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Organ Transplantation Organ Transplantation Dr Nelson L Rhodus

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					Organ Transplantation



   Dr. Nelson L. Rhodus
  Director of Oral Medicine
University of Minnesota
    Organ Transplantation
 Bone Marrow ( stem cell)
 Solid organs
  – Heart
  – Lung
  – Liver
  – Kidney
  – Pancreas
  – Small intestine
    Organ Transplantation
 Heart transplants
 First performed in 1967; first year only
  1:5 survived
 2000= 3500 performed
 Total= 53,000
 Present survival rate >70%
    Organ Transplantation
 Kidney
 First solid organ transplant ( 1954)
  performed
 Since then >490,000 kidney transplants
 Presently 581 centers perform >10,000
  kidney transplants per year: 1-year
  survival rate >90%( cadaver~80%)
     ( 5 yr. ~70%)
    Organ Transplantation
 Liver transplants
 First liver transplant in 1967
 >90,000 liver transplants
 > 8,000 liver transplants per year 1-year
  survival rate >90% ( 5 yr. ~70%)
     Organ Transplantation
   Pancreas 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 Transplantation
 Heart - lung transplants
 ~ 800 performed as of 2000
 1 year survival ~ 60 %
    Organ Transplantation
 Small 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 transplantation
 First performed in 1958
 Early = very poor prognosis
 Immunosuppression, GVHD, rejection
 2000 > 100,000
 Today = successful ( 50-80% survival
  rate-1 year)
    Organ Transplantation
 HEART TRANSPLANTS
 Reasons; cardiomyopathy, congenital
  heart disease, atherosclerotic coronary
  artery disease
 Terminal heart disease (6-12 months)
 Age <50-55 years
    Organ Transplantation
 HEART TRANSPLANTS
 Good renal and hepatic function
 No infections
 No diabetes
 Family support
    Organ Transplantation
 HEART TRANSPLANTS
 Causes of death:
 Infection               40%
 Acute graft rejection   25%
 Chronic graft rejection 10 %
 Cardiac disease         25%
    Organ Transplantation
 HEART TRANSPLANTS
 Endocarditis prevention
 Pacemakers-arrhythmias
 Medications- drugs
 Avoid epinephrine
 Anticoagulation
    Organ Transplantation
 HEART TRANSPLANTS
 Immunosuppression
 Adrenal suppression
 Bleeding
 Infection (IE)
    Organ Transplantation
 HEART TRANSPLANTS
 ACCELERATED GRAFT
  ATHEROSCLEROSIS(AGAS)
 ~ 50 % of post-transplant patients have
     AGAS
     ( same degree as pre-transplant)
    Organ Transplantation
 HEART TRANSPLANTS
 Transplanted heart has no nerve supply
 Therefore with AGAS there is NO
  ANGINA. MI will cause sudden death.
    Organ Transplantation
 LIVER TRANSPLANTATION
 Indications:
 Chronic active hepatitis
 Extrahepatic biliary atresia
 Primary biliary cirrhosis
 Budd-Chiari syndrome(hepatic vein thrombosis)
 Sclerosing cholangitis
 Hepatocellular carcinoma
    Organ Transplantation
 LIVER TRANSPLANTATION
 Primary organ disease problems
 Excessive bleeding
 Infection
 Altered drug metabolism

 Hypertension
    Organ Transplantation
 RENAL TRANSPLANTATION
 ESRD management
 Endocarditis, endarteritis
 Same as other organ transplants
 Aggessive prevention-treatment of
  infections
 Viral infections( CMV, HBV,HCV, HIV)
    Organ Transplantation
 RENAL TRANSPLANTATION
 Avoid certain drugs( acetaminophen,
  phenacetin, tetracycline,
  aminoglycosides, ASA, K+, PCN,
  Magnesium-antacids, etc.)
 Laboratory tests: urinalysis( BUN,
  creatinine, protein, electrolytes)
Bone marrow transplantation
 condition         success rate
 ALL               20-25%
 AML               40-60%
 CML               60%
 Aplastic anemia   20-25%
 Lymphoma          25-40%
 Neuroblastoma     20-30%
Bone marrow transplantation
 HISTOCOMPATABILITY
 Autologous self             30-50%
 Allogeneic   sibling        15-25%
 Syngeneic    ident. twin    < 5%
 Haploidentical     parent   < 5%
 Unrelated    any donor      25-30%
Bone marrow transplantation
 Stages:
 Medical evaluation           1 week
 Histocompatibility matching 1 day
 BM procurement (iliac crest) 1-2 weeks
 Immunosuppressive Tx (TBI)1-2 weeks
 Pancytopenic phase           4-6 weeks
 Immune recovery phase        1 year
 Long-term recovery           1-4 years
Bone marrow transplantation
 Three phases of immunosuppressive Tx
 1.) pre-transplant
 Cyclophosphimide or methotrexate
      ± TBI ( single or fractionated)
 2.) transplant( pancytopenic phase)
 3.) cyclosporine, methotrexate, IFN-a
  to prevent GVHD
Bone marrow transplantation
 Phases 2-3 pancytopenic phase
 ANC<500: severe susceptibility to
  infection : 4-6 weeks post-transplant
 Immunosuppression ( long-term)
 Recurrence of leukemia

 GVHD
   encephalitis
Bone marrow transplantation
 ORAL COMPLICATIONS
 Peak 2-3 weeks post BMT
 ( pancytopenic phase: ANC<500)
 Mucositis, xerostomia, GVHD, viral

    infections(HSV,HIV), ELP-like,
    erythema, Candidiasis
Dental management of the
 Organ Transplant patient



    Dr. Nelson L. Rhodus
   Director of Oral Medicine
 University of Minnesota
    Organ Transplantation
 Before transplant
 MEDICAL CONSULTATION
 Establish patient status
 primary organ failure-complications
 Current treatment-drugs, etc.
 Antibiotic prophylaxis
    Organ Transplantation
 LABORATORY TESTS
 CBC
 differential white count
 platelets
 PT, PTT, BT
     Organ Transplantation
 COMPLICATIONS
 Over-immunosuppression
 Side-effects of drugs
 Rejection of transplant
    – Acute
    – Chronic
    Organ Transplantation
 DENTAL EVALUATION
 Aggressive treatment prior to
  immunosuppression
 Extract teeth with poor prognosis
 Advanced perio, endo, questionable
 Aggressive oral hygiene: maintenance
    Organ Transplantation
 IMMUNOSUPPRESSION
 Prednisone
 Aziothioprine(Immuran)          33%*
 Cyclosporine                    72%*
 Antilymphocyte globulin (ALG)   84%*

        * 1 year survival rate
    Organ Transplantation
 IMMUNOSUPPRESSION
 Infection
 Delayed wound healing
 Bleeding
 Hypertension
 Heart failure
 Diabetes mellitus
    Organ Transplantation
 IMMUNOSUPPRESSION
 Tumors ( lip cancer, lymphoma)
 Adrenal crisis
 Anemia
 Osteoporosis
 GI problems
    Organ Transplantation
 DENTAL MANAGEMENT
 MEDICAL CONSULTATION
 Minimize stress, short appointments
 Monitor vitals ( HTN)
 Infections( endocarditis, endarteritis)
 Pneumonia, encephalitis
 Aggessive prevention & Tx of infection
    Organ Transplantation
 DENTAL MANAGEMENT
 Bleeding
 GI problems
 IMMUNOSUPPRESSION
 Consider steroid supplementation
 Personal Oral hygiene
       Transplantation
 ORAL COMPLICATIONS
 Bleeding, infections, poor wound
  healing
 Pain
 Mucositis, ulcers, xerostomia,
  dysguesia, dysphagia
    Organ Transplantation
 Tumors
 Lip carcinoma   8-10%
 Kaposi’s        6-7 %
 Lymphoma        20 %
 Kidney Ca       5%
    Organ Transplantation
 IMMUNOSUPPRESSION
 Minor complications
 Gingival hyperplasia
 Hirsutism
 Gynecomastia
 Depression
    Organ Transplantation
 Graft rejection
 Heart- death, retransplant( unlikely)
 Kidney- death, Hemodialysis, re-Tx
 Pancreas- death, insulin, re-Tx
    Organ Transplantation
 IMMEDIATE POST-TRANSPLANT
 No routine dental treatment ~ 6 mos.
 POH
 Emergency( conservative) treatment
 MEDICAL CONSULTATION
    Organ Transplantation
 Stable graft period ( >6 months)
 Most dental treatment can be performed
  with adequate management
 OVER-IMMUNOSUPPRESSION
 GVHD
 HTN, BLEEDING, DRUGS, etc.
 OTHER INFECTIONS
    Organ Transplantation
 CHRONIC REJECTION PERIOD
 No routine dental treatment
 POH
 Emergency( conservative) treatment
 MEDICAL CONSULTATION
    Organ Transplantation
 Salivary gland dysfunction
 Very aggressive oral hygiene program
 POH: plaque control : toothbrushing,
  flossing, fluorides
 Dietary counseling
 Perio treatment
 Chlorohexidine gluconate

				
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