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Book description

Organ Transplantation: A Clinical Guide covers all aspects of transplantation in both adult and pediatric patients. Cardiac, lung, liver, kidney, pancreas and small bowel transplantation are discussed in detail, as well as emerging areas such as face and pancreatic islet cell transplantation. For each organ, chapters cover basic science of transplantation, recipient selection, the transplant procedure, anesthetic and post-operative care, and long-term follow-up and management of complications. Important issues in donor selection and management are also discussed, including recruitment and allocation of potential donor organs and expanding the donor pool. Summary tables and illustrations enhance the text, and long-term outcome data are provided where available. Written by expert transplant surgeons, anesthetists and physicians, Organ Transplantation: A Clinical Guide is an invaluable multidisciplinary resource for any clinician involved in transplantation, providing in-depth knowledge of specialist areas of transplantation and covering the full range of management strategies.

Reviews

'… provides an excellent overview of modern transplantation medicine. The increasing number of organ recipients and their improved longevity means that many more non-specialists will need to be aware of the considerations in such patients. As such, this book is particularly suitable for the general physician or intensivist. Similarly, with the growth in donation after circulatory death, healthcare professionals working with patients at the end of life will find this book valuable reading. The strength of this book is the breadth of its coverage coupled with an accessible level of detail.'

Dr Julia Wendon - Senior Lecturer in Hepatology/Intensive Care Medicine, Kings College London, and Clinical Director of Intensive Care, Kings College Hospital, London

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Contents

Page 1 of 3

Contents
  • Chapter 6 - Recipient selection
    pp 63-69
  • View abstract

    Summary

    Transplantation of organs represents the pinnacle of medical achievement in so many different ways. This chapter presents historical perspectives of organ transplantation such as abdominal organ transplantation, cardiothoracic transplantation, combined heart and lung transplantation and lung transplantation. The area of skin grafting became of greater importance for the treatment of war burns and other injuries, and the death from kidney disease also provided impetus to focus once more on kidney transplantation. The successful intrathoracic transplantation of the heart without interrupting the circulation led to the idea that a cardiac allograft might be able to assume some of the normal circulatory load. The indications for transplantation are widening, and although kidney, liver, heart, and even lung transplantation is now seen as routine, the necessary skills are being developed to transplant other organs, such as the small intestine, pancreas, face, hand, and uterus.
  • Chapter 8 - Ventricular assist devices
    pp 76-82
  • View abstract

    Summary

    This chapter outlines the events involved in the adaptive and innate immune responses to a transplant and the subsequent mechanisms of rejection, concluding with current clinical and experimental strategies to protect transplants from immune-mediated damage. The recognition of foreign antigens by naive host (recipient) T cells is a principal step in the rejection process. Allorecognition in the presence of costimulation results in the activation and expansion of T-cells that recognize the mismatched donor alloantigens. Immunosuppressive therapy can be credited with the vast improvements in transplant survival. The chapter explores the underlying mechanisms of action in relation to the immunobiology. Newer monoclonal antibodies include alemtuzumab, rituximab, basiliximab, and daclizumab, which target specific T-cell surface proteins. The advances in immunosuppression have improved short- and medium-term graft survival rates and reduced the rates of acute rejection, but this has not been followed by a comparable reduction in long-term graft dysfunction rates.
  • Chapter 9 - Surgical procedure
    pp 83-87
  • View abstract

    Summary

    This chapter focuses on current practice, as informed by past experiences and as a basis for understanding newer therapeutics on the horizon. Long-term survival of allograft in humans first occurred with the introduction of azathioprine (AZA). Early use of cyclosporine (CyA) in animals and humans as monotherapy seemed effective in preventing acute rejection crises. Mycophenolate mofetil (MMF) was a new modified preparation of an older agent that enhanced its absorption and stability. Maintenance immunosuppression is the long-term therapy required to ensure allograft survival, administered with the dual intentions of avoiding both immunological injury and drug-related toxicity. Discovery of new agents is informed by our evolving understanding of how immunological processes injure allograft, with substantial attention now being devoted to antibody-mediated injury and lymphoid tissue of B-cell lineage. It is now common to use biologics, such as polyclonal or monoclonal antibodies, for a short time as induction of acute rejection.
  • Chapter 10 - Management during surgery
    pp 88-93
  • View abstract

    Summary

    This chapter is based on the study of data collected by Cincinnati Transplant Tumor Registry (CTTR) and the available literature published by both North American and European organ transplant centers. It reviews the characteristics of the most important de novo malignancies in organ allograft recipients. The most frequent cancers in transplant recipients are skin and lip cancer, solid organ malignancies, and post-transplant lymph proliferative disorder (PTLD). Two epidemiological studies have shown a 20- to 40- fold increased incidence of hepatocellular carcinoma (HCC) in transplant recipients compared with age-matched controls. Sarcomas, breast carcinoma, bladder, and bowel cancers are particularly seen after transplantation. Skin cancer is the second most common malignancy after PTLD, and melanomas comprised 16% of all skin cancers in children compared with 5% among adults. Understanding the increased risk of malignancy of transplant recipients, careful surveillance and screening for selected malignancy should be undertaken.
  • Chapter 11 - Postoperative care and early complications
    pp 94-101
  • View abstract

    Summary

    Chronic rejection is widely regarded as difficult to diagnose, of obscure etiology, untreatable, and irreversible. The immunological basis of transplant arteriopathy (TA) is under active investigation. The belief that the process is immunologically mediated is based on the observations that TA rarely arises in auto grafts. Three separate and possibly synergistic pathways have been identified: T-cells, antibody-mediated injury, and natural killer (NK) cells. The majority of late kidney graft losses are associated with donor-specific antibodies (DSA) and/or C4d deposition, and the risk of subsequent graft failure is significantly worse after a C4d+ biopsy. Transient lobular hepatitis may also be a feature of chronic rejection and is potentially reversible, although vanishing bile duct syndrome (VBDS) and TA are resistant to current therapy. The lesions of chronic rejection in the lung consist of TA and a lesion occluding airways that is termed obliterative bronchiolitis (OB).
  • Chapter 12 - Long-term management and outcomes
    pp 102-111
  • View abstract

    Summary

    Infections are among the most common complications after transplantation and greatly increase the morbidity and mortality of transplantation and decrease graft survival. This chapter describes a timeline of infection after transplantation. Post-transplant infections can be mitigated by preventative methods, routine vaccinations, intake of clean food and water, preventative measures during times of outbreaks visits with travel medicine specialists prior to visiting high risk regions, safer sexual practices for non-monogamous recipients, and guidance on better tattoo acquisition. Hepatitis viruses are common causes for liver transplantation and also common complications after transplant, predominantly as reactivation of latent infections. Molecular diagnostics are emerging as a diagnostic methodology for bacterial infections. Invasive fungal diseases, particularly aspergillosis, are significant causes of morbidity and mortality in transplant recipients. Treatment of individual parasitic infections can involve medications that may interact with transplant medications, or have significant side effects, and should be used carefully.
  • Chapter 13 - Pediatric heart transplantation
    pp 112-121
  • View abstract

    Summary

    This chapter discusses the physiological changes of brain death, the management of complex patients, the organization of the recovery, and new technologies that may allow increased number of organs available for transplantation. Most lethal brain injuries follow a common pathway whereby a patient suffers brainstem death secondary to sudden or gradual increases in intracranial pressure (ICP). Hemodynamic instability seen after brain death is also consequent to loading conditions imposed on the heart. The physiological changes of brain death have direct and indirect effects on lung function. Traumatic brain injury accounts for one third of all trauma related deaths. Early assessment of renal and liver quality is performed in cases of donor death secondary to trauma, exclusion of liver injury. It has been shown that treatment of ex vivo human lungs with an adenoviral vector encoding for interleukin (IL)-10 decreased inflammatory cytokine expression and led to significant improvements in graft function.
  • Chapter 14 - Recipient selection
    pp 122-127
  • View abstract

    Summary

    Heart transplantation (HT) remains the best treatment for selected patients with advanced heart failure (HF). Patients with New York Heart Association (NYHA) class IIIB and class IV HF are best discussed with the local HF/transplant center to optimize medical management and to consider high-risk non-transplant surgery where appropriate. Patients who require HT may have severe ventricular dysfunction. Exercise capacity is known to correlate with prognosis in advanced HF. Chronic HF is associated with a high left ventricular end-diastolic pressure (LVEDP), which in turn leads to pulmonary venous and pulmonary arterial hypertension. The best studied scoring system in the context of predicting the need for HT is the HF Survival Score (HFSS). Older patients run a higher risk of post-transplant malignancy and renal dysfunction as compared with younger recipients. Combined heart-liver transplantation has been increasingly performed, but data on patient and graft outcomes remain limited.
  • Chapter 16 - Surgical procedure
    pp 133-137
  • View abstract

    Summary

    Advances in surgical techniques, postoperative care, and immunosuppression have led to greatly improved survival following cardiac transplantation in the past two decades. Patients expiring from overwhelming infection have traditionally been excluded from donor evaluation due to potential transmission of pathogens. Studies of donor-related tumor transmission to transplant recipients usually distinguish between central nervous system (CNS) and non-CNS donor malignancies. Case reports have described the transplantation of hearts from donors poisoned with tricyclic antidepressants with satisfactory graft function. Recent case series report a 15-30 percentage prevalence of left ventricular hypertrophy (LVH) in donor hearts accepted for transplantation. LV dysfunction is the most frequently cited reason for non-utilization of potential cardiac allografts. Due to the severe donor organ shortage, with long recipient waiting times, non-standard or marginal donor hearts are increasingly being used for higher risk recipients and critically ill patients, leading to an expansion of both the donor and recipient pools.
  • Chapter 17 - Management during surgery
    pp 138-144
  • View abstract

    Summary

    Mechanical circulatory support devices (MCSD) include the use of extra corporeal circulatory support, implantable ventricular assist devices (VAD), and total artificial hearts. The need for smaller implantable devices, with control systems that facilitated return to community living, motivated the next generation of devices. The International Registry for Mechanically Assisted Circulatory Support (INTERMACS) has developed a classification system of heart failure (HF) that best identifies their urgency and status and is tailored to the indications of MCS. Careful selection of patients is a cornerstone in a successful VAD program. VADs provide left-, right-, or bi-ventricular support. MCSD are classified according to the duration of support, low characteristics, and/or pump mechanism. Preoperative preparation should focus on optimizing end-organ function and right ventricle (RV) function. Outpatient management represents more efficient use of health care resources and is of high importance for patient quality of life.

Page 1 of 3

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