Pre Transplant Educational Session

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Pre Transplant Kidney/PancreasEducational Session

• Miami Transplant Institute

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About the Transplant Program

• 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 (4th
  in nation 2007 behind UCLA, UPMC, UCSF)
• Success rates for transplant and patient survival
  are some of the best in the country

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Contact Information for theUnited Network for
Organ Sharing (UNOS)

• www.unos.org
• Patient Services Hotline for Concerns or
  Grievances
• 1-888-894-6361

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Who is on Your Transplant Team?

• Transplant Surgeon
• Transplant Nephrologist
• Transplant Nurse Coordinator
• Social Worker
• Pre Transplant Secretary
• Donor Team
• Patient Financial Services
• Dietician
• Transplant Psychologist/Addiction Team

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Transplant Team-Surgeons

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

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Transplant Team-Nephrologists

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

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Facts about Kidney/SPK Transplant

• Kidney, SPK transplant is a treatment for ESRD,
  diabetes, it is not a cure
• Transplantation requires taking life-long
  anti-rejection medication, follow-up and
  compliance
• Transplantation may prolong your life expectancy

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Selection Criteria for Kidney/Pancreas Transplant

• The following criteria are used by the Transplant
  Committee to determine candidacy

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Inclusion Criteria for Kidney

• Initiation of dialysis therapy or kidney function
  of 20 or less (calculated or measured)
• Age-Infants (10kg) 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)

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Exclusion Criteria(Absolute and Relative)

• 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 gt 45, unless vascular access
  has failed)
• Current psychiatric or psychological pathology

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Psychosocial Criteria

• 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

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What is my next step to becoming a Transplant
Candidate?

• Class Session-attending today
• 1st Appointment with the Transplant Team
• Physician, Nurse Coordinator, Social Worker,
  Dietician, lab work
• Must bring additional medical records and testing
  done by Nephrologist and PCP, GYN and Dietician
• copy of most recent labs for Dietician
• Bring copies of drivers license and all
  insurance cards
• Bring a Sweater
• Bring a snack
• Appointment may last hours

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What testing is required?

• Bladder ultrasound-if indicated
• Gallbladder/Abdominal ultrasound (good for 2
  years)-not required for all
• Cardiac evaluation (annual)
• One of most important aspects of evaluation
• Includes EKG, echo, stress test
• Cardiac catheterization if indicated
• Chest x-ray (annual)
• TB test (annual)
• Immunizations
• Pneumovax-good for 5 years
• Hepatitis B vaccine
• 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

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Optional testing

• 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

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When and Where Will My Testing be Done?

• 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
• MICC
• Does not include standard of care or
  pre-existing conditions testing
• GYN, oncology, surgical intervention,
  hepatology/liver biopsy

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Meeting with the Transplant Social
Worker-Psychosocial Requirements

• Funding for transplant medications
• 4,500-5,000 per month
• Must check insurance coverage and co-pays
• If transplant is covered by Medicare primary,
  anti rejection medications will be covered by
  Medicare B at 80-not
• Medicare D
• Must have a Primary Caregiver
• Housing if not a local resident-Transplant House
• Some insurance plans offer travel and lodging
  benefit
• Transportation to clinic (no driving 4-6 weeks)
• 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

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Psychosocial-Advanced Directives

• If you are unable to make medical decisions an
  Advanced Directive
• Lets your doctor know the type of medical care
  you want
• 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

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When will I be listed?

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

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Will blood testing be done?

• Yes, required in our Lab at the Transplant
  Center (Miami)
• Non-Fasting
• Several tubes

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Blood Type

• Type
• 50 O-universal donor
• 30 A
• gt10 B
• gt5 AB-universal recipient

• Donor
• O only
• A or O
• B or O
• AB, A, B, or O
• Deceased Donor-O only to type O

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Genetic Typing

• You inherit 3 Genes from Mother and
• 3 from Father6 Total
• Siblings
• 50-3 Gene Match
• 25-6 Gene Match-Identical
• 25-0 Gene Match
• Minimum 1 gene match for Deceased List

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Cross match

• 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

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What is PRA?

• Panel Reactive Antibody
• What causes antibodies
• Previous Transplants
• Transfusions
• Pregnancy
• Infection
• can have the greatest bearing on your waiting
  time and will be sent monthly when listed

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What are my Transplant Options?

• Living Related Donor (LRD)
• Living Unrelated Donor (LURD)
• Deceased Donor-Waiting List

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Living Donation

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

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Goal of Living Donation

• 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

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How do I qualify to be a Kidney Donor?

• 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

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Who is on the Donor Team?

• Transplant Surgeon
• Transplant Nephrologist
• Donor Nurse Coordinator
• Donor Advocate
• Laboratory personnel
• Secretarial staff
• Transplant Psychologist
• team will manage all aspects of Donor testing

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Kidney Donation facts

• 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/psychologic
  al reasons at any point in donation process

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How Do I Begin the Donor Process?

• Blood testing
• Blood Type
• Genetic Typing
• Cross-match
• Local donors
• Tested at Transplant Center
• Out-of Area Donors
• Will FedEx blood for testing against recipient

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What is the Next Step?

• Blood testing
• Urine testing
• Chest x-ray
• EKG
• TB test
• GTT (if diabetes in family)
• Gynecological evaluation

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Final Donor Testing

• Spiral CT Scan of Kidneys
• Psychological Evaluation
• History and Physical
• Surgical Consult
• Anesthesia Consult
• Dietician Consult

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Surgical Options

• Laparoscopic Nephrectomy
• 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

• Open Nephrectomy
• For right sided removal (individual basis)
• Longer hospitalization (additional day in the
  hospital

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Laparoscopic Nephrectomy
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Benefits of having Living Donor vs. Deceased
Transplant

• 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 longer-sometimes twice as
  long as deceased transplant

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Deceased Transplant (DD)How long am I going to
wait?

• Kidney
• Average 2 to 3 years in Miami
• Can happen at any time from listing

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Who receives the kidney?

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

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Are there other options for listing?

• Expanded Criteria Donor (ECD) list
• Discussed at listing with transplant physician
• Signed consent is required
• Separate from standard list
• Donor age 60 or older
• Donor 50-59 with two of the following
• Donor medical history of hypertension
• Creatinine above 1.5 (normal 0.8-1.4)
• Cause of death from stroke

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Other options

• Multiple listing
• Allowed by OPTN policy
• Up to individual center to accept as candidate
• May increase chances of local offer
• May shorten waiting time-no guarantee
• Wait Time Transfer
• Coordinated by transferring center
• 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

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How are organs distributed?

• Local (UM/JMH list)
• Regional UNOS region 3 (south east states)
• National- over 80,000 on waiting list
• Mandatory share
• Perfect match, highest priority

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What are my responsibilities to maintain my
active listed status?

• Keep testing updated annually
• Cardiac
• Chest x-ray
• TB
• Every other year (unless otherwise indicated)
• Gallbladder US
• Gynecological

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Listed Patient responsibilities (cont)

• Visit transplant center every 6 months
• Notify transplant team of any changes in address,
  phone, insurance or travel
• Must send monthly PRA
• Notify transplant team of any changes in health
  or medical urgency issues
• Out of vascular access

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Transplant Teams Responsibility to our patient

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

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Listed Status

• Active (1)-can be called at any time
• 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
• Medically Urgent (5)- highest priority, medical
  condition requires transplant ASAP

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What happens if you are called?

• 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

• Must remain on stand-by for up to 24 hours
• May have multiple dry-runs

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Instructions for Admission prior to Surgery

• Map with directions will be provided
• Have goodie bag ready
• List of meds/meds
• Essential toiletries
• PD supplies
• If you need financial assistance, bring a copy of
  income tax papers

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Dont bring

• Valuables
• Plants or flowers
• Visitors under the age of 14

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OR Time/Hospital Stay

• Surgery time
• Kidney 4-6 hours
• SPK 6-12 hours
• Pancreas 4-6
• Time in hospital
• 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
• 3 Days Laparoscopic Nephrectomy
• 4 days Open Nephrectomy

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Where is the kidney placed?
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Will your new kidney work right away?

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

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Post Transplant Medication and After Care Video

• Anti- rejection medications
• Diet
• Follow-up visits and labs
• Patient responsibilities

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Your kidney transplant operation is not the end
of this process it is the beginning
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Completion of Medical Lecture

• Certificate of Completion distribution
• QA
• Thank you for you attention Good Luck!