Advanced Donor Management Strategies Pre recovery Liver Biopsies Hormonal Resuscitation

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Advanced Donor Management Strategies Pre
recovery Liver BiopsiesHormonal Resuscitation

• Breakout F6
• National Learning Congress
• New Orleans
• October 19, 2006
• Faculty Susan Gunderson
• Producer Franki Chabelewski

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Presenters

• Pre Recovery Liver Biopsies
• Megan Shaughnessy, CTDN
• Robert Osorio, MD, California Pacific Medical
  Center
• Hormonal Resuscitation
• Myron Kauffman, MD, UNOS

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Advanced Management Strategies

• Questions to run on
• How can pre-recovery biopsies improve liver
  placement in my DSA?
• How can the results of hormonal resuscitation
  improve organ utilization in our DSA?
• What steps can we take by next Tuesday to
  introduce these advanced management strategies?

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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
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The story

• We had a 13 liver discard rate.
• All were related to fat or fibrosis on
  visualization or biopsy.
• Re-allocation attempts with biopsy results plus
  CIT were unsuccessful.
• So we asked ourselves
• Can we improve transplantation rates if we have
  a better assessment of the liver parenchyma
  during the liver offer?

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(No Transcript)
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Who

• Selection Criteria
• BMI gt 32
• Anti HCV
• U/S or CT suggestive of fatty infiltrate
• PMH and/or clinical indications suggestive of
  liver disease
• At surgeons request
• Significant ETOH use
• Age gt 70
• Age 65-70 with hx of DM

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What

• Tissue sample
• At least one 2cm core biopsy. Multiple cores
  preferred.
• Preservation
• Saline or RPMI dampened telfa gauze folded over
  to cover the biopsied tissue.
• Interpretation
• Permanent sections preferred, especially when
  evaluating HCV donors.
• Stat frozen sections used most frequently.
  Follow-up permanent sections available the next
  day.

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More Ws

• When
• Biopsies will be performed at the earliest
  opportunity after brain death in order to provide
  biopsy results during the organ offer process.
• Where
• Our goal is to have all pre-recovery liver
  biopsies read at a local transplant center.

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How to

• Obtain biopsy
• U/S guided at bedside
• Radiology guided (CT or U/S) in Interventional
  Radiology
• Care for donor
• Ensure CBC, PT, PTT and INR are WNL
• If platelet count is lt70,000 administer platelet
  cells prior to the procedure.
• If INR gt1.4, transfuse FFP prior to the
  procedure.
• Consult with medical director on donors with
  coagulopathy issues
• (consider transjugular bx)

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Can it be done?

• 2005 67 pre-recovery liver biopsies performed
• 1/1/06 thru 6/30/06 58 pre-recovery liver
  biopsies performed
• Complication rate of 2
• 1 donor experienced a significant drop in
  hemoglobin after biopsy
• 1 donor had 1.5 liters of blood in his abdominal
  cavity at recovery 1 donors kidney was nicked
  during the liver biopsy
• No transplantable organs were lost in any of the
  above instances.
• Of note, there have been at least three cases
  where weve chosen not to perform a biopsy due to
  irresolvable coagulopathy issues.

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What the numbers look like
CTDN began our pre-recovery liver biopsy protocol
on 1/1/05.
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What we wish wed known

• Get feedback/buy-in from local path labs on the
  front end
• Set realistic expectations of volume and
  timelines
• Provide biopsy kits with necessary materials to
  onsite staff

BIOPSIES
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Looking toward the future

• Conduct double-read study to compare donor
  hospital reads against transplant center reads
• Work with pathologists to develop a How-To
  Interpret Liver Bx for Transplant guide

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Questions to run on

• How can pre recovery liver biopsies improve
  outcomes in my DSA?
• What practices actions did you hear that youd
  like to test?

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Hormonal Resuscitation Improving Organ Use
Quality

• H. Myron Kauffman, M.D.
• John D. Rosendale MS
• Franki Chabalewski RN, MS
• Maureen A. McBride, PhD

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The ChallengeKidney Registrations at Year End
vs. Kidneys Transplanted 1988 - 2004
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The ChallengeLiver Registrations at Year End
vs. Livers Transplanted 1988 - 2004
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The ChallengeHeart Registrations at Year End
vs. Hearts Transplanted 1988 - 2004
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Wait List Removals for Death 1995-2004
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Conventional Management

• Volume Target CVP 6 10 mm Hg
• Acidosis Target pH 7.40 7.45
• Hypoxemia Target pO2 gt 80 mm Hg
• Anemia Target Hct gt 30
• B.P. Target MAP gt 60 mm Hg
• Ionotropes Target Dopamine dose lt 10ug/kg/min

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Conventional Management
Initial ECHO
LVEF gt 45
Organ Recovery
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Conventional Management
Initial ECHO
LVEF lt 45
Hormonal Resuscitation
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Increased Use of Hormonal Resuscitation 2000 -
2004
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Hormonal Resuscitation

• Methylprednisilone 15 mg/kg bolus
• Vasopressin 1 unit bolus then 0.5 4.0 u/hr.
• T3 4 ug bolus then 3ug/hr.
• T4 20 ug bolus then 10 ug/hr.
• Insulin 1u/hr (minimum)

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Hemodynamic Management (PA Catheter)

• MAP gt 60 mm Hg
• CVP 4 12 mm Hg
• PCWP 8 12 mm Hg
• Cardiac Index gt 2.4 L/min/m2
• SVR 800 1200 dyne/sec/cm5
• Dopamine/Dobutamine lt 10 ug/kg/min

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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

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Methods

• Retrospective study
• Brain dead donors recovered between January 1,
  2000, and June 30, 2001 (8,769 donors)
• Hormonal resuscitation donors (584) vs.
  non-hormonal resuscitation donors (8,185)
• Univariate analyses chi-square, t-test
• Multivariate analyses logistic regression

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Univariate Analyses
3.8
3.1
p lt 0.001
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Multivariate Logistic Regression AnalysesKidney
Model (Odds of kidney transplant)
Odds Ratios gt 1 Higher Odds of Transplant
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Multivariate Logistic Regression
AnalysesHormonal Resuscitation
Odds Ratios gt 1 Higher Odds of Transplant
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ExtrapolationBased on Adjusted Probabilities

• Additional Transplantable Organs with the use of
  Hormonal Resuscitation
• Based on the 5,921 brain dead donors recovered in
  2001
• 924 Kidneys
• 278 Hearts
• 290 Livers
• 414 Lungs
• 456 Pancreata
• 2,362 Total Organs

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Kidneys from Heart Donors

• Heart Donors
• N 6,893

• Non-Heart Donors
• N 26,885

20 more kidneys from Heart Donors DGF 18.0
vs. 24.8 plt0.001 Graft Survival 90.9 vs.
87.3 plt0.001
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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

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Multivariate Analyses

• Logistic Regression
• Patient mortality within 1-month post-transplant
• Early graft dysfunction (defined as graft failure
  within 14 days or prolonged graft dysfunction
  prior to discharge)
• Models adjusted for recipient/donor factors
• 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 gt 1.5, hormonal resuscitation (yes,
  no), recipient medical status, life support, ABO,
  etc.

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Multivariate Logistic RegressionProlonged Graft
Dysfunction
plt0.01
plt0.02
plt0.01
NS
NS
NS
NS
Odds Ratios lt 1 Lower Odds of Dysfunction
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Multivariate Logistic RegressionOdds of
Mortality at 1-Month Posttransplant
plt0.01
NS
NS
NS
NS
NS
NS
Odds Ratios lt 1 Lower Odds of Mortality
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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

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EXPANDED CRITERIA DONORS

• Any Donor Age gt 60
• Donor Age 50-59 any two
• CVA cause of death
• Creatinine gt 1.5 mg/dl
• History of Hypertension

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Probability of Kidney Being Transplanted
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All Deceased Donors 11/1/99-12/31/02
plt0.01
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Non-Expanded Criteria Donors 11/11/99-12/31/02
plt0.01
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Expanded Criteria Donors 11/11/99-12/31/02
plt0.01
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Kidney Graft Survival
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Heart Patient Survival
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Liver Patient Survival
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Summary

• HR is associated with more Tx. kidneys, livers,
  and hearts
• Which based on the 6,001 brain dead donors in
  2002 could have resulted in an additional
• 400 kidney transplants
• 150 liver transplants
• 210 heart transplants
• HR is not associated with any difference in
  1-year liver patient survival (p0.82), but is
  associated with improved 1-year kidney graft
  survival (plt0.02) and 1-year heart patient
  survival (plt0.01)

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Questions to run on

• What opportunities do you see for spreading this
  best practice?
• How can we use hormonal resuscitation more
  effectively?

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(No Transcript)
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PART Goals

• Increase the number of deceased donor organs
  transplanted
• Increase the number of non-DCD donors
• Increase the number of DCD donors
• Increase the average number of organs
  transplanted per non-DCD donor
• Increase the average number of organs
  transplanted per DCD donors

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Increase Avg. No. Organs Transplanted per Non-DCD
Donor by 0.08/Year

• FY 03 3.20 (baseline)
• FY 04 3.28
• FY 05 3.36
• FY 06 3.44
• FY 13 4.00

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Organs Recovered Per Donor by Donor Type1995
June, 2005
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Organs Transplanted Per Donor by Donor Type1995
June, 2005
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Organs Transplanted Per Donor 11/11/99-12/31/02
plt0.01