the history of organ transplant

The History of Organ Transplant

Prehistoric transplantationPrehistoric transplantation exists in mythological tales of chimeric exists in mythological tales of chimeric beingsbeings

1903-19051903-1905: Modern transplantation began with the work of Alexis : Modern transplantation began with the work of Alexis Carrel who refined vascular anastomoses as well as transplanted organs Carrel who refined vascular anastomoses as well as transplanted organs within animalswithin animals

1914-19181914-1918: Skin grafting in WWI: Skin grafting in WWI 19531953: HLA described by Medawar, Billingham and Brent: HLA described by Medawar, Billingham and Brent 19521952: Dr. Hume at Peter Bent Bringham Hospital in Boston attempted : Dr. Hume at Peter Bent Bringham Hospital in Boston attempted

allograft kidneyallograft kidney from unrelated donor and found that it functioned for a from unrelated donor and found that it functioned for a short period; attributed chronic uremia as suppressant of the immune short period; attributed chronic uremia as suppressant of the immune function for the recipientfunction for the recipient

19541954: Dr. Joseph E. Murray transplanted kidney from Ronald Herrick : Dr. Joseph E. Murray transplanted kidney from Ronald Herrick to his to his identical twinidentical twin, Richard Herrick, to allow him to survive another 8 , Richard Herrick, to allow him to survive another 8 years despite his ESRDyears despite his ESRD

19561956: First : First successful BMT successful BMT by Dr. Donnall Thomas, the recipient twin by Dr. Donnall Thomas, the recipient twin received whole body radiation prior to transplantreceived whole body radiation prior to transplant

The History of Organ Transplant Continued

19631963 : first human : first human liverliver transplantation by Thomas Starzl ( 3 years old transplantation by Thomas Starzl ( 3 years old boy with biliary atresia)boy with biliary atresia)

19661966: First : First successful pancreas successful pancreas transplant by Kelly and Lilleheitransplant by Kelly and Lillehei 19671967: First : First successful heart successful heart transplant by Christiaan Barnard in South transplant by Christiaan Barnard in South

Africa, recipient was 54 yo male who died 18 days after transplant from Africa, recipient was 54 yo male who died 18 days after transplant from Pseudomonas pneumoniaPseudomonas pneumonia. That same yr., . That same yr., first successful liver first successful liver transplant transplant performed by Thomas Starzlperformed by Thomas Starzl

19811981: First : First successful heart/lung successful heart/lung transplant by Dr. Reitz at Standfordtransplant by Dr. Reitz at Standford 19831983: First : First successful lung successful lung transplant by Dr. Joel Cooper; cyclosporin transplant by Dr. Joel Cooper; cyclosporin

approvedapproved 19841984: Congress passed the National Organ Transplant Act (NOTA) which : Congress passed the National Organ Transplant Act (NOTA) which

stated that it was illegal to buy/sell organs, OPTN and UNOS were created stated that it was illegal to buy/sell organs, OPTN and UNOS were created as well as the scientific registry of transplant recipientsas well as the scientific registry of transplant recipients

19901990: tacrolimus approved: tacrolimus approved 19951995: mycophenolate mofetil approved: mycophenolate mofetil approved 19971997: daclizumab approved: daclizumab approved 19991999: pancreatic islet cell transplant by Dr. Shapiro: pancreatic islet cell transplant by Dr. Shapiro 20082008: face transplant: face transplant

2006-7year Immunology 3

Classification of grafts Autologous grafts (Autografts)Autologous grafts (Autografts)

Grafts transplanted from one part of the body to Grafts transplanted from one part of the body to another in the same individualanother in the same individual

Skin graft in burnsSkin graft in burns Syngeneic grafts (Isografts) Syngeneic grafts (Isografts)

Grafts transplanted between Grafts transplanted between two genetically two genetically identical identical individuals of the same speciesindividuals of the same species

Identical twins Identical twins Allogeneic grafts (Allografts)Allogeneic grafts (Allografts)

Grafts transplanted between two genetically different Grafts transplanted between two genetically different individuals of the same speciesindividuals of the same species

From human to human From human to human Xenogeneic grafts (Xenografts) Xenogeneic grafts (Xenografts)

Grafts transplanted between individuals of different Grafts transplanted between individuals of different speciesspecies

Form animal to humanForm animal to human

What can be donated?

Heart (valves)Heart (valves) LungsLungs KidneysKidneys LiverLiver PancreasPancreas Small bowelSmall bowel Corneas Corneas TendonsTendons BoneBone SkinSkin

Determination of Brain Death

Defined formally in 1968 by ad Hoc Defined formally in 1968 by ad Hoc committee at Harvard headed by Beechercommittee at Harvard headed by Beecher

Defined by government in Office of the Defined by government in Office of the President with Uniform Determination of President with Uniform Determination of Death Act in 1981Death Act in 1981 Individual who has sustained either 1. irreversible Individual who has sustained either 1. irreversible

cessation of circulatory or respiratory functions or 2. cessation of circulatory or respiratory functions or 2. irreversible cessation of all functions of the entire brain, irreversible cessation of all functions of the entire brain, including brainstem, is dead. A determination of death including brainstem, is dead. A determination of death must be made in accordance with accepted medical must be made in accordance with accepted medical standards.standards.

When Etiology Determined and NOT Reversible

LACK OF CEREBRAL LACK OF CEREBRAL FUNCTIONFUNCTION

______________________________________

Deep comaDeep coma

No response to painful stimuliNo response to painful stimuli

**Can have spinal cord reflexes**Can have spinal cord reflexes

LACK OF BRAINSTEM LACK OF BRAINSTEM FUNCTIONFUNCTION

______________________________________________

Pupillary reflexesPupillary reflexesCorneal reflexesCorneal reflexesOcculocephalic reflexes Occulocephalic reflexes Occulovestibular reflexesOcculovestibular reflexesGag reflexGag reflexCough reflexCough reflex

Diagnosis of Brain Death

Pt suffered irreversible loss of brain function Pt suffered irreversible loss of brain function (either cerebral hemisphere or brainstem)(either cerebral hemisphere or brainstem)

Establish cause that accounts for loss of functionEstablish cause that accounts for loss of function Exclude reversible etiology:Exclude reversible etiology:

IntoxicationIntoxication

}-}- perform tox screen perform tox screen NM blockadeNM blockade ShockShock Hypothermia (<35 deg C)Hypothermia (<35 deg C)warming blanketwarming blanket

Apnea Testing

Brain Death Ancillary Testing to Include:Ancillary Testing to Include:

EEG – lack of waves EEG – lack of waves Nuclear scan Nuclear scan (( the brain appears hollow))(( the brain appears hollow))

Angiography for absence of cerebral blood flowAngiography for absence of cerebral blood flow

--Brain death determined after 6 hr with cessation of Brain death determined after 6 hr with cessation of brain function, 12 hr without confirmatory testingbrain function, 12 hr without confirmatory testing

-Documentation -Documentation

Organ Donation after Cardiac Death

Death declared on basis of cardiopulmonary Death declared on basis of cardiopulmonary criteria—irreversible cessation of circulatory and criteria—irreversible cessation of circulatory and respiratory function.respiratory function.

In 2005, IOM declared that donation after cardiac In 2005, IOM declared that donation after cardiac death was “an ethically acceptable practice in end-death was “an ethically acceptable practice in end-of-life care” and in March, 2007 UNOS/OPTN of-life care” and in March, 2007 UNOS/OPTN developed rules for it which became effective on developed rules for it which became effective on July 1, 2007.July 1, 2007.

Outcomes similar to those for organs transplanted Outcomes similar to those for organs transplanted after brain death.after brain death.

Non heart beating donations does exist but in this case Non heart beating donations does exist but in this case heart and pancreas cant be donated, liver and kidney can heart and pancreas cant be donated, liver and kidney can be donated be donated

Heart beating donation better results than non beating Heart beating donation better results than non beating because of oxygenation, a living donor is better than a because of oxygenation, a living donor is better than a dead donor dead donor

Kidney shows similar results in both heart beating and non Kidney shows similar results in both heart beating and non heart beating donationheart beating donation

Infection , TB , cancer , sever hypotension are all medical Infection , TB , cancer , sever hypotension are all medical causes in the donor preventing organ donation causes in the donor preventing organ donation

Key Elements in the Process of Donation after Cardiac Death

Withdrawal of life sustaining measuresWithdrawal of life sustaining measures Pronouncement of death from time of onset of Pronouncement of death from time of onset of

asystole (usually btwn 2-5 minutes); 60 sec is asystole (usually btwn 2-5 minutes); 60 sec is longest reported time of autoresuscitationlongest reported time of autoresuscitation

To avoid conflicts of interest transplantation team To avoid conflicts of interest transplantation team physicians are not a member of the end-of-life physicians are not a member of the end-of-life care or declaration of deathcare or declaration of death

Liver within 30 min and kidney within 60 minLiver within 30 min and kidney within 60 min If time to asystole exceeds 5 min, then recovery of If time to asystole exceeds 5 min, then recovery of

organs is canceledorgans is canceled

LIVER One of the largest organs

Performs numerous functions - critical for life: MetabolismMetabolism – Carbohydrate, Fat & Protein – Carbohydrate, Fat & ProteinSecretorySecretory – – BBile, ile, bbile acids, salts & pigmentsile acids, salts & pigmentsExcretoryExcretory – Bilirubin, drugs, toxins – Bilirubin, drugs, toxinsSynthesisSynthesis – Albumin, coagulation factors – Albumin, coagulation factorsStorageStorage – Vitamins, carbohydrates etc. – Vitamins, carbohydrates etc.DetoxificationDetoxification – – TToxins, ammonia, etc.oxins, ammonia, etc.

Liver failure results in multisystem effects

LIVER

Clinical symptoms and signs of liver Clinical symptoms and signs of liver pathology usually are unspecific pathology usually are unspecific and for and for

long time long time may may be be unnoticeableunnoticeable . .

symptoms and signs of liver symptoms and signs of liver pathology usually appear after pathology usually appear after

60%_70% of damage60%_70% of damage

LIVEREither primary or secondary liver injures in some Either primary or secondary liver injures in some

patients lead to acute liver failurepatients lead to acute liver failure (ALF) (ALF) or or cirrhosis.cirrhosis.

Acute liver failure may be due to toxicity most Acute liver failure may be due to toxicity most commonly paracetamol induced commonly paracetamol induced

Pharmacotherapy of end stage liver diseases and Pharmacotherapy of end stage liver diseases and its complications is still limitedits complications is still limited

Best option for end stage liver disease (cirrhosis) Best option for end stage liver disease (cirrhosis) is transplantation. is transplantation.

Surgical treatment as the only way for persistent recovery

1963 – Thomas Starzl – first human liver 1963 – Thomas Starzl – first human liver transplantation ( 3 years old boy with biliary transplantation ( 3 years old boy with biliary atresia)atresia)

1983 – National Institute of Health1983 – National Institute of Health (USA) (USA) established LT as clinically accepted definitive established LT as clinically accepted definitive therapy for end-stage liver disease (not therapy for end-stage liver disease (not experimental procedure)experimental procedure)

PRESENT SITUATION

OLTx program – in over 130 countriesOLTx program – in over 130 countries 1- year survival rate of 91- year survival rate of 955 % % 5- years survival rate of 75 % 5- years survival rate of 75 %

versus 1- year survival rate of 10 – 20% patients after 1- year survival rate of 10 – 20% patients after acute liver failure (ALF) epizode in case of acute liver failure (ALF) epizode in case of spontaneous recoveryspontaneous recovery1- year mortality of 50%- patients with 1- year mortality of 50%- patients with decompensated cirrhosisdecompensated cirrhosis

INDICATIONS FOR LIVER TRANSPALNTATION IN ADULTS

1. Postinflammatory cirrhosis after: 28.4%

- HBV infection 6.5% - HCV infection 13.1% - HCV infection & ALD 8.8%2. Cholestatic diseases: 31.6% - Primary biliary cirrhosis (PBC) 21.9% - Primary sclerosing cholangitis (PSC) 6.5% - Secondary biliary cirrhosis (SBC) 3.2%3. Alcoholic liver disease (ALD) 8.8%4.Autoimmune chronic active hepatitis (AIH) 4.8%5. Metabolic diseases: 3.2% - Wilson’s disease - hemochromatosis - Alpha-1-antitrypsin deficiency6. Budd-Chiari syndrome ( thrombosis of hepatic veins)

3.2%

INDICATIONS FOR LIVER TRANSPALNTATION IN ADULTS

7. Liver malignancies: 6.40% - primary liver carcinoma (HCC- meeting Milan criteria) - metastatic tumors – e.g. neuroendocrine carcinoma, GIST - other tumors – e.g. unresectable angiomas causing liver failure 8 Cryptogenic cirrhosis 9.6%9. Biliary tract patologies: 3.2% - Caroli disease - unresectable common bile duct cysts 10. Symptomatic polycystic liver( and renal) disease 0.8%11. Chronic drug toxicity or toxin exposure12. Acute liver failure: 12.2% - fulminant hepatitis (HBV) - drug toxicity (e.g. acetaminophen in suicide attempts) - Wilson’s disease

- toxins:Mushroom poisoningMushroom poisoning (e.g. Amanita phaloides)13. Liver injuries and spontaneous liver rupture 0.2%

INDICATIONS FOR LIVER TRANSPALNTATION IN ADULTS 1. Postinflammatory cirrhosis after: HBV, HCV, HDV and HDV infection

2. Cholestatic diseases:

- Primary biliary cirrhosis (PBC)

- Primary sclerosing cholangitis (PSC)

- Secondary biliary cirrhosis (SBC)

3. Alcoholic liver disease (ALD)

4.Autoimmune hepatitis (AIH)

5. Metabolic diseases:

- Wilson’s disease

- hemochromatosis

- Alpha-1-antitrypsin deficiency

6. Budd-Chiari syndrome

7. Liver malignancies:

- primary liver carcinoma (HCC- meeting Milan criteria)

- metastatic tumors – e.g. neuroendocrine carcinoma, GIST

- other tumors – e.g. unresectable angiomas causing liver failure

8 Cryptogenic cirrhosis

9. Biliary tract patologies:

- Caroli disease

- unresectable common bile duct cysts

10. Symptomatic polycystic liver( and renal) disease

11. Chronic drug toxicity or toxin exposure

12. Acute liver failure:

- fulminant hepatitis (HBV)

- drug toxicity (e.g. acetaminophen in suicide attempts)

- Wilson’s disease

- toxins (e.g. Amanita phaloides)

13. Liver injuries and spontaneous liver rupture

Alcoholic transplanted liver after cessation Alcoholic transplanted liver after cessation of alcohol respond better than infective or of alcohol respond better than infective or metabolic liver transplant because the cause metabolic liver transplant because the cause will be removed.will be removed.

Any person with any type of cancer cannot Any person with any type of cancer cannot donate liver except brain cancer or donate liver except brain cancer or melanoma.melanoma.

HEPATOCELLULAR CARCINOMA ’’80 – one of the most important indications 80 – one of the most important indications in next decades – limiting OLTx in this group in next decades – limiting OLTx in this group at present- patient in B or C Childa, solitary tumor less at present- patient in B or C Childa, solitary tumor less than 5 cm ( if greater than 5 cm in a solitary lesion not than 5 cm ( if greater than 5 cm in a solitary lesion not candidate cause most likely there will be mets ) or three candidate cause most likely there will be mets ) or three changes less changes less thathan 3 cm-each one, with no vascular n 3 cm-each one, with no vascular invasion, secondary tumors in the liver is not an indication invasion, secondary tumors in the liver is not an indication for transplant.for transplant.Patients of 65 years and below are candidates for liver Patients of 65 years and below are candidates for liver transplant.transplant. with with meeting criteria meeting criteria – similar results as in other – similar results as in other indicationsindications (recently) (recently) tendency to tendency to easeease criteria criteria

HEPATOCELLULAR CARCINOMA

Gold standad treatment of HCC is resection if the lesion is Gold standad treatment of HCC is resection if the lesion is periphary , coz if central and you resct the entire right lobe liver periphary , coz if central and you resct the entire right lobe liver function is affected so transplant is the preferred choice. function is affected so transplant is the preferred choice. problem- waiting timeproblem- waiting time chemoembolization, ablative therapy, ethanol injection- no chemoembolization, ablative therapy, ethanol injection- no evidence for stabilization of neoplasmatic processevidence for stabilization of neoplasmatic process LDRT in adults & childrens LDRT in adults & childrens domino transplantation for patients over 60 years (liver from domino transplantation for patients over 60 years (liver from donor with amyloid polyneuropathy)donor with amyloid polyneuropathy)

Mcq : 64 years with hepatitis C and 4 cm lesion in centre Mcq : 64 years with hepatitis C and 4 cm lesion in centre of the liver classified as child B what is the best choice for of the liver classified as child B what is the best choice for treatment ?treatment ?

1- radiofrequency ablation RFA – not good coz liver is 1- radiofrequency ablation RFA – not good coz liver is cirrhotic ( ascites is a contareindication to RFA )cirrhotic ( ascites is a contareindication to RFA )

2-embolization 2-embolization 3-resection 3-resection 4-transplant – the best 4-transplant – the best If the patient was child A and in the periphery resection if If the patient was child A and in the periphery resection if

in child A and in the center RFAin child A and in the center RFA

figure

At a certain point transplant is needed and At a certain point transplant is needed and after that we don’t transplant cause of multi after that we don’t transplant cause of multi organ failure ex hepato-renal failure.organ failure ex hepato-renal failure.

Multi organ failure is a contraindication to Multi organ failure is a contraindication to transplant transplant

TIME FOR TRANSPLANTATION qualification procedure should start from qualification procedure should start from

exexccluding patients with contraindications to luding patients with contraindications to such large surgical treatment as OLTxsuch large surgical treatment as OLTx

questions: questions: 1.1. Any contraindications? Any contraindications?

2.2. Etiology Etiology

3.3. OLTx- life extension or quality of life improvement ? OLTx- life extension or quality of life improvement ?

4.4. When transplant? When transplant?

CHILD – PUGH score

UNOS classification

MODEL END STAGE LIVER DISEASE (MELD)

all these for chronic patients

for acute we use Kings criteria

CHILD – PUGH SCORE

CriteriaCriteriaPOINTSPOINTS

112233EncephalopathyEncephalopathyNoneNoneI-III-IIIII-IVIII-IV

AscitesAscitesNoneNoneMedically Medically controlledcontrolled

Poorly Poorly controlledcontrolled

Albumin(g%)Albumin(g%)>3.5>3.52.8-3.52.8-3.5<2.8<2.8

INRINR<1.7<1.71.71-2.241.71-2.24>2.25>2.25

Bilirubin (mgBilirubin (mg%)%)

<2<22-32-3>3>3

GroupGroupA (5-6)A (5-6)B ( 7-9 )B ( 7-9 )C(10-15)C(10-15)

UNOS CLASSIFICACION – STATUS 1

conconccern patients with acute liver failure and ern patients with acute liver failure and life threat in nearest 7 days –because of:life threat in nearest 7 days –because of:

1.1. Primary graft non function – during 1st weekPrimary graft non function – during 1st week

2.2. Acute liver failureAcute liver failure

3.3. Hepatic artery thrombosis – during 1st weekHepatic artery thrombosis – during 1st week

4.4. Acute liver failure in course of Wilson’s diseaseAcute liver failure in course of Wilson’s disease

UNOS CLSSIFICACION – STATUS 2A

Patient in ICU –because of decompensation Patient in ICU –because of decompensation of liver function; with life threat in 7 days; of liver function; with life threat in 7 days; with 10 or more CP score and one of these with 10 or more CP score and one of these below:below:

1.1. Uncontrolled variceal bleedingUncontrolled variceal bleeding

2.2. Hepato-renal syndromeHepato-renal syndrome

3.3. Uncontrolled ascitesUncontrolled ascites

4.4. Encephalopathy – III or IVEncephalopathy – III or IV

UNOS CLSSIFICACION – STATUS 2B

Patient demanding permanent medical care, Patient demanding permanent medical care, with 10 CP or 7 and one from listed below : with 10 CP or 7 and one from listed below :

1.1. Uncontrolled variceal bleedingUncontrolled variceal bleeding

2.2. Hepato-renal syndromeHepato-renal syndrome

3.3. Uncontrolled ascitesUncontrolled ascites

4.4. Spontaneous bacterial peritonitis (SBP)Spontaneous bacterial peritonitis (SBP)

5.5. Hepatocelullar carcinomaHepatocelullar carcinoma

UNOS CLSSIFICACION – STATUS 3

Patient demanding permanent medical Patient demanding permanent medical care, with overcare, with over 7 7 CP and not CP and not meetingmeeting the the criteria 2B criteria 2B and one and one

MELD SYSTEM Primary used for evaluation indications for TIPSPrimary used for evaluation indications for TIPS Model for end stage liver disease , it ranges from 6 ( Model for end stage liver disease , it ranges from 6 (

in healthy individuals) to 40, a score of 12 or above in healthy individuals) to 40, a score of 12 or above is required to enter the transplant list is required to enter the transplant list

The higher the score the higher the priority of the The higher the score the higher the priority of the patient patient

modified system for qualification for liver modified system for qualification for liver transpalntationtranspalntation

1.1. Serum bilirubinSerum bilirubin

2.2. Prothrombin timeProthrombin time

3.3. Serum creatinineSerum creatinine

4.4. EtiologyEtiology

We don’t only depend on the MELD We don’t only depend on the MELD scoring we have to also consider UNOS scoring we have to also consider UNOS classification which has a higher priority.classification which has a higher priority.

FOR LIVER TRANSPLANTATION ARE QUALIFIED PATIENT WHO HAVE (BECAUSE OF LIVER DISEASE) LESS THAN 90% FOR LIVING 1 YEAR

this rule should regard complications of cirrhosis AND concomitant symptoms (fatigue, malnutrition, carcinoma)

ACUTE LIVER FAILUREمهم

irrespective ofirrespective of etiology etiology

dominant symptom- encephalopathydominant symptom- encephalopathy

Four Stages of Hepatic Encephalopathy(Trey Davidson criteria):

StageStage SymptomSymptomII Mild confusion,,agitation irritability, sleep Mild confusion,,agitation irritability, sleep disturbance, decreased attentiondisturbance, decreased attention

IIII Lethargy, disorientation, Lethargy, disorientation, inappropriate behavior, inappropriate behavior, drowsinessdrowsiness

IIIIII Somnolence but arousableSomnolence but arousable,,incomprehensible incomprehensible speechspeech, , confusionconfusion, aggression when awake, aggression when awake

IVIV ComaComa

KING’S COLLEGE HOSPITAL CRITERIA

for liver transplantation: for ACUTE ptA)A) in cases of acetaminophen toxicity : in cases of acetaminophen toxicity :

pH less than 7.3 (irrespective of grade of pH less than 7.3 (irrespective of grade of encephalopathy)encephalopathy)

OROR

Prothrombin time (PT) greater than 100 seconds = Prothrombin time (PT) greater than 100 seconds = INR greater than 10 INR greater than 10

ANDAND

Serum creatinine level greater than 3.4 mg/dL Serum creatinine level greater than 3.4 mg/dL

ANDAND

patients with grade III or IV encephalopathy patients with grade III or IV encephalopathy

KING’S COLLEGE HOSPITAL CRITERIA for liver transplantation

B) B) inin other cases of drug-induced liver failure other cases of drug-induced liver failure::

1.1. PT greater than 100 seconds (irrespective of grade of encephalopathy) PT greater than 100 seconds (irrespective of grade of encephalopathy)

OROR

Any 3 of the following criteria:Any 3 of the following criteria:

1.1. Age younger than 10 years or older than 40 years Age younger than 10 years or older than 40 years

2.2. Etiology of non-A/non-B hepatitis, halothane hepatitis, or idiosyncratic Etiology of non-A/non-B hepatitis, halothane hepatitis, or idiosyncratic drug reactions drug reactions

3.3. Duration of jaundice of more than 7 days before onset of encephalopathy Duration of jaundice of more than 7 days before onset of encephalopathy

4.4. PT greater than 50 seconds PT greater than 50 seconds

5.5. Serum bilirubin level greater than 17 mg/dL Serum bilirubin level greater than 17 mg/dL

CONTRAINDICATIONS TO LIVER TRANSPLANTATION

Hyper Na+ MCQ AIDS or HIV positiveAIDS or HIV positive Malignancy outside the liver Malignancy outside the liver Advanced cardiopulmonary or other systemic Advanced cardiopulmonary or other systemic diseasedisease Active alcohol (alcohol cessation for at least 6 Active alcohol (alcohol cessation for at least 6 months before liver transplant) or substance abuse.months before liver transplant) or substance abuse. Portal vein thrombosisPortal vein thrombosis SepsisSepsisIrreversible brain damage Irreversible brain damage

TRANSPLANTATION TECHNIQUE

the amount of liver tissue needed should equal the amount of liver tissue needed should equal 1% of the body weight ( if the patient is thin the 1% of the body weight ( if the patient is thin the left lobe alone can be sufficient) left lobe alone can be sufficient) classicclassic orthotopic liver transplantation with orthotopic liver transplantation with excision of retrohepatic part of inferior vena cava excision of retrohepatic part of inferior vena cava and temporary veno-venous extracorporeal by-and temporary veno-venous extracorporeal by-pass pass piggy back technique piggy back technique of liver transplantationof liver transplantation reduced size liver transplantation reduced size liver transplantation LDLTxLDLTx

Subclavian vein

Superior caval vein

Portal vein

Inferior caval vein

Saphena vein

HEPATIC ARTERY

COMMON

BILE DUCT

PORTAL VEIN

Infrahepatic anstomosis

5 sites of anastomosis2 in the IVC , 1 in hepatic artery, 1 in the portal vein , 1 in

the biliary system

:

COMMON

BILE DUCT

HEPATIC ARTERY

INFERIOR CAVAL VEIN

PORTAL ANASTOMOSIS

PORTAL VEIN

COMMON BILE DUCT

INFERIOR CAVAL VEIN

ARTERIAL ANASTOMOSIS

Inferior caval vein

Portal vein

Left hepatic artery

Right hepatic artery

piggy back technique of liver transplantationpiggy back technique of liver transplantation

INFERIOR CAVAL VEIN

PORTAL VEIN

COMPLICATIONS AFTER LIVER TRANSPALNTATION

Technical problems – occur in early postoperative period Technical problems – occur in early postoperative period

Portal vein thrombosisPortal vein thrombosis Primary non-functioningPrimary non-functioning Hepatic artery thrombosisHepatic artery thrombosis

Large hematomasLarge hematomas

Biliary complicationsBiliary complications


primary non function (PNF)primary non function (PNF); ; ((life threateninglife threatening ) )With vascular etiology or otherWith vascular etiology or other 6,9 – 8,5%6,9 – 8,5%Clinical signs- encephalopathy, multiorgan Clinical signs- encephalopathy, multiorgan dysfunction, serum bilirubin and transaminase elevation dysfunction, serum bilirubin and transaminase elevation tthe only treatment- RETRANSPLANTATION he only treatment- RETRANSPLANTATION albumin dialyses in meantimealbumin dialyses in meantime (Prometheus treatment) (Prometheus treatment)


bleedings: bleedings: 1.1. 88-1-122% recipients demand reoperation% recipients demand reoperation

2.2. In some cases surgical treatment is In some cases surgical treatment is inefficient because of lack obvious inefficient because of lack obvious bleeding during relaparotomybleeding during relaparotomy


early hepatic artery thrombosisearly hepatic artery thrombosis1.1. 2-8% recipients2-8% recipients2.2. ttotal thrombosis during 2 weeks aftr OLTx otal thrombosis during 2 weeks aftr OLTx 3.3. rrevascularization very rareevascularization very rare4.4. rretransplantation necessityetransplantation necessity5.5. 20-70% mortality20-70% mortality

llate hepatic artery thrombosisate hepatic artery thrombosis 1.1. may be partial may be partial 2.2. from 7 days to 2 months after OLTx from 7 days to 2 months after OLTx 3.3. usually causes biliary leak and other biliary complications usually causes biliary leak and other biliary complications 4.4. necessity of late necessity of late rretransplantationetransplantation


BILIARY COMPLICATIONS BILIARY COMPLICATIONS

1.1. 10-20% of recipients 10-20% of recipients

2.2. 80% complications during 3-6 80% complications during 3-6 months after OLTx months after OLTx

3.3. Most common causes: technical Most common causes: technical errors or ischemic injuryerrors or ischemic injury


other complications :other complications :1.1. Infections Infections

2.2. Respiratory complicationsRespiratory complications

3.3. Circulatory complicationsCirculatory complications

4.4. Renal complicationsRenal complications

5.5. Neurological complicationsNeurological complications

6.6. Coagulopathy Coagulopathy

7.7. diabetesdiabetes

RETRANSPLANTATION

10% recipients10% recipients ’ ’80- 20-25% recipients80- 20-25% recipients

Early retransplantationEarly retransplantation

Late retransplantationLate retransplantation

Liver transplantation like other Liver transplantation like other complex surgical operations requires complex surgical operations requires highly experienced team of specialists highly experienced team of specialists

Good results after OLT are obtained Good results after OLT are obtained after performing dozens of such after performing dozens of such procedures procedures

After reaching a certain level of After reaching a certain level of experience no significant improvement experience no significant improvement of results of results has been has been observedobserved. .

ConclusionsConclusions

After the team have obtained sufficient After the team have obtained sufficient experience other factors have an experience other factors have an impact on final outcome: the patient’s impact on final outcome: the patient’s condition, the time of operation and condition, the time of operation and organ matchingorgan matching..

Increasing number of Increasing number of retransplantations is related with a retransplantations is related with a higher ratio of preoperative higher ratio of preoperative complications. complications.

ConclusionsConclusions

Very imp Slide ,, MCQ we put the transplanted kidneys in RETroperitonealwe put the transplanted kidneys in RETroperitoneal

renal artery connected to Iliac ateryrenal artery connected to Iliac atery

= vein iliac= vein iliac

Directly connect the ureter to the bladder.Directly connect the ureter to the bladder.

Heart , liver >>> no need for cross matchHeart , liver >>> no need for cross match

Kidney >>> need cross matchKidney >>> need cross match

Liver and heart we only match the blood group not HLA Liver and heart we only match the blood group not HLA matching , like in kidney, so kidney rejection is more commonmatching , like in kidney, so kidney rejection is more common

Living with CKD and Lifestyle Choices

For people with chronic kidney disease, For people with chronic kidney disease, there are lifestyle choices regarding there are lifestyle choices regarding diet, exercise and smoking that may diet, exercise and smoking that may help prevent kidney disease from help prevent kidney disease from advancing to kidney failure. advancing to kidney failure.

Chronic kidney disease usually occurs Chronic kidney disease usually occurs gradually over time, therefore, finding gradually over time, therefore, finding out you have kidney disease in the early out you have kidney disease in the early stages provides an opportunity to slow stages provides an opportunity to slow the progression of CKD. the progression of CKD.

However, once a patient has lost nearly However, once a patient has lost nearly 90% of their kidney function, the only 90% of their kidney function, the only treatment options are dialysis or a treatment options are dialysis or a kidney transplant. While dialysis kidney transplant. While dialysis replaces failed renal function, a replaces failed renal function, a transplant replaces a diseased kidneytransplant replaces a diseased kidney

Liver failure will lead to death if not Liver failure will lead to death if not transplanted unlike kidney failure if on transplanted unlike kidney failure if on dialysis can still function and remain alive, dialysis can still function and remain alive, i.e. organ and patient survival are one in i.e. organ and patient survival are one in liver but in kidney when organ fails you can liver but in kidney when organ fails you can live by going back to dialysis. live by going back to dialysis.

When do you to decide?Stage 1 with normal or high GFR (GFR > 90 ml/min)Stage 2 Mild CKD (GFR = 60-89 ml/min)Stage 3 Moderate CKD (GFR = 30-59 ml/min)Stage 4 Severe CKD (GFR = 15-29 ml/min)Stage 5 End Stage CKD (GFR <15 ml/min)

How do you decide which modality is right for you?

HemodialysisHemodialysis

(Home vs. In Center)(Home vs. In Center)PeritonealPeritonealTransplantTransplantNo treatmentNo treatment

Why Kidney Transplant?

• It’s expensiveIt’s expensive

• There’s not There’s not enough donorsenough donors

• ?Quality of life ?Quality of life issuesissues

Advantages of successful transplant

• Freedom from dialysisFreedom from dialysis

• Increased strength & ability to engage in a more Increased strength & ability to engage in a more

physically active lifestylephysically active lifestyle

• Fewer dietary restrictionsFewer dietary restrictions

• Improved blood counts & improvement of uremia Improved blood counts & improvement of uremia

symptomssymptoms

• Less progression of nerve damageLess progression of nerve damage

• Improved life satisfaction, physical & emotional well beingImproved life satisfaction, physical & emotional well being

• Potential to return to work or school without disabilityPotential to return to work or school without disability

Disadvantages of kidney transplant

Unfortunately, there are no guarantees in transplantation.Unfortunately, there are no guarantees in transplantation.

Need to take anti-rejection medications as long as transplanted kidney is functioning. Need to take anti-rejection medications as long as transplanted kidney is functioning. These medications have potential for significant adverse effectsThese medications have potential for significant adverse effects. (in kidney transplant . (in kidney transplant you give a combination of 3 or 4 immunosuppressant not only one to decrease the risk you give a combination of 3 or 4 immunosuppressant not only one to decrease the risk of side effects).of side effects).

Anti-rejection medications are very expensive. Anti-rejection medications are very expensive.

If disability is dependent upon end stage organ disease, it will be discontinued after a If disability is dependent upon end stage organ disease, it will be discontinued after a successful transplant.successful transplant.

Frequent & chronic follow-up with Transplant Physician, as often as Frequent & chronic follow-up with Transplant Physician, as often as 2-3 times a week following discharge from hospital.2-3 times a week following discharge from hospital.

Worsening of current medical problemsWorsening of current medical problems

Organ may not work Organ may not work

Inhibiting Factors to Transplantation

Over 12,000 people are on transplant lists

Lack of supportive care for patients

Lack of knowledge of the transplant process

Religious beliefs

Cost of healthcare continues to rise and more patients have limited financial resources

Contraindications to Kidney Transplantation

Active malignancy (primary or secondary) e.g. lymphoma.Active malignancy (primary or secondary) e.g. lymphoma. Cirrhosis (Unless simultaneous liver transplant is planned)Cirrhosis (Unless simultaneous liver transplant is planned) Severe myocardial dysfunctionSevere myocardial dysfunction Active mental illness/Dementia Active mental illness/Dementia Severe Pulmonary HypertensionSevere Pulmonary Hypertension Non-curable diseases such as end organ dysfunction e.g. heart Non-curable diseases such as end organ dysfunction e.g. heart

failurefailure Active substance abuse: alcohol (6 months abstinence) heroinActive substance abuse: alcohol (6 months abstinence) heroin T.B or infection T.B or infection Extreme obesityExtreme obesity Non-adherence Non-adherence

No support/ financial or socialNo support/ financial or social

Conditions Requiring Treatment Prior to Transplantation Active infection even dental infections (dentist needs Active infection even dental infections (dentist needs

to clear them before transplant) because any to clear them before transplant) because any infection with immuno-suppressants will be hard to infection with immuno-suppressants will be hard to treat.treat.

Peptic ulcer disease /DiverticulitisPeptic ulcer disease /Diverticulitis MalignancyMalignancy Cardiovascular diseaseCardiovascular disease Cerebrovascular disease/Peripheral vascular diseaseCerebrovascular disease/Peripheral vascular disease Substance abuseSubstance abuse

How the Kidney Transplant

Evaluation Begins Referral from NephrologistReferral from Nephrologist

Dialysis units are regulated/mandated by CMS to address Dialysis units are regulated/mandated by CMS to address

transplant as a treatment option for every patienttransplant as a treatment option for every patient

Initial Insurance Approval for evaluationInitial Insurance Approval for evaluation

CMC has contracts with most major insurance companiesCMC has contracts with most major insurance companies

Referral reviewed by Intake Nurse/Patient contactedReferral reviewed by Intake Nurse/Patient contacted

Patient scheduled for Group Teaching SessionPatient scheduled for Group Teaching Session

If a high risk candidate, appt scheduled with nephrologistIf a high risk candidate, appt scheduled with nephrologist

Evaluation Tests

LabsLabs EKGEKG Chest X-RayChest X-Ray Other tests as indicatedOther tests as indicated Patient responsible to completePatient responsible to complete

Yearly DentalYearly Dental Yearly Pap (Females)Yearly Pap (Females) Yearly Mammogram (Females)Yearly Mammogram (Females) Colonoscopy (> age 50)Colonoscopy (> age 50) Yearly TB skin test (PPD)Yearly TB skin test (PPD)

Types of Transplant

Deceased DonorDeceased Donor

o Standard Criteria Donor (SCD)Standard Criteria Donor (SCD)o Expanded Criteria Donor (ECD)Expanded Criteria Donor (ECD)o Donation after Cardiac Death (DCDDonation after Cardiac Death (DCD))

Living DonorLiving Donor

o Living Related (LRD)Living Related (LRD)o Living Unrelated (LUR)Living Unrelated (LUR)o Good Samaritan/Altruistic DonorGood Samaritan/Altruistic Donoro Paired ExchangePaired Exchange

The Good Samaritan :A person who voluntarilyoffers, help or sympathyin times of trouble.

Altruism:Auguste Comte 1851

“Care for well-being (fitness) of another person”Caring about or helping others, even though thisbrings no advantage to yourself

SAMARITAN / ALTRUISTIC DONORS

How successful are transplants and does donor type really make a difference?

Deceased Donor

Graft Survival @ 1 year

90.4%

Deceased Donor

Patient Survival @ 1

yr.

95%

Living DonorGraft Survival @ 1 year

95.6%

Living DonorPatient Survival @ 1yr

98.2

How are Kidneys Matched?

Blood typeBlood type HLA (tissue typing)HLA (tissue typing) Time WaitingTime Waiting Medical UrgencyMedical Urgency Antibody LevelAntibody Level Geographic areas/AvailabilityGeographic areas/Availability

Blood Groups

Percentage of blood groups in the populationPercentage of blood groups in the populationO = 46 %O = 46 %A = 39%A = 39%B = 11%B = 11%AB = 4%AB = 4%

Average waiting times on the list vary Average waiting times on the list vary according to blood typeaccording to blood type ..

You wait, and wait, and wait!

Update routine health maintenance Update routine health maintenance testtest

Re-evaluation Annually or as Re-evaluation Annually or as IndicatedIndicated

And then wait a little more…..And then wait a little more…..

Getting the Call!!! And the What if’s??

• The crossmatch is positive…The crossmatch is positive… Back-up will be calledBack-up will be called

• You are not medically cleared…You are not medically cleared… Back-up will be called Back-up will be called • The kidneys are not usable…The kidneys are not usable…

You will go homeYou will go home

Surgical Work-up

Admission to RoomAdmission to Room LabsLabs Chest x-rayChest x-ray EKGEKG Evaluation by Nurse & PhysiciansEvaluation by Nurse & Physicians Dialysis (if needed)Dialysis (if needed) Other tests (if needed)Other tests (if needed)

If medically cleared, then it’s off to the operating room!!!If medically cleared, then it’s off to the operating room!!!

Transplant techniques

Recipient liver should be removed and the Recipient liver should be removed and the transplanted one should be put in the same transplanted one should be put in the same place.place.

Recipient kidney should be kept in place Recipient kidney should be kept in place and the transplanted one is just added and the transplanted one is just added retroperitoneal space (lower abdomen iliac retroperitoneal space (lower abdomen iliac fossa). fossa).

82

The History Of Heart Transplantation

3rd December 1967

Nearly 40 years and 70,000 transplants

Indication for Heart Tx

End-stage heart disease with life expectancy limited End-stage heart disease with life expectancy limited to 6-12 months. to 6-12 months.

Age of less than 55 years for coronary arteries Age of less than 55 years for coronary arteries disease; less than 60 years for cardiomyopathy disease; less than 60 years for cardiomyopathy

Absence of irreversible hepatic or renal failure Absence of irreversible hepatic or renal failure Absence of active infection Absence of active infection Absence of recent pulmonary infection Absence of recent pulmonary infection Psychosocial stability Psychosocial stability There is no lower age limit to heart transplantation There is no lower age limit to heart transplantation

Contraindications HTx Kidney, , lung, or , or liver disease disease Insulin-dependent -dependent diabetes with other organ with other organ

dysfunction dysfunction Life-threatening diseases unrelated to Life-threatening diseases unrelated to heart failure Vascular disease of the neck and leg arteries. of the neck and leg arteries. High pulmonary vascular resistance High pulmonary vascular resistance Recent Recent thromboembolism Age over 60 years (some variation between centers) Age over 60 years (some variation between centers) Substance abuse (which increases the chance of Substance abuse (which increases the chance of

lung disease) lung disease)

85

Orthotopic Implantation

Positioning Positioning of donor of donor heartheart

Creation of Creation of ieft atrial ieft atrial anastomosisanastomosis

86


Completion of Completion of right atrial right atrial anastomosis anastomosis (standard (standard tchnique)tchnique)

87

Aortic anastomosisAortic anastomosis Pulmonary artery Pulmonary artery

anastomosisanastomosis


88


Completed Completed transplanttransplant

Pacing wires on Pacing wires on donor portion of donor portion of right atrium and right atrium and ventricleventricle

Pericardium left Pericardium left openopen

89

Alternative Bicaval Approach

Left atrial Left atrial anastomosis anastomosis performedperformed

Separate inferior and Separate inferior and superior vena caval superior vena caval anastomosisanastomosis

OrganTransplants reported

through 2001

Heart61,533

Heart-Lung2,935

Lung14,588

ISHLT/UNOS Registry DatabaseNumber of Transplants Performed

Why Choose Pancreas Transplant?Why Choose Pancreas Transplant?

Pancreas transplantation is a “lifePancreas transplantation is a “life

improving” procedure which hasimproving” procedure which has

the primary purpose of halting orthe primary purpose of halting or

slowing the progression ofslowing the progression of

diabetic complications.diabetic complications.

Endocrine: –Glucagon

–Insulin –Somatostatin

Exocrine: –Digestive Enzymes

amylaselipasetrypsin

Pancreas Function

Endocrine Function

1 million islets within pancreas1 million islets within pancreas Beta cells within isletsBeta cells within islets

– – synthesize and secrete insulinsynthesize and secrete insulin

– – turn on and off when needed to maintainturn on and off when needed to maintain

– – normal blood sugar levelsnormal blood sugar levels

Complications of Diabetes

Diabetic ketoacidosisDiabetic ketoacidosis BlindnessBlindness– – retinopathy most common causeretinopathy most common cause

Renal dysfunctionRenal dysfunction– – 40%-50% of those with DM will develop renal40%-50% of those with DM will develop renal

insufficiencyinsufficiency

– – Usually develops about 20yrs after the onset of DMUsually develops about 20yrs after the onset of DM

Complications of Diabetes (Cont)

Vascular disease –Cardiac

People w/ diabetes are 2x as likely to die of CAD –Peripheral

high incidence of amputations

Neuropathy –found in 60-70% of diabetics: peripheral,

autonomic, gastroparesis

Pre-Transplant Work up

C-PeptideCardiovascular Evaluation

– at least a chemical stress test—often cardiac angiogram

Psychosocial Evaluation–post op support

Other: mammo, pap, CXR, laboratory tests.…

Pancreas Transplant

Indications:

–hypoglycemic unawareness –extreme labile diabetes

– having >1 hyperglycemic or hypoglycemic episode a month requiring intervention or

assistance –severe gastroparesis

– interferes with glucose controlDiabetes alone is not a usual indication for pancreatic transplantation, unless its with a complication e.g. ESRD they

will require both renal and pancreatic transplantation .

Pancreas Transplant (Cont)

Goal of therapy:

–to halt the progression of diabetic disease and its complications

–to potentially reverse complications of diabetes i.e,. neuropathy

–protect renal transplant or native kidneys from diabetic nephropathy

SPK)) Simultaneous Pancreas & Kidney Transplant

Pancreas after Kidney Transplant (PAK)

Pancreas Transplant Alone (PTA)

Islet Cell Transplant

Transplant Options

Contraindications toPancreas Transplantation

–Active Cancer(s) and/or history of Cancer

–Severe cardiac, vascular or pulmonary insufficiency

–Active/Chronic Hepatitis B

–Severe psychiatric disease/current substance abuse/non compliance

Enteric Drainage–Most common

75% of pancreas transplants –Primary anastamosis to the bowel

Systemic drainage Portal drainage

Bladder Drainage –Primary anastamosis to the bladder

Surgical Techniques

•More physiologic•Fewer metabolic imbalances because

pancreatic secretions are reabsorbedinto the system

DISADVANTAGES

•Infections due to possible enteric contamination

•Sepsis secondary to fistula or abscess formation

•Vascular thrombosis•Complications necessitate more

invasive procedures to correct

Handbook of Kidney Transplantation

Enteric Diversion

ADVANTAGES

:ADVANTAGES•Allows direct measurement of

graft exocrine function by measuring urine amylase

•Complications treated less invasively

DISADVANTAGES:•Pancreatitis

•Leaks•Urinary tract infections

•Metabolic acidosis from urinary loss of bicarbonate

•Hematuria •35% need enteric conversion

Handbook of Kidney Transplantation

Urinary Diversion

ADVANTAGES:

–More physiologicglucose control

–May help lipidprofile

DISADVANTAGES:

-Unable to monitorurine amylase

-Difficult to bx

Portal venous/enteric exocrine drainage

Pancreas TransplantImmunosuppression

Medication Regime Varies per Center

Induction

Campath, Thymoglobulin, Simulect,Zenapax

MaintenancePrednisonePrograf/NeoralCellcept/MyforticRapamun

Complications

Vascular Thrombosis:

–Immediate post-operative period (<72hrs) technical, microthrombin, trauma, poor vessel size match

( pediatric donors) –Clinical Signs

drop in urine amylase (if bladder drained), rapid rise in serum glucose, amylase and/or lipase,

absence of arterial or venous flow on radiological scan –Treatment

Immediate ex-lap , pancreatectomy

Complications (Cont)

Anastomotic leaks – Occur within first 3 months

– Clinical signs: Severe abdominal pain, rise in amylase and/ or lipase, radiologic testing can detect most leaks

– Treatment : Most require re-exploration with repair of

anastomotic leak


Rejection

:Clinical Diagnosis Often difficult to diagnose:

Increase in serum Amylase/Lipase Rise in serum creatinine (SPK)

> – 90% of pancreas and kidney reject simultaneously in SPK (same donor)

Decrease in urine Amylase (if bladder drained)


Rejection : Clinical Diagnosis (Cont)

- Pain over pancreas graft- Malaise/fever

- Hyperglycemia (usually late indicator) - Biopsy positive for lymphocyte infiltrates

Rejection Treatment:

Solumedrol Pulse x 3 days –For mild rejection

Thymoglobulin 7-14 days –For more severe rejection or rejection that does

not respond to solumedrol


Infection

–Common post transplant infections CMV

UTI’s (w/ bladder drainage).… Early post-operative abscesses re: duodenal leaks

BK Virus (Polyoma)

Cardiovascular Problems

–May result from pre-existing disease –Remains the leading cause of death in this patient population


Anticoagulation (Center specific) – Some centers use no anticoagulation

– IV Heparin or IV Dextran, then ASA and dipyridamol Monitor blood sugars Q1H to QID

– if suddenly high, possible acute thrombosis which requires immediate action

Monitor serum Amylase/Lipase Daily

Pancreas TransplantPost op care

Monitor Prograf levels daily and keep drug levels high (12-15) –greater risk of rejection than kidney transplant

NG tube, bowel rest

First stools may be dark brown, melena –due to bowel anastomosis

Ambulate, watch for orthostatic hypotension(autonomic neuropathy)

Pancreas TransplantPost op care (Cont)

Call Transplant Center immediately if:Signs/ symptoms rejection, infection

–Fever, malaise, abdominal pain, elevated blood sugars (>150)

–Hyper/hypotension

–Blood in stool, urine

Discharge Teaching

Stress importance of: –Taking medicines on time

–Lab and clinic appointments –Monitoring and recording vital signs –PO fluid intake (at least 2 liters/day)

This is a unique populationChronically ill since childhoodParent may be very involved

Discharge Teaching (Cont)

Avoid crowded areas and sick people for at least 1 month post transplantr Record weight daily, Temp BID, blood pressure QID, blood sugars QID, abdominal drain output (if

applicable) Lab and clinic appts BIW x 1month then

QW x 1 month


Medications:

–Maintenance ImmunosuppressionPrednisone (? discontinue if low risk for rejection)Prograf/NeoralCellcept/Rapamune


–Antibiotic Prophylaxis (approx 3 months):Antifungal (fluconazole)Antibacterial (bactrim)Antiviral (valcyte)

Medications (Cont):

ASA 325mg (indefinitely) dypiridamole (2 wks)

Anti-ulcer (protonix, Losec)Stool softener (colace, dulcolax)Pain medication (vicodin, acetaminophen)Vitamins (nephrovite, folic Acid)Florinef, sodium tablets if orthostatic


No over-the-counter drugs,vitamins, herbal supplementsunless ok with Transplant TeamCertain drugs may interact withPrograf/Neoral


ISLET CELL TRANSPLANT

–Predominately investigational at this time –International and National Centers

–Long term success for insulin independence is rare but possible

–Often requires 2-3 donor pancreas–May be predominant way of transplant in the future

Future Options?

Pancreas transplant is a procedure that can restore greater quality of life and slow or halt end organ

complications of diabetes .

Transplant surgeons and scientists continue to research ways to improve

pancreas transplantation success rates and long term patient survival.

Note: in any transplant do not match age between the donor and recipient but match weight. (approximate BMI)

Overview

the history of organ transplant

Documents