National Survey of Laparoscopic Live Donor Nephrectomy in Japan From 2002 to 2008

Laparoscopic nephrectomy (LN) has been accepted for live donor kidney transplantation. Continuous surveys on the status of LN in live donors were made from 2002 to 2008 in Japan. At first, we reported the status in 2008 at 148 Japanese kidney transplantation centers. Of 148 centers, 109 responded, and 58 performed LN. These centers performed 764 live donor nephrectomies, including 659 LN and 105 open nephrectomies. In 58 centers, 20 were performed as hand-assisted (HA) LN, 27 as non-HA (pure laparoscopic), 2 as both HA and non-HA, and 8 as laparoscope-assisted. There were 24 centers that carried out a peritoneal approach and 34 had a retro-peritoneal approach. Among 764 LN donors, not 1 had a life-threatening complication. Blood transfusions were performed in only 1 donor. Open conversions from LN were required in 13 (2.0%) cases. Minor complications not requiring a prolonged hospital stay were reported in 20 cases. The mortality after LN was 0. Among 659 recipients, 1 case was reported as primary nonfunction, but ten recipients (1.5%) needed hemodialysis after transplantation because of delayed graft function. Urinary tract complications were noted in 18 recipients (2.7%). We have discussed the trends in LN from 2002 to 2008 in Japan. At the beginning of LN, many surgeons performed LN, so the open conversion rate was low and the blood transfusion rate was high. But in the later years, surgeons performed LN in the same manner as general laparoscopic surgeries with high intention for donor safety.     

Attitudes to Brain Death and Organ Procurement Among University Students and Critical Care Physicians in Poland

Purpose

The practice of retrieving vital organs from brain-dead heart-beating donors is legally and medically accepted in Poland, but public beliefs and opinions regarding these matters have not been sufficiently explored. The purpose of this study was to evaluate the attitude of university students to the concepts of brain death and organ retrieval, compared with the attitude of critical care physicians.

Methods

The cohorts of 989 students and 139 physicians completed a questionnaire based on a survey instrument developed in an earlier reported study on Ohio residents. Participants assessed 3 scenarios: (1) brain death, (2) coma, and (3) vegetative state. More than 48% of students classified the patient from the brain death scenario as alive, and 51% of them were willing to donate organs of this patient. Ninety percent of students classified the patients in coma and in a vegetative state as alive, but still 34% of them would donate organs of those patients. The group of physicians properly determined the patients' diagnoses, but 10% of them accepted organ procurement from patients in coma and in a vegetative state.

Conclusion

Our results supported the earlier observations of low public knowledge and inadequate understanding of brain death criteria and organ procurement processes. The majority of students were willing to accept organ procurement from severely ill but alive patients, in contrast with physicians. A considerable increase in public educational activity in this field is urgently recommended.     

A Comparison of Request Process and Outcomes in Donation After Cardiac Death and Donation After Brain Death: Results From a National Study

Available literature points to healthcare providers’ discomfort with donation after cardiac death (DCD) and their perception of public reluctance toward the procedure. Using a national sample, we report on the communication content of actual DCD and donation after brain death (DBD) approaches by organ procurement organization (OPO) requesters and compare family decision makers’ (FDMs’) experiences of both modalities. We recruited 1601 FDMs using a validated protocol; 347 (21.7%) were of potential DCD donors. Semistructured telephone interviews yielded FDMs’ sociodemographic data, donation attitudes, assessment of approach, final outcomes, and substantiating reasons. Initial analysis consisted of bivariate analyses. Multilevel mixture models compared groups representing authorization outcome and DCD/DBD status. No significant differences in family authorization were found between DCD and DBD cases. Statistically significant associations were found between sociodemographic characteristics and authorization, with white FDMs more likely to authorize DCD or DBD than black FDMs. FDMs of both modalities had similar evaluations of requester skills, topics discussed, satisfaction, and refusal reasons. The findings suggest that the DCD/DBD distinction may not be notable to families. We recommend the use of similar approach strategies and communication skills and the development of education campaigns about the public's acceptance of DCD.     

The Hemodynamic Mechanisms of Lung Injury and Systemic Inflammatory Response Following Brain Death in the Transplant Donor

Brain-dead donors are the major source of lungs for transplantation. Brain death is characterized by two hemodynamic phases. Initially, massive sympathetic discharge results in a hypertensive crisis. This is followed by neurogenic hypotension. Up-regulation of pro-inflammatory mediators occurs in all organs and lung injury develops; this can adversely affect graft function post-transplantation. The mechanisms of the systemic and lung inflammation are unknown. We hypothesized that the hemodynamic changes are responsible for these inflammatory phenomena. Brain death was induced by intra-cranial balloon inflation in rats. This resulted in hypertensive crisis, followed by hypotension. There was a significant increase in blood neutrophil CD11b/CD18 expression and pro-inflammatory cytokine levels in serum and bronchoalveolar lavage, compared with control animals. Rupture of the capillary-alveolar membrane was demonstrated by electron microscopy. Elimination of the hypertensive response by α-adrenergic antagonist pre-treatment prevented inflammatory lung injury, reduced the systemic inflammatory markers and preserved capillary-alveolar membrane integrity. Correction of the neurogenic hypotension with noradrenaline ameliorated the systemic inflammatory response and improved oxygenation. We conclude that the sympathetic discharge triggers systemic and lung inflammation, which can be further enhanced by neurogenic hypotension. Management of the brain-dead donor with early anti-inflammatory treatment and vasoconstrictors is warranted.     

Crosstalk between Complement and Toll‐like Receptor Activation in Relation to Donor Brain Death and Renal Ischemia‐Reperfusion Injury

Two central pathways of innate immunity, complement and Toll‐like receptors (TLRs), play an important role in the pathogenesis of renal injury inherent to kidney transplantation. Recent findings indicate close crosstalk between complement and TLR signaling pathways. It is suggested that mitogen activated protein kinases (MAPKs) might be the key molecules linking both the complement and TLR pathways together. Complement and TLRs are important mediators of renal ischemia‐reperfusion injury (IRI). Besides IRI, complement C3 can also be upregulated and activated in the kidney before transplantation as a direct result of brain death (BD) in the donor. This local upregulation and activation of complement in the donor kidney has been proven to be detrimental for renal allograft outcome. Also TLR4 and several of its major ligands are upregulated by donor BD compared to living donors. Important and in line with the observations above, kidney transplant recipients have a benefit when receiving a kidney from a TLR4 Asp299Gly/Thr399Ile genotypic donor. The role of complement and TLRs and crosstalk between these two innate immune systems in relation to renal injury during donor BD and ischemia‐reperfusion are focus of this review. Future strategies to target complement and TLR activation in kidney transplantation are considered.     

Trends in the Use of Cameras and Computer Technology Among Dermatologists in New York City 2001–2002

Background. Photography and computers can enhance dermatologic visit documentation and care.
Objective. To determine dermatologists' use of cameras and computers.
Methods. We surveyed computer and camera use during the Dermatologic Society of Greater New York's meetings in January 2001 and 2002.
Results. Approximately 75% of dermatologists can use computers. Between 2001 and 2002, 35-mm film camera use by attending and resident dermatologists fell from 60% to 47% and 43% to 32%, respectively, and digital camera increased from 25% to 38% and 35% to 59%, respectively. Approximately 50% of dermatologists use instant cameras. Approximately 15% of dermatologists use no camera. Most find images useful; however, medical dermatologists usually image only interesting patients, and dermatologic surgeons image almost all patients. Approximately 15% of dermatologist used electronic medical records (EMRs).
Conclusion. Computers and cameras are widely used but have not changed dermatologic practice. Images are not used to track skin disease or integrated with EMRs nor are EMRs widely used, probably because of difficulty of use and limited computer literacy. Where images appear to add value, for example, for preoperative and postoperative documentation among dermatologic surgeons, camera use is common, suggesting that utility drives technology adoption.     

Attitudes Toward and Knowledge of Brain Death and Deceased Organ Donation Among Anesthesiologists in the Northeastern Region of Poland

Background. Because in Poland transplant of organs from deceased donors is the predominant form of transplant, anesthesiology and intensive care specialists play a key role in the process. Insight into the work organization in intensive care units, anesthesiologists’ and intensivists’ level of knowledge and expertise, as well as personal opinions regarding declaring brain death and critical care of potential donors may be helpful in increasing transplant rates.Aim of the study. The objective of this survey was to identify factors and challenges influencing donation rates in intensive care units of hospitals of various reference levels in region.Methods. An anonymous, 31-question survey was sent to anesthesiology and intensive care specialists working in hospitals in one of the regions of eastern Poland. The survey was completed by 133 physicians, and a quantitative analysis was conducted on the data collected from submitted answers.Results. The average age of responders was 46 years (±10.24 years). Anesthesiology and intensive care specialists made up 80.45% of respondents. A vast majority of respondents (97%) expressed positive attitude toward transplant and are willing to donate their organs after death (92.19%). Meanwhile, more than 50% of them admit their lack of sufficient knowledge when it comes to declaring brain death. More than 53% of surveyed physicians have never had the opportunity to participate in training in methodology in performing brain death provided by their hospital or know about such training taking place. A vast majority of respondents (94.76%) see the need for workshops in potential organ donor care and brain death determination and would like to attend them.Conclusions. This study shows a positive outlook toward organ donation and transplant but at the same time reveals a lack of knowledge and expertise among doctors working in intensive care units. That is why implementing education tools for identification, declaration, and maintenance of brain-dead donors could be one of the keys to enhancing donation.     

Hemoderivative Transfusion in Liver Transplantation: Comparison Between Recipients of Grafts From Brain Death Donors and Recipients of Uncontrolled Donors After Circulatory Death

IntroductionIntraoperative bleeding during liver transplantation has been correlated with a higher risk of morbidity and mortality and decrease in patient and graft survival.Materials and MethodsBetween January 2006 and December 2016 we performed 783 orthotopic liver transplants. After applying exclusion criteria, we found liver grafts from donors after circulatory death (DCD, group A) were used in 69 patients and liver grafts from donors after brain death (group B) were used in 265 patients.ResultsNo difference was found in terms of sex, body mass index, Model for End-Stage Liver Disease score, indication for transplantation, intensive care unit stay, and Child-Pugh score. The mean transfusion of hemoderivates was as follows: red blood cell 9 (0-28) units in group A vs 6 (0-20) units in group B (P = .004) and fresh frozen plasma 10 (0-29) units in group A vs 9.5 (0-23) in group B (P = .000). The only 2 factors related to massive blood transfusion (>6 units of red blood cell) were uncontrolled DCD condition (odds ratio = 2.38; 95% confidence interval, 1.32-4.31; P = .004), and higher Model for End-Stage Liver Disease score (odds ratio = 2.63; 95% confidence interval, 1.53-4.55; P = .001). Survival at 1, 3, and 5 years was 81.3%, 70.2%, and 68.9% in group A vs 89%, 83.7%, and 78% in group B (P = .070).ConclusionThe use of liver grafts from DCDs is associated with increased necessity of transfusion of hemoderivates in comparison with the use of liver grafts from donors after brain death.     

Comparison of Vascular Endothelial Growth Factor Concentration in Porcine Kidneys Removed From Living Donors After Cardiac and Brain Death

The aim of this paper was to describe the differences in vascular endothelial growth factor (VEGF) concentration in porcine kidneys removed from living donors (group I), donors after prior induction of brain death by brain herniation (group II), and donors after cardiopulmonary arrest (group III). The groups consisted of 6 animals which underwent dual renal removal procedures; kidneys were rinsed, stored for 24 hours at 4°C and rinsed again. Renal specimens (4g) were collected before and after perfusion (time 0 and 1), after 12 hours (time 2), and after reperfusion (time 3). A Western blot was used to evaluate VEGF concentration in collected tissues homogenates. Additionally, the levels of VEGF, interleukin 1β, tumor necrosis factor α, and endothelial nitric oxide synthase (eNOS) were detected with enzyme-linked immunosorbent assays. Directly after the removal procedure, no significant differences in VEGF levels (IOD) were observed depending on the donor (moderate levels were observed in all groups: 1.51 in group I, 1.48 in group II, and 1.35 in group III). As a consequence of perfusion and 12 hours of storage, a stable concentration in groups I and III was observed with a gradual increase of VEGF levels in group II (1.23, 2.08, and 1.67 in the respective groups at time 1; 1.49, 2.12, and 1.63 in the respective groups at time 2). After the following 12 hours, a statistically significant (P < .05) higher level of VEGF was observed in group II (2.34) in comparison to groups I and III (1.58 and 1.81, respectively). In group I, a correlation between VEGF concentration and IL-1β was observed, while in group II there was correlation between VEGF and eNOS levels.     

Comparison of Endothelial Nitric Oxide Synthase and Endothelin-1 Levels in Kidneys Removed From Living Pigs After Cardiac Arrest and Brain Death

Objectives

The aim of this paper was to describe differences between levels of endothelial nitric oxide synthase (NOS-3) and endothelin-1 (ET-1) in swine kidneys removed from living donors (group I) and after inducing brain death by brain herniation (group II) and cardiac arrest (group III).

Methods

Each group consisted of 3 animals who underwent dual renal removal procedure; kidneys were further rinsed according to standardized procedure with Biolasol perfusion liquid, stored for 24 hours (4°C), and rinsed again. Renal specimens of 4 g mass, including renal cortex and medulla, were collected before and after perfusion (times 0 and 1), after 12 hours (time 2), and after reperfusion (time 3). Enzyme-linked immunosorbent assay was used to describe levels of NOS-3 and ET-1 in collected tissues homogenates. Mann-Whitney U test was used to compare results in groups in relation to total protein content (ng/mg), and the correlation between the 2 substances was measured with the use of Spearman rho.

Results

Group I presented low and stable levels of NOS-3 in all time intervals (averages, 0.73, 0.99, 0.52, and 0.89, respectively). Level sof ET-1 were similar (0.87, 0.63, 0.69, and 0.86, respectively), and significant correlation between levels of the 2 substances was observed. Increased levels of NOS-3 (1.89 and 1.86) and ET-1 (1.38 and 1.49) were observed directly after removal in groups II and III and further maintained during organ storage. No correlation in group I was observed, and after perfusion significantly lower level of NOS-3 was observed in kidneys removed after brain death in relation to group III (1.77 vs 2.60).

Conclusions

The lowest and stable levels of NOS-3 and ET1 during storage were observed in kidneys removed from living donors. Levels of analyzed substances in this group showed correlation in subsequent time intervals.     

Knowledge and Attitudes of Health Care Professionals and Laypeople in Relation to Brain Death Diagnosis and Organ Donation in Hungary: A Questionnaire Study

ObjectivesThe aim of the present work was to assess the knowledge and attitudes of different health care workers and laypeople toward the donation and transplantation procedure.Subjects and methodsA survey consisting of questions regarding brain death diagnosis, legal organization or organ donation, and the transplantation procedure were sent to participants: 56 intensive care unit (ICU) doctors, 76 ICU nurses, 188 sixth-year medical students, and 320 general practitioners (GPs). Laypeople were also asked to complete the survey.ResultsThe majority of participants reported being aware of legal regulations for organ donation in Hungary (88.5%). Roughly 25% of GPs and 60% of laypeople were unaware of the opt-out system effective in the country. Less than one-third of ICU physicians (26.9%) and nurses (34.7%) were able to list the organs that may be transplanted from a deceased donor; GPs (22.4%) and medical students (20%) performed even worse on this item. The willingness of ICU specialists (57%) and ICU nurses (45%) to support donating their own organs was moderate.ConclusionsThe results of this survey indicate a need for graduate and postgraduate education and regular teaching programs regarding organ donation and transplantation. More active use of modern media is proposed to improve public awareness and acceptance of organ donation.     

The Effect of High‐Mobility Group Box 1 in Rat Steatotic and Nonsteatotic Liver Transplantation From Donors After Brain Death

High‐mobility group box 1 (HMGB1) has been described in different inflammatory disorders, and the deleterious effects of brain death (BD) may counteract the protection conferred by ischemic preconditioning (IP), the only surgical strategy that is being applied in clinical liver transplantation. Our study examined how HMGB1 may affect preconditioned and unpreconditioned steatotic and nonsteatotic liver grafts from donors after BD (DBDs) for transplantation. HMGB1 was pharmacologically modulated in liver grafts from DBDs, and HMGB1‐underlying mechanisms were characterized. We found that BD decreased HMGB1 in preconditioned and unpreconditioned livers and was associated with inflammation and damage. Exogenous HMGB1 in DBDs activates phosphoinositide‐3‐kinase and Akt and reduces hepatic inflammation and damage, increasing the survival of recipients. Combination of IP and exogenous HMGB1 shows additional benefits compared with HMGB1 alone. This study provides new mechanistic insights into the pathophysiology of BD‐derived liver graft damage and contributes to the development of novel and efficient strategies to ultimately improve liver graft quality.     

Prevalence of Family Refusal and Associated Factors in Declared Brain Death: A Six-Year Retrospective Study in Northern Cyprus

Kidney transplantation provides a higher quality of life, a longer life expectancy for end-stage renal disease patients, and a lower cost than other treatments. Unfortunately, organ shortage for kidney transplantation is a major obstacle for countries with long waiting lists. Approaches to solving organ shortages with laws and regulations differ between countries. The reasons for these differences are evaluated by considering many factors, such as religious beliefs, sociocultural differences, and distrust in health systems. Until another evidence-based treatment becomes available, efforts to increase dead donor transplants are the main solution to reducing waiting lists.In a retrospective study conducted in our region, we investigated the prevalence and potential correlation of deceased organ transplantation based on family refusal and other issues.     

肿瘤与普通内科病人抑郁、焦虑心理及其影响因素对比研究

目的了解肿瘤与普通内科住院病人抑郁和焦虑程度及其影响因素的差异性 ,为临床护理提供参考依据。方法采用抑郁自评量表 (SDS)、焦虑自评量表 (SAS)及自制影响因素调查表 ,同时对肿瘤病人 (180例 )和普通病人(134例 )进行调查。结果肿瘤病人SDS和SAS均分值及阳性率均明显高于普通内科病人 (均P <0 .0 1) ;影响因素前五位为治疗费用、治疗效果、治疗毒副反应、家庭因素及自理能力下降。结论肿瘤病人普遍存在较多的生理、心理和社会问题 ,导致较严重的抑郁和焦虑反应 ,针对性的情感支持及整体护理干预应作为肿瘤综合治疗的重要组成部分。     

Complications and Their Resolution in Recipients of Deceased and Living Donor Liver Transplants: Findings From the A2ALL Cohort Study

The purpose of this study was to explore long‐term complications in recipients of deceased donor liver transplant (DDLT) and living donor liver transplant (LDLT) in the Adult‐to‐Adult Living Donor Liver Transplantation Cohort Study (A2ALL). We analyzed 471 DDLTs and 565 LDLTs from 1998 to 2010 that were followed up to 10 years for 36 categories of complications. Probabilities of complications and their resolutions were estimated using the Kaplan–Meier method, and predictors were tested in Cox proportional hazards models. Median follow‐up for DDLT and LDLT was 4.19 and 4.80 years, respectively. DDLT recipients were more likely to have hepatocellular carcinoma and higher disease severity, including Model for End‐Stage Liver Disease score. Complications occurring with higher probability in LDLT included biliary‐related complications and hepatic artery thrombosis. In DDLT, ascites, intra‐abdominal bleeding, cardiac complications and pulmonary edema were significantly more probable. Development of chronic kidney disease stage 4 or 5 was less likely in LDLT recipients (hazard ratio [HR] 0.41, p = 0.02). DDLT and LDLT had similar risk of grade 4 complications (HR 0.89, p = 0.60), adjusted for other risk factors. Once a complication occurred, the time to resolution did not differ between LDLT and DDLT. Future efforts should be directed toward reducing the occurrence of complications after liver transplantation.     

The Effect of Employment Status in Postdisaster Recovery: A Longitudinal Comparative Study Among Employed and Unemployed Affected Residents

Population studies have shown that employed adults are healthier than unemployed adults. In this study, we examined whether this “healthy worker effect” is relevant in postdisaster mental health by examining whether trauma‐exposed employed individuals have lower postdisaster initial mental health problems and/or whether they recover faster than trauma‐exposed unemployed individuals. We compared the course of postevent intrusion and avoidance reactions, anxiety, depression, and sleeping difficulties of employed residents (n = 291) and unemployed residents (n = 269) affected by a fireworks disaster in a residential area of Enschede, The Netherlands. Measurements took place at 2–3 weeks (T1), 18 months (T2), and 4 years (T3) postdisaster. We used linear mixed‐effect models to examine the course of mental health problems. Employment status was relevant, to a degree, in posttrauma recovery; although affected employed residents had significantly lower levels of mental health problems (initially and over time) than the unemployed, ds = 0.41–0.72, the recovery rate was the same for both groups. At T1 (neglecting the DSM 1‐month criterion), T2, and T3, the prevalence of probable posttraumatic stress disorder was 45.4%, 18.9%, and 11%, respectively, among employed individuals, and 70.1%, 32.5%, and 30% among unemployed individuals. We concluded that research into the mental health of disaster victims should take employment status into account. Regarding postdisaster care, unemployed individuals may need special attention; although they may recover at the same rate as employed individuals, they suffer from more severe mental health problems, even years after the disaster.