KPD transplants. Dutch Experience. Korean experience. NEAD chain

Transcription

1 KPD transplants David Serur, MD Rogosin, NYP Weill Cornell May 2013 NEAD chain Milestones in Paired Exchange Rees, NEJM, 2009 Korean experience Single center Not computer matched 129 transplants over 11 years Dutch Experience 7 centers, computer match, q3 months match runs Central tissue typing 128 transplants Final crossmatch locally Simultaneous transplants Donor travels Park, Transplantation, 2008 deklerk, Transplantation, 2008

2 Donor travel or Kidney travel? Donor travels: foregoes the logistical complexities of organ transport, minimizes cold ischemia time, and eliminates the financial complexities related to donor costs. Kidney travels: for the donor, travel is costly, subjects him/her to an unfamiliar surgical team and hospital, and separates him/her from family support. Follow-up care, particularly if complications emerge, can be challenging. US Programs Johns Hopkins Paired Donation Network NEPKE National Kidney Registry UNOS KPD pilot Growth of kidney paired donation in the USA (10% of all LRTs) Paired Donation Network Segev, D. L. (2012) Innovative strategies in living donor kidney transplantation Nat. Rev. Nephrol. doi: /nrneph pairs, 46 transplants over 7 years Alliance for Paired donation 155 transplants to date

3 NEPKE NEPKE formed in 2005, 14 regional centers, computerized match runs MAPEP: 5 NJ centers NEPKE/MAPEP 83 transplants since 2005, most initiated by NDD Antibody screening reduced Crossmatch positivity from 50% to 18% National Kidney Registry 63 centers in 23 states Donor and recipient preferences Propagation scores of bridge donors 600 transplants in 5 years Hanto, Transplantation, 2008 NKR SITE Chain Transplantation: Initial Experience of a Large Multicenter Program NKR Chain Transplantation: Initial Experience of a Large Multicenter Program (Cornell) American Journal of Transplantation Volume 12, Issue 9, pages , 19 JUL 2012 DOI: /j x American Journal of Transplantation Volume 12, Issue 9, pages , 19 JUL 2012 DOI: /j x

4 Living donor kidney paired donation transplantation (Cornell) experience Cornell-NKR experience First 50 cases, starting ABO incompatible 9 ended to DDT list 6 CHIP 17 air travel 14 ground travel 19 in-hospital Wait: 141 days (400 UNOS days) 1 yr creat 1.3 mg% Acute rejection 6% 3 cases DGF: 2 ground, 1 in hospital (recurrent FSGS, 2 cases uereteral reimplantation) Clinical Transplantation Volume 26, Issue 3, pages E213-E222, 12 MAR 2012 DOI: /j x Source: personal communication Che Afaneh, MD, 4/27/11 Chain Transplantation: Initial Experience of a Large Multicenter Program (272 transplants in 3 yrs) Transporting Live Donor Kidneys for KPD: Initial National Results (56 transplants by car or air) 14 transcontinental, 12 hr CIT, No DGF American Journal of Transplantation Volume 12, Issue 9, pages , 19 JUL 2012 DOI: /j x American Journal of Transplantation Volume 11, Issue 2, pages , 10 JAN 2011 DOI: /j x Transporting Live Donor Kidneys for KPD (56 transplants by car or air no DGF, 1 case with creat >2 at 1 month) Source: Sign on San diego, NKR American Journal of Transplantation Volume 11, Issue 2, pages , 10 JAN 2011 DOI: /j x

5 60 Lives, 30 Kidneys, All Linked Compatible pairs in KPD NYT, 2/18/12 O donor, unsensitized recipient NKR accessed 10/5/12 Living Donor Age and Kidney Allograft Half-Life: Implications for Living Donor Paired Exchange NKR accessed 10/5/12 Chang, et al. CJASN May 2012 vol. 7 no

6 Ethical Concerns of KPD The hesitant donor has fewer opportunities to back out. Cannot invoke ABO incompatibility as a reason to withdraw. Donor has more stress as backing out will result in many people not getting transplanted. Transfer of a human organ for valuable consideration The DD list is disadvantaged(ndd can donate to DD list) Ross, et al. NEJM 1997 DeKlerk, Transplantation, 2008 Woodle, AJT, 2010 An Act To amend the National Organ Transplant Act to provide that criminal penalties do not apply to human organ paired donation, and for other purposes. <<NOTE: Dec. 21, [H.R. 710]>> Be it enacted by the Senate and House of Representatives of the United States of America in Congress <<NOTE: Charlie W. Norwood Living Organ Donation Act. 42 USC 201 note.>> assembled, SECTION 1. SHORT TITLE. This Act may be cited as the ``Charlie W. Norwood Living Organ Donation Act''. SEC. 2. AMENDMENTS TO THE NATIONAL ORGAN TRANSPLANT ACT. Section 301 of the National Organ Transplant Act (42 U.S.C. 274e) is amended-- (1) in subsection (a), by adding at the end the following: ``The preceding sentence does not apply with respect to human organ paired donation.''; Congressional record, 2007 Gentry in SIAM, 2008 Transplantation Proceedings Volume 44, Issue Gallai-Edmonds Decomposition Roth, 2008

7 Optimization Optimizedmatch.com Source: Optimizedmatch.com Pair 4 (Donor blood type O, Recipient blood type A). Pair 13 (Donor blood type B, Recipient blood type A) has fewer match opportunities because of a less-universal donor. Travel preference Source: Optimizedmatch.com Source: Optimizedmatch.com Many match opportunities exist before Pair 4 and Pair 17 are matched. Many match opportunities are lost after this one strategically wrong match. Source: Optimizedmatch.com Source: Optimizedmatch.com

8 CONCERNS THE O RECIPIENT PROBLEM Transportation issues: kidney lost, kidney grounded, cold ischemia. Recipient issues: cannot accept kidney Donor issues: backs out Financial: transporting kidney, paying donor hospitals, etc The O patient is disadvantaged: The O recipient needs an O donor but is unlikely to get one as O donors from other pairs can usually give to their own recipient. The exception is the case of positive crossmatch between O donor and his recipient. THE O RECIPIENT PROBLEM: possible solutions Altruistically Unbalanced Donation: paired exchange between an incompatible pair and a compatible pair: A O with O A Kranenburg, etal. Transp Int, 2006 THE O RECIPIENT PROBLEM: possible solutions List Exchange: Donor gives to the cadaveric list and the O recipient gets the next O kidney from the list When there are several potential living donors that are incompatible, encourage the O donor to come forward. This alleviates the injustice to the O recipients on cadaveric list Zenios, Transplantation 2001 Ackerman, AJT, 2006 THE O RECIPIENT PROBLEM: possible solutions Include compatible D/R pairs More matches possible O recipients will get organs The recipient of the compatible pair may get a younger better matched donor. Also may avoid child to mother and husband to wife donations. Gentry, AJT, 2007 US Programs Johns Hopkins Paired Donation Network NEPKE National Kidney Registry UNOS KPD pilot

9 NEED FOR A NATIONAL KPD PROGRAM Features of a KPD program, San Antonio Prospective education and consent of all donor and recipient candidates regarding KPD Comprehensive antibody analysis and HLA testing of all recipient and donor candidates Flexible assignment of unacceptable antigens into a computerized matching software program Combination of KPD with desensitization for selected highly sensitized recipients Storage of blood samples from all consenting donor candidates for future crossmatch testing Subtype all blood type A donors into A1 and A2 Use of compatible pairs Bingaman, et al. AJT August 2012 Further Features of a KPD program: NKR Further Features of a KPD program: Consensus Conference 2012 Daily Match Runs Faster matching Real-time 12 deep matching engine Modeled after NYSE Web portal for easy pair enrollment Fast center startup No personal information required Avoids HIPAA issues Automated match offer & tracking Organized & efficient Many of top centers participating For the greater good Leveraging the power of donor chains Open & closed clusters All potential NDDs should be informed about KPD as an option prior to initiating evaluation The medical and psychosocial evaluation of an NDD should be guided by the Evaluation of the Living Kidney Donor a Consensus Document from the AST/ASTS/NATCO/UNOS Joint Societies Work Group recommendations (10) NDDs should undergo preliminary (i.e. screening) assessment by a mental health professional before the medical evaluation is initiated The National Living Donor s Assistance Center should provide travel and lodging expenses to the NDDs American Journal of Transplantation 2013; 13: Further Features of a KPD program: Consensus Conference 2012 In addition to the standard informed consent donor nephrectomy, KPD donor informed consent should include these additional elements: risks and benefits of non-kpd donation options, kidney transport, possible kidney redirection due to unforeseen circumstances, and the inability to provide information about the actual recipient Donor privacy should be strictly protected. Specific consent should be obtained from the donor if their name is released to the press The donor center evaluation processes and procedures at which the donor nephrectomy takes place should be followed All evaluative studies (including anatomic imaging) should be completed before registering a donor in KPD and repeated after 12 months. Anatomical imaging, however, does not need to be routinely repeated American Journal of Transplantation 2013; 13: Ideal National KPD National KPD, other programs retired. Incompatible and compatible pairs: better matching, avoid DSAs, more 0 mm transplants. O patients get transplanted Kidneys travel, not donors. (Just like for DDTs.) Medicare pays but saves fewer repeat transplants needed, less HD needed

10 Source: UNOS NEAD chain Source: NKF First Recipient First Paired Donor Second Recipient Second Paired Donor Third Recipient Bridge Donor R-1 D-1 R-1 D-1 R-1 D-1 R-2 D-2 R-2 D-2 R-2 D-2 NDD R-3 D-3 R-3 D-3 R-3 D-3 R-4 D-4 R-4 D-4 R-4 D-4 R-100 D-100 R-99 D-99 R-98 D Possible x 1 x 99 x98 Combination 100 x 9,900 x 9,701 = 10 Billion

11 NKR website NKR NKR is a 501(c)3 non-profit corporation Started with $2,500,000 in contributions First transplants were facilitated in 2/08 24 donor chains have been started to date 230 transplants have been facilitated to date Advanced Matching Strategies NKR Utilization of non A1 donors for O and B recipients with acceptable titers Inclusion of compatible pairs in swaps Relax preference restrictions (e.g. accept shipped kidney, etc.) Raise MFI thresh-holds - combine with desensitization protocols for highly sensitized recipients Utilize multiple paired donors O donors preferred Increase pool size by encouraging other centers to join and enrolling more pairs per center (including compatible pairs) Outreach utilizing center hosted seminar on paired exchange, letter to all patients on wait list, comprehensive brochure explaining the process and results Altruistic Donors: An efficient process for screening NDDs Daily Match Runs Match Test Transplant Match Offers ed Match Acceptance ed Cross Matches Initiated Cross Matches Completed Surgery Date/Time Set Surgeries Performed 1-2 Days 10 Days 2-5 Weeks

12 Hanto, et al. Transplantation: 27 December 2008 KPD and nondirected donation (NDD) transplants per year George Taniwaki, based on UNOS data Wallis C B et al. Nephrol. Dial. Transplant. 2011;26: The Author Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please journals.permissions@oup.com Milestones in Paired Exchange : Rapaport: The case for a living emotionally related international kidney donor exchange registry : Korea: EXCHANGE DONOR PROGRAM IN KIDNEY TRANSPLANTATION : Dutch program, US programs George Taniwaki, based on UNOS data

13 The Ohio Solid Organ Transplantation Consortium (OSOTC) Founded Ohio centers Non-renal organs Evolved into PDN and APD George Taniwaki, based on UNOS data Bi-Coastal Living Donor Chain Charlton, et al, ASTS 2009 UNOS KPD Pilot

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