Skip Navigation Archive: U.S. Department of Health and Human Services U.S. Department of Health and Human Services
Archive: Agency for Healthcare Research Quality www.ahrq.gov
Archival print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to www.ahrq.gov for current information.

Innovations in Transplantation (Text Version)

Slide presentation from the AHRQ 2011 conference.

On September 19, 2011, Rolf Barth made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (10.3 MB).


Slide 1

Innovations in Transplantation:

Single-Port Donor Nephrectomy for Living-Donor  Kidney Transplantation

Face Transplantation: Preclinical and Clinical Trials

Rolf N. Barth, M.D.
Department of Surgery
University of Maryland School of Medicine
AHRQ 2011 Annual Conference
September 19, 2011

Slide 2

Single-Port Donor Nephrectomy for Living-Donor Kidney Transplantation

Slide 3

Renal Transplantation as Therapy for End Stage Renal Disease 2000-2009

Image: Line graph displays the following data:

Year Kidney Waitlist Deceased Donor Living Donor
2000 50,426 5,985 5,941
2001 53,560 6,080 6,616
2002 56,520 6,190 6,630
2003 59,688 6,457 6,828
2004 64,310 7,150 7,004
2005 68,429 7,593 6,902
2006 73,469 8,019 6,732
2007 78,337 8,085 6,315
2008 83,112 7,990 6,218
2009 88,503 8,022 6,610

 

Slide 4

Rationale for Single-Port Donor Nephrectomy Program

  • Advanced laparoscopic approach achieved with existing instrumentation and techniques.
  • Improved cosmetic appearance.
  • Potential for improved post-operative recovery.
  • Motivate recipient/donor combinations.
  • Encourage living kidney donation.

Slide 5

University of Maryland Experience

  • Performed 1300 laparoscopic donor nephrectomies.
  • Preparation for single-port:
    • Minimized ports on standard donor.
    • Observed procedures.
    • Animal lab.
  • April 2009 initiated single-port donor nephrectomy as routine approach.
  • Currently performed over 140 single-port donor nephrectomies.

Slide 6

Access Devices

  • SILS Port Device (Covidien).
  • Gelport/Gelpoint Device (Applied Medical).

Images: The SILS Port Device and Gelport/Gelpoint Device are shown.

Slide 7

Image: An operating room is shown.

Slide 8

Transumbilical Renal Extraction Minimizes Apparent Length of Incision

Images: Photographs of the incision site are shown.

Slide 9

BMI 30 Healing

Images: Photographs of the incision site on Postoperative Day (POD) 0, POD 15, and POD 22 are shown.

Slide 10

6 Months Post-Op

Image: A photograph of the incision site 6 months after the surgery is shown.

Slide 11

2 Years Post-Op

Image: A photograph of the incision site 2 years after the surgery is shown.

Slide 12

Anatomical Variants

Images: Three MRI image variants are shown: 2 arteries, 2 arteries, and lumbar vein.

Slide 13

Single vs. Multi-port

Donor Demographics SILS (n=135) Multiport (n=100) p
Age (yrs) 44±13 43±11 0.38
Gender (F) 73.1% 71.0% 0.40
Race (Non AA) 81.5% 81.0% 0.53
BMI 27±4 28±4 0.19
Renal Arteries 1.3±0.6 1.2±0.5 0.06
Renal Veins 1.0±0.2 1.0±0.2 0.88
Lumbar Veins 1.0±0.8 1.0±1.3 0.98

Donor Surgical Outcomes SILS (n=135) Multiport (n=100) p
Cross Clamp Time (hrs) 2.8±0.7 2.6±0.5 0.12
Estimated Blood loss (ml) 77±64 107±122 0.019
Length of stay (days) 2.6±0.9 2.3±0.7 0.009

Recipient Renal Function SILS (n=135) Multiport (n=100) p
Recipient Post TX eGFR 1 week 59±19 55±19 0.23
Recipient Post TX eGFR 1 month 60±18 52±16 0.003

 

Slide 14

Operative Time Learning Curve

Image: A graph labeled Operative Time Learning Curve is shown.

Slide 15

SF=36 and Survey Responses

Donor SF-36 Results SILS (n=52) Multiport (n=39) p
Physical Health (Composite) 88.3±10.8 85.8±15.5 0.36
Mental Health (Composite) 85.1±14.1 84.3±14.1 0.78
TOTAL SF36 Score 88.8±12.1 87.1±14.1 0.54

Donor Pain Levels SILS (n=52) Multiport (n=39) p
Night of Surgery 6.0±2.8 6.1±2.8 0.85
Post Op 1 5.5±2.6 5.3±2.7 0.73
Day of Discharge 4.1±2.3 4.1±2.3 0.93
Post Op 7 2.6±2.0 2.7±2.4 0.84
Post Op 30 0.8±1.2 1.0±1.6 0.40
Current 0.0±0.1 0.2±0.7 0.10

Donor Satisfication Results SILS (n=52) Multiport (n=39) p
Donation Decision 9.9±0.5 9.4±1.9 0.07
Financial Burden 8.8±2.1 9.5±1.6 0.10
Stress Level 7.7±2.5 7.5±3.1 0.68
Cosmetic Outcome 9.2±1.7 7.4±2.9 <0.0001
Overall Process 9.4±1.2 8.4±2.4 0.01

Donor Recovery Period SILS (n=52) Multiport (n=39) p
Walked Without Difficulty 2.4±1.3 2.6±1.3 0.52
Ate a Normal Diet 2.3±1.4 2.2±1.3 0.71
Stopped Pain Medication 2.9±1.2 2.7±1.3 0.46
Resumed Driving 4.0±1.0 4.0±0.9 0.92
Resumed Normal Activities 4.6±0.8 4.6±0.8 0.94
Re-Hospitalized due to donation 4.40% 3.30% 0.65

 

Slide 16

Conclusions

  • Single port donor nephrectromy is safe and may be accomplished in broad spectrum of donors with experienced team.
  • Patients report improved satisfaction with cosmesis and donation process with single port compared to multiple port technique.
  • No definite evidence regarding recovery time or pain.
  • Further investigation of implications:
    • Willingness of recipients to ask potential donors.
    • Additional kidney donors to alleviate organ shortage.

Slide 17

Face Transplantation: Preclinical and Clinical Trials

Slide 18

Incidence of Facial Trauma

  • Incidence of facial injury among soldiers in Iraq=30% (Colonel Mark Bagg MD, ASRM, Arizona, January 2006).
  • Incidence of facial injury at University of Maryland Shock Trauma Center= 15% (unreported data: ~ 7,000-10,000 admissions per year).

Slide 19

Images: Photographs of six patients with facial trauma are shown.

Slide 20

Vascularized Composite Allograft (VCA)
 

  • Composite tissue defined to elements of skin, muscle, bone.
  • Applications include:
    • Limb transplantation.
    • Transplantation for soft tissue defects.
    • Facial transplantation for devastating burn/blast injuries.
  • Results are life-saving, limb-saving, allow for avoidance of permanent disability.

Slide 21

Experimental

Image: Figures from Barth et al, Plast Reconstr Surg 123:493, 2009, captioned "Facial Subunit Composite Tissue Allografts in Nonhuman Primates: I. Technical and Immunosuppressive Requirements for Prolonged Graft Survival," are shown.

Slide 22

Prolonged Survival of Composite Facial Allografts in Non-Human Primates Associated with Posttransplant Lymphoproliferative Disorder

Image: Photographs and 3 graphs are shown.

Slide 23

Vascularized Bone Marrow-Based Immunosuppresion Inhibits Rejection of Vascularized Composite Allografts in Nonhuman Primates

Image: 3 graphs are shown.

Slide 24

Vascularized Bone Marrow-Based Immunosuppresion Inhibits Rejection of Vascularized Composite Allografts in Nonhuman Primates

  • MRI of Vascularized Bone Marrow.
  • Histology of Vascularized Bone Marrow.

Images: Photographs of vascularized bone marrow are shown.

Slide 25

Facial CTA Summary

Group Number Immuno-suppression Bone & VBM Mean FK506Level (± SD) Mean Survival(days) End Point ChimerismDetected Acute Rejection Chronic Rejection Notch Pathway Expression
1 High FK506
(n=6)
Yes 45 ± 21 116 PTLD No No No No
2 High FK506 à Rapamycin
(n=3)
Yes 40 ± 23 80 Rejection No Yes No No
3 Low FK506/ MMF
(n=4)
Yes 25 ± 13 310 Rejection Yes (3/4) Yes Yes Yes
4 Low FK506/ MMF
(n=3)
No 25 ± 12 112 Rejection Yes (1/3) Yes No No
5 Low FK506/Anti-CD28
(n= 3)
Yes 28 ± 12 101 Rejection No Yes No No

 

Slide 26

Non-Human Primate Model of Fibula Vascularized Composite Tissue Allotransplantation Demonstrates Donor-recipient Bony Union

Images: Illustrations and photographs of non-human primate bones.

Slide 27

Clinical CTA Strategies

  • Co-transplanted vascularized bone marrow may be permissive towards the development of prolonged graft survival.
  • CTA were rejected at early timepoints without calcineurin-based immunosuppression.
  • 'Prope' tolerance or minimal immunosuppression are the most attainable goals for widespread application of clinical CTA.

Slide 28

Craniofacial Composite Tissue Allotransplantation

Image: Timeline shows 3 phases from 2009 to 2012: research and preclinical model, clinical programs development, and active clinical center.

Slide 29

Minimizing Chronic Immunosuppression

  • Lymphocyte-depleting induction therapies:
    • Lowest rates of acute cellular rejection.
  • Steroid Avoidance or Weaning:
    • Nearly all kidney, pancreas, and liver transplant patients have steroids eliminated between 3 and 21 days.
  • Permissive of chronic therapy with 1 or 2 drugs.
  • Future—costimulatory blockade reagents requiring once monthly treatment.

Slide 30

Immunosuppression Induction

Images: Illustration of antibody and line graph of induction and graft survival are shown.

Humanized CAMPATH Antibody (Alemtuzumab)
CD4 T cells depleted 99.7% 2 wks, 85% at 1 year, 69% at 2 years, and 63% at 3 years
Tx Int 19 (2006): 885-892

Slide 31

CTA Immunosuppressive Regimen

Image: Chart shows the immunosuppressive regimen from Day 0 onward. Prednisone is given until POD 21; Tacrolimus and MMF continue to the end of the chart.

Slide 32

Multi-Organ Recovery Team

Image: Chart shows the positions of the recovery team and equipment around the operating table.

Page last reviewed October 2014
Internet Citation: Innovations in Transplantation (Text Version). October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/news/events/conference/2011/barth/index.html

 

The information on this page is archived and provided for reference purposes only.

 

AHRQ Advancing Excellence in Health Care