comparison of htk and uw in abdominal transplantation dr. richard s. mangus, md ms indiana...
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![Page 1: Comparison of HTK and UW in Abdominal Transplantation Dr. Richard S. Mangus, MD MS Indiana University, School of Medicine](https://reader034.vdocuments.us/reader034/viewer/2022051315/56649e415503460f94b32b4a/html5/thumbnails/1.jpg)
Comparison of HTK and UW in Abdominal
Transplantation
Dr. Richard S. Mangus, MD MS
Indiana University, School of Medicine
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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
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Indiana Organ Procurement Organization (IOPO)
Service area: Indiana
Population: 5.1 million
Hospitals: 130
Transplant centers: 7
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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”
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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
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Indiana Organ Procurement Organization (IOPO)
Cost analysis: HTK vs UW
UW flush volume / donor: 3.5 litersUW cost / liter $306.00Total cost per donor $1071
HTK flush volume / donor 3.5 litersHTK cost / liter $150.00Total cost per donor $525
Cost savings per donor $546
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Indiana Organ Procurement Organization (IOPO)
Center cost savings
Cost savings / donor $546
Annual cost savings
for average OPO (200 donors) $109,200
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Indiana University Medical Center
Abdominal Organ Transplants
Liver
Pancreas
Kidney
Islets
Small intestine / Multivisceral
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Indiana University Medical Center
Abdominal Organ Transplants
2007 Rank *
Liver 155 Top 5
Pancreas 84 1st
Kidney 255 Top 10
Small intestine 22 Top 5OVERALL (+ thoracic) 562 Top 5
* www.unos.org, 2007 data report
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Transplant Volume
Year Organs *
2001 259
2002 424
2003 506
2004 532
2005 604
2006 541
2007 562
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Transplant Volume
Year Organs *
2001 259
2002 424
2003 506
2004 532
2005 604
2006 541
2007 562
Conversion to HTK
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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.
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Renal TransplantationRenal Transplantation
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Transplants: 1990 to 1992
DGF: Need for dialysis 2 or more times during first 7-days post-transplant
Flush volume: HTK 5 – 6 LUW 1 – 2 LEC 4 L
Renal Transplantation
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Renal TransplantationRenal Transplantation
de Boer, et al, Transpl Proc, 1999; 31: 2065de Boer, et al, Transpl Proc, 1999; 31: 2065
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Renal TransplantationRenal Transplantation
de Boer, et al, Transpl Proc, 1999; 31: 2065de Boer, et al, Transpl Proc, 1999; 31: 2065
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HTK vs UW: KIDNEY Transplantation
N=91 renal transplants HTK 50 UW 41
No differences in: Delayed graft function
Graft survival
Patient survival
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Creatinine Clearance Post Transplantation
0
20
40
60
80
100
1 2 3 4 5 6 7 10 14 21 30
time (days)
ml/m
in UWHTK
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Serum Creatinine Post Transplantation
0.0
2.0
4.0
6.0
8.0
10.0
12.0
0 3 6 9 12 15 18 21 24 27 30
time (days)
mg
/dL UW
HTK
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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)
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PANCREAS TRANSPLANTATION
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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
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Pancreas Transplantation
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Pancreas Transplantation
N= 87 pancreas transplants HTK 78 UW 9
No differences in: Graft survivalPatient survivalSerum fasting blood glucosePeak serum amylaseSerial amylase levels
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Pancreas Transplantation
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Pancreas Transplantation
Pancreas clinical allograft data for 246 consecutive adult pancreas transplants at Indiana University between 2003 and 2007.
Overall (%) SKP PAK PTA P-valueNumber 247 141 (57%) 62 (25%) 44 (18%)
Graft loss within 7 days 10 (4%) 7 (5%) 1 (2%) 2 (5%) 0.53
Graft loss within 90 days 6% 7% 5% 5% 0.82
1-year* Graft survival (n=193) 91% 90% 93% 90% 0.79 Patient survival (n=174) 95% 94% 97% 96% 0.75
*For patients with minimum of 1-year follow up time.
Primary preservation solution: HTK, 2003 to 2007:
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Pancreas Islet Transplantation
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Pancreas Islet Transplantation
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LIVER TRANSPLANTATION
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Liver Transplantation
N=378 liver transplants HTK 174UW 204
Graft survival 1-month 6-month 12-month UW 91.7% 86.2% 81.7% HTK 92.0% 85.5% 80.8%
Patient survival UW 93.1% 87.7% 84.6% HTK 93.1% 86.2% 82.1%
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Liver Transplantation: ECD
N=698 liver transplants HTK 371UW 327
Groups: Standard 209 (30%)
ECD (old age) 70 (10%)
ECD (physiologic stress) 435 (62%)
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Liver Transplantation: ECD
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Liver Transplantation: ECD
N=698 HTK 371 UW 327
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Liver Transplantation: ECD
Standard donors, n=209 Extended criteria donors, n=489
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Liver Transplantation: ECD
Donor < 60 years, n=628 Donor ≥ 60 years, n=70
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Liver Transplantation: ECD
No physiologic stress, n=263 Physiologic ECD, n=435
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Liver Transplantation: ECD
Figure. Liver enzymes in the first 30-days post-transplant for the STANDARD criteria donors comparing HTK (n=111) and UW (n=98)
preservation solutions.
0
100
200
300
400
500
600
700
800
0 5 10 15 20 25 30
Days post-transplant
AS
T/A
LT
in u
/L
AST - HTK
AST - UW
ALT - HTK
ALT - UW
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Liver Transplantation
Biliary complications
Elevated liver enzymes post-transplant
Liver U/S with doppler
Biliary imaging
Liver biopsy
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Liver Transplantation
Biliary complications
Overall HTK UW p-valueOverall 698* 371* 327*
Need for biliary imaging 384/693 (55.4%) 188/367 (51.2%) 196/326 (60.1%) 0.01 Choledochocholedochostomy (n=593) 333/593 (56.2%) 163/316 (51.6%) 170/277 (61.4%) 0.02 Roux-y hepaticojejunostomy (n=100) 51/100 (51.0%) 25/51 (49.0%) 26/49 (53.1%) NS
Biliiary Leak 22/693 (3.2%) 9/367 (2.5%) 13/326 (4.0%) NS
Diffuse intrahepatic stricturing 26/693 (3.8%) 9/367 (2.5%) 17/326 (5.2%) NS
Presence of choledocholithiasis 115/693 (16.6%) 48/367 (13.1%) 67/326 (20.6%) 0.06
Presence of bile duct gravel (sludge) 51/693 (7.4%) 14/367 (3.8%) 37/326 (11.3%) 0.001* 5 patients died intraoperatively and had no biliary reconstruction, 4 HTK and 1 UW
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Liver Transplantation
Donation after cardiac death, n=43HTK 35 UW 7
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Liver Transplantation: Recent
Variables in the Equation
.263 .146 3.271 1 .071 1.301
.001 .008 .035 1 .851 1.001
.028 .009 8.930 1 .003 1.028
.014 .005 8.682 1 .003 1.014
PreservationSolution
Ageattxp
MELDTXP
DonorAge
B SE Wald df Sig. Exp(B)
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Intestinal / Multivisceral Transplantation
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“Comparison of HTK and UW in Intestinal and Multivisceral Transplantation”
- Mangus, et al. Transplantation, 2008; In Press
Intestinal Transplantation
N=57 intestinal transplants HTK 35 UW 22
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Intestinal TransplantationHTK UW
TOTAL n=35 (61%) n=22 (39%)Allograft transplanted Isolated small intestine (intestine alone) 5/35 (14%) 8/22 (36%) Modified multivisceral 3/35 (9%) 2/22 (9%) (stomach, duodenum, intestine, pancreas) Multivisceral 27/35 (77%) 12/22 (55%) (stomach, duodenum, intestine, pancreas, liver)Indication Pediatric (n=15) n = 6 n = 9 Necrotizing enterocolitis 4/6 3/9 Gastroschisis / Atresia 1/6 1/9 Volvulus 1/6 2/9 Microvillus inclusion 1/9 Pseudoobstruction 1/9 Retransplantation 1/9 Adult (n=42) n = 29 n = 13 Portomesenteric thrombosis 9/29 6/13 Short gut syndrome 6/29 3/13 Pseudoobstruction 1/29 3/13 Chron's disease 5/29 1/13 Non-resectable tumor 3/29 Retransplantation 2/29 1/13 Abdominal catastrophe 3/29 1/13
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Intestinal Transplantation
N=57 intestinal transplants HTK 35 UW 22
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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
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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
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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