Comparison of HTK and UW in Abdominal Transplantation Dr. Richard S. Mangus, MD MS Indiana...
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Transcript of Comparison of HTK and UW in Abdominal Transplantation Dr. Richard S. Mangus, MD MS Indiana...
Comparison of HTK and UW in Abdominal
Transplantation
Dr. Richard S. Mangus, MD MS
Indiana University, School of Medicine
OUTLINE
• Conversion from UW to HTK
Indiana Organ Procurement Organization
Indiana University
• Transplant outcomes: UW vs HTK
Kidney transplantation
Pancreas transplantation
Liver transplantation
Intestinal transplantation
• Future research
Indiana Organ Procurement Organization (IOPO)
Service area: Indiana
Population: 5.1 million
Hospitals: 130
Transplant centers: 7
Indiana Organ Procurement Organization (IOPO)
Potential advantages to HTK:
Decreased cost
Decrease contamination risk
No mixing
No filter
Longer shelf life
Can store at cool room temperature
Faster preparation time for coordinator
- “hang it, spike it , infuse it”
Indiana Organ Procurement Organization (IOPO)
Potential advantages to HTK:
Improved organ flushing
Lower viscosity
Faster organ cooling
No organ flushing before reperfusion
Lower K+ load decreases risks of hyperkalemia and bradycardia
Easier to work with on back bench
? Improved outcomes
Indiana Organ Procurement Organization (IOPO)
Cost analysis: HTK vs UW
UW flush volume / donor: 3.5 litersUW cost / liter $306.00Total cost per donor $1071
HTK flush volume / donor 3.5 litersHTK cost / liter $150.00Total cost per donor $525
Cost savings per donor $546
Indiana Organ Procurement Organization (IOPO)
Center cost savings
Cost savings / donor $546
Annual cost savings
for average OPO (200 donors) $109,200
Indiana University Medical Center
Abdominal Organ Transplants
Liver
Pancreas
Kidney
Islets
Small intestine / Multivisceral
Indiana University Medical Center
Abdominal Organ Transplants
2007 Rank *
Liver 155 Top 5
Pancreas 84 1st
Kidney 255 Top 10
Small intestine 22 Top 5OVERALL (+ thoracic) 562 Top 5
* www.unos.org, 2007 data report
Transplant Volume
Year Organs *
2001 259
2002 424
2003 506
2004 532
2005 604
2006 541
2007 562
Transplant Volume
Year Organs *
2001 259
2002 424
2003 506
2004 532
2005 604
2006 541
2007 562
Conversion to HTK
Natural Experiment
A naturally occurring instance which approaches or duplicates a scientific experiment. In contrast to laboratory experiments, these events aren't created by scientists, but yield scientific data. Natural experiments are a common research tool in fields where artificial experimentation is difficult, such as epidemiology.
Renal TransplantationRenal Transplantation
Transplants: 1990 to 1992
DGF: Need for dialysis 2 or more times during first 7-days post-transplant
Flush volume: HTK 5 – 6 LUW 1 – 2 LEC 4 L
Renal Transplantation
Renal TransplantationRenal Transplantation
de Boer, et al, Transpl Proc, 1999; 31: 2065de Boer, et al, Transpl Proc, 1999; 31: 2065
Renal TransplantationRenal Transplantation
de Boer, et al, Transpl Proc, 1999; 31: 2065de Boer, et al, Transpl Proc, 1999; 31: 2065
HTK vs UW: KIDNEY Transplantation
N=91 renal transplants HTK 50 UW 41
No differences in: Delayed graft function
Graft survival
Patient survival
Creatinine Clearance Post Transplantation
0
20
40
60
80
100
1 2 3 4 5 6 7 10 14 21 30
time (days)
ml/m
in UWHTK
Serum Creatinine Post Transplantation
0.0
2.0
4.0
6.0
8.0
10.0
12.0
0 3 6 9 12 15 18 21 24 27 30
time (days)
mg
/dL UW
HTK
HTK vs UW: Kidney Transplantation
N=149 renal transplants
> 16 hrs HTK 62, UW 87
No difference patient / graft survival
HTK lower DGF (24% vs 56%, p<0.01)
> 24 hrs HTK 31, UW 38
No difference in patient / graft survival
HTK lower DGF (16% vs 56%, p<0.05)
PANCREAS TRANSPLANTATION
Pancreas Transplantation
N= 20 pancreas transplants HTK 10 UW 10
No differences in: Graft survival
Patient survival
Serum fasting blood glucose
Peak serum amylase
Serial amylase levels
Pancreas Transplantation
Pancreas Transplantation
N= 87 pancreas transplants HTK 78 UW 9
No differences in: Graft survivalPatient survivalSerum fasting blood glucosePeak serum amylaseSerial amylase levels
Pancreas Transplantation
Pancreas Transplantation
Pancreas clinical allograft data for 246 consecutive adult pancreas transplants at Indiana University between 2003 and 2007.
Overall (%) SKP PAK PTA P-valueNumber 247 141 (57%) 62 (25%) 44 (18%)
Graft loss within 7 days 10 (4%) 7 (5%) 1 (2%) 2 (5%) 0.53
Graft loss within 90 days 6% 7% 5% 5% 0.82
1-year* Graft survival (n=193) 91% 90% 93% 90% 0.79 Patient survival (n=174) 95% 94% 97% 96% 0.75
*For patients with minimum of 1-year follow up time.
Primary preservation solution: HTK, 2003 to 2007:
Pancreas Islet Transplantation
Pancreas Islet Transplantation
LIVER TRANSPLANTATION
Liver Transplantation
N=378 liver transplants HTK 174UW 204
Graft survival 1-month 6-month 12-month UW 91.7% 86.2% 81.7% HTK 92.0% 85.5% 80.8%
Patient survival UW 93.1% 87.7% 84.6% HTK 93.1% 86.2% 82.1%
Liver Transplantation: ECD
N=698 liver transplants HTK 371UW 327
Groups: Standard 209 (30%)
ECD (old age) 70 (10%)
ECD (physiologic stress) 435 (62%)
Liver Transplantation: ECD
Liver Transplantation: ECD
N=698 HTK 371 UW 327
Liver Transplantation: ECD
Standard donors, n=209 Extended criteria donors, n=489
Liver Transplantation: ECD
Donor < 60 years, n=628 Donor ≥ 60 years, n=70
Liver Transplantation: ECD
No physiologic stress, n=263 Physiologic ECD, n=435
Liver Transplantation: ECD
Figure. Liver enzymes in the first 30-days post-transplant for the STANDARD criteria donors comparing HTK (n=111) and UW (n=98)
preservation solutions.
0
100
200
300
400
500
600
700
800
0 5 10 15 20 25 30
Days post-transplant
AS
T/A
LT
in u
/L
AST - HTK
AST - UW
ALT - HTK
ALT - UW
Liver Transplantation
Biliary complications
Elevated liver enzymes post-transplant
Liver U/S with doppler
Biliary imaging
Liver biopsy
Liver Transplantation
Biliary complications
Overall HTK UW p-valueOverall 698* 371* 327*
Need for biliary imaging 384/693 (55.4%) 188/367 (51.2%) 196/326 (60.1%) 0.01 Choledochocholedochostomy (n=593) 333/593 (56.2%) 163/316 (51.6%) 170/277 (61.4%) 0.02 Roux-y hepaticojejunostomy (n=100) 51/100 (51.0%) 25/51 (49.0%) 26/49 (53.1%) NS
Biliiary Leak 22/693 (3.2%) 9/367 (2.5%) 13/326 (4.0%) NS
Diffuse intrahepatic stricturing 26/693 (3.8%) 9/367 (2.5%) 17/326 (5.2%) NS
Presence of choledocholithiasis 115/693 (16.6%) 48/367 (13.1%) 67/326 (20.6%) 0.06
Presence of bile duct gravel (sludge) 51/693 (7.4%) 14/367 (3.8%) 37/326 (11.3%) 0.001* 5 patients died intraoperatively and had no biliary reconstruction, 4 HTK and 1 UW
Liver Transplantation
Donation after cardiac death, n=43HTK 35 UW 7
Liver Transplantation: Recent
Variables in the Equation
.263 .146 3.271 1 .071 1.301
.001 .008 .035 1 .851 1.001
.028 .009 8.930 1 .003 1.028
.014 .005 8.682 1 .003 1.014
PreservationSolution
Ageattxp
MELDTXP
DonorAge
B SE Wald df Sig. Exp(B)
Intestinal / Multivisceral Transplantation
“Comparison of HTK and UW in Intestinal and Multivisceral Transplantation”
- Mangus, et al. Transplantation, 2008; In Press
Intestinal Transplantation
N=57 intestinal transplants HTK 35 UW 22
Intestinal TransplantationHTK UW
TOTAL n=35 (61%) n=22 (39%)Allograft transplanted Isolated small intestine (intestine alone) 5/35 (14%) 8/22 (36%) Modified multivisceral 3/35 (9%) 2/22 (9%) (stomach, duodenum, intestine, pancreas) Multivisceral 27/35 (77%) 12/22 (55%) (stomach, duodenum, intestine, pancreas, liver)Indication Pediatric (n=15) n = 6 n = 9 Necrotizing enterocolitis 4/6 3/9 Gastroschisis / Atresia 1/6 1/9 Volvulus 1/6 2/9 Microvillus inclusion 1/9 Pseudoobstruction 1/9 Retransplantation 1/9 Adult (n=42) n = 29 n = 13 Portomesenteric thrombosis 9/29 6/13 Short gut syndrome 6/29 3/13 Pseudoobstruction 1/29 3/13 Chron's disease 5/29 1/13 Non-resectable tumor 3/29 Retransplantation 2/29 1/13 Abdominal catastrophe 3/29 1/13
Intestinal Transplantation
N=57 intestinal transplants HTK 35 UW 22
Intestinal Transplantation
• No difference between HTK and UW in graft and patient survival at 30- and 90-days, and 1-year post-transplant
• No differences noted in:
* Initial function
* Appearance on early magnification endoscopy
* Rejection episodes
* Transplant pancreatitis
CONCLUSIONS
• Cost savings associated with HTK use
• No demonstrated difference in outcomes for: kidney
pancreas
pancreatic islets
liver
intestine
• Possible decrease in biliary complications for HTK in liver transplantation
• Possible long-term improvement in survival with HTK in liver transplantation
HTK vs UW: FUTURE RESEARCH
HTK vs UW
• Prolonged cold ischemia time
• Transplant pancreatitis
• DCD allografts
• Biliary complications / Flush of microcirculation
• Multicenter data – large volume data analysis