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SITUACIÓN ACTUAL DE LA DONACIÓN Y PERSPECTIVAS A MEDIO PLAZO
Barcelona 22 de Noviembre 2012
Martí Manyalich, MD, PhD, Assoc.Prof. Universitat de Barcelona
Asesor de Trasplantes Hospital Clínic de Barcelona
Jornadas de Otoño “Trasplante Hepático”
International Registry in Organ Donation
IRODaT
35,3
35
29,3
28,5
26
25,6
24,8
23,5
23,2
21,9
20,3
19,4
18
17,9
17,6
17,25
17
15,5
15,5
15,4
15,1
15,1
14,7
14,5
13,2
13,1
13,1
12,8
12,7
12,2
11,8
11
10,7
10,1
8,6
7,4
7,2
7,2
6,9
6,6
6,3
6,2
5,8
5,6
4,7
4,6
3,8
3,7
3,4
3,3
3,1
2,5
2,1
1,8
0,9
0,6
0,6
0,5
0,1
Spain
Croatia
Belgium
Portu
gal
USA
Norway
France
Puerto Rico
Austria
Italy
Uruguay
Estonia
Luxembourg
Latvia
Czech Rep
Finland
UK
Slovenia
Sweden
*Canada
Australia
Argentina
Germany
Poland
Netherlands
Denmark
Hungary
Switzerland
Slovak Rep
Lithuania
Israel
Colom
bia
Brazil
Belarus
New
Zealand
Panama
South Ko
rea
Greece
*Cyprus
Chile
Iceland
Costa Rica
Taiwan
Iran
Hong Ko
ng
Turkey
Venezuela
Rom
ania
Saudi A
rabia
Russia
Mexico
Lebanon
Ecuador
Dom
inican Rep
Japan
Bulgaria
Tunisia
*Ukraine
Morocco
0
5
10
15
20
25
30
35
40
Deceased Donors (pmp) 2011
International Registry in Organ Donation
IRODaT
International Registry in Organ Donation
IRODaT
Global Activity in Organ Transplantation 2010 Estimates
Trasplante Hepático. Actividad en España
19932011
The Declaration of Istanbul
Propuestas
1. Responder a las necesidades de aumentar la donación de cadaver.
2. Asegurar la protección y seguridad de los donantes vivos. Combatir el turismo de trasplante, el trafico de órganos y el comercio de trasplante.
Turkey, 30.5.2008
World Health Organization
Who Guiding Principles on Human Cell, Tissue and Organ Transplantation.
Endorsed by the 63rd World Health Assembly in May 2010,
in Resolution WHA63.22
Revised Guiding Principles summarized:
3. Donation from deceased persons should be developed to its maximum therapeutic potential.
4. In general, living donors should be genetically, legally or emotionally related to their recipients.
The Madrid Resolution on Organ Donation & Transplantation
•National Responsibility in Meeting the Needs of Patients.
•Guided by the WHO Principles •Participants in the Madrid Consultation urged WHO, its Member States and professionals in the field to regard organ donation and transplantation as part of every nation’s responsibility to meet the health needs of the population in a comprehensive manner, addressing the conditions leading to transplantation from prevention to treatment.
•Every country, in light of its own level of economic and health system development, should progress towards the global goal of meeting patients' needs on the basis of resources obtained within the country,for that country’s population, and through regulated and ethical regional or international cooperation when needed. The strategy of striving for self‐sufficiency encompasses the following features: actions should (i) begin locally; (ii) include broad public health measures both to decrease the disease burden in a population and to increase the availability of organ transplantation; (iii) enhance cooperation among the stakeholders involved and (iv) be carried out on the basis of the WHO Guiding Principles and the Declaration of Istanbul, in particular emphasizing voluntary donation, non‐ commercialization, maximization of donation from the deceased, support for living kidney donation, and meeting the needs of the local population in preference to “transplant tourists”.
Critical Pathway for Organ Donation
Beatriz DomínguezGil, Francis L. Delmonico, Faissal A.M. Shaheen, Rafael Matesanz, Kevin O’Connor, Marina Minima, Elmi Muller, Kimberly Young, Martí Manyalich, Jeremy Chapman, Günter Kirste, Mustafa AlMousawi, Leen Coene, Valter Duro García, Seguei Gautier, Tomonori Hasegawa, Vivekanand Jha, Tong Kiat Kwek, Zhonghua Klaus Chen, Bernard Loty, Alessandro Nanni Costa, Howard M. Nathan, Turger Ploeg, Oleg Reznik, John D. Rosendale, Annika Tibell, George Tsoulfas, Anantharaman Vathsala and Luc Noël.
The critical pathway for deceased donation: reportable uniformity in the approach to deceased donation. Transplant Internacional 24 (2011):373378
ELIGIBLE DCD DONOR A medically suitable person who has been declared dead based on the irreversible absence of circulatory and respiratory functions as stipulated by the law of the relevant jurisdiction, within a time frame that enables organ recovery.
POTENTIAL DBD DONOR
A person whose clinical condition is suspected to fulfill brain death criteria.
ELIGIBLE DBD DONOR
A medically suitable person who has been declared dead based on neurologic criteria as stipulated by the law of the relevant jurisdiction.
Critical pathways for organ donation* POSSIBLE DECEASED ORGAN DONOR
A patient with a devastating brain injury or lesion OR a patient with circulatory failure AND apparently medically suitable for organ donation
UTILIZED DCD DONOR
An actual donor from whom at least one organ was transplanted.
POTENTIAL DCD DONOR
A.A person whose circulatory and respiratory functions have ceased and resuscitative measures are not to be attempted or continued.
or
B.A person in whom the cessation of circulatory and respiratory functions is anticipated to occur within a time frame that will enable organ recovery.
Donation after BrainDeath (DBD) Treating physician to identify/refer a potential donor
ACTUAL DBD DONOR A consented eligible donor:
A. In whom an operative incision was made with the intent of organ recovery for the purpose of transplantation.
or B. From whom at least one organ was
recovered for the purpose of transplantation.
UTILIZED DBD DONOR
An actual donor from whom at least one organ was transplanted.
ACTUAL DCD DONOR A consented eligible donor:
A. In whom an operative incision was made with the intent of organ recovery for the purpose of transplantation.
or B. From whom at least one organ was
recovered for the purpose of transplantation.
Donation after Circulatory Death (DCD)
*The “dead donor rule” must be respected. That is, patients may only become donors after death, and the recovery of organs must not cause a donor’s death.
Reasons why a potential donor does not become a utilized donor
System • Failure to identify/refer a potential or eligible donor • Brain death diagnosis not confirmed (e.g. does not fulfill criteria) or completed (e.g. lack of technical resources or clinician to make diagnosis or perform confirmatory tests)
• Circulatory death not declared within the appropriate time frame.
• Logistical problems (e.g. no recovery team) • Lack of appropriate recipient (e.g. child, blood type, serology positive)
Donor/Organ • Medical unsuitability (e.g. serology positive, neoplasia) • Haemodynamic instability / unanticipated cardiac arrest
• Anatomical, histological and/or functional abnormalities of organs
• Organs damaged during recovery • Inadequate perfusion of organs or thrombosis
Permission • Expressed intent of deceased not to be donor • Relative’s refusal of permission for organ donation • Refusal by coroner or other judicial officer to allow donation for forensic reasons
Organ Donors 2010
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Spain USA UK
DBD DCD LD
*Percentage over the total number of donors
77.8%
7.4%
14.8%
6,46%
45%
31.2%
18%
50.8%
48,54%
1625 1436 1364
1112 1169 1132 1071 1097 1032 944
1136 1264 1262
101 116 121 38 41 22 25 67 116 124 129 133 106
0
500
1000
1500
2000
2500
3000
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Liver waiting list Deceased donor transplants Living donor transplants
Liver waiting list and transplants Eurotransplant 1995 ‐ 2007
2429
ALTERNATIVAS PARA LA DONACIÓN
1) Donantes en muerte encefálica (DBD)
2) Donantes a corazón parado (DCD)
3) Donantes vivos (LD)
4) Rescate órganos. Domino, Split.
5) Criterios Distribucion
6) Terapia celular: Utilización de hepatocitos
Donantes muerte encefálica
(DBD)
•DISMINUCIÓN
•DE LAS MUERTES
•ENCEFÁLICAS
DONACIONES DE
ÓRGANOSPARA TRASPLANTE
•IMPRESCINDIBLE OPTIMIZAR LA DONACIÓN EN MUERTE ENCEFÁLICA Y
•BUSCAR VÍAS ALTERNATIVAS QUE ASEGUREN LA DISPONIBILIDAD DE ÓRGANOS PARA TRASPLANTE
•TRÁFICO
•ENF. CEREBROVASC.
•CRANIECTOMÍA
Desciende el potencial de donación en muerte encefálica en
España
•De la Rosa G, et al. Am J Transplant 2012; 12:2507
•IMPRESCINDIBLE OPTIMIZAR LA DONACIÓN EN MUERTE ENCEFÁLICA Y
•BUSCAR VÍAS ALTERNATIVAS QUE ASEGUREN LA DISPONIBILIDAD DE ÓRGANOS PARA TRASPLANTE
23
Spain. Age groups
Spain: mean age of deceased donor
Causa de muerte de los donantes
Causas de muerte en los donantes hepáticos
Hígados no válidos para trasplante. 19902011
Mejora Continua de la obtenció de Órganos
üUSA . Give of Life. (40 pmp)
ü Teheran. Modelo Shiraz
ü Urgéncias OPO
üVentilación electiva para muerte encefálica
üDCD controlada
ü DCD no controlada, Mayor Potencial
ü Donantes vivos
ü Higados descartados para trasplantes
Donantes a corazón parado
CPR in Europe
¢ 350.000 cases/year ¢ 1000 cases/day ¢ Recuperated 40% ¢ Hospital survival 15% ¢ One year survival 12%
Bernd Böttiger, ColoniaGermany European resucitation councill (ERC) 1 st Panhellenic congress on Emergency Prehospital Care. April 2012.
Thessaloniki, Greece.
Potential uDCD in Europe
¢ 1000 cpr/day ¢ 600 no recuperated. Potential uDCD ¢ 400 recuperated ¢ 250 death in hospital. Potential cDCD ¢ 150 alive in hospital
Bernd Böttiger, ColoniaGermany European resucitation councill (ERC) 1 st Panhellenic congress on Emergency Prehospital Care. April 2012. Thessaloniki, Greece.
Adapted by M. Manyalich analisys
Uncontrolled DCD
Necesita:
1. Sistema de emergencias
2. Equipo de donación a corazón parado
3. Sistema de recirculación normotérmica
4. Perfusión exsitu para realizar la validación órganos:
Riñón, pulmón, corazón e hígado.
Organ Care System
Machine Preservation Equipment
LifePort ® Kidney Transporter: • Standalone machine • Portable
Normothermic Ex Vivo Lung Perfusion (EVLP)
TransMedic preserved hearts up to 12h • Prediction of viability in marginal organs (?)
Heart perfusion Machines
Dr. C. Fondevila
Donación en asistolia en el mundo. Número absoluto (pmp) de donantes en asistolia. Año 2011
Canadá: 65 (1,9)
Estados Unidos: 1055 (3,4)
Australia: 86 (3,8)
Nueva Zelanda: 2 (0,5)
Singapur: 3 (0,6)*
Rep.Corea: 4 (0,1)*
Japón: 81 (0,6)*
>3 pmp 13 pmp < 1pmp
Rusia: 187 (1,3)
*Dato correspondiente a 2010
•1 (0,2)
•117 (2,5)
•6 (0,1)
•58 (0,9)
•405 (6,5)
•1 (0,1)
•13 (5,9)
•6 (0,7) •3 (0,4) •64 (5,8)
•117 (7)
Donación en asistolia en Europa. Número absoluto (pmp) de donantes en asistolia. Año 2011
•>3 pmp
•13 pmp
•< 1pmp
El tipo de donación en asistolia predominante varía entre países. Europa 2008
NO CONTROLADA CONTROLADA
Austria 3
Bélgica 2 40
España 77
Francia 47
Holanda 6 85
Italia 2
Letonia 11
Reino Unido 264
Rep. Checa 1
Suiza
137 401
Controlada predominante en Australia, Can adá y Estados Unidos
DomínguezGil et al. Transplant Int 2011; 24: 276
Centros de uDCD en España
Donación en asistolia en España por Centros
•32
•18
•49 •56
•71 •71 •76
•88 •77
•108
•130 •117