Quality Outcomes

Emory Transplant Center Performs Its First HIV to HIV Kidney Transplant

Emory Transplant Center performs its 1st HIV to HIV kidney transplant

Made possible by the HIV Organ Policy Equity (HOPE) Act, Emory Transplant Center has performed its first HIV-positive kidney transplant from an HIV-positive deceased donor. Not only was this Emory’s first HIV to HIV kidney transplant, it is also the first of its kind in Georgia and the first HIV to HIV positive kidney transplant in 2017.

Emory and eight other centers nationwide are taking part in the HOPE in Action clinical trial — a prospective, pilot study to evaluate the safety of HIV-positive deceased donor solid organ transplants (kidney and liver) in HIV-positive recipients.

Stable HIV-infected adults with end-stage kidney disease who meet study-specific HIV criteria for organ transplantation will be offered enrollment in the study at Emory. Currently, Emory is enrolling participants for HIV-positive to HIV-positive kidney transplants, with a plan to include liver transplant patients in the near future.

“With 120,000 people on the wait list for a kidney transplant, and about 10,000 people living with HIV who are on dialysis, the HOPE Act gives us new opportunities to save more lives, rather than turning down organ donations from HIV-positive donors,” says Nicole Turgeon, MD, kidney transplant surgeon, Emory Kidney Transplant Program and principal investigator of this study at Emory.

“Patients living with HIV are living longer because their disease is now considered manageable with good antiretroviral therapies. This means we are seeing more patients who are HIV-positive in need of organ transplants. The HOPE Act ensures a greater number of people will receive the life-saving transplant they need,” explains Turgeon.

The HOPE Act was enacted in November 2013, but did not become effective until November 2015. In 2016, 20 patients at four different centers received new organs in the HOPE in Action clinical trial. Research shows that HIV-positive transplant recipients have similar patient survival rates and kidney and liver graft survival rates post-transplant as non-HIV-positive recipients. This is good news for patients with HIV who need a transplant.

“We thank this donor and the donor’s family for giving life to others during their time of sorrow, and the excellent work of Life Link of Georgia that made this transplant possible” says Turgeon. “We want to encourage others, with or without HIV, to register to be organ donors and to tell their families of their decision to help others. Go to Donate Life of Georgia to learn more.”

 

Finding a Better Antifungal Agent for Lung Transplant Patients

Transplant_7-16Because human airways are open to airborne fungal spores and pathogens, lung transplant patients are especially susceptible to infections, a major cause of post-transplant disease and even death. A reliable means of preventing fungal infection in lung transplant patients is the drug posaconazole. Even though it serves well for preventing infection, the oral suspension has poor bioavailability, or absorption into the bloodstream, and patients need to have low gastric pH and high dietary fat intake for adequate systemic exposure.

In November 2013, the FDA approved a new formulation, a posaconazole extended-release tablet, which doctors at Emory Transplant Center began prescribing to patients because of its predictable absorption and improved systemic exposure.

“The purpose of the research study was to compare the oral suspension with the extended-release tablets and determine the likelihood of achieving therapeutic posaconazole levels, which provides the optimal benefit for patients,” says Michael Hurtik, clinical pharmacist for the heart and lung transplant programs, who was the first author on the study. He and the team’s pulmonologists, including Emory Lung Transplant Program medical director, Dr. David Neujahr, looked at data from a cohort of Emory Transplant Center patients who received single or bilateral lung transplantation between January 2013 and October 2014, and were treated for four months post-transplant with nebulized amphotericin and posaconazole oral suspension or the extended-release tablets.

The results showed that the use of the new posaconazole extended-release tablets resulted in therapeutic blood levels for fungal prophylaxis more often (87% of patients) than the oral suspension formulation (39%). The lung transplant patients studied also tolerated the tablets well and no one needed a dose reduction or discontinuation of the medication. This study was successful in finding a better antifungal agent for our lung transplant patients that also provides the most optimal health benefit.

Learn more about the Emory Transplant Center.

Emory Liver Transplant Program Raises the Bar

transplant quality measuresAccording to the December 2014 Scientific Registry of Transplant Recipients (SRTR) report, Emory’s adult and pediatric liver transplant program is the second busiest in the nation, establishing the Emory Liver Transplant Program as a leader across the U.S. This feat is made more remarkable by the fact that while volume in the adult program has more than doubled over the past six years, survival outcomes have also dramatically improved, according to the SRTR data.

The Scientific Registry of Transplant Recipients (SRTR) is a national database of transplant statistics. The registry evaluates both the scientific and clinical status of solid organ transplantation for all programs across the nation. This includes the number of transplants performed, wait-list candidates, transplant recipients, and survival statistics for each program.

The liver teams at the Emory Transplant Center and Children’s Healthcare of Atlanta performed 145 adult and 18 pediatric liver transplants (one of which was from a living donor) in calendar year 2014. This is up from a total of 91 adult and pediatric transplants in 2008.

In the most recent SRTR report, Emory’s one-year adult patient and graft survival rates were 92.8% and 89.8%, respectively, both rates were higher than expected. We credit this to the team of talented and committed individuals who work hard work each and every day.

“We have come a long way over the years in the adult program, increasing volume while still improving outcomes,” says Dr. James Spivey, medical director of the program. “Much of the credit goes to a restructuring of our clinical teams to improve outcomes and increase quality of care, productivity of our teams and efficiency in the transplant process for patients. For example, we were able to increase waitlist additions. Through the generous gift of organ donation, this has helped result in increased transplant rates in recent years.”

iCHOOSE Kidney – An Education App for Prospective Kidney Transplant Patients

iChoose Kidney AppFor patients suffering from end-stage renal disease (ESRD), there are two major treatment options: dialysis and kidney transplant. Of these two options, medical studies have shown that receiving a kidney transplant offers a better chance of survival and quality of life, eliminating the need for hours of dialysis treatment.

Although it is required by law for clinicians or physicians to discuss kidney transplant as a treatment option for their ESRD patients, Emory epidemiologist Rachel Patzer, PhD, MPH, assistant professor of surgery, says that many eligible patients are not being referred for kidney transplantation. Through her research, Patzer found that such disparities were often present in regions outside the Atlanta area.

“There are disparities in who is getting access to that information about transplant, which I think is leading to some of the disparities we see in access to getting on the waiting list and receiving a transplant,” Patzer says.

In order to address these treatment disparities and help patients understand the best treatment option for their individual cases, Patzer and the Emory transplant team created the iCHOOSE Kidney iPad application. The iCHOOSE Kidney app is a shared-decision making tool for providers or clinicians to use with their patients to inform them about potential risks and benefits of each treatment. “The app basically walks you through different risks for treatment options,” Patzer says.

While Patzer says the optimal treatment for kidney disease is transplant, she says this depends on patients’ individualized risk profile, which includes factors such as their age and other possible medical conditions they may have.

Upon a patient’s initial diagnosis of end-stage kidney disease, physicians or clinicians can enter in patient data into the iCHOOSE Kidney app, which in turn calculates the risks of dying on dialysis versus a kidney transplant. The app calculates both relative and absolute risks based on data from a national database of almost 700,000 patients.

The app tries to keep things simple for patients by presenting data in a picture format. Patzer says illustrating information visually is one of the best ways to convey risks to patients. “Showing patients you’re going to live this many years longer or that this is 10 times better is really more powerful than just giving them the average,” Patzer says.

The app is currently being used at the Emory Transplant Center and in the surrounding community. Patzer says that the Emory transplant surgeons and nephrologists use the iCHOOSE Kidney app as part of their communication and education with patients. You can find the iChoose Kidney app by searching your App Store.

Emory Transplant Center is a Top 10 Transplant Center in the U.S.

Living Organ Donation Donate Life MonthThe latest data from OPTN/UNOS of adult organ transplants performed in 2012 show that the Emory Transplant Center performed 426 transplants, making it the largest transplant center in the state and the 10th largest in the country. If we add the 60 pediatric transplants performed at Children’s Healthcare of Atlanta, the ETC is the 5th largest transplant center in the country.

Of course, the ETC is much more than these numbers, but volume is one indication of just how busy our center is — and our programs are growing. In 2011, Emory performed 360 adult and 70 pediatric transplants. That means the total number of transplants increased 13% from 2011 to 2012. Each program is growing, too. The kidney program expanded from 204 transplants in 2011 to 230 in 2012, and the liver program grew from 93 transplants in 2011 to 111 in 2012. There were 11 kidney and pancreas transplants at the ETC in 2011 and 17 in 2012. The heart team transplanted 23 in 2011 and 34 in 2012, and the lung program transplanted 29 in 2011 and 34 in 2012.

This accomplishment never would have been possible without the gracious gifts of life organ donors provide to our transplant recipients. We are ever grateful to the donors who have indicated their wishes and the families that have made the decision to donate and save or restore the lives of our patients.

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Emory Transplant Center Achieves and Sustains Outstanding Quality Outcomes

Transplant Center OutcomesThe idea of replacing an organ via transplant can be a scary topic for people faced with a condition that may require one. At Emory, we’re consistently taking steps to improve transplant survival rates and hopefully, remove some of this fear for our patients. We’ve just received results from the January 2011 transplant center-specific report on outcomes from the Scientific Registry of Transplant Recipients (SRTR). We’re very pleased to announce that the Emory kidney transplant program, liver transplant program, and lung transplant program have all demonstrated consistently strong and in some cases better-than-expected patient outcomes.

Kidney Transplant

  • Emory’s overall one-year graft survival rate of 95.85% for the most recent cohort studied (July 2007 – December 2009) is statistically higher (p = .026) than the expected rate of 92.81%.
  • Emory’s living-donor graft survival rate of 100% is statistically higher (p =.033) than the expected rate of 96.36%.
  • Emory’s deceased donor graft survival rate is also numerically higher than expected (93.69% observed vs. 90.95% expected).

We’re pleased to also note that in 2010, the Emory transplant team performed 207 kidney transplants, and 22 pancreas transplant procedures – the largest number of transplants in the history of the kidney and pancreas transplant program. Of the 207 kidney transplants, 31% (64) involved living donors.

Lung Transplant

  • Emory’s one-year patient survival rate for the latest cohort (July 2007 – December 2009) is 90.14%, compared to a risk-adjusted expected rate of 82.74%.
  • Emory’s graft survival rate is 85.29%, compared to a risk-adjusted expected rate of 81.10%.

This past year, the Emory Transplant Center and team of transplant doctors performed its 300th lung transplant. The lung program has come a long way to reach this milestone, performing 35 transplants in 2010, a 300% increase over the annual total just 10 years ago.

Liver Transplant

Emory’s liver transplant program continues to achieve and sustain outstanding outcomes, with patient survival rates >91% following transplantation.

Since July 2008, our surgical transplant team has performed 241 liver transplantations (216 liver only, 25 liver/kidney combination transplants). Between January 1, 1988 – November 30, 2010, Emory has performed 67.9% (1,496 of 2,203) of all liver transplants in the state of Georgia.

Our transplant center continues to excel with statistically significant patient organ transplantation outcomes, demonstrating a commitment to high quality and patient success. If you have questions about our transplant program or outcomes, please leave them in the comments section below.

Emory Transplant Program Milestone – 300 Lung Transplants

For a young mother of two teen-aged sons, living life attached to an oxygen tank is not an ideal situation. For Jo Ellen Kimball, 40, however, this was the life she had grown accustomed to living with idiopathic pulmonary fibrosis (IPF), a condition that essentially turns the lungs to stone. As Jo Ellen’s physician and Medical Director of Lung Transplantation at Emory Transplant Center, Dr. Clinton Lawrence puts it, “Imagine trying to breathe through lava rock every day of your life.” The five-year survival rate of IPF is less than 20% and as of now, lung transplantation is the only known treatment.

Since September 17th, however, Jo Ellen’s outlook on life and future has changed drastically. It was on this day that she underwent her double lung transplant at Emory University Hospital.

After the procedure, Jo Ellen was able to regain her ability to breathe on her own after only nine days, a remarkable achievement. And after six years of life spent facilitated by an oxygen tank, Jo Ellen Kimball can now return to a normal life and possibly even return to her position as a fourth grade teacher.

As if this positive momentous life change for Jo Ellen wasn’t enough, she was also informed that her procedure resulted in even further celebration– Jo Ellen’s procedure was the 300th lung transplant performed by Emory’s Transplant Program (established in 1993).

Much like the journey Jo Ellen has experienced to free herself from the constraints of IPF, Emory’s lung transplant program has traveled quite a distance in reaching this milestone. The program is not a high-volume transplant program when compared to Emory’s other solid organ transplant programs. In fact, in 2009, 35 lung transplants were performed by the program, its most ever in a single year and a 300% increase from a decade before.

With generous donations and the help of doctors like Clinton Lawrence and Jo Ellen’s surgeon and Surgical Director of Lung Transplantation at Emory Transplant Center, Dr. Seth Force, the lung transplant program continues to grow and gain momentum.

“Emory has the only lung transplant program in the state,” notes Dr. Lawrence. “We provide a necessary and quality service to individuals from all walks of life from Georgia and surrounding states, including Florida, Alabama, Arkansas, and Louisiana.”

After a few weeks of recovery at Emory, Jo Ellen has since returned home to Conyers, GA to rest and recover with her family. We will be sure to keep you updated on her journey.

Belatacept Transplant Drug Offers Hope for Preserving Kidney Function

Today, kidney transplantation provides patients with invaluable benefits—it prolongs lifespan and restores vitality and health. However, this hasn’t always been the case. As recently as the 1980s, results of transplants were fairly poor, and kidneys were often lost from rejection. In 1983, the cyclosporine class of drugs entered the equation, revolutionizing transplantation. Short-term outcomes improved greatly, and we expected most of our patients to survive with a functioning graft—90% of them at the 1-year mark.

Unfortunately, while cyclosporine is ideal for short-term outcomes, it causes many side effects that affect long-term outcomes in patients. Cyclosporine is toxic to the kidney—over time, this causes excess scarring and eventually even leads to loss of kidney function.

In approximately one-third of patients, cyclosporine causes post-transplant diabetes, requiring most patients to take blood pressure lowering medications. Additionally, most must take medications to lower their cholesterol. (High blood pressure and increased cholesterol counts are both side effects of cyclosporine.) Ultimately, patients must take the anti-rejection drugs along with a host of other drugs to combat the side effects, all of which can lead to death from cardiovascular disease. On average, the kidney transplant patient survival rate is only 8-10 yrs, which is clearly short of what we’d like to see.

Sufficed to say, there’s been a tremendous need for better drugs to prevent rejection in kidney transplants, without causing life-threatening side effects.

Introducing Belatacept

When kidney patients suffer from transplant rejection, the immune system essentially recognizes the new kidney as a foreign object, causing lymphocytes and T-cells to attack, and generating immune damage to the transplant. Consequently, we introduce drugs to dampen the immune system. The issue with cyclosporine is that it doesn’t just affect the immune response; it hits several other targets throughout the body, causing the negative side effects. Fortunately, there’s hope on the horizon with a newer drug called belatacept.

Like Cyclosporine, belatacept blocks the immune system from transplant rejection. However, the target of belatacept is only expressed in the immune system, so it suppresses undesired immune responses of rejection without the off target side effects (e.g. high blood pressure, increased cholesterol and diabetes) seen with Cyclosporine. We refer to these off-target responses as “costimulatory signals”.

In transplantation, our goal is to achieve a normal life span for our patients, and to ideally have them move on from surgery dialysis-free. At Emory, we’ve dedicated years to developing new and improved therapies that avoid major complications from kidney transplants, including cardiovascular issues, infections and malignancies.

Recent belatacept studies indicate that this drug could quite possibly help us in achieving these goals. Over 1400 patients have been studied with belatacept’s use in kidney transplant, and the results continue to be extremely promising. Further, the drug could conceivably have advantages for other types of organ transplantation, including liver, heart, lung, and intestinal.

Do you have any questions about belatacept, or about kidney transplantation in general? If so, please let me know in the comments.