Challenges in Pediatric Transplantation

Cavallieri, Silvana (Chile) WCA 2012 Buenos Aires

1. Review figures and data regarding childrens donation and heart transplant throughout the world 2. Emphasize challenges surrounding pediatric donation and transplant
a. Discuss definitions and conditions for diagnosis of brain death in children b. Discuss the management of pediatric donors c. Discuss special issues in pediatric cardiac donors

Aspect that are milestone in organ harvesting for pediatric transplant

 Without donors there are no transplants Every country should have an organization COMITTED TO
Alleviating the organ and tissue shortage Organ allocation

Devastati ng Brain injury

Transplant Utilized donor

Possible donor

Medicall y suitable

Fulfill Brain Death Criteria

Potential donor

Actual donor
Organ procurement Consent

Elegible donor

Brai n Deat h
confirmed

Transplant Int 2011, 24: 373-378

 40-50 x million inhbts/year die of encephalic death

Taking into account

15% deceased in ICU 2% deceased in a hospital

What is required to obtain a donor?

Pediatric heart 1. An adequate legislation 2. An organized system of procurement 3. A well educated and sensitive population 4. Financial and medical resources

The person and relatives decide

All citizens are donors

Opting in
Expressed Consent

Opting out
Presumed consent

The Madrid Resolution on Organ Donation and

Adapted from Organs Tissues & Cells. July 2011

30

 The philosophy of the Spanish approach is that improving the organization of the whole process will result in increased organ donation
The Donts Do not place too much energy in changing the legal system Do not place much effort in public campaigns

Actual Donor Rates: Comparison between countries (2011)

Adapted from Organs Tissues & Cells.

 Weak organ & procurement system

We DETECT ONLY half of the possible donors in our population Possible donors are not a priority Financial and logistic problems

We do not have a sensitive and well educated population

High rate of FAMILY REFUSAL

What happens with FAMILY REFUSAL in different countries?

From ONT (Spain), Corporacin del Trasplante (Chile)

ILHTS. J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132

# of Centers Reporting

ILHTS. J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132

DISTRIBUTION OF TRANSPLANTS by Donor/Recipient Weight Ratio

(International Heart and Lung Transplant Registry. 2003-june 2010)
% of t r a n s p l a n t

Which are the figures regarding pediatric donors?

Yea rs Year s Yea rs Yea rs Yea rs Yea rs

ONT, Spain,

3 kg:
AB: A: B. O: 0.16 0.14 0.10 0.09

60 kg:
AB: A: B. O: 0.66 0.61 0.047 0.44

J Paediatr Child Health, 2007. 43(1-2):

10% organ pool increase J Pediatr. 2011;158:31-6

1. Obtaining an adequate donor ?? 1. Carrying out the explant and transplant 2. Perioperative handling of the recipient 3. Immunosuppression/rejection 4. Follow up

 General:
Infectious disease (HIV or viral hepatitis), Over 65 Disseminated malignancies IV drug abuse

Specific for cardiac transplant

Dr. L. Bailey performed the first infant heart transplant in in 1985

Congenital Cardiomyophaty Retransplant :

Numbers of pediatric heart trasplant and age of recipient per year

J Heart Lung Transplant. 2011 Oct; 30 (10): 1071-1132

Age <1

C100 75 f o 50 25 % 0

Myopathy

Congenital

Age 1-10

100 75 50 25 0
100

Age 10-17

a 75 C o f 50 % 25
0

 1-year survival rate: 2-year survival rate: 5-year survival rate: in experienced centers

80-90% 80-85% 70-80%

 The most critical step is obtaining a (cardiac) donor, and problems are usually related to...

Special difficulties in diagnosis of brain death in pediatric donors

Known structural disease or irreversible systemic metabolic cause that can explain the clinical picture

Pediatrics, 2011;128: e720e740

 Exclusion

of conditions that confound diagnosis of brain death (electrolyte abnormalities, intoxication, hypothermia or drugs) hypnotics agents that age or neuromuscular blocking

and

correction

Absence of recent doses of sedatives, Absence of significant hypotension for

Pediatrics, 2011;128: e720e740

 Observation period 12 hours: for infants and children (30

d to 18 y)

24 hours: from 37 weeks gestational

age to 30 d

2 neurological examinations
Assessment of neurologic function following CPR should be deferred for 24 hours Pediatrics. 2011;128:
e720e740

 Harvard criteria
Set in 1968 Reviewed 1987 Dead Donor Rule

requires

patients to be declared dead before the removal of life-sustaining organs for transplantation

1. Coma

2. Absence of brainstem reflexes 3. Apnea

Formal neurological examination

It is a requisite to have a known structural

I: Coma

(Absence of Brain Functions)

unreactive coma is a condition where responses to painful stimuli in cranial nerves territory are not present

II. Absence of Brainstem Reflexes

certify the absence of brainstem reflexes

 Pupillary response
Mid-position or fully dilated pupils that do not respond to light.

Vestibulo-ocular reflex
(Cold caloric test)

Oculo-cephalic reflex
Doll's eye movement)

Absence of bulbar function including facial and oropharyngeal muscles

III. Apnea test

 Assesment of electrical activity

- EEG

Assesment of Cerebral Blood Flow

- Radionuclide cerebral blood flow These ancillary tests
Pediatrics. 2011;128:

 Programs for organ transplantation from anencephalic infants have been approved in Germany, Japan and Holland. Is this ethical?

Hypotension Diabetes Insipidus IDC Arrhythmias Cardiac Arrest Hypothermia Oliguria

81 % 65-90% 28% 27% 25% 23% 17%

 Full monitoring should be set up because of the unstable condition of a patient in brain death

 Resuscitation Oxygen delivery to the tissues Hydration and perfusion: vasopressor, vasopressin Restoration of normal ventilation Thermal regulation Regulation of neuroendocrine function

 Improved quality

organ-

Vasopressi n Thyroid hormone replaceme nt Corticoids

THT

Canadian Medical Association Journal 2006, 174(6)

UNOS evidence for THT in heart transplant

Use of T4 or T3/ Vasopressin/methylprednisolone : retrospective studies

Hearts procured from donors

receiving THT:
Improved one-month survival rate as compared to those donors not receiving THT. Reduced early cardiac graft dysfunction 1. Rosendale JD, et al. Hormonal resuscitation associated with more transplanted organs with
suppl 1:17 1. Canadian recommendations for donor management . Canadian Medical Association Journal . 2006, 174(6)
no sacrifice in survival.Transplantation2004;78(2)

Limited supply of cadaveric organ donors Societal concerns about the definition of BD Cultural and family concerns The difficulties of medical management BD organ donor Legal & logistical concerns

 Figures regarding donation and transplants worldwide Figures concerning the number of transplants and results of cardiac transplant in children Issues for Brain Death diagnosis and BD management in children.