What is it How does it work

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Donor Management ClassPulsatile Perfusion

• What is it? How does it work?
• Why do we do it?

Jim Locke, CTOP IICertified Transplant Organ
Preservationist
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Introduction

• The Quality of organ at the time of transplant
  significantly influences both short long term
  outcome.

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Definitions

• Perfusion - to introduce a liquid into tissue or
  an organ by circulating it through blood vessels
  or other channels within the body
• Warm Ischemic Time (WIT) the time an organ is
  without hemo-perfusion, usually uncontrolled
• Cold Ischemic Time (CIT) controlled organ
  perservation time, 4-8C
• Delayed Graft Function (DGF) -- guess

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Todays Message

• DGF is BAD
• Rejection with DGF is BAD
• Pulsatile Preservation is GOOD

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Points to Ponder

• Preservation From Donor to Recipient
• Intracellular
• Extracellular
• Nutrients, metabolites, waste products

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Preservation Methods

• Cold Static Storage (CSS)
• Normothermic static storage
• Normothermic machine preservation
• Hypothermic Pulsatile Perfusion (or Machine
  Preservation MP)
• Combined methods -- OneLegacy

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Perfusion of Isolated Organs

• Loebel 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
• 1964 Belzer/Najarian UCSF developed Renal Tx
  Program/hypothermic pres

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What is Pulsatile Perfusion?

• Best example ..
• lub dub.. lub dub lub dub

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UNOS Multi-Center Data

• The preservation method exhibited a highly
  significant impact on the need for first week
  dialysis. (60,827 cad renal TX 1988 to 1995)
• Ice preserved a 2.13 fold increase in dialysis
  over PP
• Ice preserved donor gt55 years of age a 2.33 fold
  increase in dialysis over PP
• Ice preserved cold time gt24 hours a 2.19 fold
  increase in dialysis over PP
• Ice preserved African American recipients a 2.29
  fold increase in dialysis over PP
• National Impact of Pulsatile Preservation on
  Cadaver Kidney Transplantation.
• James Burdick et al Transplantation Vol. 64,
  1730-1733, no 12, Dec. 27 1997.

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UNOS Multi-Center Data

• Effect of Pumping on Delayed Graft Function (DGF)
  
• The odds ratio (of functioning grafts) for pumped
  vs. non-pumped kidneys was .56 with a highly
  significant p value.
• There was no interaction between pumping and ECD
  status meaning that the effect was similar
  whether it was an ECD kidney or non-ECD kidney
  (SCD) kidney and kidneys with the lowest
  resistance had the highest odds for DGF
• - In conclusion, ECD kidneys experienced more
  delayed graft function, pumped kidneys
  experienced significantly less delayed graft
  function and pumping was similarly beneficial for
  both ECD and SCD kidneys

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Kidney Pumping Benefits

• Continuous evaluation for predictable results
• Lower Delayed Graft Function (DGF) within 7 days
  postop
• Lower hospital costs/shorter LOS
• Improves long term graft survival
• Kidneys pumped 30 plus hrs equal to kidneys iced
  less than 12 hours

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Kidney Pumping Benefits (contd)

• The best predictor of early function based on a
  linear regression analysis of these five
  variables
• Renal blood flow
• Final resistance
• Patient age
• Cold perfusion time
• 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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Advantages

• Increases high energy phosphate stores within the
  kidney
• Removes (or dilutes) products of ongoing
  metabolism
• Maintains dilated vasculature, i.e. avoids
  vasoconstriction

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Disadvantages

• Increased costs
• Endothelial injury
• Potential equipment failure

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Where Does It Make a Difference?

• MP CS
• LOS 9.8 /-5 11.9 /-4
• MP-Ext CS-Ext
• LOS 11.1 /-3 17.9/-3
• THE INFLUENCE OF PULSATILE PRESERVATION ON RENAL
  TRANSPLANTATION IN THE 1990s TRANSPLANTATION
  Vol. 69 249-258 No2 Jan 2000 MMR Polyak, et.al.,
  Organ Preservation Unit, Division of
  Transplantation, The New York Presbyterian
  Hospital, Weil, NY

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What Difference Does It Make?
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Renal Resistance
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More Definitions
Primary Pulsatile Perfusion Initially preserved
from the O.R. via MP Secondary PP Initial
simple cold storage followed by MP
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What About Timing?

• Whether Primary Pulsatile Perfusion or Secondary
  PP was used had no effect on initial graft
  function.

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OneLegacy Parameters

• SUBMITTED FOR CONSIDERATION BY MEDICAL DIRECTOR
• Kidneys from donors gt 60 years (extended
  criteria) if placement is delayed beyond 18 hours
• Kidneys from donors less than 60 years with a
  creatinine over 2.0 but less than 3.0 with good
  urine output. (high output failure)
• Kidneys from donors less than 30 years with a
  serum creatinine of 3.0 or more with good urine
  output. (high output failure)
• Kidneys from non-heart beating donors as
  requested
• Kidneys (Import or Local) with preservation times
  anticipated to exceed 24 hours
• Kidneys from crashing donors, downtime, prolonged
  hypotension, IDDM, hypertension (non-medicated)
• Kidneys at the discretion of the medical director

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Kidney
Single, Single, Single
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Divot
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Architectural Nightmare
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Big Macs, Pizza, Smoking, etc.
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Disseminated Intravascular Coagulation (DIC)
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Waters Instruments
The Boat Anchor
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Waters Instruments
Waters RM3
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Organ Recovery Systems
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Can You Imagine??

• Every other day in a dialysis chair resulting in
• Years of illness followed by
• Years of waiting followed by
• Days/weeks of waiting

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Ronald Taubman
Ron is a kidney-pancreas recipient who received
his transplant in July 2001 at UCLA.  After being
a diabetic for 44 years he no longer requires
insulin.  Arden is his wife and caretaker. He
also serves as the president of TRIO, Transplant
Recipients International Organization.
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Patricia Elizarraraz
Patricia beautifully represents the healing power
of transplantation. Patricia is a three time
kidney recipient (1 from a deceased donor and 2
from living donors) and speaks eloquently about
her transplants.  She is bilingual and has a
great deal of experience speaking to groups and
conducting radio interview.  Her commitment is to
raising awareness in the Latino community .
Riding the Rose Parade Float
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Michelle Huddleston
Diabetic for over 30 years, Michele waited for
two years for a kidney and pancreas.  Her
pancreas rejected and was removed July 1998. 
Michelle received a second transplant April 2,
1999.  OneLegacy sponsored her as a recipient
athlete for the 2008 US transplant games in
Pittsburgh were she competed in bowling.
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Only One Bullet??
From art to science.
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