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PubMed2001

Organ transplantation: present scenario and future strategies for transplant programme (specially cadaveric) in India: socio-administrative respects.

Organ transplantation was enacted by a law "Transplantation of Human Organ Act" in 1994 but still, getting the consent from the relatives of brain dead person is a very difficult task and hence cadaveric transplant accounts for a minimum number. In India, most of the transplantations carried out are related to living donor and very few are cadaveric. The poor status of cadaver transplantation may be attributed to the moral, emotional and religious beliefs and taboos that inhibit the relatives of the deceased to come forward to donate organ(s) of a brain dead person.Non-existence of a trained transplant co-ordinator who is the backbone of any successful transplant programme is another reason for poor response in cadaver transplantation. The great task is to motivate and prepare the relatives for organ donation of their near and dear ones. Transplant co-ordinators are being prepared for motivating individuals or relatives for donation. To promote human organ transplantation government's initiative is very important. Mass media supported by the government can develop better awareness among the people. Non-government organisations (NGOs) can help in the similar ways. All hospitals are not authorised for the procedure of human organ transplantation. Other hospitals can help the process by informing the authorised hospitals about recent admission of potential donor (brainstem death). Role of transplant coordinator is crucial. He/she is the real inspiration to make agree the relatives for organ donation. Overall success of transplant programme is based on co-ordinated activity. Involvement of all agencies to motivate the person to pledge for organ donation during his/her life time is the first and the foremost requirement for successful planning and programme of organ transplantation.

Cadaver↗
PubMed2002

Pancreas transplant outcomes for United States (US) and non-US cases as reported to the United Network for Organ Sharing (UNOS) and the International Pancreas Transplant Registry (IPTR) as of October 2002.

As of October 10, 2002, nearly 19,000 pancreas transplants had been reported to the IPTR, approximately 14,000 in the US and approximately 5,000 outside the US. An era analysis of US cases from 1987-2002 showed a progressive improvement in outcome (p < 0.04), with pancreas transplant graft survival rates (GSRs) going from 75% at one year for 1988-89 to 85% for 2000-2001 SPK cases, from 53% to 77% for PAK cases, and from 48% to 73% for PTA cases. The improvements were due both to decreases in technical failure (TF) rates (from 16% to 8% in SPK, 16% to 9% in PAK, and 19% to 13% in PTA) and immunological failure rates (going from 5% to 2% for SPK, from 27% to 6% for PAK, and from 37% to 9% for PTA cases). The proportion of recipients > 45 years old increased from 9-11% for 1987-92 to 25-30% for 1999-2002 cases, and the improved outcomes encompassed the older patients as well. Contemporary pancreas transplant outcomes were calculated separately for 1996-2002 US and non-US cases. The results of the US analysis are summarized first. US patient survival rates at one year were > or = 94% in each recipient category, with one-year primary pancreas GSRs of 84% for SPK (n = 5.784), 76% for PAK (n = 1,033), and 77% for PTA (n = 470) (p < 0.0001). The immunological graft failure rates for 1996-2002 technically successful SPK, PAK and PTA cases were 2% (n = 5,231), 7% (n = 907), and 8% (n = 404) at one year (p = 0.0001). There was a progressive increase in the use of ED as opposed to BD) for duct management. For 1996-2002 US primary pancreas transplants, ED was used in 65% of SPK, 50% of PAK and 46% for PTA cases. Of the ED transplants, venous drainage via the portal system was used for 23% or SPK, 27% of PAK and 43% of PTA cases. Pancreas GSRs were not significantly different for 1996-2002 ED (n = 3,708) and BD (n = 1,942) SPK transplants (84% and 85%, respectively, at one year), nor was there a difference in pancreas GSRs for systemic (n = 2,859) versus portal (n = 842) venous drained ED SPK transplants (84% vs. 85% at one year). Kidney GSRs were slightly higher for ED versus BD SPK cases, 92% versus 90% at one year (p < 0.003). Pancreas GSRs for PAK transplants were 80% at one year for BD (n = 495; all systemic venous drainage) versus 72% for ED with systemic (n = 357) versus 71% for ED with portal (n = 134) venous drainage (p = 0.004 overall, but p = ns for ED portal vs. systemic). For PTA cases, one-year GSRs were 78% with BD (n = 240; all systemic venous drainage) versus 70% for ED with systemic (n = 115) versus 81% for ED with portal (n = 88) venous drainage (p = 0.2 overall, and 0.09 for ED portal vs. ED systemic). BD transplants were associated with a 12% conversion rate to ED by 2 years posttransplant in all 3 recipient categories. The age of US pancreas transplant recipients made little difference for outcome in the SPK category, with one-year pancreas GSRs ranging from 82% to 85% for patients grouped by age in decades from 10-19 to 60-69 years. In the PAK category, one-year GSRs progressively increased with each decade of age, going from 69% for those 20-29 to 83% for those 60-69 years old. Likewise, in the PTA category one-year GSRs increased with each decade of age, going from 41% for the 10-19 to 65% for the 20-29 to 76% for the 30-39 to 83% for the 40-49 to 85% for the 60-69 year old recipients. Pancreas GSRs were identical (84% at one year) for 1996-2002 US SPK recipients reported to have Type 1 (n = 5,356) or Type 2 (n = 288) diabetes (5% classified as Type 2). TAC+MMF was the dominant maintenance immunosuppressant for 1996-2002 US cases (approximately 60%), and with this regimen one-year GSRs were > or = 80% in all 3 recipient categories. An analysis of GSRs according to type of anti-T-cell antibody agents (depleting vs. non-depleting vs. none) for induction therapy in TAC+MMF treated recipients did not detect significant differences in any of the categories. The absolute numbers and the proportions of US pancreas grafts that were retransplants in the SPK and PTA categories (1% and 10% respectively) were relatively small, while a large number of the PAK grafts were retransplants (n = 346; 32% of the total). The majority of the latter were done after isolated failure of a pancreas graft in SPK recipients. In the SPK (n = 78) and PTA (n = 53) categories, the retransplant GSRs were significantly (p --> 0.06) lower than those for primary transplants. In the PAK category, however, GSRs were not significantly different (p = 0.14) for retransplant versus primary cases (72% and 76%, respectively, at one year). Known causes of death in 1996-2002 US pancreas recipients were tabulated for each category. Most were from cardio-cerebro-vascular accidents (1.3-2.6% incidence) or from infections (1.2-1.4% incidence), while death from malignancy or PTLD was reported in < or = 0.6% of recipients. In regard to non-US pancreas transplants, the overwhelming majority were in the SPK category (n = 2,163 for 1996-2002), with one-year patient, kidney and pancreas survival rates of 96%, 91% and 85% as good or better than the outcomes for US cases. In summary, with modern immunosuppression (TAC + MMF for maintenance) 1996-2002 pancreas transplant graft survival rates were > or = 80% at one year in all categories of recipients (SPK, PAK, PTA). The solitary pancreas transplant outcomes continue to improve as more are done.

Demography↗
PubMed2005

Studies on post-transplant dyslipidemia in kidney transplant patients.

This study was performed to retrospectively compare changes in the levels of total cholesterol, non-HDL cholesterol, triglycerides, and immunosuppressive drugs, cyclosporine A and steroids in patients with living-relation renal transplants with those from non-heart-beating donors. We experienced 11 cases of kidney transplants from non-heart-beating donors during the period from April 1995 to May 2003. We evaluated 13 cases of kidney transplants from living-relation donors during the same period. The immunosuppressants used included mainly cyclosporine A as well as mycophenolate mofetil or azathioprine, steroid and ALG, or basiliximab. Over-night fasting lipids (total cholesterol, triglycerides and HDL cholesterol) were studied before renal transplantation and repeated after renal transplantation at 1, 3, 6 and 12 months. The levels of total cholesterol and triglycerides remained in the normal range before transplantation. However, the levels of total cholesterol increased siginificantly 1 and 3 months after transplantation from non-heart-beating donors and remained at higher levels up to 12 months after transplantation. A similar pattern in the levels of triglycerides was observed. The levels of HDL cholesterol remained unchanged and stayed in the normal range before and 1, 3, 6, and 12 months after transplantation from non-heart-beating donors. On the other hand, significant increases in non-HDL cholesterol were observed 3 and 6 months after transplantation from non-heart-beating donors. After transplantation from living-relation donors, levels of total cholesterol, triglycerides, and non-HDL cholesterol remained unchanged and remained in the normal range up to 12 months after transplantation. Although there were no significant differences in the total dosage of cyclosporine A between the patients with living-relation donors and those with non-heart-beating donors, a significant increase in the total dosage of methylprednisolone was observed in patients with non-heart-beating donors compared with those in the patients with living-relation donors. Renal function recovery in patients with living-relation donors was better than in those with non-heart-beating donors. These results may suggest that significant increases in total cholesterol, especially non-HDL cholesterol and triglycerides, were probably partly due to an increased use of immunosuppressants, steroids. It is necessary to aggressively control post-transplant hyperlipidemia and important to reduce or withdraw steroids in the selected, low-risk recipients as early as possible from the viewpoint of preventing post-transplant hyperlipidemia.

Adult↗
PubMed1982

Loss of stem cell repopulating ability upon transplantation. Effects of donor age, cell number, and transplantation procedure.

Long-term functional capacities of marrow cell lines were defined by competitive repopulation, a technique capable of detecting a small decline in repopulating abilities. There was little or no difference between cells from old and young donors, but a single serial transplantation caused a large decline in repopulating ability. Varying the numbers of marrow cells transplanted into the initial carrier from 10(5) to 10(7) did not alter the ability of the carrier's marrow cells to repopulate in competition with previously untransplanted cells. This ability was improved only in carriers that had received 10(8) marrow cells, although deleterious effects of transplantation were still present. These effects were not solely caused by cell damage from the transplantation procedure, because transplantation by parabiosis, or recovery from sublethal irradiation without transplantation, reduced repopulating abilities as much as transplanting 10(5) to 10(7) marrow cells. The transplantation effect also was not caused solely by irradiation, because the same effect appeared in unirradiated W/Wv carriers. The transplantation effect was more pronounced when donors were identified by hemoglobin type than by chromosome markers, implying that nonerythroid cell lines may be less affected by transplantation than erythroid precursor cells. When the effects of a lifetime of normal function and a single transplantation were compared, the latter caused 3-7 times more decline in repopulating abilities of phytohemagglutinin-responsive cell precursors, and at least 10-20 times more decline in erythroid cell precursors. Stem cell lines can be serially transplanted at least five times before losing their ability to repopulate and save lethally irradiated recipients or to cure genetically anemic mice. Therefore, if transplantation causes an acceleration of the normal aging process, these figures suggest that stem cells should be able to function normally through at least 15-50 life spans.

Aging↗
PubMed1995

UK National Transplant Database: a digest of published audit material. UKTSSA National Transplant Database.

The analyses undertaken on the national transplant database for the UK and Republic of Ireland on behalf of the participating transplant units have shown some factors influencing survival to be common to all organ types, and an improvement in survival over the last ten years for all organ transplant groups. The increasing use of older donors is also a general problem, despite the differing definition of 'old donors' for each organ group. The main findings from the multifactorial analysis are summarised below, both for those factors influencing 1-year transplant survival, and survival over distinct posttransplant epochs. The number of previous transplants had a significant influence on survival across all organ types. For heart transplants, the effects of recipient sex, age, primary disease and donor cause of death were strongest during the first 28 days, and donor age influenced survival from 29 days onwards. The number of previous transplants was found to be the only influence on heart/lung transplants but for lung(s) transplants, the weight of the recipient was also found to influence survival throughout. Recipient primary disease was found to influence survival in the first 21 days, while donor sex, CMV match and donor cause of death influenced survival over 21 days. The majority of factors influencing liver transplant survival were present in both the first 21 days and beyond. Differences were found between the early and late epochs, with younger recipients influencing early survival, and recipients over age 40 influencing survival after 21 days. Analyses of factors associated with kidney transplant survival have shown significant improvement over time. Retransplantation, and the use of kidneys from older (>55 years), younger (<19 years), and non-trauma victim donors continue to carry significantly higher risks of failure. Female donor to male recipient, exchanged and non-beneficially matched transplants, along with grafts given to younger and older recipients, were also associated with inferior survival. The analysis of 4 distinct posttransplant intervals further confirmed that, for some factors, the risk persisted while, for others, their effect was transient.

Adolescent↗
PubMed2000

Development of a combined cardiac and aortic transplant model to investigate the development of transplant arteriosclerosis in the mouse.

BACKGROUND: The degree of transplant arteriosclerosis in murine cardiac allografts is difficult to assess. Aortic allografts represent an alternative model for evaluating the impact of novel transplant strategies on transplant arteriosclerosis in which the vascular changes can be quantified easily. However, it remains controversial as to whether vascular lesions seen in this model are equivalent to those that develop in solid-organ transplants. The aim of this study was to develop a model of combined cardiac and aortic transplantation to allow more precise quantification of transplant arteriosclerosis and to establish a correlation between the lesions that develop in the 2 types of graft. METHODS: CBA (H2(k)) recipients received a C57BL/10 (H2(b)) cervical cardiac allograft on Day 0 and a C57BL/10 (H2(b)) abdominal aortic allograft on Day 1. Recipients were treated with anti-CD154 mAb (MR1) on Days 0, 2, and 4. We performed histology and morphometric measurements for both grafts 30 days after transplantation. RESULTS: We observed significant intimal proliferation in both the cervical cardiac and abdominal aortic allografts from recipients treated with anti-CD154 mAb (heart, 64% +/- 9%; aorta, 67% +/- 8%; n = 5). Abdominal aortic grafts transplanted alone into anti-CD154-treated recipients developed a degree of transplant arteriosclerosis equivalent to that seen in the aortic grafts of the combined group (aorta alone, 68% +/- 9%, vs aorta + heart, 67% +/- 8%; n = 5). CONCLUSIONS: This combined cardiac and aortic transplant model permitted quantitative assessment of transplant arteriosclerosis while monitoring graft survival by cardiac palpation. Furthermore, development of transplant arteriosclerosis was equivalent in abdominal aortic allografts either in the presence or absence of an additional solid- organ transplant.

Animals↗
PubMed2002

The incidence of invasive aspergillosis among solid organ transplant recipients and implications for prophylaxis in lung transplants.

BACKGROUND: Invasive aspergillosis (IA) is associated with significant morbidity and mortality in solid organ transplant recipients but data on the incidence rates stratified by type of solid organ are limited. OBJECTIVE: To describe the attack rates and incidence of IA in solid organ transplant recipients, and the impact of universal Aspergillus prophylaxis (aerosolized amphotericin B or oral itraconazole) in lung transplant recipients. PATIENTS: The 2,046 patients who received solid organ transplants at the Cleveland Clinic Foundation from January 1990 through 1999 were studied. METHODS: Cases were ascertained through computerized records of microbiology, cytology, and pathology reports. Definite IA was defined as a positive culture and pathology showing septate hyphae. Probable IA was clinical disease and either a positive culture or histopathology. Disseminated IA was defined as involvement of two or more noncontiguous anatomic sites. RESULTS: We identified 33 cases of IA (28% disseminated) in 2,046 patients (attack rate = 1.6%) for an incidence of 4.8 cases per 1,000 patient-years (33 cases/6,813 pt-years). Both the attack and the incidence rates were significantly higher for lung transplant recipients vs. other transplant recipients: lung 12.8% (24 cases/188 patients) or 40.5 cases/1,000-pt year vs. heart 0.4% (3/686) or 1.4 per 1,000-pt year vs. liver 0.7% (3/439) or 2.1 per 1,000-pt year vs. renal 0.4% (3/733) or 1.2 per 1,000-pt year (P < 0.01). The incidence of IA was highest during the first year after transplantation for all categories, but cases occurred after the first year of transplantation only in lung transplant recipients. The attack rate of IA in lung transplant recipients was significantly lower after institution of routine Aspergillus prophylaxis (4.9% vs. 18.2%, P < 0.05). CONCLUSIONS: The highest incidence and attack rate of invasive aspergillosis among solid organ transplant recipients occurs in lung transplant recipients and supports the routine use of Aspergillus prophylaxis for at least one year after transplantation in this group.

Adult↗
PubMed2000

Second allogeneic hematopoietic stem cell transplantation as treatment for leukemia relapsing following a first transplant.

We report 27 patients with relapsed acute or chronic leukemia who underwent a second hematopoietic stem cell transplant (HSCT) from a related or unrelated donor. Seventeen patients were diagnosed with acute myelogenous leukemia (AML), six with acute lymphocytic leukemia (ALL) and four with chronic myeloid leukemia (CML). Ages ranged from 22 to 49 years (median 37); 13 patients were female and 14 male. Relapse was diagnosed between 1 and 45 months after the first HSCT. Sixteen patients who relapsed had received an autologous transplant initially and 11 an allogeneic transplant. Ten patients relapsed within 6 months and 17 patients later than 6 months. Chemotherapy was used as reinduction for relapse after HSCT in 16 patients who had received an autologous transplant and in three who had received an allogeneic transplant, since the latter did not respond to reduction of immunosuppression to induce a graft-versus-leukemia (GVL) reaction. Five of these 19 patients (26%) achieved complete remission (CR), seven patients did not respond to chemotherapy and seven achieved a partial remission (PR). The stem cell source for the second HSCT included bone marrow (n = 12) and PBSC (n = 4) from genotypically identical unrelated donors, PBSC (n = 7) and bone marrow (n = 3) from related donors. Currently eight of the 27 patients are alive and disease-free after the second HSCT. One patient is alive and disease-free after two allogeneic transplants (day +1538), eight patients, who relapsed after an autologous transplant followed by an allogeneic transplant (days +248 to +1140), acute myeloid leukaemia (n = 6) and chronic myeloid leukemia (n = 2) are alive and disease-free. The overall disease-free survival is 30% (8/27). The overall disease-free survival of autologous transplant patients subsequently undergoing an allogeneic transplant is 43% (P = 0.049). It is suggested that a second HSCT is possible for patients with leukemia relapse following the first autologous transplant. A second transplant might also be offered to patients relapsing after the first allogeneic HSCT. Bone Marrow Transplantation (2000) 25, 41-45.

Acute Disease↗
PubMed1991

Morbidity of pancreas transplantation during cadaveric renal transplantation.

Simultaneous transplantation of the pancreas is an option for diabetic patients undergoing kidney transplantation to attempt to halt progression of diabetic complications, but the additional risk imposed by the procedure is unclear. Our aim was to determine the morbidity attributable to pancreas transplantation during simultaneous pancreas and kidney transplantation. We compared the first posttransplant year of 18 consecutive recipients of combined pancreas and kidney transplantation to 18 consecutive recipients of kidney transplantation alone. All patients received cadaver donor allografts between 1986 and 1989, and had type I diabetes mellitus with chronic renal failure. There were no differences in patient survival (94% both groups) or satisfactory renal allograft function (89% pancreas/kidney group, 83% kidney group) up to 18 months after transplantation. Eighty-eight percent of pancreas allografts were functioning satisfactorily at 18 months. There was a mean (+/- SD) of 1.5 +/- 1.0 acute rejection episodes per patient for the pancreas/kidney group compared to 0.8 +/- 6 for the kidney-only group (P less than 0.02). Cytomegalovirus infection and wound complications were each encountered more often after pancreas/kidney transplantation than kidney transplantation alone, and together with rejection accounted for a difference in days of hospitalization during the first year (71 +/- 34 vs. 27 +/- 13, P less than 0.001). We conclude that simultaneous pancreas transplantation during cadaver donor kidney transplantation accounted for more frequent rejection episodes, CMV infections, and wound complications. These complications resulted in more hospitalization for patients undergoing simultaneous pancreas/kidney transplantation than kidney transplantation alone.

Adult↗
PubMed2003

Mechanically ventilated pediatric stem cell transplant recipients: effect of cord blood transplant and organ dysfunction on outcome.

OBJECTIVES: To compare survival of pediatric umbilical cord blood and bone marrow transplant recipients requiring admission to a pediatric intensive care unit for mechanical ventilation and to determine the effect of organ dysfunction on outcome. DESIGN: Retrospective chart review. SETTING: Tertiary care referral center for pediatric stem cell transplants. PATIENTS: All children 0-18 yrs old admitted to the pediatric intensive care unit for mechanical ventilation after receiving a stem cell transplant. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were collected from medical records of 86 patients who received a stem cell transplant and were subsequently admitted to the pediatric intensive care unit for mechanical ventilation. Demographic data were collected at the time of intubation, and physiologic data were collected at 6 hrs and 96 hrs after intubation. The pediatric intensive care unit, hospital, and 2-yr survival rates for umbilical cord blood transplant recipients were 37%, 25%, and 19%, respectively. The survival rates for bone marrow transplant recipients were 47%, 32%, and 21% for the same time periods. Umbilical cord blood and bone marrow transplant recipients with hepatic dysfunction had a significantly worse outcome, as did patients admitted for respiratory failure or sepsis. CONCLUSIONS: Pediatric recipients of an umbilical cord blood transplant who subsequently required mechanical ventilation had lower pediatric intensive care unit and hospital survival rates compared with patients receiving bone marrow transplantation. Survival at 2 yrs for umbilical cord blood transplant and bone marrow transplant patients was similar. Predictors of outcome for all stem cell transplant recipients requiring mechanical ventilation included pediatric intensive care unit diagnosis requiring intubation and hepatic function. Predictors of outcome can be identified shortly after intubation in pediatric stem cell transplant recipients and may aid in therapeutic decision making and family counseling.

Bone Marrow Transplantation↗
PubMed2005

[Experimental study of transplanted endothelial progenitor cells transfected with VEGF165 gene augment the survival volume of transplanted fat tissue].

OBJECTIVE: To investigate the feasibility of transplanting endothelial progenitor cells (EPCs) transfected with VEGF165 gene to free transplanted fat tissue for increasing neovascularization and the survival. METHODS: EPCs isolated from human cord blood were cultured in vitro and identified by immunocytochemistry. After transfection by VEGF165 gene, the expression of VEGF was assessed using ELISA. Then EPCs with (VEGF gene transfection group) and without VEGF165 gene transfection (EPCs group) were transplanted to free transplanted fat tissue at 18 nude mice's back, and nine nude mice transplanted with free fat tissue were injected with M199 (control group). CM-DiI was used to trace the transplanted cells. The capillary density of transplanted fat tissue was detected by CD34 immunohistochemistry. RESULTS: EPCs expressed cell markers CD34, KDR and CD133. After transfection, the expression of VEGF was positive. Transplanted EPCs survived and proliferated, and transplanted EPCs were incorporated into the capillary networks in the transplanted fat tissue. The percent of survival volume of transplanted fat tissue of VEGF gene transfection group was (96.2 +/- 8.6)%, significantly higher than that of the EPCs group [(75.3 +/- 6.8)%, P < 0.05) and M199 group [(40.2 +/- 2.5)%, P < 0.05). The capillary density of transplanted fat tissue of VEGF gene transfection group was significantly higher than those of the EPCs group and M199 group (P < 0.05). CONCLUSIONS: EPCs from human cord blood can increase free transplanted fat tissue neovascularization and the survival volume, and the ability of promoting neovascularization of EPCs transfected with VEGF165 gene is more potent than EPCs alone.

Adipose Tissue↗
PubMed1994

Does heart transplantation confer additional benefit over medical therapy to patients who have waited > 6 months for heart transplantation?

OBJECTIVES: This study compared the survival of patients with heart failure who have waited > 6 months for heart transplantation with that patients who undergo heart transplantation after a similarly prolonged waiting period. BACKGROUND: There are little data describing outcome in patients with severe heart failure who have waited for extended periods of time on the heart transplant waiting list. METHODS: Sixty-three consecutive patients who spent > 6 months on the heart transplant waiting list were examined. Mean (+/- SD) age was 53 +/- 9 years, mean left ventricular ejection fraction was 19 +/- 6%, and all were taking digoxin and diuretic and vasodilator agents. Patients who underwent transplantation during the follow-up period were censored from the pretransplantation analysis, and their survival was examined as part of the posttransplantation phase of the study. RESULTS: Of the 63 original patients examined, 25 underwent transplantation, 10 during inotropic or mechanical circulatory support. The pretransplantation mortality rate was 6% at 6 months after the 6-month milestone on the waiting list, 12% at 12 months and 22% at 18 months. The posttransplantation mortality rate was 5% at 6 months, 10% at 12 months and 24% at 18 months. There were no differences in survival at any time between the two phases of the study. CONCLUSIONS: Survival of patients who have survived > 6 months on the heart transplant waiting list is generally good. Although heart transplantation did not appear to confer additional survival advantage over medical therapy, a large proportion of the patients who underwent transplantation were critically ill at the time of transplantation and would undoubtedly have died of progressive heart failure had they not undergone transplantation. We conclude that heart transplantation should still be considered a therapeutic alternative in patients with heart failure even after a prolonged waiting period on the heart transplant waiting list.

Actuarial Analysis↗
PubMed2004

Cardiac angiotensin II receptors as predictors of transplant coronary artery disease following heart transplantation.

AIMS: We tested the hypothesis that cardiac angiotensin II (Ang II) receptor gene transcription may predict the development of transplant coronary artery disease (TCAD) following heart transplantation. METHODS AND RESULTS: We examined the gene transcripts of Ang II type 1 (AT1R) and type 2 receptors (AT2R) in endomyocardial biopsy specimens from 50 heart transplant recipients. The progression of TCAD was measured as change in maximal intimal thickness (CMIT) and change in plaque volume (CPV) by intravascular ultrasound (IVUS) examinations from baseline to one year after transplantation. The development of transplant vasculopathy was defined as a CMIT of > or = 0.3 mm over one year. The level of AT(1)R mRNA was associated with that of AT2R in transplanted hearts (regression coefficient=1.77, 95% CI 0.85-2.89, p<0.0001). AT1R and AT2R gene transcripts were univariate predictors of CMIT (AT1R: regression coefficient 0.10, 95% CI 0.06-0.14, p<0.0001; AT2R: regression coefficient 0.28, 95% CI 0.17-0.40, p<0.0001 ) or CPV (AT1R: regression coefficient 0.41, 95% CI 0.17-0.65, p<0.0001 ; AT2R: regression coefficient 1.25, 95% CI 0.49-2.01, p=0.002 ). By one year, 21 (46%) transplant recipients showed evidence of transplant vasculopathy and the rest did not. The vasculopathic group demonstrated a higher level of expression of cardiac AT1R than the non-vasculopathic group (3.7+/-2.9 vs 1.6+/-1.7 folds; p=0.006). The level of AT(1)R mRNA in transplanted heart was identified as a discriminator that predicted the development of transplant vasculopathy with a sensitivity of 75% and specificity of 83%. CONCLUSIONS: Cardiac Ang II receptor gene transcripts are associated with the progression of TCAD following heart transplantation. Only AT1R gene transcripts predicted the development of transplant vasculopathy in this preliminary study. These findings potentially support a role of Ang II receptors in the progression of TCAD following cardiac transplantation.

Acute Disease↗
PubMed2004

Lobar transplantation, split lung transplantation and peripheral segmental resection--reliable procedures for downsizing donor lungs.

OBJECTIVES: The increasing scarcity of donor lungs, especially for small and pediatric recipients has stimulated the development of new operative techniques, which allow larger lungs to be downsized for use in smaller recipients. This approach has only recently gained widespread use-especially for highly urgent recipients-however, it is still not considered a standard procedure. METHODS: This report reviews the Vienna University experience with cadaveric split lung transplantation, lobar transplantation and by means of peripheral resection size reduced lung transplantation within the years 2001-2002. Peri-operative complications and outcome of those patients were retrospectively analysed and compared to the patients undergoing standard single or double lung transplantation during the observation period. RESULTS: During the observation period 98 primary lung transplantations were performed, of which 27 (27.6%) were size reduced transplantations. Size reduction was achieved by lobar transplantation (n=9), split lung transplantation (n=2) or peripheral segmental resection (n=16). There was no statistically significant difference between the size reduced and standard lung transplantation group with regard to the rate of bronchial healing problems (n=3/7; P=0.85) and the rate of post-operative bleeding (n=5/12; P=0.85). No other major thoracic surgical complications were observed. Three months survival rate was 85.2% in the size reduced group, compared to 92.9% in the standard group (P=0.13). CONCLUSIONS: Size reduced lung transplantation, including split lung transplantation, lobar transplantation and peripheral segmental resection, is a reliable procedure providing equal results compared to standard lung transplantation.

Adolescent↗
PubMed1996

Long-term results of cardiac transplantation in patients older than sixty years. UTAH Cardiac Transplant Program.

Advanced age has traditionally been a contraindication to cardiac transplantation. We have, however, offered cardiac transplantation to patients older than 60 years with end-stage heart failure if they were otherwise acceptable candidates. From 1985 to 1994, 527 patients underwent cardiac transplantation. Among these patients, 101 were older than 60 years at transplantation. The mean follow-up of this group is 6 years. Patients older than 60 years had significantly fewer rejection episodes per patient than those who were younger than 60 years at transplantation (1.9 +/- 1.3 vs 2.6 +/- 1.8, p = 0.009). No difference in the number of infectious complications per patient was detected between the two groups. Both short-term and long-term survival after transplantation were significantly lower for patients who were older than 60 years at transplantation than for younger patients (p < 0.05). The 6-year actuarial survival after transplantation for patients older than 60 years was 54% compared with 72% for patients younger than 60 years at transplantation (p < 0.05). Patients older than 60 years at transplantation were more likely to die of infectious complications or malignant disease after transplantation (p < 0.05). We believe caution is warranted in offering cardiac transplantation to patients older than 60 years. This group of patients should be carefully observed for the development of potentially life-threatening infectious complications or new malignant tumors after transplantation.

Age Factors↗
PubMed2003

Mortality in candidates waiting for combined liver-intestine transplants exceeds that for other candidates waiting for liver transplants.

The United Network for Organ Sharing (UNOS) reports indicate that mortality on the intestine transplant waiting list is higher than on other transplant waiting lists. The goals of this study were (1) to determine whether most of the intestinal transplant candidate deaths have occurred in those who also need liver transplants, and (2) to compare the waiting list mortality in the liver-intestine candidate subset with the overall liver transplant candidate population. We found that 90% of intestine transplant waiting list deaths have occurred in candidates who also needed liver transplants. Since 1994, annual mortality has been higher in liver-intestine transplant candidates than in the overall liver transplant candidate population, and these differences have been statistically significant since 1996. These mortality differences applied to all age groups. Also, status 2B, 3, and 7 candidate mortality was significantly higher in liver-intestine candidates than in the overall liver transplant candidate population. Because there were so few liver-intestine transplant candidates listed as status 1 or 2A, a meaningful comparison was not possible in these statuses. These data indicate that liver-intestine transplant candidates are a unique subset of liver transplant candidates with a significantly higher risk of dying on the waiting list. Recent changes in UNOS liver allocation policy that gives higher priority to liver-intestine candidates may help to reduce this discrepancy. However, further research into the etiology of liver disease in patients on long-term parenteral nutrition and earlier referral of high-risk short bowel syndrome patients to centers with special expertise in their management are needed for an ultimate solution to this problem.

Adult↗
PubMed1998

Should all human immunodeficiency virus-infected patients with end-stage renal disease be excluded from transplantation? The views of U.S. transplant centers.

BACKGROUND: Human immunodeficiency virus (HIV)-infected patients have generally been excluded from transplantation. Recent advances in the management and prognosis of these patients suggest that this policy should be reevaluated. METHODS: To explore the current views of U.S. transplant centers toward transplanting asymptomatic HIV-infected patients with end-stage renal disease, a written survey was mailed to the directors of transplantation at all 248 renal transplant centers in the United States. RESULTS: All 148 responding centers said they require HIV testing of prospective kidney recipients, and 84% of these centers would not transplant an individual who refuses HIV testing. The vast majority of responding centers would not transplant a kidney from a cadaveric (88%) or a living donor (91%) into an asymptomatic HIV-infected patient who is otherwise a good candidate for transplantation. Among the few centers that would consider transplanting an HIV-infected patient, not a single center had performed such a transplant in the year prior to the survey. Most centers fear that transplantation in the face of HIV infection would be harmful to the individual, and some believe that it would be a waste of precious organs. CONCLUSIONS: The great majority of U.S. renal transplant centers will not transplant kidneys to HIV-infected patients with end-stage renal disease, even if their infection is asymptomatic. However, advances in the management of HIV infection and a review of relevant ethical issues suggest that this approach should be reconsidered.

HIV Infections↗
PubMed1993

Bone marrow transplantation in Europe: major geographical differences. The European Group for Bone Marrow Transplantation [EBMT].

In 1991 171 teams in 21 European countries performed 4976 bone marrow transplants. There were 1829 transplants from an HLA-identical sibling donor, 101 from a nonidentical family member, 30 from a twin, 217 from an unrelated volunteer donor and 2799 autologous transplants. Indications for transplants were leukaemias in 2569 (52%), lymphoproliferative disorders in 1472 (30%), solid tumours in 549 (11%), aplastic anaemia and thalassaemia in 261 (5%), inborn errors in 97 and miscellaneous disorders in 28 patients. There are marked differences between the participating European countries. They relate to absolute numbers, indications and techniques. Less than 10 transplants per 10-million inhabitants are performed in Eastern European countries. Ten to fifty transplants per 10-million inhabitants are done in two, 50-100 transplants per 10-million inhabitants in five, 100-200 transplants per 10-million inhabitants in eight countries and more than 200 per 10-million inhabitants in one country (P < 0.01). The number of transplant teams ranges from less than one to twelve per 10-million inhabitants (P < 0.01). For the continent it becomes 3.3 per 10-million inhabitants. The reasons for these differences are not explained by this survey. The most likely explanation for the differences in transplant activity is availability of transplant beds, trained staff and resources. Bone marrow transplants are expensive. However, the demand is increasing and will increase further with the routine availability of unrelated volunteer donors. Clearly, criteria are required in Europe to define the indications and solutions to meet the legitimate requirements for transplantation in the various regions of Europe.

Bone Marrow Transplantation↗