Abdominal Organ Transplant Program Mayo Clinic Arizona 2006 Review

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Abdominal Organ Transplant Program Mayo Clinic
Arizona 2006 Review

• Annual Report to CPC / Board of Governors
• David D. Douglas, MD
• Raymond L. Heilman, MD
• David C. Mulligan, MD
• Pamela L. Gillette, MPH, RN
• Todd E. Wilkening / Duffy Suba / Susanne M.
  Gauthier

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Presentation Outline

• Overview and History
• Academic/Research Activity
• Liver Transplant Program
• Kidney/Pancreas Transplant Program
• DSS Financial Analysis for 2005
• Strategic Plan and Targets for 2007

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Mayo ClinicLargest Transplant Entity in U.S.
1469 Total Transplants in 2006
717
446
306
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MCA Abdominal Organ Transplant HistoryThen and
Now

• Liver Transplant Program
• Deceased Donor Liver Transplantation (1999)
• Living Donor Liver Program (2001) 1st in AZ
• 2006 7th largest in the US
• Kidney Transplant Program
• Living Donor Kidney Program (1999)
• 2006 15th largest in the US
• Laparoscopic Donor Procedure (1999)
• First in the Foundation Arizona
• Pancreas Transplant Program
• November 2002 UNOS Certified
• First K/P Transplant in July 2003
• 2006 7th largest in the US

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2006 Overview Summary

• Total Annual Transplants Decreased by 6
• 2005 238, 2006 - 224
• Transplant Annual Evaluations - 15 Increase
• 2005 548, 2006 - 630
• Waitlist Growth Increased in Kidney, Pancreas and
  Liver Transplant
• Program Quality Maintained
• Graft and Patient Survival Rates Exceed Expected
• Patient Satisfaction in PRC Survey
• 80.2 in Overall Top Box Score in 2006, up
  from 2005 73.9
• Market Distinction
• Leader in Living Donor Liver Transplant

• Heart Transplant data removed for separate
  presentation

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MCA Abdominal Transplant ProgramNational
Regional PresenceAcademic Research Activity
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MCA Abdominal Transplant ProgramNational /
Regional Leadership

• AASLD and ILTS Journal Liver Transplantation
• Co-Editor Dr. Rakela
• Associate Editor Dr. Vargas, Dr. Kusne, Dr.
  Mulligan
• AASLD
• Chair, Education Committee
• Dr. Vargas
• ASTS
• Chair, Standards on Organ Transplantation
  Committee
• Dr. Mulligan
• AST
• Liver and Intestinal Committee member
• Dr. Douglas
• Kidney Pancreas Committee member
• Dr. Heilman

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MCA Abdominal Transplant ProgramNational /
Regional Leadership

• United Network for Organ Sharing (UNOS)
• Councilor Region 5, Board of Directors
• Chair, MPSC Workgroup for Organ Allocation
• Dr. Mulligan
• Region 5 Liver Transplant Regional Review Board
• Dr. Douglas
• Region 5 Transplant Administrator / TAC
• Kevin Paige
• Region 5 Finance
• Pam Gillette
• Donor Network Arizona
• Board of Directors
• Dr. Mulligan

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MCA Abdominal Transplant ProgramNational /
Regional Leadership

• Intermountain End-Stage-Renal-Disease Network
• Board of Directors
• Dr. Heilman
• American Liver Foundation, AZ Chapter
• Board of Directors
• Pam Gillette
• Arizona Coalition for Transplantation
• Board of Directors
• Kevin Paige
• Pam Gillette
• Arizona Transplant House Board of Directors
• Victoria Miller-Cage, Todd Wilkening, Tom Byrne,
  Paul Hottenstein, Mandy Impson, Susan Misztal,
  Kevin Paige

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MCA Abdominal Transplant ProgramPublications,
Presentations and Research

• Publications By Transplant Program
• 2006 Unique Peer Reviewed Journal Articles - 36
• 2006 Authored Book Chapters - 3
• Presentations at National Meetings 2006
• ATC - 4 Oral and 6 Poster Presentations
• ILTS 3 Oral and 2 Poster Presentations
• AASLD - 3 Oral and 9 Poster Presentations
• UNOS Administrator's Forum 2006 1 Oral and 3
  Poster Presentations
• AGA - 6 Poster Presentations
• Research Activity
• 30 Ongoing Protocols

MCA Librarian Database
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MCA Abdominal Transplant ProgramEducation
Programs

• Hepatology MD Fellowship Program (1999-Present)
• Hepatology PA Fellowship Program (2003-2007)
• Both Programs AASLD Funded
• Hepatobiliary Liver Transplant Rotation
• General Surgery Residents, Internal Medicine
  Residents, Gastroenterology Fellows
• Social Worker Internship Program
• ASU Collaboration
• Liver Transplant CME Course 1995, 1997, 1999,
  2001, 2003, 2005, 2006 and 2007

Pending initial ACGME accreditation 2007
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Liver Transplant Program2006
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MCA Liver Transplantation Program

• 1999 to 2006 Volume Data
• Liver Transplants - 345
• Living Donor Transplants - 64 (18)
• 2006 Volume Data
• Liver Transplants - 43 (Target 73)
• 8 of 43 Transplants - Living Donor
• 2006 Outcome Data
• 1 Year Patient Survival
• 91.85 Actual vs. 88.18 National Avg (Combined)
• 1 Year Graft Survival
• 89.41 Actual vs. 84.43 National Avg (Combined)

SRTR National Data Base - January 2007 Release
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Mayo System and National Comparison 1 Year
Patient and Graft Survival
SRTR National Data Base - January 2007
Release Deceased Donor Only for Appropriate
Comparison
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Mayo System and National ComparisonMedian Length
of Stay Post Transplant
SRTR National Data Base - January 2007
Release Median LOS for Deceased Donor
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Liver Waitlist Transplants2001 - 2006
Wait List Size as of Last Day of Year
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Etiology of Liver Disease
Q1 2007
Liver disease transplanted Q1 2007
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Cold Ischemia Time (hours)Cumulative

• Average CIT 6.02 hrs
• Median CIT 5.75 hrs
• Range 1.5 -23 hrs

Q1 2007
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Benchmarking National Centers of Excellence
UNOS Patient Survival Data(7/01/03 - 12/31/05 w/
1 Mo. 1 Yr. Cohorts 01/01/01 - 6/30/03 w/ 3
Yr. Cohort)
Q1 2007
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Benchmarking National Centers of Excellence
UNOS Graft Survival Data (7/01/03 - 12/31/05 w/
1 Mo. 1 Yr. Cohorts 01/01/01 - 6/30/03 w/ 3
Yr. Cohort)
Q1 2007
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The Impact of Gender Mismatch on Living Donor
Liver Transplantation

• Kristin L. Mekeel, Adyr A. Moss, David D.
  Douglas, M.E. Harrison, Hugo E. Vargas, Thomas J.
  Byrne, Vijay Balan, Elizabeth J. Carey, Jorge
  Rakela, Kunam S. Reddy and David C. Mulligan
• Divisions of Transplant Surgery and Hepatology
• Mayo Clinic Arizona

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Background

• In liver transplantation
• Gender mismatch has been associated with
  decreased graft survival, especially female to
  male transplantation.
• In adult living donor liver transplantation
• The ratio between graft size and recipient weight
  (GRWR) has been shown to be essential to graft
  function, preventing small graft for size
  syndrome.

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Purpose

• The combination of smaller graft size and gender
  mismatch could lead to inferior results for
  female to male LDLT.
• The purpose of this study is to compare the
  outcomes of female to male LDLT with male to
  female and gender matched transplants.

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Methods

• This is a retrospective study 70 living donor
  liver transplants completed at our institution
  between January 2001 and April 2007.
• All grafts were right lobes, preserved with
  custodial HTK after the 15th transplant.

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Methods

• GRWR was estimated pre-operatively with CT
  volumetry and the graft was weighed after
  resection to determine actual GRWR, which is used
  for this presentation.
• The right paramedian sectoral vein was routinely
  preserved starting after the 26th transplant.

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Methods

• Analyses of variance were carried out to assess
  differences between groups on the continuous
  variables.
• Kruskal-Wallis tests were used for non-parametric
  continuous variables.
• Chi-square analyses were used to assess
  differences between groups on the categorical
  variables.

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Patient Demographics

• Demographic GM (32) MF (16) FM (22) P-value
• Age 1768 (49) 3066 (49) 3067 (55) 0.27
• GRWR 0.81.5 (1.19) 0.81.9 (1.42) 0.71.2
  (0.94) 0.0001
• Donor age 1946 (33.3) 2154 (36.8) 1856
  (41.7) 0.02
• MELD 822 (14.3) 620 (11.7) 722 (14.1) 0.11
• HCV 48 37.5 50 0.89
• Operative time 3251017 (513) 252659
  (440) 326809 (510) 0.3732
• CIT (min) 150285 (214) 150270 (196) 150285
  (208) 0.35

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Results

• Outcomes GM (32) MF (16) FM(22) P-value
• LOS (days) 517 (7.84) 422 (9.88) 223
  (8.9) 0.47
• FU (months) 0.764.2 (24) 0.362 (19.9) 0.363.5
  (20.4) 0.16
• Acute rejection 3 (9.6) 2 (12.5) 1(4.5) 0.59
• HAT 4 (12.9) 3 (18.75) 6 (27.3) 0.42
• Bile Leak or 18 (58) 10 (56.3) 12 (54.5) 0.95
• Stricture
• Re-transplant 2 (6.5) 2 (12.5) 1 (4.5) 0.63
• Pt Survival 27 (87) 12 (75) 20 (91) 0.37
• (actual)

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Results

• Causes of Death
• GM (4)
• Recurrent hepatocellular carcinoma (2)
• Fungal sepsis after biliary leak (1)
• Hepatic artery thrombosis and graft failure (1)
• MF (4)
• Recurrent hepatitis C virus (2)
• Systemic aspergillosis (1)
• Hepatic artery thrombosis, re-transplantation
  and graft failure (1)
• FM (2)
• Intra-operative cardiac arrest after
  re-perfusion (1)
• Fungal pneumonia and sepsis (1)

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Conclusions

• Despite a lower graft to recipient weight ratio,
  female to male LDLT recipients do not have an
  increased risk of complications or diminished
  graft or patient survival compared to gender
  matched or male to female cohorts
• Gender should not be a factor in determining
  suitability for living donation.

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Kidney / Pancreas Transplant Program2006
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MCA Kidney Transplantation Program

• 1999 to 2006 Volume Data
• Kidney Transplants - 705
• Living Donor Kidney Transplants - 367 (53)
• Pancreas Transplants - 65
• 2006 Volume Data
• Kidney Transplants - 152
• Living Donor Kidney Transplants - 81 (53)
• Pancreas Transplants - 27
• 2006 Outcome Data Kidney Transplant
• 1 Year Patient Survival
• 96.13 Actual vs. 96.47 Expected
• 1 Year Graft Survival
• 92.83 Actual vs. 93.34 Expected

SRTR National Data Base - January 2007
Release Combined Living and Deceased Donor
Transplants
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Mayo System and National Comparison 1 Year
Patient and Graft Survival
SRTR National Data Base - January 2007
Release Combined Living and Deceased Donor
Transplants
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Mayo System and National ComparisonLength of
Stay - Time on Wait List
SRTR National Data Base - January 2007
Release LOS for Deceased Donor, Wait Times
Includes Both Living and Deceased Donor
Transplants
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Kidney Waitlist Transplants2001 - 2006
Wait List Size as of Last Day of Year
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Donor Source (N654)Cumulative

• Living Related Donor 238
• Living Unrelated Donor 154
• Deceased Donor 262

Q1 2007
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Pancreas Transplantation at MCA
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Pancreas Transplants at MCA by type of transplant
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Type of Surgical Procedure
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MCH Patient/Graft Survival for KP Txs
(Kaplan-Meier)
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MCH Patient/Graft Survivalfor PAK PTA
(Kaplan-Meier)
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Immunosuppression

• Thymoglobulin
• Prograf
• MMF
• Long-term steroids

• Campath
• Prograf
• MMF
• Rapid steroid taper

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Acute Rejection during the first year

• Kidney-Pancreas 17
• Solitary Pancreas 32

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Kidney-Pancreas Steroid Avoidance

• 37 patients
• Patient survival 100
• Graft Survival
• Kidney 97
• Pancreas 95
• Acute Rejection 11

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Historical Total Transplant Volumes 2001 to
present
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Support for Organ Donation in AZ

• Active Mayo Participation in Multiple
  Organizations
• AKF, ALF, ACT, DNA
• DNA, ACT and Mayo Collaborations
• AZ Medal Ceremony for Donors
• Active Participation in National Donor Week
• Continue Participation in National Collaborative
• Bronze Level Sponsor of Team AZ at Transplant
  Games

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Program Summary

• High Quality Transplant Program
• Distinguished by
• Mayo Model of Care
• Living Donor Liver Transplant
• Controlled Growth
• Strong Education Focus
• Strong Research Focus
• National and Regional Presence
• Financial Enhancement to MCA

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Conclusions

• Strong clinical academic solid organ transplant
  practice with complete conversion from UW to
  Custodial HTK in 2003 without any negative effect
• Improved outcomes using Custodial for Living
  Donor Liver Transplantation
• Recommendation for HTK for DCD donors to improve
  outcomes