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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.
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.
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