Heart transplantation in children in foreign countries with reference to medical, transportation, and financial issues

Heart transplantation is increasingly becoming accepted worldwide as therapy for end-stage heart failure not only in adult patients but also in pediatric practice. The new law in Japan for organ transplantation from brain-dead patients was established on 16 October 1998, but there is no definite law or protocol for brain death in children under the age of 6 years and children less than 15 years of age cannot become donors. These facts make organ transplantation from the cadavers of neonates, infants and young children almost impossible in Japan, even though there are children who need heart or heart-lung transplantation. The present authors have to date transferred 8 patients to the USA or Germany for heart transplantation: 4 successfully underwent heart transplantation, but 4 died during the waiting period overseas. There are many things to consider; not only the medical problems involved in transportation, but also the financial issues when transferring patients to other countries. This report details the experience with the 8 cases that were transferred overseas for heart transplantation, and highlights the problems that need to be considered.     

Cardiac transplantation: a comprehensive nursing perspective. Part 1

Orthotopic cardiac transplantation has become the treatment of choice for selected patients with end-stage heart disease. Proliferation of cardiac transplantation centers and relaxed selection criteria have resulted in increasing populations of transplant candidates and recipients. As these numbers continue to grow, so too do the numbers of nursing personnel who must respond to the intricacies and demands of cardiac transplantation. Nursing care begins with physiologic and psychologic support of a patient with terminal cardiac disease and continues throughout the transplantation evaluation, waiting, surgical, postoperative, and outpatient periods. In addition to routine postsurgical care, the nurse involved in cardiac transplantation needs to be familiar with the function of a denervated heart, as well as with the effects of unbalanced immunosuppression and immunocompetence. The surge of organ transplantation in the last several years has brought about administrative concerns regarding the financial impact of increasing numbers of transplantations, as well as an inadequate supply of necessary donor organs. This critical shortage of suitable donors demands that nurses and other health care professionals become active in enlarging the donor organ pool by identifying potential organ donors, maintaining optimal hemodynamics and oxygenation so as to ensure organ viability, and providing emotional support of the grieving family.     

Liver transplantation: evolving patient selection criteria.

The widespread recognition of the success of liver transplantation as a treatment for most types of acute and chronic liver failure has led to increased referrals for transplantation in the setting of a relatively fixed supply of cadaver donor organs. These events have led to a marked lengthening of the waiting time for liver transplantation, resulting in increased deaths of those on the waiting list and sicker patients undergoing transplantation. Nearly 5000 liver transplantations were performed in the United States in 2000, while the waiting list grew to over 17,000 patients. The mounting disparity between the number of liver transplant candidates and the limited supply of donor organs has led to reassessment of the selection and listing criteria for liver transplantation, as well as revision of organ allocation and distribution policies for cadaver livers. The development of minimal listing criteria for patients with chronic liver disease based on a specific definition for decompensation of cirrhosis has facilitated the more uniform listing of patients at individual centres across the United States. The United Network for Organ Sharing, under pressure from transplant professionals, patient advocacy groups and the federal government, has continuously revised allocation and distribution policies based on the ethical principles of justice for the individual patient versus optimal utility of the limited organ supply available annually. Beginning in 2002, it is likely that the Model for End-stage Liver Disease (MELD) score will be implemented to determine disease severity and direct donor organs to the sickest patients rather than to those with the longest waiting times.     

Coronary angiography utilization in the evaluation of a potential heart donor by age: a narrative review

Heart transplant is the gold standard treatment for patients with heart failure. The limitation to providing heart transplantation to patients suffering from end stage heart disease is the stable organ supply within the United States despite increasing demand. Transplant centers across the United States have begun to expand traditional cardiac donor selection metrics previously utilized. As a result, the use of extended criteria donors, such as older donors, those with longer ischemic times, and donors considered high risk has increased. Current guidelines suggest that coronary angiography be performed when evaluating a donor above the age of 45. Angiographic guidelines for evaluation of the donor heart are based specifically on age, with little evidence based guidance surrounding the use of angiography in a younger donor with comorbidities or increased risk behavior which may lead to premature coronary artery disease. Recently, we have seen an increase in younger heart donors, many of whom have succumbed due to drug overdose with ensuing high risk behaviors. Given the increased risk nature of these donors, consideration of performing coronary angiography is determined by clinical “gestalt” of the transplant center evaluating the heart for use, which may lead to underutilization of donor organs without evidence to support the practice. Here, we review the guidelines, literature, and controversy surrounding the use of coronary angiography in evaluating donor hearts for transplantation.     

Cardiomyopathy and heart transplantation in children

Cardiomyopathy is one of the most common causes of death in children with heart disease. Increasingly, dilated cardiomyopathy is recognized to be familial, and specific gene products related to the myocyte cytoskeleton and contractile proteins have been identified. Other associations with metabolic disease, dysmorphic syndromes, and neuromuscular disease are important to establish, particularly in pediatric patients, to guide therapy and patient selection for transplantation. Survival in children with dilated cardiomyopathy depends on accurate diagnosis and aggressive therapy. Patients may respond to conventional treatment for heart failure or may deteriorate, requiring mechanical support. Extracorporeal membrane oxygenation has been used effectively for mechanical support in children until improvement occurs or as a bridge to transplantation. For those who are listed, the mortality rate while waiting for a donor organ averages approximately 20%. Survival after transplantation is good, with an intermediate survival rate of approximately 70%. Late survival remains to be determined in the current cyclosporin era but may in fact be improving. However, increased organ donation or strategies to increase the size of the organ donor pool, such as xenotransplantation, are needed to significantly reduce the rate of mortality while waiting.     

Outcomes in children with advanced heart failure in Japan: importance of mechanical circulatory support

The Japanese organ transplant law was revised in July 2010 in order to enable children aged <15 years to donate organs. However, the waiting time for orthotopic heart transplantation (HTx) is as long as 636 days in children due to a shortage of organ donors. Ventricular assist devices (VADs) have been widely used as a bridge to transplantation in Western countries, whereas experience with VADs is limited in Japan due to a lack of device availability for small children. This study aimed to clarify the clinical profiles and outcomes of children with advanced heart failure in Japan and to investigate the importance of mechanical circulatory support (MCS), VADs, and extracorporeal membrane oxygenation (ECMO) in children. A retrospective chart review of patients with advanced heart failure who were eligible for HTx between January 2006 and May 2015 was performed at the Department of Pediatric Cardiology, Tokyo Woman’s Medical University, Japan. Patients were divided into two groups based on need for MCS. Clinical data pre- and post-revision of the Japanese organ transplant law were compared. Preoperative clinical conditions were evaluated based on Interagency Registry for Mechanically Circulatory Support (INTERMACS) profiles. Twenty-two patients were included in the study, 12 of whom required MCS. VADs were implanted in nine patients and ECMO was needed in seven patients. Of the MCS group, 5 deaths occurred in patients with a preoperative INTERMACS profile-1. High total bilirubin was found to be associated with mortality by multivariate logistic regression analysis (OR 7.8, p = 0.02). Wait list mortality was 32 % and no difference in clinical profiles pre- and post-revision of the Japanese organ transplant law was observed. Approximately 55 % of pediatric patients with advanced heart failure required MCS support. Preoperative conditions such as INTERMACS profile-1 and high total bilirubin were associated with poor outcomes. The Japanese organ transplant law revision had no significant influence on patient profiles or outcomes.     

Current indications for heart transplantation and left ventricular assist device: A practical point of view

Heart transplantation (HTx) is considered the “gold standard” therapy of refractory heart failure (HF), but it is accessible only to few patients because of the paucity of suitable heart donors. On the other hand, left ventricular assist devices (LVADs) have proven to be effective in improving survival and quality of life in patients with refractory HF. The challenge encountered by multidisciplinary teams in dealing with advanced HF lies in identifying patients who could benefit more from HTx as compared to LVAD implantation and the appropriate timing. The decision-making is based on clinical parameters, imaging-based data and risk scores. Current outcome of HF patients supported by LVAD (2-year survival around 70%) is rapidly improving and leads the way to a new therapeutic strategy. Patients who have a low likelihood to gain access to the heart graft pool could benefit more from LVAD implantation (defined as bridge to transplantation indication) than from remaining on HTx waiting list with the likely risk of clinical deterioration or removal from the list because patients are no longer suitable for transplantation. LVAD has also demonstrated to be effective in patients who are not considered eligible candidates for HTx with a destination therapy indication. HTx should be reserved to those patients for whom the maximum clinical benefit can be expected, such as young patients with no comorbidities. Here we discuss the current listing criteria for HTx and indications to implant of LVAD for patients with refractory acute and chronic HF based on the guidelines and the practical experience of our center.     

Effects of cold preservation and warm reperfusion on rat fatty liver

INTRODUCTION Although liver transplantation for irreversible liver diseases is increasingly prevalent worldwide, patient die while waiting for donors because of organ shortages. One important problem commonly encountered is that fatty livers often affect the outcome of liver transplantation. It is reported that the incidence of abnormal fatty livers in autopsies after accidental death ranged from 15% to 24%.Since fatty livers may result in a primary nonfunction (PNF) liver graft, which contributes to an increased risk of mortality[1], they are usually out of consideration in liver transplantation.However, some fatty livers can be successfully transplanted. Therefore, how to choose fatty livers as donor organs correctly is the crux of success in liver transplantation.     

Review of Recent Results Using Computational Fluid Dynamics Simulations in Patients Receiving Mechanical Assist Devices for End-Stage Heart Failure

Many end-stage heart failure patients are not eligible to undergo heart transplantation due to organ shortage, and even those under consideration for transplantation might suffer long waiting periods. A better understanding of the hemodynamic impact of left ventricular assist devices (LVAD) on the cardiovascular system is therefore of great interest. Computational fluid dynamics (CFD) simulations give the opportunity to study the hemodynamics in this patient population using clinical imaging data such as computed tomographic angiography. This article reviews a recent study series involving patients with pulsatile and constant-flow LVAD devices in which CFD simulations were used to qualitatively and quantitatively assess blood flow dynamics in the thoracic aorta, demonstrating its potential to enhance the information available from medical imaging.     

A review of public policies to procure and distribute kidneys for transplantation

The purpose of this article is to provide an up-to-date review of the current status of frequently changing public policies for the procurement and distribution of donor kidneys for transplantation. Issues in procurement involve the Uniform Anatomical Gift Act, criteria for brain death, routine inquiry/required request policies, and the use of living kidney donors. Issues in distribution involve access to the transplant waiting list and use of the new national point system to select recipients from the list. These public policies are relevant for internists, who often care for potential organ donors and patients with end-stage renal disease. The issues are also relevant for policy-minded physicians because renal transplantation is the paradigm for organ transplant policy.     

Ethical issues in transplantation: living related donation in the setting of severe neurological damage without brain death

The waiting list for renal transplantation has grown at an alarming rate over the last 2 decades, resulting in increased waiting times and deaths on the waiting list. To increase the number of available organs for transplantation, aggressive public education programs have been developed. The federal government has strengthened hospital regulations ensuring referral of all potential donors to organ recovery agencies, and living donor programs no longer limit donation to genetically related donors and recipients. We present a case that illustrates the complex ethical issues that are integral to the field of transplantation and the allocation of a scarce resource: a 50-year-old man who has a daughter with end-stage renal disease has suffered a severe cerebral vascular accident but is neither brain-dead nor a candidate for "non-heart-beating" donation. Given his poor prognosis, should the father be able to donate his kidney to the daughter in his compromised condition?     

Allokation von Nierentransplantaten

Children and adolescents with end-stage renal disease are given priority in most organ allocation systems worldwide, because a prolonged waiting time on dialysis leads to irreversible disturbances of growth and of somatic and mental development, also because school education and professional training are hampered. The current regulations for the allocation of a kidney transplant for children and adolescents within Eurotransplant are problematic because of a relatively long waiting time (approximately 2 years), a fixed age limit of 16 years for the definition of a “pediatric patient,” and no consideration of a certain age match between donor and recipient. In an intense discussion during the last 2 years in the Eurotransplant Kidney Advisory Committee (ETKAC) and in the Commission for Organ Transplantation of the German Board of Physicians important improvements of the allocation rules for pediatric patients could be achieved, such as a higher pediatric bonus to shorten the waiting time on dialysis and granting the pediatric bonus also to those adolescent patients above 16 years of age who still have the potential for growth.     

Pediatric liver transplantation

In previous decades, pediatric liver transplantation has become a state-of-the-art operation with excellent success and limited mortality. Graft and patient survival have continued to improve as a result of improvements in medical, surgical and anesthetic management, organ availability, immunosuppression, and identification and treatment of postoperative complications. The utilization of split-liver grafts and living-related donors has provided more organs for pediatric patients. Newer immunosuppression regimens, including induction therapy, have had a significant impact on graft and patient survival. Future developments of pediatric liver transplantation will deal with long-term follow- up, with prevention of immunosuppression-related complications and promotion of as normal growth as possible. This review describes the state-of-the-art in pediatric liver transplantation.     

Responsibilities of primary physicians in organ donation

As transplantation success rates have improved, the demand for donor organs has steadily increased. A shortage of donor organs has led to legislation requiring hospital personnel to provide families routinely with the opportunity to authorize organ donation. Primary physicians have an important role in identifying potential donors while continuing to assure that the survivors' needs are met. The major implications of organ donation for the primary physician are reviewed. Patients who die will more frequently be eligible as cornea, skin, or bone donors, but the criteria for both tissue and internal organ donation are reviewed. Ethical issues unique to organ donation and responses of survivors to donation requests are described. If appropriately offered, the opportunity to authorize an anatomic gift can be a source of comfort to survivors while the donation provides the benefits of transplantation to persons on organ waiting lists.     

The obesity paradox and discrepancy between peak oxygen consumption and heart failure prognosis--it's all in the fat

The authors present the case of an obese patient with advanced heart failure that demonstrates the paradox between obesity and heart failure prognosis. In addition, the authors discuss the rationale for the correction of cardiopulmonary stress data (used as predictors of survival and listing for cardiac transplantation) for lean weight (as opposed to total body weight), a consideration that may be particularly important in obese patients with a high percentage of body fat.     

Outcomes for children with cardiomyopathy awaiting transplantation

OBJECTIVE: To determine factors associated with outcomes after listing for transplantation in children with cardiomyopathies. BACKGROUND: Childhood cardiomyopathies form a heterogeneous group of diseases, and in many, the prognosis is poor, irrespective of the etiology. When profound heart failure develops, cardiac transplantation can be the only viable option for survival. METHODS: We included all children with cardiomyopathy listed for transplantation between 12/89 and 4/98 in this historical cohort study. RESULTS: We listed 31 patients, 15 male and 16 female, 27 with dilated and 4 with restrictive cardiomyopathy, for transplantation. The median age at listing was 5.7 years, with a range from fetal life to 17.8 years. Transplantation was achieved in 23 (74%), with a median interval from listing of 54 days, and a range from zero to 11.4 years. Of the patients, 14 were transplanted within 30 days of listing. Five patients (16%) died before transplantation. Within the Canadian algorithm, one of these was in the third state, and four in the fourth state. One patient was removed from the list after 12 days, having recovered from myocarditis, and two remain waiting transplantation after intervals of 121 and 476 days, respectively. Patients who died were more likely to be female (5/5 vs. 11/26; p=0.04) and to have been in the third or fourth states at listing (5/5 vs. 15/26; p=0.04). The use of mechanical ventricular assistance, in 10 patients, was not a predictor of an adverse outcome. While not statistically significant, survival to transplantation was associated with treatment using inhibitors of angiotensin converting enzyme, less mitral regurgitation, a higher mean ejection fraction and cardiac index, and lower right ventricular systolic pressure. CONCLUSIONS: Children with cardiomyopathy awaiting transplantation have a mortality of 16% related to their clinical state at the time of listing.     

Living donor liver transplantation in adults

Adult-to-adult living donor liver transplantation (LDLT) using right hemi-liver has become a promising treatment modality for patients with end-stage liver disease. The rapid adoption of the procedure has been triggered mainly by the significant gap between available cadaver grafts and the number of patients on the waiting list for liver transplant. Since the arguments against LDLT focus only on the safety of the donor, the demonstration that the donor operation can be performed with minimal morbidity will make it more ethically acceptable. The advantages of LDLT are the possibility of performing an elective operation, access to a graft in best condition, and the possibility of lowering the likelihood of death while waiting for a suitable organ. As well as the standard indications for liver transplantation, LDLT opens up the possibility of treatment of patients with borderline indications. Further improvement of surgical and medical technology, careful long-term follow-up of donors and recipients, and profound analysis of socioeconomic aspects are essential issues for the transplantation community.     

Donor management in cardiac transplantation

The most important limitation in organ transplantation is donor availability. Canada is facing a serious situation with respect to organ donation rates and transplantation. The number of patients listed for heart transplant continues to increase while the number of available donors has plateaued. Several steps can be taken to address this growing mismatch. The proper identification and assessment of potential donors together with improvements in medical management may increase the donor pool. Additionally, the use of marginal donors and the development of new organ preservation techniques may lead to an increase in the number of potential heart transplants in Canada. This paper summarizes the identification, evaluation and management of heart transplant donors, and defines strategies to improve procurement activity in heart transplantation.     

A call for government accountability to achieve national self-sufficiency in organ donation and transplantation

Roughly 100,000 patients worldwide undergo organ transplantation annually, but many other patients remain on waiting lists. Transplantation rates vary substantially across countries. Affluent patients in nations with long waiting lists do not always wait for donations from within their own countries. Commercially driven transplantation, however, does not always ensure proper medical care of recipients or donors, and might lengthen waiting times for resident patients or increase the illegal and unethical purchase of organs from living donors. Governments should systematically address the needs of their countries according to a legal framework. Medical strategies to prevent end-stage organ failure must also be implemented. In view of the Madrid Resolution, the Declaration of Istanbul, and the 63rd World Health Assembly Resolution, a new paradigm of national self-sufficiency is needed. Each country or region should strive to provide a sufficient number of organs from within its own population, guided by WHO ethics principles.     

Successful heart‐kidney transplantation from a Hepatitis C viremic donor to negative recipient: One year of follow‐up

Every year the number of patients waiting for a heart transplant increases faster than the number of available donor organs. Some potential donor organs are from donors with active communicable diseases, including hepatitis C virus (HCV), potentially making donation prohibitive. The advent of direct‐acting antiviral agents for HCV has drastically changed the treatment of HCV. Recently, these agents have been used to treat HCV in organ donor recipients who acquired the disease from the donor organ. We report a case of heart‐kidney transplantation from an HCV viremic donor to HCV negative recipient with successful treatment and sustained virologic response.