1 / 29

Exchange donor program Experiences from the very first paired exchange program in the world

25 Jan. 2014 Terasaki Festschrift 2014 . Exchange donor program Experiences from the very first paired exchange program in the world. Kiil Park M.D, Ph.D. Department Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea .

ziarre
Download Presentation

Exchange donor program Experiences from the very first paired exchange program in the world

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 25 Jan. 2014 Terasaki Festschrift 2014 Exchange donor program Experiences from the very first paired exchange program in the world Kiil Park M.D, Ph.D. Department Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea

  2. Yearly Census of Kidney Transplantation, Korean National Data 1969, First Living donor Kidney Transplantation 1979, First Deceased donor Kidney Transplantation Before 1995, Majority of kidney transplantation is living donor Brain Death was legally approved at 2000 Feb. Kidney Transplantation before 1996 KONOS Era Deceased, n=286, 3.6% DD ratio=43.1% Living, n=7,640, 96.4% Yearly kidney transplant census

  3. Living related Living unrelated Deceased Kidney Transplantation in YUHS, Severance hospital Total Census until 2013 = 3,635 cases 1977, Centralized Hemodialysis Unit 1978, Tissue typing Lab. 1979, First Kidney transplantation in YUHS ABOi LCM negative conversion Exchange (single center) Exchange (Web-based) Yearly census 1991-09-20 2005-11-23 2002-01-30 2010-06-16

  4. LURD Program Unrelated Living Donor Program in YUHS Graft survival of unrelated living donor is similar with that of related living donor transplantation Multvariate and univariate analysis of risk factors affecting graft survival of 700 primary living donor renal transplants based on Yonsei University Medical Center experience. JKSS 1993;44:730

  5. LURD Program Unrelated Living Donor Program in YUHS Excellent long-term patient and graft survivals were achieved among LURD kidney transplant recipients. Analysis of Risk Factors Affecting the Graft Survival in Living Unrelated Donor Kidney Transplantation. JKST 2004;18:155

  6. Exchange Program History of Exchange Donor Program • First Report by Park & Kwak in Korea, 1991 • Reports on algorithm for Exchange donor program Exchange donor program in YUMC. Kim SI, et al. Clin Transplant 186, 2004

  7. Exchange Program Exchange Donor Program in Kidney Transplant Swap around program Direct Exchange program

  8. Media Report 1 Direct Exchange program

  9. Media Report 2 Swap around program

  10. Exchange Program Exchange program by a Web-based Algorithm in Korea

  11. Exchange Program Exchange Donor Program; Experience in YUHS Transplantation 2008;86:430-435

  12. Exchange Program Advantage of Exchange Donor Program • Prevent loss of suitable living kidney donors; extra (living donor) kidney transplant is created • Standard immunosuppression with excellent results; comparable to the results of one-haplo matched LRD grafts • Emotional gain to donor and recipient families

  13. Exchange Program Limitation of Exchange Donor Program • Discrepancy in quality of exchange kidneys • Psychological stress to donor and family • Conflicts between donor’s or patient’s families, if different outcome after transplantation • Blood type O recipients , Recipients with blood type AB donors - highly HLA-sensitized - difficult to find compatible donors in exchange program

  14. Strategies for Expansion of Living Donor Pool “Trials of living donor kidney transplantation using an incompatible donor by conventional transplantation concept ” Poor HLA Matching Highly Sensitized Recipients ABO-Incompatible Positive LCM High PRA need Pre-transplant Immunologic modulation for transplantation or avoidance by donor change Desensitization for LCM positive or high PRA Desensitization for ABO blood type incompatible Exchange donor program

  15. Exchange Program Exchange versus Desensitization “ Problems in blood O type recipient “ Proportion of recipient blood type in Exchange program in Desensitization protocol O 25% A 32% A 41% < O 47% n=116 n=19 B 34% B 21% Exchange program in Korea, YUHS experience N=129 of exchange program Pre-transplant Desensitization YUHS Experience, N=24 of desensitization trial

  16. Change of Therapeutic Strategies, YUHS Exchange program Exchange (single center) Exchange (Web-based) Exchange 9.9% LCM negative conversion ABOi Spouse 4.1% N=690 LCM NC program Transplantation Cases LCM NC 2.7% ABOi 16.1% Exchange 13.3% LCM NC 2.2% Spouse 7.9% N=806 Exchange 4.5% N=186 Spouse 16.1% ABOi Year

  17. Exchange Program Exchange Donor Program; Experience in YUHS Reasons for Exchange program Incompatible ABO blood type, 65.1% Positive LCM, 4.7% HLA mismatching beyond our criteria, 30.2% For transplantation with LURDs, including exchange donors, more than one human leukocyte antigen (HLA)-DR matching or two of four HLA-A/B matching policy was maintained firmly. Transplantation 2008;86:430-435

  18. Therapeutic Strategies for Unacceptable Recipients * HS: Hypersensitized Patient

  19. Thank You For Your Attention Exchange donor program Experiences from the very first paired exchange program in the world Kiil Park M.D, Ph.D. Department Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea

  20. Exchange Program Process of Exchange Donor Program • Potential donor • evaluation of social and medical factors • do not accept commercially obtained LURDs • Approval of Korean Network for Organ Sharing (KONOS) • Informed consent for exchange program • Kidney transplantation on same day or over • 2 consecutive days

  21. Case Presentation 1 : First case of exchange donor program in YUHS 1st Transplant, unknown 1st Transplant, HCV positive Recipient 17Y 7Mo 26.0/1.5 17Y 7Mo 19.6/1.18 ABO incompatible ABO incompatible Donor Wife Uncle ???

  22. Case Presentation 2 2nd Transplant, Chronic rejection 1st Transplant, DM nephropathy Recipient 5Y 2Mo 21.5/1.1 5Y 2Mo 22.1/1.2 HLA mismatching ABO incompatible Donor Husband Wife’s brother

  23. Exchange Program Exchange Donor Program; Experience in YUHS Clinical manifestations : prolonged pre-transplant dialysis, Elder & female donor Transplantation 2008;86:430-435

  24. Exchange Program Exchange Donor Program; Experience in YUHS Excellent graft survival by using the exchange donor renal transplantation program versus other type of living donor transplantation Transplantation 2008;86:430-435

  25. Exchange (n=129) Non-exchange (n=269) One-haplo LRD (n=563) Exchange Program Exchange Donor Program; Experience in YUHS Excellent graft survival by using the exchange donor renal transplantation program versus other type of living donor transplantation Two haplo LRD (n=129) Graft survival rate p=0.2994* Deceased (n=73) 0 Post-transplant years Transplantation 2008;86:430-435

  26. Exchange Program Exchange Donor Program; Experience in YUHS Exchange donor is not independent risk factors affecting graft survival in multivariate analysis Transplantation 2008;86:430-435

  27. Exchange Program Allocation of blood O type donors in Exchange program Blood-type O recipients are less likely to benefit from this current exchange donor program when compared to blood-type A or B recipients. * P-value between exchange and non-exchange group Transplantation 2008;86:430-435

  28. Therapeutic Strategies for Unacceptable Recipients, YUHS Exchange (Web-based) Exchange (single center) LCM negative conversion ABOi Transplantation Cases 2005-11-23 1995-09-20 Year 2002-01-30 2010-06-16

  29. Social Barriers in Exchange Program Emotionally unacceptable exchange-donor = Strict application of equal quality of kidneys between exchange donor pairs examples, avoid female or elderly donor >> Male or young donor Inter-familial conflicts by non-medical problems such as race, religion, and occupation of donor Shift of exchange donor to recipient hospital  unfamiliar situation to exchange donor

More Related