Pre Transplant KidneyPancreas Educational Session Miami Transplant Institute

Pre Transplant Kidney/Pancreas Educational Session Miami Transplant Institute

About the Transplant Program n n n n Started in 1979 Have performed over 4, 000 kidney transplants 200+ kidney transplants per year (279 in 2009) 25 -30 kidney/pancreas transplants per year Only center in FL performing all transplant types One of the top 10 busiest centers in the US (4 th in nation 2007 behind UCLA, UPMC, UCSF) Success rates for transplant and patient survival are some of the best in the country

Contact Information for the United Network for Organ Sharing (UNOS) www. unos. org n Patient Services Hotline for Concerns or Grievances 1 -888 -894 -6361 n

Who is on Your Transplant Team? n n n n n Transplant Surgeon Transplant Nephrologist Transplant Nurse Coordinator Social Worker Pre Transplant Secretary Donor Team Patient Financial Services Dietician Transplant Psychologist/Addiction Team

Transplant Team-Surgeons n George Burke, MD-Director K/P Program n Dianne Peers, RN-305 -355 -5156 n Gaetano n Tyann Barnes, RN-305 -355 -5082 n Linda Chen, MD. Director Donor Team n Michelle n Ciancio, MD-Asst. Director Gascon, RN-305 -355 -5194 Junichiro Sageshima, MD n Michelle Gascon, RN-305 -355 -5194

Transplant Team. Nephrologists David Roth, MD-Medical Director n Warren Kupin, MD, Asst Director n Giselle Guerra, MD, Medical Director Donor Team n Adela Mattiazzi, MD, Transplant Nephrology n

Facts about Kidney/SPK Transplant Kidney, SPK transplant is a “treatment” for ESRD, diabetes, it is not a cure n Transplantation requires taking life-long anti-rejection medication, follow-up and compliance n Transplantation may prolong your life expectancy n

Selection Criteria for Kidney/Pancreas Transplant The following criteria are used by the Transplant Committee to determine candidacy

Inclusion Criteria for Kidney n n Initiation of dialysis therapy or kidney function of 20% or less (calculated or measured) Age-Infants (10 kg) to adult (no limit) Hepatitis B or C without cirrhosis (evaluated by liver biopsy) HIV infection on HAART therapy (may qualify for current study protocol)

Exclusion Criteria (Absolute and Relative) n n n n Malignancy within the past 2 years (other than skin cancer) Severe Cardiac Disease Severe Pulmonary pathology Hepatitis B or C with documented cirrhosis on liver biopsy HIV + and not on HAART therapy Evidence of current alcohol or substance abuse Morbid Obesity (BMI > 45, unless vascular access has failed) Current psychiatric or psychological pathology

Psychosocial Criteria n n Ability to follow a complex regime of medication and post transplant follow-up (compliance) by oneself or by an identified support person Identified support person available Coverage for medications Transportation

n n What is my next step to becoming a Transplant Candidate? Class Session-attending today 1 st Appointment with the Transplant Team n Physician, Nurse Coordinator, Social Worker, Dietician, lab work n Must bring additional medical records and testing done by Nephrologist and PCP, GYN and Dietician n copy of most recent labs for Dietician n Bring copies of driver’s license and all insurance cards n Bring a Sweater n Bring a snack n Appointment may last hours

What testing is required? n n n n Bladder ultrasound-if indicated Gallbladder/Abdominal ultrasound (good for 2 years)-not required for all Cardiac evaluation (annual) n One of most important aspects of evaluation n Includes EKG, echo, stress test n Cardiac catheterization if indicated Chest x-ray (annual) TB test (annual) Immunizations n Pneumovax-good for 5 years n Hepatitis B vaccine n Varicella Titer-Zoster IGG Gynecological evaluation (done by PCP, good for 2 years, unless indicated otherwise) Vascular studies *any testing done in the 6 months is accepted

Optional testing… n n n n n Pulmonary evaluation CT of abdomen/pelvis (PKD) UGI/endoscopy Colonoscopy (PCP) Dental evaluation (outside) Sustacal Challenge Test (SPK) Ophthalmology evaluation Hepatology consult/liver biopsy-hepatitis (PCP) All other consults (outside) *any other testing as directed by your Past medical history

When and Where Will My Testing be Done? n n Diagnostic testing is required to be arranged by the Transplant Center to be performed at UM/JMH or one of the outlying clinics Biscayne Imaging n MICC n Does not include “standard of care” or pre-existing conditions testing n GYN, oncology, surgical intervention, hepatology/liver biopsy

Meeting with the Transplant Social Worker-Psychosocial Requirements n Funding for transplant medications $4, 500 -$5, 000 per month n Must check insurance coverage and co-pays n If transplant is covered by Medicare primary, anti rejection medications will be covered by Medicare B at 80%-not Medicare D n n n Must have a Primary Caregiver Housing if not a local resident-Transplant House n n Some insurance plans offer travel and lodging benefit Transportation to clinic (no driving 4 -6 weeks) n n n Transplant Center/Pompano Satellite Lab visits 3 x/ week (month 1) 2 x/ week (month 2 ) 1 x / week (month 3) Every other week (4 -6 months) Eventually once a month or every other month depending on status

Psychosocial-Advanced Directives n n If you are unable to make medical decisions an Advanced Directive: n Lets your doctor know the type of medical care you want n Allows you to choose someone you trust (health care surrogate) to carry out your wishes regarding your medical treatment Your Transplant Social Worker can provide you with an Advanced Directive. If you have one already, bring a copy to the hospital when you are admitted for transplant

When will I be listed? n Meet criteria established at this center for listing n n Complete required diagnostic testing and have F/U appt. for initial medical approval Majority approval by Transplant Team (Listing Conference-every Monday

Will blood testing be done? n n n Yes, required in our Lab at the Transplant Center (Miami) Non-Fasting Several tubes

Blood Type n n n n 50% “O”-universal donor 30% ”A” >10% “B” >5% “AB”-universal recipient n Donor n n “O” only “A” or “O” “B” or “O” “AB”, “A”, “B”, or “O” *Deceased Donor-”O” only to type “O”

Genetic Typing You inherit 3 Genes from Mother and 3 from Father=6 Total n Siblings n 50%-3 Gene Match n 25%-6 Gene Match-Identical n 25%-0 Gene Match n *Minimum “ 1” gene match for Deceased List

Cross match n n Mixing of blood between Donor and Recipient Can be performed may times during evaluation Will be final test performed prior to transplant PRA has bearing on results of cross match

What is PRA? n n “Panel Reactive Antibody” What causes antibodies Previous Transplants n Transfusions n Pregnancy n Infection *can have the greatest bearing on your waiting time and will be sent monthly when listed n

What are my Transplant Options? n n n Living Related Donor (LRD) Living Unrelated Donor (LURD) Deceased Donor. Waiting List

Living Donation n Donors an be identified any time (3 at a time only) To Referral Team n To Nurse Coordinator n n Donor n must make contact All donors living here or elsewhere will be phone-screened and provided information and instructions

Goal of Living Donation… n n To make sure that the living donor is not only “willing” to donate but also “able” to donate a kidney safely Risks of the surgical procedure are minimal if medically cleared by the Donor Team Potential donor needs to contact Nurse Coordinator directly for referral to Donor Team Donor can be blood tested any time after recipients blood is drawn

How do I qualify to be a Kidney Donor? n n n n 18 -65 years old No diabetes No hypertension Healthy with no physical problems with kidney Family member-blood relative Extended family member. Non-blood relative Only 3 donors will be blood tested at a time Only 1 donor in active workup at a time

Who is on the Donor Team? Transplant Surgeon n Transplant Nephrologist n Donor Nurse Coordinator n Donor Advocate n Laboratory personnel n Secretarial staff n Transplant Psychologist *team will manage all aspects of Donor testing n

Kidney Donation facts… n n n n All testing is done as an outpatient –preferably at the Transplant Center There are no costs to the donor for evaluation, surgery or immediate post-operative care Recovery time is 2 -6 weeks No heavy lifting for 6 weeks Women can become pregnant after kidney donation Surgery is 3 -4 hours Hospitalization is 3 -4 days The donor can be ruled out for medical/psychological reasons at any point in donation process

How Do I Begin the Donor Process? n Blood testing n n Local donors n n Blood Type Genetic Typing Cross-match Tested at Transplant Center Out-of Area Donors n Will Fed. Ex blood for testing against recipient

What is the Next Step? n n n n Blood testing Urine testing Chest x-ray EKG TB test GTT (if diabetes in family) Gynecological evaluation

Final Donor Testing… n n n Spiral CT Scan of Kidneys Psychological Evaluation History and Physical Surgical Consult Anesthesia Consult Dietician Consult

Surgical Options… n Laparoscopic Nephrectomy n n n Done for left sided kidney removals, beginning to do right lap cases (individual basis) Recovery is quicker Less pain Improved cosmetic results Higher rate of organ donation Decision is based on spiral CT results n Open Nephrectomy n n For right sided removal (individual basis) Longer hospitalization (additional day in the hospital

Laparoscopic Nephrectomy

Benefits of having Living Donor vs. Deceased Transplant n n n Usually a better genetic match Kidney usually functions right away Transplant can be planned Do not have to wait on waiting list for donor Transplant may last longersometimes twice as long as deceased transplant

Deceased Transplant (DD) How long am I going to wait? n Kidney n Average 2 to 3 years in Miami n Can happen at any time from listing

Who receives the kidney? n Based on a point system UNOS-new list is run for each kidney Seniority (days on the list) n Genetic match (better match, more points) n Antibody level (PRA)-higher lever, more points n Up to age 18 -”Kid points” n n Highest point with negative cross match receives kidney

Are there other options for listing? n Expanded Criteria Donor (ECD) list n Discussed at listing with transplant physician n Signed consent is required Separate from standard list n Donor age 60 or older n Donor 50 -59 with two of the following n n Donor medical history of hypertension n Creatinine above 1. 5 (normal 0. 8 -1. 4) n Cause of death from stroke

Other options… n Multiple listing n Allowed by OPTN policy n n Up to individual center to accept as candidate May increase chances of local offer May shorten waiting time-no guarantee Wait Time Transfer n Coordinated by transferring center n n UNOS Form required to be signed by patient/Coordinator/Physician Must be approved by transferring center or you may risk losing all previous wait time

How are organs distributed? Local (UM/JMH list) n Regional – UNOS region 3 (south east states) n National- over 80, 000 on waiting list n Mandatory share n n Perfect match, highest priority

What are my responsibilities to maintain my active listed status? n Keep testing updated annually Cardiac n Chest x-ray n TB n n Every other year (unless otherwise indicated) Gallbladder US n Gynecological n

Listed Patient responsibilities (con’t) Visit transplant center every 6 months n Notify transplant team of any changes in address, phone, insurance or travel n Must send monthly PRA n Notify transplant team of any changes in health or medical urgency issues n n Out of vascular access

Transplant Team’s Responsibility to our patient n Listing letter n n Patient Nephrologist Dialysis center Annual Listed letter n Listed status continues, testing required, hold status issues n n n Patient Nephrologist Dialysis center Insurance company Transplant Informed Consent n n Signed by patient/Coordinator/Transplant Physician Copy to you and your patient file

Listed Status Active (1)-can be called at any time n Hold (7)-will not be called for transplant but time continues to accrue. Can be placed on hold at any time due to medical, psychological or social issues n Medically Urgent (5)- highest priority, medical condition requires transplant ASAP n

What happens if you are called? n n Can be called 24/7 If on dialysis, finish treatment-not first come, first served Can call in 5 -10 people for kidney transplant, unless mandatory share Call in 2 people for SPK/PA n n Must remain on standby for up to 24 hours May have multiple “dryruns”

Instructions for Admission prior to Surgery Map with directions will be provided n Have “goodie bag” ready n List of meds/meds n Essential toiletries n PD supplies n If you need financial assistance, bring a copy of income tax papers n

Don’t bring… Valuables n Plants or flowers n Visitors under the age of 14 n

OR Time/Hospital Stay n Surgery time n n Kidney 4 -6 hours SPK 6 -12 hours Pancreas 4 -6 Time in hospital n n n Discharge teaching will begin from time of admission for transplant-have support system available Discharge when medically stable-even if you may not feel ready Kidney 5 -6 days, may go home with Foley catheter or other new devices (glucometer) SPK 7 days Donors n n 3 Days Laparoscopic Nephrectomy 4 days Open Nephrectomy

Where is the kidney placed?

Will your new kidney work right away? Most kidneys work immediately n Some take a period of time to begin functioning n n n Might require dialysis session(s) Rarely, the kidney never functions n If within 90 days of transplant can be reactivated on the list with no time lost

Post Transplant Medication and After Care Video… n n Anti- rejection medications Diet Follow-up visits and labs Patient responsibilities

Your kidney transplant operation is not the end of this process… it is the beginning

Completion of Medical Lecture n n n Certificate of Completion distribution Q&A Thank you for you attention …Good Luck!