Pre Transplant Pre Transplant Kidney/PancreasKidney/Pancreas

Educational Educational SessionSessionMiami Transplant InstituteMiami Transplant Institute

About the Transplant About the Transplant ProgramProgram

Started in 1979Started in 1979 Have performed over 4,000 kidney transplantsHave performed over 4,000 kidney transplants 200+ kidney transplants per year (279 in 2009)200+ kidney transplants per year (279 in 2009) 25-30 kidney/pancreas transplants per year25-30 kidney/pancreas transplants per year Only center in FL performing all transplant Only center in FL performing all transplant

typestypes One of the top 10 busiest centers in the US (4One of the top 10 busiest centers in the US (4thth

in nation 2007 behind UCLA, UPMC, UCSF)in nation 2007 behind UCLA, UPMC, UCSF) Success rates for transplant and patient Success rates for transplant and patient

survival are some of the best in the countrysurvival are some of the best in the country

Contact Information for theContact Information for theUnited Network for Organ United Network for Organ

Sharing (UNOS)Sharing (UNOS)

www.unos.org Patient Services Patient Services

Hotline for Hotline for Concerns or Concerns or GrievancesGrievances

1-888-894-63611-888-894-6361

Who is on Your Transplant Who is on Your Transplant Team?Team?

Transplant SurgeonTransplant Surgeon Transplant NephrologistTransplant Nephrologist Transplant Nurse Transplant Nurse

CoordinatorCoordinator Social WorkerSocial Worker Pre Transplant Pre Transplant

SecretarySecretary Donor TeamDonor Team Patient Financial Patient Financial

ServicesServices DieticianDietician Transplant Transplant

Psychologist/Addiction Psychologist/Addiction TeamTeam

Transplant Team-Transplant Team-SurgeonsSurgeons

George Burke, MD-Director K/P George Burke, MD-Director K/P ProgramProgram Dianne Peers, RN-305-355-5156Dianne Peers, RN-305-355-5156

Gaetano Ciancio, MD-Asst. DirectorGaetano Ciancio, MD-Asst. Director Tyann Barnes, RN-305-355-5082Tyann Barnes, RN-305-355-5082

Linda Chen, MD. Director Donor TeamLinda Chen, MD. Director Donor Team Michelle Gascon, RN-305-355-5194Michelle Gascon, RN-305-355-5194

Junichiro Sageshima, MDJunichiro Sageshima, MD Michelle Gascon, RN-305-355-5194Michelle Gascon, RN-305-355-5194

Transplant Team-Transplant Team-NephrologistsNephrologists

David Roth, MD-Medical DirectorDavid Roth, MD-Medical Director Warren Kupin, MD, Asst DirectorWarren Kupin, MD, Asst Director

Giselle Guerra, MD, Medical Giselle Guerra, MD, Medical Director Donor TeamDirector Donor Team

Adela Mattiazzi, MD, Transplant Adela Mattiazzi, MD, Transplant NephrologyNephrology

Facts about Kidney/SPK Facts about Kidney/SPK TransplantTransplant

Kidney, SPK transplant is a Kidney, SPK transplant is a “treatment” for ESRD, diabetes, it is “treatment” for ESRD, diabetes, it is not a curenot a cure

Transplantation requires taking life-Transplantation requires taking life-long anti-rejection medication, long anti-rejection medication, follow-up and compliance follow-up and compliance

Transplantation may prolong your Transplantation may prolong your life expectancylife expectancy

Selection Criteria for Kidney/Pancreas

TransplantThe following criteria are used by the Transplant

Committee to determine candidacy

Inclusion Criteria for Kidney

Initiation of dialysis therapy or kidney function of 20% or less (calculated or measured)

Age-Infants (10kg) to adult (no limit) Hepatitis B or C without cirrhosis

(evaluated by liver biopsy) HIV infection on HAART therapy (may

qualify for current study protocol)

Exclusion Criteria(Absolute and Relative)

Malignancy within the past 2 years (other than skin cancer)

Severe Cardiac Disease Severe Pulmonary pathology Hepatitis B or C with documented cirrhosis

on liver biopsy HIV + and not on HAART therapy Evidence of current alcohol or substance

abuse Morbid Obesity (BMI > 45, unless vascular

access has failed) Current psychiatric or psychological pathology

Psychosocial Criteria

Ability to follow a complex regime of medication and post transplant follow-up (compliance) by oneself or by an identified support person

Identified support person available Coverage for medications Transportation

What is my next step to What is my next step to becoming a Transplant becoming a Transplant

Candidate?Candidate? Class Session-attending todayClass Session-attending today 11stst Appointment with the Appointment with the

Transplant TeamTransplant Team Physician, Nurse Physician, Nurse

Coordinator, Social Worker, Coordinator, Social Worker, Dietician, lab workDietician, lab work

Must bring additional Must bring additional medical records and testing medical records and testing done by Nephrologist and done by Nephrologist and PCP, GYN and Dietician PCP, GYN and Dietician

copy of most recent labs for copy of most recent labs for DieticianDietician

Bring copies of driver’s Bring copies of driver’s license and all insurance license and all insurance cards cards

Bring a SweaterBring a Sweater Bring a snackBring a snack Appointment may last hoursAppointment may last hours

What testing is required?What testing is required? Bladder ultrasound-if indicatedBladder ultrasound-if indicated Gallbladder/Abdominal ultrasound Gallbladder/Abdominal ultrasound

(good for 2 years)-not required for (good for 2 years)-not required for allall

Cardiac evaluation (annual)Cardiac evaluation (annual) One of most important aspects One of most important aspects

of evaluationof evaluation Includes EKG, echo, stress testIncludes EKG, echo, stress test Cardiac catheterization if Cardiac catheterization if

indicatedindicated Chest x-ray (annual)Chest x-ray (annual) TB test (annual)TB test (annual) ImmunizationsImmunizations

Pneumovax-good for 5 yearsPneumovax-good for 5 years Hepatitis B vaccineHepatitis B vaccine Varicella Titer-Zoster IGGVaricella Titer-Zoster IGG

Gynecological evaluation (done by Gynecological evaluation (done by PCP, good for 2 years, unless PCP, good for 2 years, unless indicated otherwise)indicated otherwise)

Vascular studiesVascular studies

*any testing done in the 6 months is accepted*any testing done in the 6 months is accepted

Optional testing…Optional testing… Pulmonary evaluationPulmonary evaluation CT of abdomen/pelvis CT of abdomen/pelvis

(PKD)(PKD) UGI/endoscopyUGI/endoscopy Colonoscopy (PCP)Colonoscopy (PCP) Dental evaluation (outside)Dental evaluation (outside) Sustacal Challenge Test Sustacal Challenge Test

(SPK)(SPK) Ophthalmology evaluationOphthalmology evaluation Hepatology consult/liver Hepatology consult/liver

biopsy-hepatitis (PCP)biopsy-hepatitis (PCP) All other consults (outside)All other consults (outside)

*any other testing as *any other testing as directed by your Past directed by your Past medical historymedical history

When and Where Will When and Where Will My Testing be Done?My Testing be Done?

Diagnostic testing is required to be Diagnostic testing is required to be arranged by the Transplant Center to be arranged by the Transplant Center to be performed at UM/JMH or one of the performed at UM/JMH or one of the outlying clinics outlying clinics Biscayne ImagingBiscayne Imaging MICCMICC

Does not include “standard of care” or Does not include “standard of care” or pre-existing conditions testingpre-existing conditions testing GYN, oncology, surgical intervention, GYN, oncology, surgical intervention,

hepatology/liver biopsyhepatology/liver biopsy

Meeting with the Transplant Meeting with the Transplant Social Worker-Psychosocial Social Worker-Psychosocial

RequirementsRequirements Funding for transplant medicationsFunding for transplant medications $4,500-$5,000 per month$4,500-$5,000 per month Must check insurance coverage and co-paysMust check insurance coverage and co-pays If transplant is covered by Medicare primary, anti rejection If transplant is covered by Medicare primary, anti rejection

medications will be covered by Medicare B at 80%-not medications will be covered by Medicare B at 80%-not Medicare DMedicare D

Must have a Primary CaregiverMust have a Primary Caregiver Housing if not a local resident-Transplant HouseHousing if not a local resident-Transplant House

Some insurance plans offer travel and lodging benefit Some insurance plans offer travel and lodging benefit Transportation to clinic (no driving 4-6 weeks)Transportation to clinic (no driving 4-6 weeks)

Transplant Center/Pompano SatelliteTransplant Center/Pompano Satellite Lab visits 3 x/ week (month 1)Lab visits 3 x/ week (month 1) 2 x/ week (month 2 )2 x/ week (month 2 ) 1 x / week (month 3)1 x / week (month 3) Every other week (4-6 months)Every other week (4-6 months) Eventually once a month or every other month depending on statusEventually once a month or every other month depending on status

Psychosocial-Advanced Psychosocial-Advanced DirectivesDirectives

If you are unable to make medical decisions an If you are unable to make medical decisions an Advanced Directive:Advanced Directive: Lets your doctor know the type of medical Lets your doctor know the type of medical

care you wantcare you want Allows you to choose someone you trust Allows you to choose someone you trust

(health care surrogate) to carry out your (health care surrogate) to carry out your wishes regarding your medical treatmentwishes regarding your medical treatment

Your Transplant Social Worker can provide you Your Transplant Social Worker can provide you with an Advanced Directive. If you have one with an Advanced Directive. If you have one already, bring a copy to the hospital when you already, bring a copy to the hospital when you are admitted for transplantare admitted for transplant

When will I be listed?When will I be listed?

Meet criteria established at this Meet criteria established at this center for listingcenter for listing Complete required diagnostic testing Complete required diagnostic testing

and have F/U appt. for initial medical and have F/U appt. for initial medical approvalapproval

Majority approval by Transplant Majority approval by Transplant Team (Listing Conference-every Team (Listing Conference-every MondayMonday

Will blood testing be Will blood testing be done?done?

Yes, required in Yes, required in our Lab at the our Lab at the Transplant Center Transplant Center (Miami)(Miami)

Non-FastingNon-Fasting Several tubesSeveral tubes

Blood TypeBlood Type TypeType

50% “O”-universal 50% “O”-universal donordonor

30% ”A”30% ”A” >10% “B”>10% “B” >5% “AB”->5% “AB”-

universal recipientuniversal recipient

DonorDonor ““O” onlyO” only ““A” or “O”A” or “O” ““B” or “O”B” or “O” ““AB”, “A”, “B”, or AB”, “A”, “B”, or

“O”“O”

*Deceased Donor-”O” *Deceased Donor-”O” only to type “O”only to type “O”

Genetic TypingGenetic Typing

You inherit 3 Genes from Mother andYou inherit 3 Genes from Mother and3 from Father=6 Total 3 from Father=6 Total

SiblingsSiblings 50%-3 Gene Match50%-3 Gene Match 25%-6 Gene Match-Identical25%-6 Gene Match-Identical 25%-0 Gene Match25%-0 Gene Match

*Minimum “1” gene match for Deceased *Minimum “1” gene match for Deceased ListList

Cross matchCross match Mixing of blood Mixing of blood

between Donor and between Donor and RecipientRecipient

Can be performed Can be performed may times during may times during evaluationevaluation

Will be final test Will be final test performed prior to performed prior to transplanttransplant

PRA has bearing on PRA has bearing on results of cross matchresults of cross match

What is PRA?What is PRA? ““Panel Reactive Panel Reactive

Antibody” Antibody” What causes What causes

antibodiesantibodies Previous TransplantsPrevious Transplants TransfusionsTransfusions PregnancyPregnancy InfectionInfection*can have the greatest *can have the greatest

bearing on your bearing on your waiting time and will waiting time and will be sent monthly when be sent monthly when listedlisted

What are my Transplant What are my Transplant Options?Options?

Living Related Living Related Donor (LRD)Donor (LRD)

Living Unrelated Living Unrelated Donor (LURD)Donor (LURD)

Deceased Donor-Deceased Donor-Waiting ListWaiting List

Living Donation

Donors an be identified any time (3 at a time only) To Referral Team To Nurse Coordinator

Donor must make contact All donors living here or elsewhere will

be phone-screened and provided information and instructions

Goal of Living Donation…Goal of Living Donation… To make sure that the living To make sure that the living

donor is not only “willing” to donor is not only “willing” to donate but also “able” to donate but also “able” to donate a kidney safely donate a kidney safely

Risks of the surgical Risks of the surgical procedure are minimal if procedure are minimal if medically cleared by the medically cleared by the Donor TeamDonor Team

Potential donor needs to Potential donor needs to contact Nurse Coordinator contact Nurse Coordinator directly for referral to Donor directly for referral to Donor Team Team

Donor can be blood tested Donor can be blood tested any time after recipients any time after recipients blood is drawnblood is drawn

How do I qualify to be a Kidney How do I qualify to be a Kidney Donor?Donor?

18-65 years old18-65 years old No diabetes No diabetes No hypertensionNo hypertension Healthy with no physical Healthy with no physical

problems with kidney problems with kidney Family member-blood Family member-blood

relativerelative Extended family member-Extended family member-

Non-blood relativeNon-blood relative Only 3 donors will be Only 3 donors will be

blood tested at a timeblood tested at a time Only 1 donor in active Only 1 donor in active

workup at a timeworkup at a time

Who is on the Donor Who is on the Donor Team?Team?

Transplant SurgeonTransplant Surgeon Transplant NephrologistTransplant Nephrologist Donor Nurse CoordinatorDonor Nurse Coordinator Donor AdvocateDonor Advocate Laboratory personnelLaboratory personnel Secretarial staffSecretarial staff Transplant PsychologistTransplant Psychologist

*team will manage *team will manage allall aspects of Donor aspects of Donor testingtesting

Kidney Donation facts…Kidney Donation facts… All testing is done as an outpatient –preferably All testing is done as an outpatient –preferably

at the Transplant Centerat the Transplant Center There are no costs to the donor for evaluation, There are no costs to the donor for evaluation,

surgery or immediate post-operative caresurgery or immediate post-operative care Recovery time is 2-6 weeksRecovery time is 2-6 weeks No heavy lifting for 6 weeksNo heavy lifting for 6 weeks Women can become pregnant after kidney Women can become pregnant after kidney

donationdonation Surgery is 3-4 hoursSurgery is 3-4 hours Hospitalization is 3-4 daysHospitalization is 3-4 days The donor can be ruled out for The donor can be ruled out for

medical/psychological reasons at any point in medical/psychological reasons at any point in donation processdonation process

How Do I Begin the Donor How Do I Begin the Donor Process?Process?

Blood testingBlood testing Blood TypeBlood Type Genetic TypingGenetic Typing Cross-matchCross-match

Local donorsLocal donors Tested at Transplant Tested at Transplant

CenterCenter Out-of Area DonorsOut-of Area Donors

Will FedEx blood for Will FedEx blood for testing against testing against recipientrecipient

What is the Next Step?What is the Next Step? Blood testingBlood testing Urine testingUrine testing Chest x-rayChest x-ray EKGEKG TB testTB test GTT (if diabetes in GTT (if diabetes in

family)family) Gynecological Gynecological

evaluationevaluation

Final Donor Testing…Final Donor Testing…

Spiral CT Scan of Spiral CT Scan of KidneysKidneys

Psychological Psychological EvaluationEvaluation

History and History and PhysicalPhysical

Surgical ConsultSurgical Consult Anesthesia ConsultAnesthesia Consult Dietician ConsultDietician Consult

Surgical Options…Surgical Options… Laparoscopic Laparoscopic

NephrectomyNephrectomy Done for left sided kidney Done for left sided kidney

removals, beginning to do removals, beginning to do right lap cases (individual right lap cases (individual basis)basis)

Recovery is quickerRecovery is quicker Less painLess pain Improved cosmetic Improved cosmetic

resultsresults Higher rate of organ Higher rate of organ

donationdonation Decision is based on Decision is based on

spiral CT resultsspiral CT results

Open Open NephrectomyNephrectomy For right sided For right sided

removal (individual removal (individual basis)basis)

Longer Longer hospitalization hospitalization (additional day in (additional day in the hospitalthe hospital

Laparoscopic Laparoscopic NephrectomyNephrectomy

Benefits of having Living Benefits of having Living Donor vs. Deceased Donor vs. Deceased

TransplantTransplant Usually a better Usually a better

genetic matchgenetic match Kidney usually Kidney usually

functions right awayfunctions right away Transplant can be Transplant can be

plannedplanned Do not have to wait on Do not have to wait on

waiting list for donorwaiting list for donor Transplant may last Transplant may last

longer-sometimes longer-sometimes twice as long as twice as long as deceased transplantdeceased transplant

Deceased Transplant (DD)Deceased Transplant (DD)How long am I going to How long am I going to

wait?wait? KidneyKidney

Average 2 to 3 years in Average 2 to 3 years in Miami Miami

Can happen at any time Can happen at any time from listingfrom listing

Who receives the kidney?Who receives the kidney?

Based on a point system UNOS-new Based on a point system UNOS-new list is run for each kidneylist is run for each kidney Seniority (days on the list)Seniority (days on the list) Genetic match (better match, more Genetic match (better match, more

points)points) Antibody level (PRA)-higher lever, more Antibody level (PRA)-higher lever, more

pointspoints Up to age 18-”Kid points”Up to age 18-”Kid points”

Highest point with negative cross Highest point with negative cross match receives kidneymatch receives kidney

Are there other options for Are there other options for listing?listing?

Expanded Criteria Donor (ECD) listExpanded Criteria Donor (ECD) list Discussed at listing with transplant Discussed at listing with transplant

physicianphysician Signed consent is required Signed consent is required

Separate from standard listSeparate from standard list Donor age 60 or olderDonor age 60 or older Donor 50-59 with two of the followingDonor 50-59 with two of the following

Donor medical history of hypertensionDonor medical history of hypertension Creatinine above 1.5 (normal 0.8-1.4)Creatinine above 1.5 (normal 0.8-1.4) Cause of death from strokeCause of death from stroke

Other options…Other options…

Multiple listing Multiple listing Allowed by OPTN policyAllowed by OPTN policy

Up to individual center to accept as candidateUp to individual center to accept as candidate May increase chances of local offer May increase chances of local offer May shorten waiting time-no guaranteeMay shorten waiting time-no guarantee

Wait Time TransferWait Time Transfer Coordinated by transferring centerCoordinated by transferring center

UNOS Form required to be signed by UNOS Form required to be signed by patient/Coordinator/Physicianpatient/Coordinator/Physician

Must be approved by transferring center or Must be approved by transferring center or you may risk losing all previous wait timeyou may risk losing all previous wait time

How are organs How are organs distributed?distributed?

Local (UM/JMH list)Local (UM/JMH list) Regional – UNOS region 3 (south Regional – UNOS region 3 (south

east states)east states) National- over 80,000 on waiting listNational- over 80,000 on waiting list Mandatory shareMandatory share

Perfect match, highest priorityPerfect match, highest priority

What are my What are my responsibilities to maintain responsibilities to maintain

my active listed status?my active listed status? Keep testing updated annually Keep testing updated annually

CardiacCardiac Chest x-rayChest x-ray TBTB

Every other year (unless otherwise Every other year (unless otherwise indicated)indicated) Gallbladder USGallbladder US Gynecological Gynecological

Listed Patient Listed Patient responsibilities (con’t)responsibilities (con’t)

Visit transplant center every 6 monthsVisit transplant center every 6 months Notify transplant team of any changes Notify transplant team of any changes

in address, phone, insurance or travelin address, phone, insurance or travel Must send monthly PRAMust send monthly PRA Notify transplant team of any changes Notify transplant team of any changes

in health or medical urgency issuesin health or medical urgency issues Out of vascular accessOut of vascular access

Transplant Team’s Transplant Team’s Responsibility to our Responsibility to our

patient patient Listing letterListing letter

Patient Patient Nephrologist Nephrologist Dialysis centerDialysis center

Annual Listed letter Annual Listed letter Listed status continues, testing required, hold status Listed status continues, testing required, hold status

issuesissues Patient Patient NephrologistNephrologist Dialysis centerDialysis center Insurance companyInsurance company

Transplant Informed ConsentTransplant Informed Consent Signed by patient/Coordinator/Transplant PhysicianSigned by patient/Coordinator/Transplant Physician Copy to you and your patient fileCopy to you and your patient file

Listed StatusListed Status

Active (1)-can be called at any timeActive (1)-can be called at any time Hold (7)-will not be called for Hold (7)-will not be called for

transplant but time continues to transplant but time continues to accrue. Can be placed on hold at any accrue. Can be placed on hold at any time due to medical, psychological time due to medical, psychological or social issues or social issues

Medically Urgent (5)- highest Medically Urgent (5)- highest priority, medical condition requires priority, medical condition requires transplant ASAPtransplant ASAP

What happens if you are What happens if you are called?called?

Can be called 24/7Can be called 24/7 If on dialysis, finish If on dialysis, finish

treatment-not first treatment-not first come, first servedcome, first served

Can call in 5-10 Can call in 5-10 people for kidney people for kidney transplant, unless transplant, unless mandatory sharemandatory share

Call in 2 people for Call in 2 people for SPK/PASPK/PA

Must remain on Must remain on stand-by for up to stand-by for up to 24 hours24 hours

May have multiple May have multiple “dry-runs”“dry-runs”

Instructions for Admission Instructions for Admission prior to Surgeryprior to Surgery

Map with directions will be providedMap with directions will be provided Have “goodie bag” readyHave “goodie bag” ready

List of meds/medsList of meds/meds Essential toiletriesEssential toiletries PD suppliesPD supplies If you need financial assistance, bring a If you need financial assistance, bring a

copy of income tax paperscopy of income tax papers

Don’t bring…Don’t bring…

ValuablesValuables Plants or flowersPlants or flowers Visitors under the age of 14Visitors under the age of 14

OR Time/Hospital StayOR Time/Hospital Stay Surgery timeSurgery time

Kidney 4-6 hoursKidney 4-6 hours SPK 6-12 hoursSPK 6-12 hours Pancreas 4-6Pancreas 4-6

Time in hospital Time in hospital Discharge teaching will begin from time of admission Discharge teaching will begin from time of admission

for transplant-have support system available for transplant-have support system available Discharge when medically stable-even if you may not Discharge when medically stable-even if you may not

feel readyfeel ready Kidney 5-6 days, may go home with Foley catheter or Kidney 5-6 days, may go home with Foley catheter or

other new devices (glucometer)other new devices (glucometer) SPK 7 daysSPK 7 days Donors Donors

3 Days Laparoscopic Nephrectomy3 Days Laparoscopic Nephrectomy 4 days Open Nephrectomy4 days Open Nephrectomy

Where is the kidney Where is the kidney placed?placed?

Will your new kidney work Will your new kidney work right away?right away?

Most kidneys work immediatelyMost kidneys work immediately Some take a period of time to begin Some take a period of time to begin

functioningfunctioning Might require dialysis session(s)Might require dialysis session(s)

Rarely, the kidney never functionsRarely, the kidney never functions If within 90 days of transplant can be If within 90 days of transplant can be

reactivated on the list with no time lostreactivated on the list with no time lost

Post Transplant Post Transplant Medication and After Care Medication and After Care

Video…Video… Anti- rejection

medications Diet Follow-up visits

and labs Patient

responsibilities

Your kidney transplant Your kidney transplant operation is not the end of operation is not the end of

this process… it is the this process… it is the beginningbeginning

Completion of Medical Lecture

Certificate of Completion distribution

Q&A Thank you for you

attention …Good Luck!