Post on 15-Aug-2020
transcript
Donation After Circulatory DeathLocal Transplant Outcomes
Dr. Jeff Zaltzman
Director Division Nephrology, Medical Director Diabetes Comprehensive Care Program, St. Michael’s Hospital
CMO Transplant, Trillium Gift of Life Network
Professor of Medicine , University of Toronto
Objectives
• DCD in Canada
• DCD impact on DBD
• Local transplant outcomes from DCD donors
Canada 2015: 651 deceased donors, 138 DCD(21%)Record year
Pop: 35,851,000RPM=18.1
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2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Canada 2001-2015
NDD DCD
Canadian DCD activity 2006-2015
PROVINCE TOTAL DCD 2006-2015 % of all DCD
CANADA 637 100
BC 64 10.0
ALBERTA* 24 3.8
SASK 1 0.15
MANITOBA* 0 0
ONTARIO 426 67
QUEBEC 99 15.5
NOVA SCOTIA 23 3.6
NEW BRUNSWICK 0 0
PEI 0 0
NFLD 0 0
* Both Calgary and Manitoba have begun DCD activity in 2016
Donation after circulatory death CD RPM 2006-2015 (courtesy of CBS)
Ontario Deceased Donation 2015 :269 DD, 84(31%) DCD, both records! 2016 will smash these #s, 295 DD (90 DCD) as of Oct 31 2016!!!!!
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2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
DCD
NDD
Ontario: 13.5 millionDonor RPM=22 (2016 Expected Donor RPM~25)
Ontario DCD transplants June 1 2006-Sept 30 2016503 DCD donors
Organs Transplanted Organ Number
KIDNEY 850
LIVER 168
LUNG 135
PANCREAS (whole) 33
TOTAL 1186*
Has DCD impacted on DBD donors in Ontario?
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CVA/Stroke Head Trauma Anoxia Other
Pre (2002/03 - 2005-06) Post 1 (2006/07 - 2009/10)
Post 2 (2010/11 - 2013/14)
Cause of Death; all donors
3 Eras: Pre DCD, Post DCD 1(2006-2010), Post DCD2 (2010-2014)
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Pre (2002/03 - 2005-06) Post 1 (2006/07 - 2009/10) Post 2 (2010/11 - 2013/14)
NDD Donors DCD Donors All Donors
No reduction in Transplant activity since DCD
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Kidney Liver Lung Heart KP & P
Local transplant outcomes from DCD donors
Age 36 years (±15)
Gender 59 male (69%)
Brain Injury
32 trauma (37%)
24 stroke/bleed (28%)
28 anoxic injury (33%)
2 other (2%)
BMI 24 kg/m2 (±4)
WIT (from WDLS) 29 minutes (±17)
DCD Donor CharacteristicsLHSC and TGH Experience Courtesy Dr. R Hernandez
n = 91
Aims:
• Develop a definition of f-WIT based on hemodynamic parameters
• Primary Outcomes:
1) Graft Failure2) Biliary Complications
Methods:
• Multi-center (London and Toronto, Canada)
• July 2006- Sept 2013
• All recipients of Maastricht Category III DCD liver allografts
DCD Liver Graft Survival Rates
72.87%
62.91%
88.11%
78.16%
84.11%
58.77%
65.47%
79.43%
73.78%
83.26%
68.81%
77.04%
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6 12 24 36MONTHS POST TRANSPLANT
GR
AF
T S
UR
VIV
AL R
AT
E
)15,644(SCD )903(DCD )4,910(ECD
Deceased Donor Liver Transplants Performed 1/04 – 6/07*
*Based on OPTN data as of March 7, 2008
Intrahepatic Cholangiopathy
• 33–50% incidence of IC
• High rate of graft failure and re-Tx
DCD Recipient CharacteristicsLHSC and TGH Experience
Age 54.5 years (±9)
Gender 74% male
Diagnosis Most common: HCV and Etoh
MELD (uncorrected) 21 (±7)
HCC 23 %
CIT 5.6 hours (±1.4)
DCD – ResultsLHSC and TGH Experience
Patient survival 83.0%
Graft survival 79.5%
PNF 4.0%
Re-LT 4.0%
Biliary complications 18%
Ischemic cholangiopathy 6.3%
Vascular complications 0%
n = 91 DCD-LT, Mean follow-up = 5 years
Graft Failure
OR p value
Donor Age 1.08 0.019
WIT 1.02 0.163
MAP <50mmHg 1.02 0.622
MAP <55mmHg 1.02 0.153
Systolic <55mmHg 1.01 0.863
• Univariate analysis• total warm ischemia time (WIT) • oxygen saturation• mean arterial pressure (MAP) • systolic pressure (sBP)
• Donor age was a significant predictor of outcome (p=0.019)• dichotomized at 55 years
none were
predictive of graft
failure
Age Graft Failure
<55 7%
>55 33%
Results: Graft Failure
Biliary Complications:
OR p value
Donor Age 1.02 0.258
WIT 1.02 0.134
MAP <50mmHg 1.1 0.013
MAP <55mmHg 1.1 0.017
Systolic <55mmHg 1.12 0.021
Systolic <50mmHg 1.14 0.02
Saturation <70% 1.02 0.285
Saturation <60% 1.02 0.345
OR of univariate analysis
Time Biliary Complications
<25 min 9%
>25 min 56%
Results: Biliary Complications
• MAP <50 mmHg
Primary Endpoints:
• Graft failure was observed in 4% of patients
• Biliary complications occurred in 24% of patients
Conclusions
• Donor age was the only good predictor of graft failure
• MAP <50mmHg was the best predictor of biliary complications• Relatively low risk when <25min
• Total WIT and oxygen saturation were not good predictors of failure or biliary complications
26 26
Toronto General: DCD vs. NDD Lung
Transplants Courtesy Dr. M. Cypel
1983-09/2016 (YTD)
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Total DCD performed to-date(N=135)
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DCD donors +/- EVLP2007- 09/2016 (YTD)
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N for DCD-Tx to-date =135DCD-EVLP-Tx= 91/135 (67.4%)
2011
• DCD donors / All deceased donors= 42/220 (19%)
• DCD LungTx / All Lung Tx= 16/102 (16%)
• DCD Lung Tx / All DCD donors(utilization)= 15/42 (38%)
475 Lung TxJan 07-Dec 11
432 BDD Transplants
BDD Group N= (413)
19 ECLS bridge to Tx(excluded)
3 ECLS bridge to Tx(excluded)
DCD group (n=40)
43 DCD Transplants
Outcomes of DCD vs BDDVariable DCD
(N=40)
BDD
(N=413)
P Value
PGD 3 at ICU arrival (%) 27.5 17 0.12
PGD 3 at 72h (%) 12.5 10 0.62
ECMO (%) 5 2.7 0.12
Mechanical ventilation ( median days) 2.2 2.7 0.78
ICU stay (median days) 4 4 0.69
Hospital stay (median days) 22 22 0.58
30 Mortality (%) 5 4 0.10
Survival
0 365 730 1095 1460 18250
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100BDD
DCD
p= 0.48
87%
71%
55%
Days after transplantation
Perc
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Ontario DCD kidneys
• By Sept 30, 2016, 850 kidney transplants from DCD donors in Ontario
• Most kidneys (all types) are placed on pulsatile perfusion pumps
• In 2016, decision by kidney working group to increase age of acceptance of DCD kidneys from 65 to 70 ( 80 for NDD)
Definition of Extended criteria donor (ECD):
1) any donor 60 yrs or older
2) donor 50-59 with 2/3 of following: a) hypertension, b) ICH,
c) terminal sCr 132 umol/l
December 2014: USA went to new KAS, using Kidney Donor RiskKDRI or KDPI and recipient risk
St. Michael’s Hospital data Recent Era of DCD : 2012-2016
• Reported on 3 year Ontario outcomes 2006-2009 Organ donation after cardiac death: donor and recipient outcomes after the first three years of the Ontario experience. Hernandez et al. Can J anaesth 2011 58(7):599
• DCD and and NDD were equal
• DCD/ECD worse renal function.
• Early DCD were highly selected.
• In more recent era of DCD, donors are sicker older. More anoxic brain injury
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CVA/Stroke Head Trauma Anoxia Other
Pre (2002/03 - 2005-06)Post 1 (2006/07 - 2009/10)Post 2 (2010/11 - 2013/14)
Cause of Death; all donors, Ontario
DCD patient and Kidney graft survival: 2006-2009
• 1 year patient survival- 96%
• 1 year death censored allograft survival-97%
• 1 year graft survival- 92%
• Patient deaths : 1 CVA, 1 MVA, 1 lymphoma, 1 mesothelioma, 1 progressive neurologic
• Graft losses: 2 venous thrombosis, 1 recurrent GN
Organ donation after cardiac death: donor and recipient outcomes after the first three years of the Ontario experience. Hernandez et al. Can J anaesth 2011 58(7):599
Other Kidney DCD outcomes
• DGF ( need for dialysis) – 67%
• Use of ALG induction- 90%
• Mean WIT – 42 ± 13 min
• Mean CIT - 8.3 ± 3.8 hr
• Use of pumps - 34%
• ECD/DCD - 20/126 (16%)
Renal Function DCDSDC vs ECD
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Dy3 Dy7 Mth1 Mth3 Mth6 Mth12
SDC
ECD
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St. Mikes living/deceased donor recipients 2012-2016
LD=189, DD=445
LD DD
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Deceased Donor typesRecipient outcomes
2012-2016
NDD SCD NDD ECD DCD SCD DCD ECD
N= 169 119 89 29
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Allograft Survival by donor type
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NDD SCD NDD ECD DCD SCD DCD ECD
Death-censored graft survival by donor type
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Summary
• DCD is fastest growing source of deceased donors in Canada
• Canada DCD rates now exceed USA
• No evidence that DCD impacts DBD donor rates
• Ontario has largest % DCD donors in all North American jurisdictions
• Transplant outcomes with lungs appear comparable with NDD
• Liver outcomes less favourable, but donor age and MAP pre death time play a role
• Kidney allografts slightly inferior, but differences diminish when death censored graft loss is accounted for