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Journey to Transplant: How Patients Facing Organ Failure Get on the Transplant Waiting List

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Journey to Transplant: How Patients Facing Organ Failure Get on the Transplant Waiting List Christine Lee, RN, BSN, CCTC Leeanne Shinn, RN UCLA Kidney and Pancreas ... – PowerPoint PPT presentation

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Title: Journey to Transplant: How Patients Facing Organ Failure Get on the Transplant Waiting List


1
Journey to TransplantHow Patients Facing Organ
Failure Get on the Transplant Waiting List
  • Christine Lee, RN, BSN, CCTC
  • Leeanne Shinn, RN
  • UCLA Kidney and Pancreas Transplant Program

2
How To Be
  • Being in Action!
  • The Answers Are In the Room
  • Report out on Questions to Run-on
  • Scribe
  • Spokesperson
  • All Teach / All Learn

3
Question to Run on?
  • What can you do to educate your patients or
    community on the Journey to Transplant?

4
Introductions
  • Christine Lee
  • Leeanne Shinn

5
Objectives
  • Understand the referral, evaluation and listing
    process for organ transplant kidney
    transplantation
  • Provide overview of the national wait list and
    review various deceased donor options
  • Discuss living donor transplant options

6
Treatment Options
  • Heart/Lung/Liver failure Organ transplant
  • Heart - LVAD as bridge to transplant
  • End stage renal disease (ESRD)
  • Dialysis
  • Kidney Transplant
  • Type 1 diabetes
  • Insulin therapy
  • Pancreas alone (PA), kidney/pancreas transplant
    (SPK)

7
What is the goal of kidney transplant?
  • Freedom from dialysis
  • Better quality of life
  • Prolongs life compared to dialysis
  • To maximize survival

8
  • Fig. 1. Overall unadjusted actuarial survival
    probabilities for transplanted recipients and
    haemodialysis patients
  • Mazzuchi, N. et al. Nephrol. Dial. Transplant.
    1999 142849-2854 doi10.1093/ndt/14.12.2849

9
Kidney Transplant
  • Cons
  • Not for everyone compliance, health
  • Long wait time due to organ shortage
  • Require strict adherence to daily medications
  • Transplant medications for life

10
Referral Process
  • For kidney transplant - Referral made by
    physician, dialysis social worker, insurance case
    manager or patient
  • Find a local transplant program
  • Necessary documents
  • HP, Social worker note, most recent lab, cardiac
    tests, imaging studies, ABO
  • Medicare Entitlement Form (2728 form)
  • Schedule an appointment with the transplant team
    for evaluation

11
Selecting a Transplant Program
  • The experience of the transplant team
  • Insurance coverage
  • Geographical proximity to the program
  • The travel time to the transplant center is
    important when patient is waiting for an organ
    and is a key factor considered in organ
    distribution.
  • The quality and availability of pre- and
    post-transplant services.
  • Availability of friends and family for assistance

12
Evaluation Process
  • Patient Education Orientation
  • Consultation with the transplant team
  • Transplant Physician
  • Surgeon
  • Transplant Nurse Coordinator
  • Social Worker
  • Dietician

13
(No Transcript)
14
Evaluation Process
  • Other consultation as needed
  • Cardiology, Hepatology, Infectious Disease,
    Psychiatry, Hematology, Dermatology, Oncology,
    etc
  • Pending tests
  • Lab Blood type x2, HLA, PRA, serology
  • Cardiac tests EKG, Stress test, Echocardiogram,
    Coronary angiogram
  • Radiology CXR, renal/abdominal ultrasound, CT
    scan, MRI
  • Screening tests PSA, pap smear, mammogram,
    colonoscopy

15
Patient Selection Criteria
  • Must be accepted as a candidate before listing
  • Selection Criteria
  • In general, all end-stage renal failure patients
    who, after having been informed of the risks of
    the transplant surgery and the inevitable chronic
    immunosuppressive therapy, still express a clear
    desire for this modality of treatment, will be
    accepted as candidates for evaluation.
  • Exclusion criteria
  • Presence of disseminated or recent malignancy
  • Active infection
  • Severe coronary artery disease and/or peripheral
    vascular disease
  • Underlying disease states such as multiple
    myeloma, scleroderma, oxalosis, sickle-cell
    anemia
  • Serious psychosocial problems
  • Squamous cell skin cancer
  • Renal cell carcinomas
  • BMI gt 35
  • Partial insurance coverage
  • Patients that are wheelchair bound, require
    oxygen, or are severely disabled
  • Patients who are unwilling to accept blood
    transfusions under any circumstances while taking
    anticoagulations

16
Patient Selection Criteria
  • After completion of the workup, Selection
    Committee will review the case
  • The Committee is made up of Transplant
    Nephrologists, Surgeons, Nurse Coordinators,
    Social workers, dietician, pharmacist and other
    consultants
  • Once decision is made, the patient and physician
    will be notified in writing

17
Listing Process
  • Medical clearance by the Selection Committee
  • Financial clearance
  • Eligibility for wait time accrual
  • On maintenance dialysis
  • GFR 20 or less
  • Notification within 10 days to the patient,
    physician and dialysis social worker

18
UNOS Wait List
  • National Wait List - United Network for Organ
    Sharing (UNOS)
  • 107,337 patients are waiting for all organs
  • 84,000 patients are waiting for kidney
    transplant

19
U.S. Waiting List Candidates by Organs
  • Based on current OPTN data as reported on May 7,
    2010. Data subject to change based on future data
    submission or correction.

20
UNOS Wait List
  • About 16,000 transplants per year
  • 6,000 living donor transplant (doubled over 15
    yrs)
  • 10,000 deceased donor
  • California Wait List
  • 16,250 patients are waiting for kidney
  • Average wait time 7 to 10 years

21
(No Transcript)
22
(No Transcript)
23
Allocation Strategies
  • Dialysis Wait Time
  • wait time starts as initial dialysis start date
  • Dual organ transplant
  • kidney/pancreas
  • Liver/Kidney
  • Heart/Kidney
  • Multiple listing

24
Is there a way to reduce the waiting time?
  • Expanded Criteria Donor (ECD) kidney
  • A kidney from a donor age over 60 years or over
    age 50 with a history of HTN, cause of death due
    to CVA, or a terminal creatinine greater than 1.5
    mg/d
  • Hepatitis C list
  • Only for the patients with hepatitis C
  • Donation after cardiac death (DCD)
  • A kidney from a donor who was declared dead based
    on a lack of a heartbeat.
  • These kidneys are less likely to function
    immediately may have a greater risk of
    rejection
  • The Centers for Disease Control (CDC) increased
    risk
  • Higher risk for the transmission of viral disease
    including HIV Hepatitis
  • Donation Point
  • Living Donor Transplant

25
Living Donor Transplant Options
  • Compatible Recipient-Donor pairs
  • Desensitization Protocols
  • Blood Type incompatible
  • Kidney Exchange Program
  • AKA Paired Exchange or Chain Transplant

26
(No Transcript)
27
Living Donation
  • Related vs. Unrelated
  • Requirements
  • Age 18 65
  • Health Concerns (diabetes, high blood pressure,
    cancer, hepatitis, weight issue)
  • Lifestyle substance abuse

28
Blood type compatibility chart
Candidates Blood Type O A B AB
Donors Blood Type O A or O B or O A, B,
AB or O
29
Compatible Recip-Donor Pairs
  • Blood types are compatible
  • Cross match testing indicates low risk of early
    rejection
  • Donor can donate directly to recipient

30
But
  • What if the donor and the recipient
  • are not compatible?

31
  • At least one third of patients with a willing
    living donor are excluded due to incompatible
    blood type and positive cross match
  • 35 of any two people will be blood type
    incompatible
  • 30 of patients needing a kidney transplant will
    be sensitized because of previous transplants,
    pregnancies or transfusions

32
Desensitization
  • Advantages include increasing the donor pool and
    the friend or love one can donate to the intended
    recipient
  • Disadvantages include cost which averages
    approximately 30,000
  • Decreased patient survival (5yr 87 vs. 94)
    AJT 2004
  • Unpredictable rates of accelerated rejection
  • Decreased graft survival (1yr. 84 vs. 96 ) AJT
    2004
  • Decreased 5 yr. graft survival (69 vs. 81) AJT
    2009

33
Blood Type Incompatible
  • Living donor has different blood type
  • No other donor available
  • Requires analysis of antibody levels
  • Insurance authorization for treatment
  • Pre-operative treatment protocol over several
    weeks to achieve safe window for transplantation
    with your living donor

34
ABOi
  • Molecules present or absent on blood cells
    determine blood type
  • When blood types are mixed, these molecules act
    as antigens that trigger ABO incompatibility
    reaction
  • Preconditioning is done to cleanse the blood of
    these circulating antibodies and depends on blood
    type and amount of antibodies present

35
ABOi Therapies
  • Plasmapheresis- remove antibodies
  • Immunoglobulin-decrease antibodies which are
    destructive to the graft
  • Splenectomy
  • Anti-CD20 Antibody (rituximab)- depletes CD20
    protein which is found on the wall of most B
    cells

36
Paired Donation
  • Initially slow to take off because 1984 NOTA
    unlawful to acquire organ in exchange for
    valuable consideration
  • 2007 Senate bill valuable consideration does not
    apply to paired donation

37
Donor Exchange
  • Recipient/donor pair have incompatible blood
    types
  • Other donor/recipient pair have incompatible
    blood types
  • Donors evaluated/accepted for donation
  • Donor/recipient pairs exchange donor kidneys
  • Exchange is anonymous until after surgery

38
Paired donor exchange
  • Pair 1
  • Recip blood type A
  • Donor blood type B
  • B to A is not compatible
  • Pair 2
  • Recip blood type B
  • Donor blood type A
  • A to B is not compatible

39
Paired Donor Exchange
  • Pair 1 Pair 2
  • Recipient A Recipient B
  • Donor B Donor A
  • Blood-type incompatible Recip/Donor pairs
  • exchange blood-type compatible kidneys

40
Down Side of Paired Donation
  • If one living donor backs out then the other pair
    is disadvantaged
  • Requires simultaneous O.R. start

41
Donor Exchange Chains
  • Participation of multiple pairs of donors and
    recipients
  • Usually started by a non-directed or altruistic
  • One donor is left over to begin a new section
    of the chain

42
Donor Chains
  • Living donor can donate local to where they live
  • Kidneys are shipped using established OPO
    protocols on commercial flights
  • Do not need simultaneous O.R. start times

43
(No Transcript)
44
Donor Chains
  • Very time intensive, high work load for low yield
  • Only about 120 done to date
  • Potential for 1,000 -2,000 additional kidney
    transplants per year
  • If there is a delay in donation, donor may back
    out

45
In short, there are new options
  • Standard living donor transplant
  • Highly-sensitized
  • Blood-type incompatible
  • Paired or triple exchange
  • Donor exchange chains

46
Conclusion
  • Timely referral to transplant center
  • Communication and collaboration between the
    referring physician, patient, dialysis unit and
    the transplant team are the key
  • Advances in living donation are providing
    patients with more opportunities for transplant

47
Question to Run on?
  • What can you do to educate your patients or
    community on the Journey to Transplant?
  • 3 minutes to work at your tables and report back,
    Go!

48
Transition to Breakout Session 2
  • Next Breakout Session starts at 1130
  • Please see your agenda for specific room
    locations
  • Enjoy the Learning!

49
Journey to TransplantHow Patients Facing Organ
Failure Get on the Transplant Waiting List
  • Christine Lee, RN, BSN, CCTC
  • Leeanne Shinn, RN
  • UCLA Kidney and Pancreas Transplant Program

50
How To Be
  • Being in Action!
  • The Answers Are In the Room
  • Report out on Questions to Run-on
  • Scribe
  • Spokesperson
  • All Teach / All Learn

51
Question to Run on?
  • What can you do to educate your patients or
    community on the Journey to Transplant?

52
Introductions
  • Christine Lee
  • Leeanne Shinn

53
Objectives
  • Understand the referral, evaluation and listing
    process for organ transplant kidney
    transplantation
  • Provide overview of the national wait list and
    review various deceased donor options
  • Discuss living donor transplant options

54
Treatment Options
  • Heart/Lung/Liver failure Organ transplant
  • Heart - LVAD as bridge to transplant
  • End stage renal disease (ESRD)
  • Dialysis
  • Kidney Transplant
  • Type 1 diabetes
  • Insulin therapy
  • Pancreas alone (PA), kidney/pancreas transplant
    (SPK)

55
What is the goal of kidney transplant?
  • Freedom from dialysis
  • Better quality of life
  • Prolongs life compared to dialysis
  • To maximize survival

56
  • Fig. 1. Overall unadjusted actuarial survival
    probabilities for transplanted recipients and
    haemodialysis patients
  • Mazzuchi, N. et al. Nephrol. Dial. Transplant.
    1999 142849-2854 doi10.1093/ndt/14.12.2849

57
Kidney Transplant
  • Cons
  • Not for everyone compliance, health
  • Long wait time due to organ shortage
  • Require strict adherence to daily medications
  • Transplant medications for life

58
Referral Process
  • For kidney transplant - Referral made by
    physician, dialysis social worker, insurance case
    manager or patient
  • Find a local transplant program
  • Necessary documents
  • HP, Social worker note, most recent lab, cardiac
    tests, imaging studies, ABO
  • Medicare Entitlement Form (2728 form)
  • Schedule an appointment with the transplant team
    for evaluation

59
Selecting a Transplant Program
  • The experience of the transplant team
  • Insurance coverage
  • Geographical proximity to the program
  • The travel time to the transplant center is
    important when patient is waiting for an organ
    and is a key factor considered in organ
    distribution.
  • The quality and availability of pre- and
    post-transplant services.
  • Availability of friends and family for assistance

60
Evaluation Process
  • Patient Education Orientation
  • Consultation with the transplant team
  • Transplant Physician
  • Surgeon
  • Transplant Nurse Coordinator
  • Social Worker
  • Dietician

61
(No Transcript)
62
Evaluation Process
  • Other consultation as needed
  • Cardiology, Hepatology, Infectious Disease,
    Psychiatry, Hematology, Dermatology, Oncology,
    etc
  • Pending tests
  • Lab Blood type x2, HLA, PRA, serology
  • Cardiac tests EKG, Stress test, Echocardiogram,
    Coronary angiogram
  • Radiology CXR, renal/abdominal ultrasound, CT
    scan, MRI
  • Screening tests PSA, pap smear, mammogram,
    colonoscopy

63
Patient Selection Criteria
  • Must be accepted as a candidate before listing
  • Selection Criteria
  • In general, all end-stage renal failure patients
    who, after having been informed of the risks of
    the transplant surgery and the inevitable chronic
    immunosuppressive therapy, still express a clear
    desire for this modality of treatment, will be
    accepted as candidates for evaluation.
  • Exclusion criteria
  • Presence of disseminated or recent malignancy
  • Active infection
  • Severe coronary artery disease and/or peripheral
    vascular disease
  • Underlying disease states such as multiple
    myeloma, scleroderma, oxalosis, sickle-cell
    anemia
  • Serious psychosocial problems
  • Squamous cell skin cancer
  • Renal cell carcinomas
  • BMI gt 35
  • Partial insurance coverage
  • Patients that are wheelchair bound, require
    oxygen, or are severely disabled
  • Patients who are unwilling to accept blood
    transfusions under any circumstances while taking
    anticoagulations

64
Patient Selection Criteria
  • After completion of the workup, Selection
    Committee will review the case
  • The Committee is made up of Transplant
    Nephrologists, Surgeons, Nurse Coordinators,
    Social workers, dietician, pharmacist and other
    consultants
  • Once decision is made, the patient and physician
    will be notified in writing

65
Listing Process
  • Medical clearance by the Selection Committee
  • Financial clearance
  • Eligibility for wait time accrual
  • On maintenance dialysis
  • GFR 20 or less
  • Notification within 10 days to the patient,
    physician and dialysis social worker

66
UNOS Wait List
  • National Wait List - United Network for Organ
    Sharing (UNOS)
  • 107,337 patients are waiting for all organs
  • 84,000 patients are waiting for kidney
    transplant

67
U.S. Waiting List Candidates by Organs
  • Based on current OPTN data as reported on May 7,
    2010. Data subject to change based on future data
    submission or correction.

68
UNOS Wait List
  • About 16,000 transplants per year
  • 6,000 living donor transplant (doubled over 15
    yrs)
  • 10,000 deceased donor
  • California Wait List
  • 16,250 patients are waiting for kidney
  • Average wait time 7 to 10 years

69
(No Transcript)
70
(No Transcript)
71
Allocation Strategies
  • Dialysis Wait Time
  • wait time starts as initial dialysis start date
  • Dual organ transplant
  • kidney/pancreas
  • Liver/Kidney
  • Heart/Kidney
  • Multiple listing

72
Is there a way to reduce the waiting time?
  • Expanded Criteria Donor (ECD) kidney
  • A kidney from a donor age over 60 years or over
    age 50 with a history of HTN, cause of death due
    to CVA, or a terminal creatinine greater than 1.5
    mg/d
  • Hepatitis C list
  • Only for the patients with hepatitis C
  • Donation after cardiac death (DCD)
  • A kidney from a donor who was declared dead based
    on a lack of a heartbeat.
  • These kidneys are less likely to function
    immediately may have a greater risk of
    rejection
  • The Centers for Disease Control (CDC) increased
    risk
  • Higher risk for the transmission of viral disease
    including HIV Hepatitis
  • Donation Point
  • Living Donor Transplant

73
Living Donor Transplant Options
  • Compatible Recipient-Donor pairs
  • Desensitization Protocols
  • Blood Type incompatible
  • Kidney Exchange Program
  • AKA Paired Exchange or Chain Transplant

74
(No Transcript)
75
Living Donation
  • Related vs. Unrelated
  • Requirements
  • Age 18 65
  • Health Concerns (diabetes, high blood pressure,
    cancer, hepatitis, weight issue)
  • Lifestyle substance abuse

76
Blood type compatibility chart
Candidates Blood Type O A B AB
Donors Blood Type O A or O B or O A, B,
AB or O
77
Compatible Recip-Donor Pairs
  • Blood types are compatible
  • Cross match testing indicates low risk of early
    rejection
  • Donor can donate directly to recipient

78
But
  • What if the donor and the recipient
  • are not compatible?

79
  • At least one third of patients with a willing
    living donor are excluded due to incompatible
    blood type and positive cross match
  • 35 of any two people will be blood type
    incompatible
  • 30 of patients needing a kidney transplant will
    be sensitized because of previous transplants,
    pregnancies or transfusions

80
Desensitization
  • Advantages include increasing the donor pool and
    the friend or love one can donate to the intended
    recipient
  • Disadvantages include cost which averages
    approximately 30,000
  • Decreased patient survival (5yr 87 vs. 94)
    AJT 2004
  • Unpredictable rates of accelerated rejection
  • Decreased graft survival (1yr. 84 vs. 96 ) AJT
    2004
  • Decreased 5 yr. graft survival (69 vs. 81) AJT
    2009

81
Blood Type Incompatible
  • Living donor has different blood type
  • No other donor available
  • Requires analysis of antibody levels
  • Insurance authorization for treatment
  • Pre-operative treatment protocol over several
    weeks to achieve safe window for transplantation
    with your living donor

82
ABOi
  • Molecules present or absent on blood cells
    determine blood type
  • When blood types are mixed, these molecules act
    as antigens that trigger ABO incompatibility
    reaction
  • Preconditioning is done to cleanse the blood of
    these circulating antibodies and depends on blood
    type and amount of antibodies present

83
ABOi Therapies
  • Plasmapheresis- remove antibodies
  • Immunoglobulin-decrease antibodies which are
    destructive to the graft
  • Splenectomy
  • Anti-CD20 Antibody (rituximab)- depletes CD20
    protein which is found on the wall of most B
    cells

84
Paired Donation
  • Initially slow to take off because 1984 NOTA
    unlawful to acquire organ in exchange for
    valuable consideration
  • 2007 Senate bill valuable consideration does not
    apply to paired donation

85
Donor Exchange
  • Recipient/donor pair have incompatible blood
    types
  • Other donor/recipient pair have incompatible
    blood types
  • Donors evaluated/accepted for donation
  • Donor/recipient pairs exchange donor kidneys
  • Exchange is anonymous until after surgery

86
Paired donor exchange
  • Pair 1
  • Recip blood type A
  • Donor blood type B
  • B to A is not compatible
  • Pair 2
  • Recip blood type B
  • Donor blood type A
  • A to B is not compatible

87
Paired Donor Exchange
  • Pair 1 Pair 2
  • Recipient A Recipient B
  • Donor B Donor A
  • Blood-type incompatible Recip/Donor pairs
  • exchange blood-type compatible kidneys

88
Down Side of Paired Donation
  • If one living donor backs out then the other pair
    is disadvantaged
  • Requires simultaneous O.R. start

89
Donor Exchange Chains
  • Participation of multiple pairs of donors and
    recipients
  • Usually started by a non-directed or altruistic
  • One donor is left over to begin a new section
    of the chain

90
Donor Chains
  • Living donor can donate local to where they live
  • Kidneys are shipped using established OPO
    protocols on commercial flights
  • Do not need simultaneous O.R. start times

91
(No Transcript)
92
Donor Chains
  • Very time intensive, high work load for low yield
  • Only about 120 done to date
  • Potential for 1,000 -2,000 additional kidney
    transplants per year
  • If there is a delay in donation, donor may back
    out

93
In short, there are new options
  • Standard living donor transplant
  • Highly-sensitized
  • Blood-type incompatible
  • Paired or triple exchange
  • Donor exchange chains

94
Conclusion
  • Timely referral to transplant center
  • Communication and collaboration between the
    referring physician, patient, dialysis unit and
    the transplant team are the key
  • Advances in living donation are providing
    patients with more opportunities for transplant

95
Question to Run on?
  • What can you do to educate your patients or
    community on the Journey to Transplant?
  • 3 minutes to work at your tables and report back,
    Go!

96
Transition to Lunch
  • Lunch is from 1230 130
  • In the Crystal Ballroom, on the main level of the
    hotel
  • Open seating
  • Bon Appétit!
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