TRANSPLANTATION

TODAY
LILLY BARBA, M.D.
MEDICAL DIRECTOR RENAL TRANSPLANT
PROGRAM
HARBOR-UCLA MEDICAL CENTER
APRIL 12, 2010
 THE HISTORY OF TRANSPLANTATION
AS DEPICTED IN ART
• The possibility to transplant limbs and
organs predates the modern technology of
organ transplantation.
• The legend of the “Miracle of the Black
Leg” describes two surgeon brothers, who
lived during the 3rd century in Asia Minor.
• The legend relates their miraculous
removal of the diseased leg of a Caucasian
Roman named Justinian and its
replacement with the leg of a recently
deceased black African.

The Miracle of Cosmas & Damian (15th c.)

 SIGNIFICANT EVENTS IN
TRANSPLANTATION
 AS EARLY AS THE 6TH CENTURY BC
THE INDIAN SURGEON SUSHRUTA
DESCRIBED RECONSTRUCTION OF
DISFIGURING FACIAL WOUNDS BY
TRANSPLANTATING SKIN AND
CARTILAGE
 EARLY INTEREST IN THE
POSSIBILITY OF TRANSPLANTATION
 TRANSPLANTATION AS A
VIABLE CLINICAL PROCEDURE
 1905 FIRST SUCCESSFUL HUMAN
CORNEAL TRANSPLANT
 1930’S HISTOCOMPATIBILITY
ANTIGENS DISCOVERED IN MICE
 1954 FIRST SUCCESSFUL KIDNEY
TRANSPLANT PERFORMED
BETWEEN IDENTICAL TWINS
 1957 AZATHIOPRINE DEVELOPED
 TRANSPLANTATION AS A
VIABLE CLINICAL PROCEDURE
 1962 FIRST SUCCESSFUL DECEASED DONOR
KIDNEY TRANSPLANT
 1963 DR. HARDY PERFORMS FIRST
SUCCESSFUL LUNG TRANSPLANT
 1966 FIRST SUCCESSFUL PANCREAS
TRANSPLANT
 1967 DR. BARNARD PERFORMS THE FIRST
SUCCESSFUL HEART TRANSPLANT. DR.
STARZL PERFORMS THE FIRST
SUCCESSFUL LIVER TRANSPLANT
 TRANSPLANTATION AS A
VIABLE CLINICAL PROCEDURE
 1981 DR. SHUMWAY PERFORMS THE
FIRST HEART/LUNG TRANSPLANT
 1983 CYCLOSPORINE APPROVED FOR
PREVENTION OF REJECTION
 1988 FIRST SUCCESSFUL SMALL
INTESTINE TRANSPLANT
 1990 TACROLIMUS APPROVED FOR
PREVENTION OF REJECTION
 1995 MYCOPHENOLATE APPROVED
 TRANSPLANTATION AS A
VIABLE CLINICAL PROCEDURE
 1996 USE OF SPLIT LIVERS
 1997 DACLIZUMAB APPROVED FOR
PREVENTION OF ACUTE REJECTION
 1999 SUCCESSFUL ISLET CELL
TRANSPLANTATION USING THE
EDMONTON PROTOCOL
 2005 FIRST SUCCESSFUL PARTIAL
FACE TRANSPLANT PERFORMED
TRANSPLANTATION TODAY
 THE WAITING LIST
 SUCCESS RATE OF ORGAN
TRANSPLANTATION
 REVIEW OF TRANSPLANTATION 2009
 THE OPTN
 The Organ Procurement and
Transplantation Network (OPTN) was
established by Congress under the National
Organ Transplant Act (NOTA) of 1984
 The OPTN is operated by a private, non-
profit organization under federal contract.
 UNOS
UNITED NETWORK FOR ORGAN
SHARING
 UNOS was awarded the first OPTN
contract in 1986
 UNOS has continued to administer the
OPTN under contract with the Health
Resources and Services Administration of
the U.S. Department of Health and Human
Services (HHS) for more than 20 years.
 What is the purpose of the OPTN?
 The OPTN is a public-private partnership
linking all of the professionals involved in
the donation and transplantation system.
 The primary goals of the OPTN are to:
1. increase and ensure the effectiveness,
efficiency and equity of organ sharing in
the national system of organ allocation
2. increase the supply of donated organs
available for transplantation
 THE WAITING LIST

 Initiated on October 25, 1999, UNet contains data

regarding every organ donation and transplant
event occurring in the U.S. since 1986.
 UNet enables the nation's organ transplant
institutions to:
 register patients for transplants
 match donated organs to waiting patients
 manage the clinical data of all patients, before
and after their transplants
 UNOS
Waiting list candidates as of April 11, 2010
All 106,842
Kidney 84,295
Pancreas 1,467
Kidney/Pancreas 2,190
Liver 15,931
Intestine 243
Heart 3,153
Lung 1,831
Heart/Lung 72
All candidates will be less than the sum due to
candidates waiting for multiple organs
Transplants performed January 2010
UNOS

Total 2,198

Deceased Donor 1,682

Living Donor 516

Based on OPTN data as of 04/02/2010
 DONORS
UNOS

Donors recovered January 2010

Total 1,139

Deceased Donor 623

Living Donor 516

Based on OPTN data as of 04/02/2010

Waitlist and Transplant Activity for Liver,
1999-2008
Waitlist and Transplant Activity for Kidneys,
1999-2008
Waitlist and Transplant Activity for Heart,
1999-2008
Waitlist and Transplant Activity for Lung,
1999-2008
TRANSPLANTATION TODAY
 THE WAITING LIST
 SUCCESS RATE OF ORGAN
TRANSPLANTATION
 REVIEW OF TRANSPLANTATION 2009
Patient Survival Until Five Years After Transplant
Patients Transplanted 2001-2007
 One Year Unadjusted Graft Survival by Year,
Living and Deceased Donor Kidney Transplants
 One Year Unadjusted Graft Survival by Year,
Living and Deceased Donor Liver Transplants
One Year Unadjusted Patient Survival by Year,
Living and Deceased Donor Liver Transplants
One Year Unadjusted Graft Survival by Year,
Deceased Donor Heart Transplants
One Year Unadjusted Patient Survival by Year,
Deceased Donor Heart Transplants
One Year Unadjusted Graft Survival by Year,
Deceased Donor Lung Transplants
One Year Unadjusted Patient Survival by Year,
Deceased Donor Lung Transplants
 Annual Report of the OPTN and SRTR
Trends in K and P Transplants
1998 to 2007
• The number of patients awaiting transplantation increased
from 40,825 to 76,070 (86%) between 1998 and 2007, reflecting
an increase in the number of patients listed “inactive status”.
Active patients increased by 4,510 between 2002 and 2007,
from 44,263 to 48,773.

• There were 6,037 living donor and 10,082 deceased donor

kidney transplants in 2007. Patient and allograft survival was
best for recipients of living donor kidneys, least for expanded
criteria donor (ECD) deceased donor kidneys, and intermediate
for non-ECD kidneys.

• The total number of pancreas transplants peaked at 1,484 in

2004 and has since declined to 1,331. Among pancreas
recipients, those with simultaneous pancreas-kidney (SPK)
transplants experienced the best pancreas graft survival rates:
86% at one year and 53% at 10 years.

SRTR
 Liver and Intestine Transplantation
In the United States, 1998-2007
• Liver transplantation numbers in the United States remained
constant from 2004-2007, while the number of waiting list
candidates has trended down.

• In 2007, the waiting list was its smallest since 1999, with
adults ≥50 years representing the majority of candidates.
Most age groups had decreased waiting list death rates,
however, children <1 year had the highest death rate.

• Non-cholestatic cirrhosis was most commonly diagnosed.

Hepatocellular carcinoma exceptions increased slightly.

SRTR
 Liver and Intestine Transplantation
In the United States, 1998-2007
• Use of liver allografts from donation after cardiac death donors
increased in 2007.

• Model for End-stage Liver Disease (MELD)/Pediatric Model for End-

stage Liver Disease (PELD) scores <15 accounting for 75% of the
waiting list.

• Over the same period, the number of transplants for MELD/PELD

<15 decreased from 16.4% to 9.8%.

• The intestine transplantation waiting list decreased from 2006, with

the majority of candidates being children <5 years old.

• Death rates remain at about 14 % . Policy changes have been

implemented to improve allocation and recovery of intestine grafts
to positively impact mortality

SRTR
 Heart Transplantation in the U.S., 1998-2007

• The number of candidates actively awaiting heart

transplantation has declined steadily, from 2,525 in
1998 to 1,408 in 2007, a 44% decrease.

• Despite this decline, a larger proportion of patients

are listed as either Status 1A or 1B, likely secondary
to increased use of mechanical circulatory support.

SRTR
 Heart Transplantation in the U.S., 1998-2007
• The overall death rate among patients awaiting heart
transplantation fell from 220 to 142 patients per 1,000
patient-years at risk.

• Likely reflects better medical and surgical options for

those with end-stage heart failure.

• This trend was noted across all racial groups, both

sexes, all disease etiologies (re-transplantation
excepted), and all status groups.

SRTR
 Heart Transplantation in the U.S., 1998-2007
• Recipient numbers were relatively stable over the past
decade. In 2007, 2,207 transplants were performed,
although the proportion of patients transplanted as
Status 1A shifted from 34% to 50%. A trend toward
transplanting more patients above 65 years of age was
seen.
• Adjusted patient (and graft) survival at three months,
one, five, and 10 years after transplantation has
gradually, but significantly, improved during the same
period.
• Current patient survival estimates are 93%, 88%, 74%,
and 55%, respectively (for 3m, 1yr, 5 yr, 10 y).

SRTR
 Lung Transplantation in the United
States,1998-2007

• The most significant change in lung transplantation over the

last decade was implementation of the Lung Allocation Score
(LAS) allocation system in May 2005.

• Subsequently, the number of active wait-listed lung

candidates declined 54% from pre-LAS (2004) levels to the
end of 2007. There was also a reduction in median waiting
time, from 792 days in 2004 to 141 days in 2007.

• The number of lung transplants performed yearly increased

through the decade to a peak of 1,465 in 2007; the greatest
single year increase occurred in 2005.

SRTR
 Lung Transplantation in the United
States,1998-2007
• Despite higher LAS scores being transplanted in the LAS
era, recipient death rates have remained relatively stable
since 2003, and better than in previous years.

• Idiopathic pulmonary fibrosis (IPF) became the most common

diagnosis group to receive a lung transplant in 2007.
Emphysema was the most common diagnosis in years prior.

• The number of re-transplants and transplants in those >65yrs

have increased significantly since 1998, up 295% and 643%,
respectively.

• A decreasing percentage of lung transplant recipients are

children (3.5% in 2007, n=51).

SRTR
 TRANSPLANTATION TODAY

• THE WAITING LIST

• SUCCESS RATE OF ORGAN TRANSPLANTATION
• REVIEW OF TRANSPLANTATION 2009

SRTR
 Review of topics in transplantation

• Machine Perfusion or Cold Storage in Deceased-

Donor Kidney Transplantation
(NEJM 360:7,2009) : randomized, controlled trial
showed machine perfusion associated with a
reduced risk of delayed graft function and
improved graft survival in the first year post
transplant (94 % vs 90 %)

SRTR
 Review of topics in transplantation
• Outcomes and Utilization of Kidneys from Deceased
Donors with Acute Kidney Injury (AJT 2009:9):The
relative risk of graft loss was similar for recipients of
SCD kidneys with sCr of 1.6–2.0 and >2.0 mg/dL,
compared to ≤1.5 mg/dL. For ECD recipients, the relative
risk of graft failure significantly increased with
increasing sCr
• Calculating Life Years from Transplant (LYFT): Methods
for Kidney and Kidney-Pancreas Candidates (AJT
2008:8:997) :Prioritizing candidates with higher LYFT
scores for each available kidney could substantially
increase total years of life among both transplant
candidates and recipients

SRTR
 Other topics in transplantation

• PAIRED EXCHANGE/CHAIN DONORS

• SURVIVAL OF KIDNEY DONORS

• PREGNANCY IN YOUNG WOMEN AFTER

DONATION

SRTR
 CONCLUSIONS:

• TRANSPLANTATION SAVES LIFES, IMPROVES

THE QUALITY OF LIFE
• ALLOGRAFT AND PATIENT SURVIVALS HAVE
IMPROVED
• MORE DONORS ARE NEEDED

SRTR