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Comparison of HTK and UW in Abdominal Transplantation

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

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Comparison of HTK and UW in Abdominal Transplantation

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  1. Comparison of HTK and UW in Abdominal Transplantation Dr. Richard S. Mangus, MD MS Indiana University, School of Medicine

  2. 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

  3. Indiana Organ Procurement Organization (IOPO) Service area: Indiana Population: 5.1 million Hospitals: 130 Transplant centers: 7

  4. 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”

  5. 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

  6. Indiana Organ Procurement Organization (IOPO) Cost analysis: HTK vs UW UW flush volume / donor: 3.5 liters UW cost / liter $306.00 Total cost per donor $1071 HTK flush volume / donor 3.5 liters HTK cost / liter $150.00 Total cost per donor $525 Cost savings per donor $546

  7. Indiana Organ Procurement Organization (IOPO) Center cost savings Cost savings / donor $546 Annual cost savings for average OPO (200 donors) $109,200

  8. Indiana University Medical Center Abdominal Organ Transplants Liver Pancreas Kidney Islets Small intestine / Multivisceral

  9. Indiana University Medical Center Abdominal Organ Transplants 2007Rank * Liver 155 Top 5 Pancreas 84 1st Kidney 255 Top 10 Small intestine 22 Top 5 OVERALL (+ thoracic) 562Top 5 * www.unos.org, 2007 data report

  10. Transplant Volume

  11. Transplant Volume Conversion to HTK

  12. 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.

  13. Renal Transplantation

  14. Renal Transplantation Transplants: 1990 to 1992 DGF: Need for dialysis 2 or more times during first 7-days post-transplant Flush volume: HTK 5 – 6 L UW 1 – 2 L EC 4 L

  15. Renal Transplantation de Boer, et al, Transpl Proc, 1999; 31: 2065

  16. Renal Transplantation de Boer, et al, Transpl Proc, 1999; 31: 2065

  17. HTK vs UW: KIDNEY Transplantation N=91 renal transplants HTK 50 UW 41 No differences in: Delayed graft function Graft survival Patient survival

  18. Creatinine Clearance Post Transplantation 100 80 60 UW ml/min HTK 40 20 0 1 2 3 4 5 6 7 10 14 21 30 time (days)

  19. Serum Creatinine Post Transplantation 12.0 10.0 8.0 UW 6.0 mg/dL HTK 4.0 2.0 0.0 0 3 6 9 12 15 18 21 24 27 30 time (days)

  20. 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)

  21. PANCREAS TRANSPLANTATION

  22. 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

  23. Pancreas Transplantation

  24. Pancreas Transplantation N= 87 pancreas transplants HTK 78 UW 9 No differences in: Graft survival Patient survival Serum fasting blood glucose Peak serum amylase Serial amylase levels

  25. Pancreas Transplantation

  26. Pancreas Transplantation Primary preservation solution: HTK, 2003 to 2007:

  27. Pancreas Islet Transplantation

  28. Pancreas Islet Transplantation

  29. LIVER TRANSPLANTATION

  30. Liver Transplantation N=378 liver transplants HTK 174 UW 204

  31. Liver Transplantation: ECD N=698 liver transplants HTK 371 UW 327 Groups: Standard 209 (30%) ECD (old age) 70 (10%) ECD (physiologic stress) 435 (62%)

  32. Liver Transplantation: ECD

  33. Liver Transplantation: ECD N=698 HTK 371 UW 327

  34. Liver Transplantation: ECD Standard donors, n=209 Extended criteria donors, n=489

  35. Liver Transplantation: ECD Donor ≥ 60 years, n=70 Donor < 60 years, n=628

  36. Liver Transplantation: ECD No physiologic stress, n=263 Physiologic ECD, n=435

  37. Liver Transplantation: ECD

  38. Liver Transplantation Biliary complications

  39. Liver Transplantation Biliary complications

  40. Liver Transplantation Donation after cardiac death, n=43 HTK 35 UW 7

  41. Liver Transplantation: Recent

  42. Intestinal / Multivisceral Transplantation

  43. Intestinal Transplantation “Comparison of HTK and UW in Intestinal and Multivisceral Transplantation” - Mangus, et al. Transplantation, 2008; In Press N=57 intestinal transplants HTK 35 UW 22

  44. Intestinal Transplantation

  45. Intestinal Transplantation N=57 intestinal transplants HTK 35 UW 22

  46. 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

  47. 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

  48. 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

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