9/30/2016. Chris E. Freise, MD Professor of Surgery UCSF Transplant Division

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1 Chris E. Freise, MD Professor of Surgery UCSF Transplant Division Clear advantages over deceased donation for kidney transplant Shorter wait times Better short and long term function Improved graft half-life Ability to desensitize Program started 1964 Volume per year living donor Despite many resources dedicated to program, still only about % of kidney transplants are living donor Adult Program : Pediatric Program: 3 half day eval clinics per week on main campus Multiple outreach sites Dedicated Transplant Floor Reserved OR block time Good access to consultants, radiology Separate Campus 1 half day eval clinic Reserved OR block time Donors done at main campus 1

2 The Living Donor Team Donor RN Coordinator 2.6 Outreach Coordinator 0.4 LD Recipient Coordinator 1.0 LD Recip Coordinator NKR 1.0 LD Facilitator 1.0 NP 0.5 ILDA 0.7 Financial Counselor 0.75 Psychiatrist 0.05 Pharmacist 0.05 Data Coordinator 0.75 Admin Assistant 3.5 New Evaluations 890 Donor HHQ reviewed 1770 Donor Progressed to DWU Living Donor Transplants 100 (202 deceased donor) Surgeons 9 (4 donor surgeons) Nephrologists 7 The Transplant Funnel Recipients Donors Challenges: Educating recipients on survival advantage Timely work-up of donor and recipient Minimizing hassles for donor Tracking donors and recipients in process Maintaining high quality care (ie Outcomes) Compliance with regulations Coordinating multiple providers required interactions with donors and recipients Producing results to justify support Initial Eval Appropriate testing Selection Prepare Donor HHQ DWU 1 DWU2 Selection Prepare Transplant 2

3 Phases of Care Recipient Eval Breeze Donor Questionnaire Donor Workup 1 Donor Workup 2 Preop Visit Surgery Postop Cares Donors and Recipients tracked through phases electronic database Recipient Evaluation Half day visit Nephrologist/Surgeon, Coordinator, Finance, Social Work, Dietician Education on aspects of transplant, Video Program Introduction special programs High Risk donor High KDPI donor HCV positive donor Bariatric program Emphasis on living donor On Site Selection, Select Cases to Formal Selection 3

4 Recipient Evaluation If patient meets listing criteria, placed on UNOS list Further work-up proceeds based on proximity to estimated transplant time If living donor HHQ received, further recipient work-up shifts to LD coordinator once donor clears DWU 1 milestone Donor Evaluation INTAKE Electronic HHQ (BREEZE) Screening questions Can rule out based on weight, other criteria HHQ reviewed by dedicated coordinator Phone contact with donor, review HHQ, discussion of phases of workup, consented for donor evaluation Donor Workup 1 Local Lab tests GFR measurement ABO typing Blood Pressure Measurement (Voucher for BP checks) Request of records Review and cleared by Dedicated Coordinator with input from nephrology Donor Workup 2 Donor case forwarded to new coordinator to complete workup Review of outside records Extra testing scheduled (echo, specialty consults) ABO type (A2, paired exchange) HLA typing and crossmatch Clinic Visit Nephrology/Surgery face to face clinic visit CT angiogram ILDA eval, psychiatry if needed On to selection conference when work-up completed of recipient 4

5 Recipient Workup progresses in parallel with DWU 2, When studies completed, seen for re-evaluation for final clearance On to selection conference Physician Support Throughout work-up phase of donors and recipients, nephrologists are available to navigate through abnormal results, further testing (Buddy docs) Single surgeon reviews all CT imaging of donors for clearance Same surgeon also reviews donor workup for any other issues of concern Donor surgeons meet with all potential donors at donor workup 2 to discuss procedure Other Considerations Discussion about Paired kidney Exchange Possibility of internal swaps explored Assessment of interest in compatible pairs participating in exchange program Formal Selection Conference Discussion of all potential living donors and recipients for final clearance If approved, surgery can be scheduled If any concerns about pain management referral made to pain service Pharmacist will review donor meds, as well as outpatient prescriptions filled for pain meds. If significant, referral to pain service for preop assessment If cleared, surgery date arranged 5

6 Preop Visits Repeat essential labs Final crossmatch Infectious disease testing Meeting with anesthesia Meeting with respective surgeons (if not seen before) Discussion of eligibility for studies Hardstop Report Hardstop Report Reviewed by donor and recipient surgeon, as well as nephrologist After review, each person above replies by verifying infectious disease clearance Now include immunosuppression plan (based on final crossmatch information) 6

7 Surgery All donors done via laparoscopic approach Recipients done in parallel Protocols for floor management Followed in clinic by nephrology/ NP s Long Term Care of Donors Contact with ILDA to remind of follow-up Triggers sent automatically Option of returning to UCSF offered New program of Thank You card sent to donors at yearly milestones up to year 5, with inserts addressing importance of healthy lifestyle QA/QI Can track time between phases as metric of efficiency Weekly meeting with living donor team to discuss areas for change/improvement Participation of surgical director, medical director, transplant administration Meeting agenda developed by lead living donor coordinator Recently established leadership meeting to further evaluate workflow for areas of improvement Increasing Number of Donors Goal for all transplant centers First step is proper education recipient Initial information at first evaluation Could improve education efforts through dialysis units, referring nephrologists. Utilize novel methods to identify potential donors for a given recipient Social network tools/apps Donor Champion program 7

8 A Smartphone App for Increasing Live Organ Donation Smartphone App Cameron et.al. AJT 2016 Allows for recipients to create Facebook post about need for organ Is a passive method of relaying information about need to potential donors that might be in social network In limited study use of method increased donors coming forward by 6 fold American Journal of Transplantation 10 AUG 2016 DOI: /ajt Live Donor Champion Program Developed at Johns Hopkins Series of educational sessions, role playing exercises to train advocate for potential recipient (Living donor champion) on methods to spread awareness of need of recipient for transplant. Transfers the barrier of how to ask from the recipient to the live donor champion. 8

9 Live Donor Champion Program at UCSF Modeled after Hopkins Program Will be condensed into two sessions Educational materials now available to centers Future Directions to Increase Living Donors Further decrease disincentives Build on NLDAC Reimbursement of donor costs for all donors Protection of employment status (Donor Protection Act) Remove risk of increased health care premiums for donors Donor Health Insurance Would ensure access to proper lifelong follow-up Catastrophic insurance for periop events Non Directed donors who enter exchange program allowed to identify family members who could receive a kidney in future if they developed renal failure. 9

10 Conclusions Living donor kidney transplant remains the gold standard as an organ source Transplant centers need to commit appropriate resources for a successful program Process needs to be efficient for both donor and recipient Future directions with an advocacy approach need to be further explored 10

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