Transplantation Dealing with the Landmines

Information about Transplantation Dealing with the Landmines

Published on January 14, 2008

Author: Penelope

Source: authorstream.com

Content

Transplantation: Dealing with Landmines:  Transplantation: Dealing with Landmines Shamkant Mulgaonkar MD Chief Transplant Division Saint Barnabas Health Care System New Jersey Slide2:  Death Death Death Death Death Death Death Death Slide3:  Nancy 28 year Old Dialysis nurse Type I Diabetes age 5 High BP, Proteinuria age 18 Age: 23, Creatinine 3.5 Creatinine Clearance 25 Healthy Parents 50’s 3 Healthy Siblings Age: 26, Develops Retinopathy Starts PD Peritonitis Hemodialysis.. Access problems Slide4:  Age: 27, Develops Dyspnea CHF Toe gangrene Age 28, Referred for Transplant Issues upon arrival Abnormal NST Abnormal ECHO Low EF Abnormal Carotids Abnormal PV studies Age 29, Needs CABG Carotid Bypass Stent both femorals Died at age 29 Death Slide5:  Team approach to serious problems Cardiac testing Vascular w/u Immediate transplant Referral to transplant Kidney or SPK Explore Living donors Dialysis preparation Diagnosis Treatment, tight BS+BP control ACEI ARB Pancreas or islet cell transplant Treatment of newly diagnosed DM Tight BS control Nancy 28 year Old Dialysis nurse Type I Diabetes age 5 High BP, Proteinuria age 18 Age: 23, Creatinine 3.5 Creatinine Clearance 25 Healthy Parents 50’s 3 Healthy Siblings Age: 26, Develops Retinopathy Starts PD..Peritonitis Hemodialysis.. Access problems Slide6:  Died at age 29 Vasculopathy Needs aggressive w/u Arrives alone, blind in a wheelchair Support, many problems Advanced cardiovascular Ineligible ! Age: 27, Develops Dyspnea CHF Toe gangrene Age 28, Referred for Transplant Issues upon arrival Abnormal NST Abnormal ECHO Low EF Abnormal Carotids Abnormal PV studies Age 29, Needs CABG Carotid Bypass Stent both femorals Death What have we learned ?:  What have we learned ? Reduce progression to ESRD : 10 years Surveillance cardiovascular : 10 years Early referral to transplant Prepare for dialysis Adequate dialysis Avoid cardiac and infection problems Early transplant with the best kidney : 20 years Early SPK or PAK transplant : 10 years Projected life expectancy: 65 years Slide8:  Jack 54 year old Truck driver African American ESRD unknown cause Permacath Hemodialysis Noncompliant from Day 1 5 foot 11 inches 312 lbs 1 ppd smoker Access clotted 4 times Transfused 4 units PC Unemployed Lost insurance Slide9:  Remains on dialysis 5 years Family ? No car Uncontrolled BP Dietary noncompliance 8 lb weight gain bet HD Referred to transplant center Leg Graft 59 year old, High PRA No work up in 5 years 2 brothers healthy 1 daughter All in Alabama Slide10:  W/u Renal tumor Hypernephroma Abnormal NST stent COPD Uncontrolled BP Dietary noncompliance 8 lb weight gain bet HD Continues to smoke Listed after w/u, insurance and counseling High PRA 90 % + crossmatch family no LD Died of MI at age 60 Death Slide11:  Jack 54 year old Truck driver African American ESRD unknown cause Permacath Hemodialysis Noncompliant from Day 1 5 foot 11 inches 312 lbs 1 ppd smoker Access clotted 4 times Transfused 4 units PC Unemployed Lost insurance Proper assessment of vascular access Coagulation studies Psychosocial issues Assist with insurance Approach to Obesity Smoking cessation Referral to transplant Creation of AV access Recurrent Nephropathy Slide12:  Remains on dialysis 5 years Family ? No car Uncontrolled BP Dietary noncompliance 8 lb weight gain bet HD Referred to transplant center Leg Graft 59 year old, High PRA No work up in 5 years 2 brothers healthy 1 daughter All in Alabama Willing donors Now an emergency !! Highly sensitized ? Medical problems of ESRD, Smoking, obesity Role of MD/RN/Dietitian Compliance Lost wait time for transplant Where is the family? Importance of transportation Slide13:  W/u Renal tumor Hypernephroma Abnormal NST stent COPD Uncontrolled BP Dietary noncompliance 8 lb weight gain bet HD Continues to smoke Listed after w/u, insurance and counseling High PRA 90 % + crossmatch family no LD Died of MI at age 60 May never get a transplant PERFECT PATIENT !!! Cancer and transplantation Stent or CABG and wait time Sleep apnea, COPD Death What have we learned?:  What have we learned? Diagnose cause of ESRD : Recurrence Surveillance cardiovascular Early referral to transplant W/U Hypercoagulation Aggressive counseling: Dialysis Compliance, Diet, Meds, Cigarette Smoking, Pot Involve family members Assist in insurance matters Adequate dialysis Avoid anemia and transfusions Early transplant with the best kidney Who is responsible for the death of Nancy and Jack?:  Who is responsible for the death of Nancy and Jack? Patient and family Society Internist Endocrinologist Nephrologist Predialysis educator Dialysis nurse Dialysis social worker Transplant center Slide16:  Projected Years of Life from WL for WL Dialysis vs. Transplant Patients by Age Group Projected Years of Life 40 0 20-39 40-59 60-74 Wait List Dialysis Transplant Age Group 20 00079 Slide17:  Projected Years of Life from WL for WL Dialysis vs. Transplant by DM (Age 40-59) DM Non-DM Projected Years of Life 40 0 20 Wait List Dialysis Transplant 00082 Slide18:  63 % 29 % 58 % 78 % Graft survival in of 2,405 recipients of paired kidneys months post-transplant 0-6 months on dialysis >24 months on dialysis Take Charge :  Take Charge Think Death Think Early intervention Think Team approach Think Family Think Insurance Think Compliance Assume responsibility Think Death Conclusions:  Conclusions Renal transplantation is associated with a survival advantage This survival advantage over maintenance dialysis is maintained even when marginal kidneys are used for transplantation Waiting time on dialysis is associated with an increased risk for graft loss and patient death after renal transplantation Incompatible Renal Transplantation or High Risk Transplantation:  Incompatible Renal Transplantation or High Risk Transplantation High Risk Renal Transplantation:  High Risk Renal Transplantation Demographic : Child or age>60, African American Medical : Diabetic, Uncontrolled BP, cardiac problems, High BMI, + Viral infections, Sickle cell disease Surgical : Major abdominal surgery, access, vascular Psychosocial : Noncompliance, Lack of family support, Lack of insurance, alcohol/substance abuse Allograft : Imported, DCD or ECD Immunologic :High PRA, Sensitizing events, Incompatible Blood group Incompatible Renal Transplantation:  ABO Blood Group Incompatible HLA (Cross Match) Incompatible Incompatible Renal Transplantation Blood Group: ABO:  Blood Group: ABO O : Universal donor can receive only O or A2 A : Can receive from A or O B: Can receive from B or O AB : Universal recipient, Can receive from A,B,AB or O Facts:  Facts It is possible that blood group antigens may be shared by some bacteria, leaves and seeds of plants. Infants have low levels and older patients have higher levels due to this exposure. Jill:  Jill 25 year old type I diabetes age 4. Creatinine 5 ( Creatinine clearance 10). Blood group O. Parents : Medical problems. 1 Brother willing donor : Blood group A. No other donors. Slide27:  Plasma exchange IVIG Outcomes Short term Long term:  Outcomes Short term Long term Post transplant:  Post transplant Nonadherance Introduction:  Introduction “Drugs don’t work in patients who don’t take them” -C. Everett Koop, M.D. Non-adherence to transplant medications Important and leading cause of transplant failure Gaston RS, Hudson SL, Ward M, Jones P, Macon R. Late renal allograft loss: noncompliance masquerading as chronic rejection. Transplantation Proceedings. 1999;31(4, Supplement 1):21S-23S. Precedes over 1/3 of transplant failures Butler JA, Roderick P, Mullee M, Mason JC, Peveler RC. Frequency and impact of nonadherence to immunosuppressants after renal transplantation: a systematic review. Transplantation. 2004;77(5):769-776. Non-adherence in general nephrology:  Non-adherence in general nephrology Hemodialysis Newmann JM, Litchfield WE. Adequacy of dialysis: the patient's role and patient concerns. Semin Nephrol. 2005;25(2):112-9. Hecking E, Bragg-Gresham JL, Rayner HC, et al. Haemodialysis prescription, adherence and nutritional indicators in five European countries: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS). Nephrol Dial Transplant. 2004;19(1):100-7. Peritoneal dialysis Bernardini J, Piraino B. Compliance in CAPD and CCPD patients as measured by supply inventories during home visits. Am J Kidney Dis. 1998;31(1):101-7. Case:  Case 39 year old Black female ESRD due to HTN s/p deceased donor renal transplant 5/2002 Creatinine 0.8 in 2004 Recent serum Cr in 2.5-3.0 range Transplant biopsy spring 2005 Moderate chronic allograft nephropathy Immunosuppressive regimen Prednisone Cyclosporine (Neoral) Mycophenolate mofetil (Cellcept) Case (continued):  Case (continued) On emergency visit to transplant clinic, Complained of SOB and DOE for past week Ran out of metoprolol several weeks before Serum Cr 8.5 Admitted to Saint Barnabas Medical Center Repeat transplant biopsy Severe chronic allograft nephropathy Acute cellular rejection, grade 1B Treated with high-dose corticosteroids Upon further questioning, patient admitted Not taking prednisone for past several months Not taking mycophenolate mofetil for past 3 weeks Awaiting mail delivery of prescriptions Case (continued):  Case (continued) Hospital course Started on hemodialysis for uremic symptoms Immunosuppressive medications changed Cyclosporine replaced with tacrolimus When dialysis held, transplant failed to show any function Patient returned to maintenance dialysis Profiles of non-adherent patients:  Profiles of non-adherent patients Greenstein S, Siegal B. Compliance and noncompliance in patients with a functioning renal transplant: a multicenter study. Transplantation. 1998;66(12):1718-26. “Accidental” non-compliers Disorganized Medication ingestion is not a priority “Invulnerables” Believe that they do not need to take their immunosuppressive medications regularly “Decisive” noncompliers Independent rationales for non-adherence Reasons for non-adherence: Medication costs:  Reasons for non-adherence: Medication costs Anti-rejection medications with 20% co-pay: $260.64 Other transplant medications: $1101.41 Having a working transplant kidney and staying off dialysis: Priceless Reasons for non-adherence: Complexity of treatment regimen:  Reasons for non-adherence: Complexity of treatment regimen Increased dosing frequency Leads to decreased adherence Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther. 2001;23:1296-310. Reasons for non-adherence: Psychosocial factors:  Reasons for non-adherence: Psychosocial factors Depression Kiley DJ, Lam CS, Pollak R. A study of treatment compliance following kidney transplantation. Transplantation. 1993;55:51-6. Stress Frazier PA, Davis-Ali SH, Dahl KE. Correlates of noncompliance among renal transplant recipients. Clin Transplant. 1994;8:550-7. Health locus of control Raiz LR, Kilty KM, Henry ML, Ferguson RM. Medication compliance following renal transplantation. Transplantation. 1999;68:51-5. Race Schweizer RT, Rovelli M, Palmeri D, Vossler E, Hull D, Bartus S. Noncompliance in organ transplant recipients. Transplantation. 1990;49:374-7. Reasons for non-adherence: Side effects of medicines:  Reasons for non-adherence: Side effects of medicines Medication side effects are under-recognized by transplant professionals Peters TG, Spinola KN, West JC, Aeder MI, Danovitch GM, Klintmalm GB, et al. Differences in patient and transplant professional perceptions of immunosuppression-induced cosmetic side effects. Transplantation. 2004;78:537-43. Cosmetic changes Important cause of non-adherence among adolescents and young adults Prevalence of non-adherence:  22% of transplant recipients were non-adherent Median of 36.4% of graft losses are associated with prior non-adherence Probably underestimates the actual incidence Prevalence of non-adherence Interventions to increase adherence:  Interventions to increase adherence Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487-97. Patient education Improved dosing schedules Improved communication between physicians and patients Why there will not be a Steroid booth at Meetings ?:  Why there will not be a Steroid booth at Meetings ? Weight gain Mood changes Cataract Osteoporosis Avascular necrosis Hypertension Diabetes mellitus Depression Peptic ulcer Infections Skin friability Abdominal strae Hyperlipidemia Cosmetic changes: moon face, hirsutism, acne SBHCS Protocol : Immunosuppression:  SBHCS Protocol : Immunosuppression Thymoglobulin 6 mg/kg over 3-4 days starting intra op Solumedrol 500 mg pre-op, then 250 mg bid post-op day 1, 125 mg bid post op day 2 and 60 mg bid post op day 3 Tacrolimus:Trough levels 10 for 90 days, 8-10 until 365 days,5-8 after 365 days Mycophenolate Mofetil 1 gram bid In Sirolimus arm : Levels 10 for 90 days, 5-8 until 365 days and 5 thereafter. Suspected ACR: Biopsy and treatment with Thymoglobulin, no steroids Prophylaxis: Bactrim DS, Mycelex, Valcyte Results:  Results 120 patients March 2003-March 2006 Patient survival 98% Kidney survival 96% BP controlled with less meds Decreased incidence of NOD No bone fractures Cosmesis excellent No psych problems Improved adherence Graft Loss:  Graft Loss Acute rejection Chronic allograft nephropathy Impact of return to dialysis Treatment of Acute Rejection:  Treatment of Acute Rejection Chronic Rejection Chronic Allograft Nephropathy [CAN]:  Chronic Rejection Chronic Allograft Nephropathy [CAN] One of the most common causes of CKD 25 % Patients waiting for TSP have chronic allograft failure. 20% Kidneys go to patients who have failed 1 or more transplants. Slide51:  HLA Matching Acute rejection Non adherence Infections Hypertension Recurrent disease

Related presentations


Other presentations created by Penelope

7E Acids and Alkalis
22. 01. 2008
0 views

7E Acids and Alkalis

India and Power
21. 01. 2008
0 views

India and Power

522 bioremediation
19. 01. 2008
0 views

522 bioremediation

MOLLUSKS 4 13 07
08. 01. 2008
0 views

MOLLUSKS 4 13 07

paper liners that work
10. 01. 2008
0 views

paper liners that work

Nazroo
11. 01. 2008
0 views

Nazroo

partnership
12. 01. 2008
0 views

partnership

N95 Respirator Training
13. 01. 2008
0 views

N95 Respirator Training

CISSIP Bahamas
15. 01. 2008
0 views

CISSIP Bahamas

schiffman08
17. 01. 2008
0 views

schiffman08

4 Unit 11
17. 01. 2008
0 views

4 Unit 11

06sw2aslides
18. 01. 2008
0 views

06sw2aslides

rastogi slides
23. 01. 2008
0 views

rastogi slides

HND203 Mail Routing Mastery
04. 02. 2008
0 views

HND203 Mail Routing Mastery

futureofgadgets2006
04. 02. 2008
0 views

futureofgadgets2006

TheCeramicsIndustry
11. 02. 2008
0 views

TheCeramicsIndustry

ifpte2002plenary
09. 01. 2008
0 views

ifpte2002plenary

ChesapeakeBayProject Web
15. 01. 2008
0 views

ChesapeakeBayProject Web

Doha Cotton feb05
25. 01. 2008
0 views

Doha Cotton feb05

turningtorso
25. 01. 2008
0 views

turningtorso

federal estate gift tax
28. 01. 2008
0 views

federal estate gift tax

outline5
14. 02. 2008
0 views

outline5

beowulf
18. 02. 2008
0 views

beowulf

consumerbehavior
28. 01. 2008
0 views

consumerbehavior

Compton
29. 02. 2008
0 views

Compton

notes week12 priv tech
31. 01. 2008
0 views

notes week12 priv tech

Surrealist ethnography
03. 03. 2008
0 views

Surrealist ethnography

gapped summary 2005
08. 03. 2008
0 views

gapped summary 2005

WEDDING
05. 02. 2008
0 views

WEDDING

fy2006 04 tourism ecom impact
14. 03. 2008
0 views

fy2006 04 tourism ecom impact

Hazan Netart Seoul 2004
19. 03. 2008
0 views

Hazan Netart Seoul 2004

Benchmarking for ITE 06
21. 03. 2008
0 views

Benchmarking for ITE 06

week 8 logistics processes 2006
24. 03. 2008
0 views

week 8 logistics processes 2006

TBC Overview
07. 02. 2008
0 views

TBC Overview

Travel Seminar 02072008
07. 04. 2008
0 views

Travel Seminar 02072008

Business An$wers Only
08. 04. 2008
0 views

Business An$wers Only

ziegler
24. 01. 2008
0 views

ziegler

gc06 7
15. 04. 2008
0 views

gc06 7

pptgame
12. 02. 2008
0 views

pptgame

Passage b
17. 04. 2008
0 views

Passage b

Terry Young FEI OC China 5 9 07
22. 04. 2008
0 views

Terry Young FEI OC China 5 9 07

Altec Group Internet
24. 04. 2008
0 views

Altec Group Internet

Dr Sachin Chaturvedi
07. 05. 2008
0 views

Dr Sachin Chaturvedi

PD2
07. 02. 2008
0 views

PD2

temporal reasoning CAA 04 12
02. 05. 2008
0 views

temporal reasoning CAA 04 12

SECCHI STEREOswg04v6
22. 01. 2008
0 views

SECCHI STEREOswg04v6

TheCaseforPro LifeDems
10. 01. 2008
0 views

TheCaseforPro LifeDems

UTIL WaterConservationTips 03 06
03. 03. 2008
0 views

UTIL WaterConservationTips 03 06

ch10 1
13. 01. 2008
0 views

ch10 1

GetCleanPresentation
22. 01. 2008
0 views

GetCleanPresentation

COTAR Nov02 ReportAPSEPG2002
23. 01. 2008
0 views

COTAR Nov02 ReportAPSEPG2002

CurrentTrendsGlassRe cycling
09. 01. 2008
0 views

CurrentTrendsGlassRe cycling

BIC
17. 01. 2008
0 views

BIC

celle
07. 03. 2008
0 views

celle

bodewits
16. 01. 2008
0 views

bodewits