Achieving Adequate Renal Xenograft Perfusion and Function in an LVAD Recipient with Strict Systolic and Pulse Pressure Parameters
Presented During: Welcome Reception and Poster Competition | Sponsored by: TransMedics
NYU Langone hospital
Ljubljana, ON
Slovenia - Contact Me
I am a second-year postdoctoral fellow in the Griesemer Lab at NYU Langone Health's Transplant Institute and a General Surgery Resident at NewYork-Presbyterian/Columbia University Irving Medical Center, with an interst in transplant immunology. My predoctoral research in the Madsen and Alessandrini Labs at Massachusetts General Hospital focused on mechanisms of peripheral tolerance induction, particularly in murine heart and kidney transplant models. Currently, at NYU, I am investigating the immunologic and physiological barriers to clinical heart, liver, and kidney xenotransplantation using a brain-dead human decedent model.
Friday, September 20, 2024: 5:00 PM - 6:30 PM
Omni King Edward Hotel
Description
Purpose (50 words): Individuals with end-stage renal disease and contraindication to transplant are not considered for a left ventricular assist device (LVAD) as destination therapy due to high mortality rates. We report the course of the first 30 days of porcine renal xenograft perfusion and function in a human recipient with an LVAD.
Methods (150 words): The patient underwent a re-operative sternotomy with HeartMate III LVAD implantation. A week later after being maintained on CRRT, an alpha-gal knock-out porcine thymokidney was transplanted into the left iliac fossa. Hourly hemodynamic data and LVAD parameters were recorded. A complete metabolic panel was collected every 4 hours. Renal ultrasounds with color flow doppler and spectral analysis were performed weekly. Approval for this procedure was obtained from the FDA under a single patient expanded access Investigational New Drug application and the New York University Grossman School of Medicine Institutional Review Board.
Results (200 words): Renal xenograft dopplers demonstrated patent vasculature without stenosis or thrombosis throughout the duration of the study. Following transplant, main renal artery peak systolic velocity (MRA-PSV) was 53.4cm/s (normal: 60-100cm/s) with a resistive index (RI) of 0.7 (normal: 0.5-0.8). Spectral doppler showed a monophasic waveform with continuous antegrade flow. On post-operative day (POD) 2 creatinine clearance (CrCl) declined to 12mL/min from 75.8mL/min secondary to low effective circulating volume in setting of hypotension. Serum creatinine (Cr) peaked to 1.55mg/dL on POD4. Hemodynamic goals were broadened to prioritize a pulsatile flow with systolic blood pressure (SBP) of greater than 100mmHg per standard renal allotransplant protocols by a combination of inotropic and vasopressor support. When a SBP of >100mmHg and pulse pressure (PP) of >25mmHg was achieved, serum Cr and CrCl returned to baseline. Serum Cr reached a nadir of 0.48 mg/dL and CrCl increased to 72.9 mL/min on POD7. MRA-PSV and RI were normal at 88.4cm/s and 0.8, respectively. Renal artery doppler confirmed improved pulsatility with a sharp systolic upstroke. Between POD7 and POD30, serum Cr ranged from 0.49-1.11 mg/dL, and CrCl ranged from 35.9-72.9 mL/min. MRA-PSV and RI remained in reference range. LVAD flows were stable at 3.7L/min (range 3.1-4.4L/min).
Conclusions (50 words): Adequate xenograft perfusion was achieved in an LVAD recipient demonstrated by normal MRA-PSV and RI. Renal function normalized following an ischemic injury by maintaining a SBP of >100mmHg and PP of >25mmHg. Long-term impact of continuous flow on a transplanted kidney remains unclear, maintaining pulsatile flow seems beneficial.
Authors
Imad Aljabban (1), Ian Jaffe (2), Randal Goldberg (2), Alex Reyentovich (2)
Institutions
(1) NYU Langone, United States, (2) NYU Langone Health, New York, NY
Methods (150 words): The patient underwent a re-operative sternotomy with HeartMate III LVAD implantation. A week later after being maintained on CRRT, an alpha-gal knock-out porcine thymokidney was transplanted into the left iliac fossa. Hourly hemodynamic data and LVAD parameters were recorded. A complete metabolic panel was collected every 4 hours. Renal ultrasounds with color flow doppler and spectral analysis were performed weekly. Approval for this procedure was obtained from the FDA under a single patient expanded access Investigational New Drug application and the New York University Grossman School of Medicine Institutional Review Board.
Results (200 words): Renal xenograft dopplers demonstrated patent vasculature without stenosis or thrombosis throughout the duration of the study. Following transplant, main renal artery peak systolic velocity (MRA-PSV) was 53.4cm/s (normal: 60-100cm/s) with a resistive index (RI) of 0.7 (normal: 0.5-0.8). Spectral doppler showed a monophasic waveform with continuous antegrade flow. On post-operative day (POD) 2 creatinine clearance (CrCl) declined to 12mL/min from 75.8mL/min secondary to low effective circulating volume in setting of hypotension. Serum creatinine (Cr) peaked to 1.55mg/dL on POD4. Hemodynamic goals were broadened to prioritize a pulsatile flow with systolic blood pressure (SBP) of greater than 100mmHg per standard renal allotransplant protocols by a combination of inotropic and vasopressor support. When a SBP of >100mmHg and pulse pressure (PP) of >25mmHg was achieved, serum Cr and CrCl returned to baseline. Serum Cr reached a nadir of 0.48 mg/dL and CrCl increased to 72.9 mL/min on POD7. MRA-PSV and RI were normal at 88.4cm/s and 0.8, respectively. Renal artery doppler confirmed improved pulsatility with a sharp systolic upstroke. Between POD7 and POD30, serum Cr ranged from 0.49-1.11 mg/dL, and CrCl ranged from 35.9-72.9 mL/min. MRA-PSV and RI remained in reference range. LVAD flows were stable at 3.7L/min (range 3.1-4.4L/min).
Conclusions (50 words): Adequate xenograft perfusion was achieved in an LVAD recipient demonstrated by normal MRA-PSV and RI. Renal function normalized following an ischemic injury by maintaining a SBP of >100mmHg and PP of >25mmHg. Long-term impact of continuous flow on a transplanted kidney remains unclear, maintaining pulsatile flow seems beneficial.
Authors
Imad Aljabban (1), Ian Jaffe (2), Randal Goldberg (2), Alex Reyentovich (2)
Institutions
(1) NYU Langone, United States, (2) NYU Langone Health, New York, NY