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Pulsatile Perfusion OverviewRalph Aguilar, SRPPT

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OneLegacy

• Federally designated OPO

• Education

• Family/Patient Advocate

• Donor Identification

• Donor Management

• Procurement coordination

• Organ preservation

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Transplant Process

• Patient Identification

• Pre-tx work-up, psycho-social work, dental activity, bloodwork maintenance, LRD?, Cad?, etc

• Peri-transplant activity

• Post-transplant follow up

• ……….Organ Procurement

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What

• is kidney pumping?

Another method of organ storage during transport

Active preservation of kidneys allowing benefits not provided by static storage.

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When

will my kidneys get on the pump?

after biopsy is read

after delivered from OR/UCLA/NIT

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is going on in the pumping world?

Two FDA approved pumps

Waters Instruments Organ Recovery Systems

What

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Where

OneLegacy Corporate Office

221 South Figueroa Street

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Organ Preservation

“The goal of optimal organ preservation is to

maintain viability for transplant.”

Robert Hoffman, BS, CPTC, James Southard, Ph.D.,

Folkert O. Belzer, MD

Organ Preservation, UNOS,

ORGAN PROCUREMENT, PRESERVATION AND

DISTRIBUTION IN TRANSPLANTATION

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Perfusion of Isolated OrgansLoebel 1849; 1st attempt

Langendorf 1895; siphon tube/gravity

Carrel 1905; “Anastomosis and Transplantation of Blood Vessels”

Lindbergh 1930s; sister-in-law, introduced to Carrel, mechanical pump for cardiac surgery; sterilizable, pulsating

Carrel/Lindbergh 1937; hypothermia; War

USSR 1960s; limbs/kidneys

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Organ Preservation

The ideal preservation method for [organs] during any ischemia – both warm or cold, MUST

• Maximize the quality of the organ

• Minimize the chance for delayed graft function (DGF)

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What can we do with Renal Preservation?

Normo-thermic

Cold Static Storage (CSS)

Pulsatile Perfusion

Combination

CADAVERIC KIDNEY TRANSPLANTS

UNOS 1998 SR & OPN Annual Reports

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Preservation is Critical

Patients who required dialysis within the first week postransplant had lower graft survival and patient survival rates at all time points than those who did not require dialysis soon after transplant. Graft survival for the dialysis group was 83% at one year and 53% at five years postransplant compared to 93% at one year and 68% at five years for the nondialysis group.”

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What is Renal Pulsatile Perfusion?

Kidneys are connected to a machine that allows a solution to actively maintain organs for transplant preservation, and provide additional information to aid in determination of organ viability.

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The RM3 Renal Perfusion System

“The Ultimate Pumping Machine…”

Tom Mone, CEO OneLegacy

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Observations

Objective

• Flow

• Pressure

• Resistance (MAP/flow=rr)

• Labs (pH, O2, CO2, Osmo)

• Chemotherapy (mannitol, verapamil, papavarine, etc.)

Subjective

• Visualization assessment

• Bounce

• Gestalt

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Early Function Prediction

The best predictor of early function based on a linear regression analysis of these five variables:

1. Renal Blood Flow

2. Final Resistance (mean pressure/flow)

3. Patient age

4. Cold perfusion time

5. Warm ischemia time

was determined to be:

Final Resistance.

Renal Blood Flow and Intrarenal Resistance Predict Immediate Renal Allograft Function ML Henry, BG Sommer and RM Ferguson 1986 Grune & Stratton 0041-1345/86/1803005.

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Cold Static Storage vs Machine Perfusion

MP CS MP-Extended CS-Extended

Donor age 40+/-8 37+/-16 54+/-9 51+/-9

LOS 9.8+/-5 11.9+/-4 11.1+/-3 17.9+/-3

DGF 9 24 14 37

1 YR 95 90 88 79

“Renal allograft preservation by continuous hypothermic preservation conferred an advantage in both immediate graft function and LT graft survival when compared to cold storage in UW solution.”

THE INFLUENCE OF PULSATILE PRESERVATION ON RENAL TRANSPLANTATION IN THE 1990’S TRANSPLATATION Vol. 69 249-258 No2Jan 2000. MMR Polyak, etal. Organ Preservation Unit, Division of Transplantation, The New York Presbyterian Hospital-Weil, NY.

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Pulsatile Perfusion Benefits

• Two kidneys singly or enbloc

• Continuous evaluation for predictable results

• Lower Delayed Graft Function (DGF) within 7 days postop

• Lower costs and shorter LOS

• Stimulates ATP synthesis (with Belzer MPS)

• Expansion to include marginal donors (older & hypertensive) as well as DACD

• Elective surgery

• Improves long term graft survival

• Kidneys pumped 30 plus hrs equal to kidneys iced less than 12 hours

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How much does PP save?

Cadaveric Transplants n = 170

DGF(34) No DGF(136)

Room 11,700 +/- 9,850 4,860 +/- 1,500

Pharmacy 11,400 +/- 8,900 6,085 +/- 3,400

Radiology 2,470 +/- 1,700 668 +/- 440

Laboratory 11,900 +/-11,300 4,750 +/- 1,650

Dialysis 9,300 +/- 8,000 330 +/- 75

Surgery/Supplies 4,430 +/- 1,500 6,007 +/- 1,200

Total $51,200 +/- 41,250 $22,700 +/- 8,265

The High Cost of Delayed Graft Function in Cadaveric Renal Transplantation. T.Rosenthal, MD et. al. TRANSPLANTATION VOL. 51 1115-1139, No.5 May 1991.

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SVMC Experience

41 consecutive cases utilizing RPP, 2002, 6 month data:

• 28 had Cr ≤2.0

• 4 had Cr 2.1-2.9

• 3 deceased

• 1 being followed at another center

• 4 relisted

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Th-th-that’s

all, folks!

Thank you

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