 0.108 1.22 Missing 0.002 1.47 0.001 1.46 0.32-0.60 0.250 1.14 0.177 1.16 0.24-0.31 Ref 1.00 Ref 1.00 0.18-0.23 0.881 1.02 0.954 0.99 0-0.17 Resistance < 0.0001 3.03 < 0.0001 2.43 DCD Ref 1.00 Ref 1.00 Non-DCD p OR p OR Adjusted* Unadjusted
    8. 8. THE AGING KIDNEY Prevalence of Moderate to Severe Renal Failure = 20.6% Without Hypertension and Diabetes = 10.8% Brenner & Rector’s The Kidney 7 th Ed 54 Million 2010 35 Million 2000 USA Population Age > 65
    9. 9. AGING AND GFR Brenner & Rector's The Kidney, 7th ed. , Copyright © 2004 Saunders, An Imprint of Elsevier                                                                                                                                      Figure 53-13 Percentiles of glomerular filtration rate (GFR) and Cockcroft-Gault creatinine clearance (CCr) by age, plotted on the same graph as data by Davies and Shock[ 124 ] on inulin clearance in healthy men. Percentiles are calculated using a fourth-order polynomial weighted quantile regression. The solid line shows a polynomial regression to the inulin data. Dashed lines without symbols show the 5th and 95th percentiles for GFR estimates. (Reprinted with permission from Coresh J, Astor BC, Greene T, et al: Prevalence of chronic kidney disease and decreased kidney function in the US population: Third National Health and Nutrition Examination Survey. Am J Kidney Dis 41:1–12, 2003.) Brenner & Rector’s The Kidney 7 th Ed 2004 Saunders
    10. 10. THE AGING & EXTENDED CRITERIA DONOR KIDNEYS <ul><li>Decreased Renal Weight and Mass </li></ul><ul><li>Thickening Intra-Renal Vasculature </li></ul><ul><ul><li>Arteriolar Hyaline Thickening </li></ul></ul><ul><li>Glomerulosclerosis </li></ul><ul><ul><li>Ischemia of Cortex </li></ul></ul><ul><ul><ul><li>Vascular Disease </li></ul></ul></ul><ul><ul><ul><li>Decreased Endothelial Growth Factors </li></ul></ul></ul><ul><ul><li>Numbers Decrease 30%-50% by Age 70 </li></ul></ul><ul><li>Tubulointerstitial Fibrosis </li></ul><ul><li>Metabolic Derangements </li></ul><ul><li>Donation Process </li></ul>
    11. 11. Deceased Cardiac Donor (DCD) <ul><li>Profound Tissue Stresses – </li></ul><ul><ul><li>Ischemia / Hypoxemia </li></ul></ul><ul><li>What Objective Measures Predict Transplant Outcomes In The Recipient?? </li></ul><ul><ul><li>Standardize Recording & Definitions of DCD Events </li></ul></ul><ul><ul><li>Understand The Tolerance Of Operative Procedures Used In The Donation Process </li></ul></ul><ul><ul><li>Objective Measures ? </li></ul></ul><ul><ul><ul><li>Pump Preservation Characteristics </li></ul></ul></ul><ul><ul><ul><ul><li>Simultaneously Limiting DGF & ? Improved Outcome </li></ul></ul></ul></ul><ul><ul><ul><li>Biopsy Analysis </li></ul></ul></ul>
    12. 12. Kidney Selection Process <ul><li>Know Parameters Reflective of Outcomes </li></ul><ul><ul><li>SCD, DCD and ECD Characteristics </li></ul></ul><ul><ul><li>? DCD / ECD and ? Unstable SCD </li></ul></ul><ul><li>Objective Data of Individual Kidneys </li></ul><ul><ul><li>Preservation Time, etc </li></ul></ul><ul><ul><li>Performance on Pumping </li></ul></ul><ul><ul><li>Biopsy Findings </li></ul></ul><ul><ul><ul><li>Adequacy of Specimen – Sample Size </li></ul></ul></ul><ul><ul><ul><li>Alignment of Specimen for Processing </li></ul></ul></ul><ul><ul><ul><ul><li>Frozen Section and Permanent Slides </li></ul></ul></ul></ul><ul><ul><ul><li>Standardization of Reporting </li></ul></ul></ul>
    13. 13. Pumped Kidneys: Unadjusted and Adjusted Models for Delayed Graft Function, 7/1/04-5/1/06 <ul><li>Adjusted for donor age, sex, race, hypertension status, diabetic status, cause of death </li></ul><ul><li>, creatinine and ECD status, recipient age, sex, race, cause of ESRD and PRA, </li></ul><ul><li>HLA matching, ABO compatibility, shared status and cold ischemia time. </li></ul>Non-DCD (n=15640) DCD (n=1249) 0.020 1.35 0.108 1.22 Missing 0.002 1.47 0.001 1.46 0.32-0.60 0.250 1.14 0.177 1.16 0.24-0.31 Ref 1.00 Ref 1.00 0.18-0.23 0.881 1.02 0.954 0.99 0-0.17 Resistance < 0.0001 3.03 < 0.0001 2.43 DCD Ref 1.00 Ref 1.00 Non-DCD p OR p OR Adjusted* Unadjusted
    14. 14. High Risk of Discard (HRD) Kidneys <ul><li>Deceased Donor Kidneys with at Least Four of the Following: </li></ul><ul><ul><li>DCD </li></ul></ul><ul><ul><li>Not Pumped </li></ul></ul><ul><ul><li>HCV Positive </li></ul></ul><ul><ul><li>Hepatitis B Core Antibody Positive </li></ul></ul><ul><ul><li>Creatinine Clearance < 62 </li></ul></ul><ul><ul><li>Pumped with Resistance Greater Than 0.349 </li></ul></ul><ul><ul><li>Donor Age 45 or Greater </li></ul></ul><ul><ul><li>Donor Creatinine > 2.0 </li></ul></ul><ul><ul><li>Donor History of Diabetes </li></ul></ul><ul><ul><li>Donor Cause of Death CNS Tumor or Other </li></ul></ul><ul><ul><li>Percentage Glomerulosclerosis >5% </li></ul></ul><ul><ul><li>Donor History of Hypertension </li></ul></ul>
    15. 15. DONOR QUALITY AND DISCARD RATE SRTR 11-1-2003 to 10-31-2005 16.5% 21,366 25,590 Total 51.6% 2,104 4,343 Yes No 9.3% 19,262 21,247 HRD? Total 8.7% 16,917 18,530 Total 38.0% 809 1,304 Yes No 6.5% 16,108 17,226 HRD? SCD 41.2% 3,149 5,358 Total 58.2% 1,093 2,614 Yes No 25.1% 2,056 2,744 HRD? ECD 23.6% 1,300 1,702 Total 52.5% 202 425 Yes No DCD 14.0% 1,098 1,277 HRD? Donor Type Percent Discarded Number Transplanted Number Recovered
    16. 16. ECD Kidneys Recovered For Transplant And Discarded SRTR 2000-2004 P< 0.001 61.5 % 81.2 % > 20% P< 0.001 46.5 % 63.6 % 16-20% P< 0.001 30.3 % 48.5 % 11-15% P< 0.01 29.5 % 37.9 % 6-10% P< 0.01 22.2 % 27.3 % 0-5% Pumped Not Pumped GS %
    17. 17. LCDS SELECTIVE BX & PUMP PRESERVATION <ul><li>Pump Preservation 1971 – Present </li></ul><ul><li>Waters (RM3) 1971 – 2005 </li></ul><ul><li>Lifeport ORS 2005 – Present </li></ul><ul><li>Pump Preservation </li></ul><ul><ul><li>DCD </li></ul></ul><ul><ul><li>ECD </li></ul></ul><ul><ul><li>OTHER SELECTIVE CASES </li></ul></ul><ul><ul><li>PROCEDURE </li></ul></ul><ul><ul><ul><li>DONOR KIDNEYS BIOPSIED </li></ul></ul></ul><ul><ul><ul><li>FROZEN SECTIONS READ AT DONOR HOSPITAL </li></ul></ul></ul><ul><ul><ul><ul><li>PATHOLOGIST AND SURGEON </li></ul></ul></ul></ul><ul><ul><ul><li>IF ACCEPTABLE PLACED ON PUMP </li></ul></ul></ul><ul><ul><ul><ul><li>Ω - 0.25 Acceptable; 0.25-0.40 ? DGF, > 0.40 ? PNF </li></ul></ul></ul></ul><ul><ul><ul><li>IF TRANSPLANTED PERMANENT SECTIONS REVIEWED POST TRANSPLANT </li></ul></ul></ul>
    18. 18. LCDS SELECTIVE BX & PUMP PRESERVATION 2003*-06 NOT PUMPED PUMPED TOTAL * ECD Defined 10.8 8/74 16.7 39/233 15.2 47/309 TOTAL 12.5 2/16 N/A ZERO/ZERO 12.5 2/16 DCD 15.4 6/39 73.4 14/19 34.5 20/58 ECD 0.0 ZERO/21 11.7 25/214 10.6 25/235 SCD Discard % DISCARD/ TOTAL Discard % DISCARD/ TOTAL Discard % DISCARD/TOTAL
    19. 19. PUMP PRESERVATION <ul><li>Organ Procurement Organization </li></ul><ul><ul><li>COST ? </li></ul></ul><ul><ul><li>PERSONEL ? </li></ul></ul><ul><ul><li>BENEFITS TRANSPLANT CENTER vs OPO ? </li></ul></ul><ul><li>Transplant Center </li></ul><ul><ul><li>INCREASED ORGAN COSTS FROM SAC FEES ? </li></ul></ul><ul><ul><li>BENEFITS PATIENT </li></ul></ul><ul><ul><li>AND CENTER </li></ul></ul><ul><ul><ul><li>LESS DGF </li></ul></ul></ul><ul><ul><ul><li>LIMITS EFFECTS OF CIT </li></ul></ul></ul><ul><ul><ul><li>DECREASED LOS </li></ul></ul></ul><ul><ul><ul><li>DECREASED COSTS </li></ul></ul></ul>6 P<0.0001 15314 No DGF 9 4315 DGF LOS Number 7/04-6/06 SRTR
    20. 20. COSTS RELATED TO PUMP PRESERVATION (LCDS) * Based on 2 kidneys WATERS RM3 LIFEPORT ORS ONE TIME COSTS COSTS FOR PUMPIMG 2 KIDNEYS $1600 $1074 + TOTAL $400 $400 BIOPSY $37,400 $35,500 TOTAL EXTRA HR MONITORING ? STAFF TIME $2000 $1404 + TOTAL $1400 $1000 TRAINING N/A $500 MAINTENCE KIT $468 N/A $234 $40 SOLUTIONS ADDITIVES $1100 $800 CASSETTE N/A $4000 CANULARS $36,000* $30,000* UNIT COST
    21. 21. ESTIMATED BENEFIT AND COSTS TO OPO WITH PUMP PRESERVATION AND BIOPSY <ul><li>Additional 6 Kidney Tx’s </li></ul><ul><ul><li>SAC $20,000 = $120,000 </li></ul></ul><ul><ul><li>Pumping Costs = $4,800 </li></ul></ul><ul><ul><li>Procurement Costs = $21,000 </li></ul></ul><ul><ul><li>Biopsies = $2,400 </li></ul></ul><ul><ul><li>Buy Out Costs = $3,036 </li></ul></ul><ul><ul><li>TOTAL COSTS = $31,236 </li></ul></ul><ul><li>OPO TOTAL = + $88,764 </li></ul><ul><li>ORS Disposables = $1600 </li></ul><ul><ul><li>2 Kidneys </li></ul></ul><ul><ul><li>FTE Time </li></ul></ul><ul><li>Procurement Costs = $7000 </li></ul><ul><ul><li>1 Donor = 2 Kidneys </li></ul></ul><ul><li>Buy Out Lifeport = $506 </li></ul><ul><ul><li>Cost Per Kidney </li></ul></ul><ul><li>Biopsy = $400 </li></ul><ul><ul><li>Per Kidney </li></ul></ul>16.5% 21,366 25,590 Total 8.7% 16,917 18,530 SCD 41.2% 3,149 5,358 ECD 23.6% 1300 1702 DCD Percent Discarded Number Transplanted Number Recovered Donor Type ≈ 2 11.1% 23.6% 12.5% 16 DCD ≈ 4 6.7% 41.2% 34.5% 58 ECD ADDED KIDNEYS % ∆ Of Discard SRTR Discard Rate LCDS Discard Rate LCDS#
    22. 22. ESTIMATED BENEFIT AND COSTS TO OPO WITH PUMP PRESERVATION AND BIOPSY METHODOLOGY <ul><li>Additional 499 Kidney Tx’s </li></ul><ul><ul><li>SAC $20,000 = $10,980,000 </li></ul></ul><ul><ul><li>Pumping Costs = $439,200 </li></ul></ul><ul><ul><li>Procurement Costs = $1,925,000 </li></ul></ul><ul><ul><li>Biopsies = $219,600 </li></ul></ul><ul><ul><li>Buy Out Costs = $277,794 </li></ul></ul><ul><ul><li>TOTAL COSTS = $2,861,594 </li></ul></ul><ul><li>OPO TOTAL = + $8,118,406 </li></ul><ul><ul><li>549 Additional Transplants </li></ul></ul><ul><li>ORS Disposables = $1600 </li></ul><ul><ul><li>2 Kidneys </li></ul></ul><ul><ul><li>FTE Time </li></ul></ul><ul><li>Procurement Costs = $7000 </li></ul><ul><ul><li>1 Donor = 2 Kidneys </li></ul></ul><ul><li>Buy Out Lifeports = $506 </li></ul><ul><ul><li>Cost Per Kidney </li></ul></ul><ul><li>Biopsy = $400 </li></ul><ul><ul><li>Per Kidney </li></ul></ul>SRTR 11-1-2003 to 10-31-2005 *Based on LCDS Discard Rates 23.6% 1300 1702 DCD 16.5% 21,366 25,590 Total 8.7% 16,917 18,530 SCD 41.2% 3,149 5,358 ECD Percent Discarded Number Transplanted Number Recovered Donor Type 359 6.7% 5,358 ECD 549 Total 190 11.1% 1702 DCD Additional Kidneys Percent ∆* Discarded Number Recovered Donor Type
    23. 23. CONCLUSIONS <ul><li>Cold Storage vs Pump Preservation </li></ul><ul><ul><li>OUTCOME / DEBATE GOES ON </li></ul></ul><ul><li>Pump Preservation </li></ul><ul><ul><li>Provides Objective Data </li></ul></ul><ul><ul><li>Decreased DGF (Decreased LOS) </li></ul></ul><ul><ul><li>Decreased Discard Rates / Increases Transplants </li></ul></ul><ul><ul><li>Financially Friendly to the OPO </li></ul></ul><ul><ul><li>Financially Friendly to the Transplant Center </li></ul></ul><ul><ul><li>Advantageous to the RECIPIENT </li></ul></ul>
    24. 24. ACKNOWLEDGEMENTS SURGEONS HARTFORD HOSPITAL & BAYSTATE MEDICAL CENTER GEORGE LIPKOWITZ, MD LIFECHOICE DONOR SERVICES DEB SAVARIA & LAINE KRISIUNAS PRESERVATIONISTS DAN DURKIN DONOR KIDNEY PUMPING FROM OPO / TRANSPLANT CENTER PERSPECTIVE
    25. 25. END
    26. 26. DATA FOR DCD AND DGF AND Ω Table 3.3: Sample Size and Number of Delayed Graft Function Events, 7/1/04-5/1/06 * According to OPO 40.1 184 459 17.9 385 2153 Pumped During Transfer* 44.2 349 790 24.0 3235 13493 Not Pumped During Transfer* 42.8 128 299 14.9 213 1431 Pumped by OPO and Center 46.3 19 41 22.8 218 955 Pumped by Center only 41.3 209 506 23.5 234 994 Pumped by OPO only 43.9 177 403 24.1 2955 12260 Not Pumped % delayed N % delayed N DCD (n=1249) Non-DCD (n=15640) Status
    27. 28. 1/2001 – 10/2005 16.5% 21,366 25,590 Total 8.7% 16,917 18,530 SCD 41.2% 3,149 5,358 ECD 23.6% 1300 1702 DCD Percent Discarded Number Transplanted Number Recovered Donor Type
    28. 29. Table 3.4: Unadjusted and Adjusted Models for Delayed Graft Function, 7/1/04-5/1/06 <ul><li>Adjusted for donor age, sex, race, hypertension status, diabetic status, cause of death </li></ul><ul><li>, creatinine and ECD status, recipient age, sex, race, cause of ESRD and PRA, </li></ul><ul><li>HLA matching, ABO compatibility, shared status and cold ischemia time. </li></ul>Non-DCD (n=15640) DCD (n=1249) 0.3268 0.89 0.21 0.86 Pumped During Transfer Ref 1.00 Ref 1.00 Not Pumped During Transfer 0.0005 0.58 0.15 0.78 Pumped by OPO and Center 0.0605 0.80 0.94 0.99 Pumped by Center only 0.0003 0.70 0.94 0.99 Pumped by OPO only Ref 1.00 Ref 1.00 Not Pumped < 0.0001 3.11 < 0.0001 2.61 DCD Ref 1.00 Ref 1.00 Non-DCD p OR p OR Adjusted* Unadjusted
    29. 30. Table 3.3: Sample Size and Number of Delayed Graft Function Events, 7/1/04-5/1/06 * According to OPO 40.1 184 459 17.9 385 2153 Pumped During Transfer* 44.2 349 790 24.0 3235 13493 Not Pumped During Transfer* 42.8 128 299 14.9 213 1431 Pumped by OPO and Center 46.3 19 41 22.8 218 955 Pumped by Center only 41.3 209 506 23.5 234 994 Pumped by OPO only 43.9 177 403 24.1 2955 12260 Not Pumped % delayed N % delayed N DCD (n=1249) Non-DCD (n=15640) Status
    30. 31. Pumping and Outcomes of Deceased Donor Kidneys: Review of Recent SRTR Analyses <ul><li>Laura L. Christensen, M.S. </li></ul><ul><li>Scientific Registry of Transplant Recipients </li></ul><ul><li>Arbor Research Collaborative for Health </li></ul><ul><li>October 26, 2006 </li></ul>
    31. 32. Background <ul><li>OPTN Organ Availability Committee has long been interested in the benefits of pumping of kidneys </li></ul><ul><li>SRTR has performed many analyses examining the relationship between pumping and: </li></ul><ul><ul><li>Discard </li></ul></ul><ul><ul><li>Delayed Graft Function (DGF) </li></ul></ul><ul><ul><li>Graft Survival </li></ul></ul>
    32. 33. Ascertainment of Pumping Data <ul><li>Until recently, pumping of kidneys was only reported by the OPO </li></ul><ul><li>Beginning July 1, 2004, transplant centers began to report pumping </li></ul>
    33. 34. Analyses Based on OPO Pumping Only
    34. 35. Pulsatile Perfusion by OPO and Organ Type* Range: 0-85% Median: 8% Discard Rate: 16.5% Range: 0-84% Median: 2.3% Discard Rate: 8.7% Range: 0-94% Median: 18% Discard Rate: 41.2% Range: 0-100% Median: 73% Discard Rate: 23.5% *13 OPOs w/ 0 DCDs, 13 OPOs w/ 1-4 DCDs *Non-preemptive kidney-only transplants 7/1/04 – 6/30/05
    35. 36. Complications of Varying OPO Pumping Practice <ul><li>OPOs that never pump give us no information about pumping outcomes </li></ul><ul><li>OPOs that pump selectively appear to mostly pump kidneys perceived as poor quality </li></ul><ul><li>OPOs that pump most kidneys appear to not pump the poorest organs </li></ul>
    36. 37. SCD Kidneys: % DGF by OPO Pumping Practice n OPOs: n Kidneys: 24 8377 30 6 13565 20 151 1569 OR for 100% vs. 0% pumped by OPO: 0.45; p < 0.0001 OR for kidney level pumped vs. not: 0.51; p < 0.0001 Among non-preemptive deceased donor transplants, January 1, 2001 to July 31, 2004
    37. 38. DCD Kidneys: % DGF by OPO Pumping Practice n OPOs: n Kidneys: 15 187 8 20 287 139 77 521 OR for 100% vs. 0% pumped by OPO: 0.64; p=0.11 OR for kidney level pumped vs. not: 0.76; p=0.12 Among non-preemptive deceased donor transplants, January 1, 2001 to July 31, 2004
    38. 39. ECD Kidneys: % DGF by OPO Pumping Practice n OPOs: n Kidneys: 27 1806 20 13 1425 514 302 662 OR for 100% vs. 0% pumped by OPO: 0.50; p=0.008 OR for kidney level pumped vs. not: 0.58; p < 0.0001 Among non-preemptive deceased donor transplants, January 1, 2001 to July 31, 2004
    39. 40. Adjusted Cox Regression for Graft Failure/Death Among deceased donor transplants, January 1, 2001 to July 31, 2004
    40. 41. SCD Kidneys: % Discard by OPO Pumping Practice n OPOs: n Kidneys: 22 8941 32 6 17592 831 1091 2139 OR for 100% vs. 0% pumped by OPO: 1.54; p=0.27 OR for kidney level pumped vs. not: 0.65; p=0.04 Among deceased donor kidneys recovered for transplant, January 1, 2001 to July 31, 2004
    41. 42. DCD Kidneys: % Discard by OPO Pumping Practice n OPOs: n Kidneys: 15 249 9 19 379 198 94 628 OR for 100% vs. 0% pumped by OPO: 1.03; p=0.95 OR for kidney level pumped vs. not: 0.52; p=0.02 Among deceased donor kidneys recovered for transplant, January 1, 2001 to July 31, 2004
    42. 43. ECD Kidneys: % Discard by OPO Pumping Practice n OPOs: n Kidneys: 22 2420 34 4 3728 1352 93 318 OR for 100% vs. 0% pumped by OPO: 0.68; p=0.38 OR for kidney level pumped vs. not: 0.47; p < 0.0001 Among deceased donor kidneys recovered for transplant, January 1, 2001 to July 31, 2004
    43. 44. Analyses Based on OPO and Center Pumping
    44. 45. Pumping at the OPO and Center 7/1/04 – 5/1/06 Non-DCD Kidneys DCD Kidneys
    45. 46. Relationship between Pumping and Delayed Graft Function 7/1/04-5/1/06, n=16,889 Adjusted for donor age, sex, race, hypertension status, diabetic status, cause of death, creatinine and ECD status, recipient age, sex, race, cause of ESRD and PRA, HLA matching, ABO compatibility, cold ischemia time and shared status.
    46. 47. Among Pumped Kidneys: Resistance and Delayed Graft Function 7/1/04-5/1/06, n=4,226 Adjusted for donor age, sex, race, hypertension status, diabetic status, cause of death, creatinine and ECD status, recipient age, sex, race, cause of ESRD and PRA, HLA matching, ABO compatibility, shared status and cold ischemia time.
    47. 48. Conclusions <ul><li>Pumping practice varies widely by OPO for each type of kidney (SCD, DCD, ECD) </li></ul><ul><li>Varying practices introduce selection bias </li></ul><ul><li>Associations between pumping and discard/DGF vary by kidney type and pumping practice </li></ul><ul><li>Analyses at OPO and kidney levels are not always consistent </li></ul><ul><li>A randomized controlled trial is needed to determine whether pumping provides beneficial effects </li></ul>

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