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Organ TransplantationOrgan Transplantation
Dr. Nelson L. RhodusDr. Nelson L. Rhodus
Director of Oral MedicineDirector of Oral Medicine
University of MinnesotaUniversity of Minnesota
Organ TransplantationOrgan Transplantation
Bone Marrow ( stem cell)Bone Marrow ( stem cell) Solid organsSolid organs
– HeartHeart
– LungLung
– LiverLiver
– KidneyKidney
– PancreasPancreas
– Small intestineSmall intestine
Organ TransplantationOrgan Transplantation
Heart transplantsHeart transplants First performed in 1967; first year only First performed in 1967; first year only
1:5 survived1:5 survived 2000= 3500 performed2000= 3500 performed Total= 53,000Total= 53,000 Present survival rate >70%Present survival rate >70%
Organ TransplantationOrgan Transplantation
KidneyKidney First solid organ transplant ( 1954) First solid organ transplant ( 1954)
performedperformed Since then >490,000 kidney transplantsSince then >490,000 kidney transplants Presently 581 centers perform >10,000 Presently 581 centers perform >10,000
kidney transplants per year: 1-year kidney transplants per year: 1-year survival rate >90%( cadaver~80%) survival rate >90%( cadaver~80%)
( 5 yr. ~70%)
Organ TransplantationOrgan Transplantation
Liver transplantsLiver transplants First liver transplant in 1967First liver transplant in 1967 >90,000 liver transplants>90,000 liver transplants > 8,000 liver transplants per year> 8,000 liver transplants per year 1-1-
year survival rate >90% year survival rate >90% ( 5 yr. ~70%)
Organ TransplantationOrgan Transplantation
Pancreas transplantsPancreas transplants first pancreas transplant was performed in
1966, by Kelly and Lillehei at the University of Minnesota
2000 >3500 transplants performed >2000 at the U of M ! 1 year survival rate >85% ( 5 yr. ~70%) survival rate w/o pancreas transplant = about
the same ! ( JAMA- Dec. ‘03)
Organ TransplantationOrgan Transplantation
Heart - lung transplantsHeart - lung transplants ~ 800 performed as of 2000~ 800 performed as of 2000 1 year survival ~ 60 %1 year survival ~ 60 %
Organ TransplantationOrgan Transplantation
Small intestine transplantsSmall intestine transplants less than 50 performed (some
combined with liver transplants) four transplant centers (Cambridge;
London, Ontario; Pittsburgh, and Omaha).
current 1-year survival rate at 70%.1
Bone marrow transplantationBone marrow transplantation
First performed in 1958First performed in 1958 Early = very poor prognosisEarly = very poor prognosis Immunosuppression, GVHD, rejectionImmunosuppression, GVHD, rejection 2000 > 100,0002000 > 100,000 Today = successful ( 50-80% survival Today = successful ( 50-80% survival
rate-1 year)rate-1 year)
Organ TransplantationOrgan Transplantation
HEART TRANSPLANTSHEART TRANSPLANTS Reasons; cardiomyopathy, congenital Reasons; cardiomyopathy, congenital
heart disease, atherosclerotic coronary heart disease, atherosclerotic coronary artery diseaseartery disease
Terminal heart disease (6-12 months)Terminal heart disease (6-12 months) Age <50-55 yearsAge <50-55 years
Organ TransplantationOrgan Transplantation
HEART TRANSPLANTSHEART TRANSPLANTS Good renal and hepatic functionGood renal and hepatic function No infectionsNo infections No diabetesNo diabetes Family supportFamily support
Organ TransplantationOrgan Transplantation
HEART TRANSPLANTSHEART TRANSPLANTS Causes of death:Causes of death: InfectionInfection 40%40% Acute graft rejectionAcute graft rejection 25%25% Chronic graft rejectionChronic graft rejection 10 %10 % Cardiac diseaseCardiac disease 25%25%
Organ TransplantationOrgan Transplantation
HEART TRANSPLANTSHEART TRANSPLANTS Endocarditis preventionEndocarditis prevention Pacemakers-arrhythmiasPacemakers-arrhythmias Medications- drugsMedications- drugs Avoid epinephrineAvoid epinephrine AnticoagulationAnticoagulation
Organ TransplantationOrgan Transplantation
HEART TRANSPLANTSHEART TRANSPLANTS ImmunosuppressionImmunosuppression Adrenal suppressionAdrenal suppression BleedingBleeding Infection (IE)Infection (IE)
Organ TransplantationOrgan Transplantation
HEART TRANSPLANTSHEART TRANSPLANTS ACCELERATED GRAFT ACCELERATED GRAFT
ATHEROSCLEROSIS(AGAS)ATHEROSCLEROSIS(AGAS) ~ 50 % of post-transplant patients have~ 50 % of post-transplant patients have
AGASAGAS( same degree as pre-( same degree as pre-
transplant)transplant)
Organ TransplantationOrgan Transplantation
HEART TRANSPLANTSHEART TRANSPLANTS Transplanted heart has no nerve supplyTransplanted heart has no nerve supply Therefore with AGAS there is NO Therefore with AGAS there is NO
ANGINA. MI will cause sudden death.ANGINA. MI will cause sudden death.
Organ TransplantationOrgan Transplantation
LIVER TRANSPLANTATIONLIVER TRANSPLANTATION Indications:Indications: Chronic active hepatitisChronic active hepatitis Extrahepatic biliary atresiaExtrahepatic biliary atresia Primary biliary cirrhosisPrimary biliary cirrhosis Budd-Chiari syndromeBudd-Chiari syndrome(hepatic vein thrombosis)(hepatic vein thrombosis)
Sclerosing cholangitisSclerosing cholangitis Hepatocellular carcinomaHepatocellular carcinoma
Organ TransplantationOrgan Transplantation
LIVER TRANSPLANTATIONLIVER TRANSPLANTATION Primary organ disease problemsPrimary organ disease problems Excessive bleedingExcessive bleeding InfectionInfection Altered drug metabolismAltered drug metabolism
HypertensionHypertension
Organ TransplantationOrgan Transplantation
RENAL TRANSPLANTATIONRENAL TRANSPLANTATION ESRD managementESRD management Endocarditis, endarteritisEndocarditis, endarteritis Same as other organ transplantsSame as other organ transplants Aggessive prevention-treatment of Aggessive prevention-treatment of
infectionsinfections Viral infections( CMV, HBV,HCV, HIV)Viral infections( CMV, HBV,HCV, HIV)
Organ TransplantationOrgan Transplantation
RENAL TRANSPLANTATIONRENAL TRANSPLANTATION Avoid certain drugsAvoid certain drugs( acetaminophen, ( acetaminophen,
phenacetin, tetracycline, phenacetin, tetracycline, aminoglycosides, ASA, K+, PCN, aminoglycosides, ASA, K+, PCN, Magnesium-antacids, etc.)Magnesium-antacids, etc.)
Laboratory tests: urinalysis( BUN, Laboratory tests: urinalysis( BUN, creatinine, protein, electrolytes)creatinine, protein, electrolytes)
Bone marrow transplantationBone marrow transplantation
conditioncondition success ratesuccess rate ALLALL 20-25%20-25% AMLAML 40-60%40-60% CMLCML 60%60% Aplastic anemiaAplastic anemia 20-25%20-25% LymphomaLymphoma 25-40%25-40% NeuroblastomaNeuroblastoma 20-30%20-30%
Bone marrow transplantationBone marrow transplantation
HISTOCOMPATABILITYHISTOCOMPATABILITY AutologousAutologous selfself 30-50%30-50% AllogeneicAllogeneic siblingsibling 15-25%15-25% SyngeneicSyngeneic ident. twinident. twin < 5%< 5% HaploidenticalHaploidentical parentparent < 5%< 5% UnrelatedUnrelated any donorany donor 25-30%25-30%
Bone marrow transplantationBone marrow transplantation
Stages:Stages: Medical evaluationMedical evaluation 1 week1 week Histocompatibility matchingHistocompatibility matching 1 day1 day BM procurement (iliac crest)BM procurement (iliac crest) 1-2 weeks1-2 weeks Immunosuppressive Tx (TBI)1-2 weeksImmunosuppressive Tx (TBI)1-2 weeks Pancytopenic phasePancytopenic phase 4-6 weeks4-6 weeks Immune recovery phaseImmune recovery phase 1 year1 year Long-term recoveryLong-term recovery 1-4 years1-4 years
Bone marrow transplantationBone marrow transplantation
Three phases of immunosuppressive TxThree phases of immunosuppressive Tx 1.) pre-transplant1.) pre-transplant Cyclophosphimide or methotrexateCyclophosphimide or methotrexate
± TBI ( single or fractionated)± TBI ( single or fractionated) 2.) transplant( pancytopenic phase)2.) transplant( pancytopenic phase) 3.) cyclosporine, methotrexate, IFN-a3.) cyclosporine, methotrexate, IFN-a
to prevent GVHD to prevent GVHD
Bone marrow transplantationBone marrow transplantation
Phases 2-3 pancytopenic phasePhases 2-3 pancytopenic phase ANC<500: severe susceptibility to ANC<500: severe susceptibility to
infection : 4-6 weeks post-transplantinfection : 4-6 weeks post-transplant Immunosuppression ( long-term)Immunosuppression ( long-term) Recurrence of leukemiaRecurrence of leukemia
GVHDGVHD encephalitisencephalitis
Bone marrow transplantationBone marrow transplantation
ORAL COMPLICATIONSORAL COMPLICATIONS Peak 2-3 weeks post BMTPeak 2-3 weeks post BMT ( pancytopenic phase: ANC<500)( pancytopenic phase: ANC<500) Mucositis, xerostomia, GVHD, viral Mucositis, xerostomia, GVHD, viral
infectionsinfections(HSV,HIV),(HSV,HIV), ELP-like, ELP-like,
erythema, erythema, CandidiasisCandidiasis
Dental management of the Dental management of the Organ Transplant patientOrgan Transplant patient
Dr. Nelson L. RhodusDr. Nelson L. Rhodus
Director of Oral MedicineDirector of Oral Medicine
University of MinnesotaUniversity of Minnesota
Organ TransplantationOrgan Transplantation
Before transplantBefore transplant MEDICAL CONSULTATIONMEDICAL CONSULTATION Establish patient statusEstablish patient status primary organ failure-complicationsprimary organ failure-complications Current treatment-drugs, etc.Current treatment-drugs, etc. Antibiotic prophylaxisAntibiotic prophylaxis
Organ TransplantationOrgan Transplantation
LABORATORY TESTSLABORATORY TESTS CBCCBC differential white countdifferential white count plateletsplatelets PT, PTT, BTPT, PTT, BT
Organ TransplantationOrgan Transplantation
COMPLICATIONSCOMPLICATIONS Over-immunosuppressionOver-immunosuppression Side-effects of drugsSide-effects of drugs Rejection of transplantRejection of transplant
– AcuteAcute– ChronicChronic
Organ TransplantationOrgan Transplantation
DENTAL EVALUATIONDENTAL EVALUATION Aggressive treatment prior to Aggressive treatment prior to
immunosuppressionimmunosuppression Extract teeth with poor prognosisExtract teeth with poor prognosis Advanced perio, endo, questionableAdvanced perio, endo, questionable Aggressive oral hygiene: maintenanceAggressive oral hygiene: maintenance
Organ TransplantationOrgan Transplantation
IMMUNOSUPPRESSIONIMMUNOSUPPRESSION PrednisonePrednisone Aziothioprine(Immuran)Aziothioprine(Immuran) 33%*33%* CyclosporineCyclosporine 72%*72%* Antilymphocyte globulin (ALG)Antilymphocyte globulin (ALG)84%*84%*
* 1 year survival rate* 1 year survival rate
Organ TransplantationOrgan Transplantation
IMMUNOSUPPRESSIONIMMUNOSUPPRESSION InfectionInfection Delayed wound healingDelayed wound healing BleedingBleeding HypertensionHypertension Heart failureHeart failure Diabetes mellitusDiabetes mellitus
Organ TransplantationOrgan Transplantation
IMMUNOSUPPRESSIONIMMUNOSUPPRESSION Tumors ( lip cancer, lymphoma)Tumors ( lip cancer, lymphoma) Adrenal crisisAdrenal crisis AnemiaAnemia OsteoporosisOsteoporosis GI problemsGI problems
Organ TransplantationOrgan Transplantation
DENTAL MANAGEMENTDENTAL MANAGEMENT MEDICAL CONSULTATIONMEDICAL CONSULTATION Minimize stress, short appointmentsMinimize stress, short appointments Monitor vitals ( HTN)Monitor vitals ( HTN) Infections( endocarditis, endarteritis)Infections( endocarditis, endarteritis) Pneumonia, encephalitisPneumonia, encephalitis Aggessive prevention & Tx of infectionAggessive prevention & Tx of infection
Organ TransplantationOrgan Transplantation
DENTAL MANAGEMENTDENTAL MANAGEMENT BleedingBleeding GI problemsGI problems IMMUNOSUPPRESSIONIMMUNOSUPPRESSION Consider steroid supplementationConsider steroid supplementation Personal Oral hygienePersonal Oral hygiene
TransplantationTransplantation
ORAL COMPLICATIONSORAL COMPLICATIONS Bleeding, infections, poor wound Bleeding, infections, poor wound
healinghealing PainPain Mucositis, ulcers, xerostomia, Mucositis, ulcers, xerostomia,
dysguesia, dysphagiadysguesia, dysphagia
Organ TransplantationOrgan Transplantation
Tumors Tumors Lip carcinomaLip carcinoma 8-10%8-10% Kaposi’sKaposi’s 6-7 %6-7 % LymphomaLymphoma 20 %20 % Kidney CaKidney Ca 5 % 5 %
Organ TransplantationOrgan Transplantation
IMMUNOSUPPRESSIONIMMUNOSUPPRESSION Minor complicationsMinor complications Gingival hyperplasiaGingival hyperplasia HirsutismHirsutism GynecomastiaGynecomastia DepressionDepression
Organ TransplantationOrgan Transplantation
Graft rejectionGraft rejection Heart- death, retransplant( unlikely)Heart- death, retransplant( unlikely) Kidney- death, Kidney- death, HemodialysisHemodialysis, re-Tx, re-Tx Pancreas- death, insulin, re-TxPancreas- death, insulin, re-Tx
Organ TransplantationOrgan Transplantation
IMMEDIATE POST-TRANSPLANTIMMEDIATE POST-TRANSPLANT No routine dental treatment ~ 6 mos.No routine dental treatment ~ 6 mos. POHPOH Emergency( conservative) treatmentEmergency( conservative) treatment MEDICAL CONSULTATIONMEDICAL CONSULTATION
Organ TransplantationOrgan Transplantation
Stable graft period ( >6 months)Stable graft period ( >6 months) Most dental treatment can be performed Most dental treatment can be performed
with adequate managementwith adequate management OVER-IMMUNOSUPPRESSIONOVER-IMMUNOSUPPRESSION GVHDGVHD HTN, BLEEDING, DRUGS, etc.HTN, BLEEDING, DRUGS, etc. OTHER INFECTIONSOTHER INFECTIONS
Organ TransplantationOrgan Transplantation
CHRONIC REJECTION PERIODCHRONIC REJECTION PERIOD No routine dental treatment No routine dental treatment POHPOH Emergency( conservative) treatmentEmergency( conservative) treatment MEDICAL CONSULTATIONMEDICAL CONSULTATION
Organ TransplantationOrgan Transplantation
Salivary gland dysfunctionSalivary gland dysfunction Very aggressive oral hygiene programVery aggressive oral hygiene program POH: plaque control : toothbrushing, POH: plaque control : toothbrushing,
flossing, fluoridesflossing, fluorides Dietary counselingDietary counseling Perio treatmentPerio treatment Chlorohexidine gluconateChlorohexidine gluconate