Anesthetic management of the pediatric patient undergoing solid organ transplantation

Solid organ transplantation is now routinely performed at many institutions. Pediatric organ recipients present difficult challenges to pediatric anesthesiologists. Physiologic, anatomic, and pharmacologic derangements in this population may make both the surgical procedure and the anesthetic management complicated. This article presents an overview of the unique problems and the strategies to solve them in this population.     

美国器官捐献和移植立法主要事件

1968年哈佛大学提出“脑死亡定义”1968年《人体器官捐献法》对以移植为目的的器官和组织捐献进行了法律规范 1971年修订《人体器官捐献法》，赋予器官捐献卡片法律效力     

Pediatric solid organ transplantation

Solid organ transplantation offers hope for long-term survival and more normal lifestyles for children. Many of the procedures used are scaled-down versions of those used in adults and are associated with distinct challenges in children. Recent studies have provided insights into how transplantation can best serve these patients.     

Immunobiology of solid organ transplantation

The field of organ transplantation is entering a very exciting phase in which tolerance induction may become a therapeutic possibility. The induction of tolerance would allow patients to enjoy the benefits of their transplanted organ without risking the mortality and morbidity associated with long-term pharmacological immunosuppression. In this review, we explore the immunobiology of solid organ transplantation, discussing the immunological mechanisms responsible for allograft rejection, and outlining the rational behind a range of successful experimental tolerance induction strategies.     

Chagas' disease and solid organ transplantation

This review summarizes relevant published data on transplant recipients with Chagas' disease and of naïve recipients transplanted with organs from infected donors. Unpublished experience from some of the largest transplant centers in Argentina is also included. The review outlines the guidelines for pretransplant evaluation and for posttransplant management formulated by the Chagas Disease Argentine Collaborative Transplant Consortium.     

Gynecologic cancers and solid organ transplantation

Solid organ transplant (SOT) recipients have an approximately 2‐fold greater risk of developing and dying from a malignancy compared to the general population. Among the gynecologic cancers, including uterine, cervical, vaginal, vulvar, and ovarian, the HPV‐related cancers are known to increase among women posttransplant compared to women in the general population, but less is known about the risk of uterine and ovarian cancers. This review provides an overview of the epidemiology of gynecologic cancers after solid organ transplantation, as well as the pathophysiology, management, and specific risk factors associated with these cancers. Closer surveillance for cervical cancers is warranted and larger studies are needed to assess whether and how uterine and ovarian cancers are associated with excess incidence and mortality. Such studies may lead to improvements in screening, prevention, and treatment before and after transplantation.     

Stress and coping in caregivers of patients awaiting solid organ transplantation

Caregivers for patients undergoing solid organ transplantation play an essential role in the process of transplantation. However, little is known about stress and coping among these caregivers. Six hundred and twenty-one primary caregivers of potential candidates for lung (n = 317), liver (n = 147), heart (n = 115), and/or kidney (n = 42) transplantation completed a psychometric test battery at the time of the candidate's initial pre-transplant psychosocial evaluation. Caregivers were generally well adjusted, with only 17% exhibiting clinical symptoms of depression (Beck Depression Inventory-II score >13) and 13% reporting clinical levels of anxiety (State Trait Anxiety Inventory score >48). Greater caregiver burden and negative coping styles were associated with higher levels of depression. Greater objective burden and avoidant coping were associated with higher levels of anxiety. Caregivers evidenced a high degree of socially desirable (i.e., defensive) responding, which may reflect a deliberate effort to minimize fears or worries so as to not jeopardize patients' listing status.     

Infections complicating solid organ transplantation

The requirements for immune suppression after solid organ transplantation increases the risk of infection with a myriad of organisms. There are many unique and evolving aspects of infection after solid organ transplantation. Advances in immunosuppressive therapy and improved protocols for infection prophylaxis have resulted in changes in the timing and clinical presentation of opportunistic infections. Vigilance in the diagnostic evaluation of suspected infection in the solid organ transplant recipient is essential. This article reviews the basic evaluation and treatment options for many of the infectious conditions peculiar to the immunosuppressed patient.     

Fertility following solid organ transplantation

Fertility is usually restored in women after solid organ transplantation, and successful pregnancies have been reported in female recipients of kidney, liver, heart, pancreas-liver, and lung transplants. However, women with solid organ allografts have higher incidence of pregnancy complications like hypertension, preeclampsia, preterm delivery. Hypertension appears to be dependent on the type of immunosuppressive agents. The influence of pregnancy on the risk of rejection is poorly known on the basis of available data. Rejection rate appears to be at least similar to the nonpregnant population. In some cases, such as in liver transplant pregnant women, even higher as compared to the nonpregnant population. Maintaining appropriate blood levels of immunosuppressive drugs is currently recommended. Malformation rate in the offsprings of transplanted women appears to not be increased; long-term follow- up of children born to allograft recipients is necessary to investigate possible developmental, immunological, or oncological disorders. We followed 70 pregnancies after kidney transplantation and nine after liver transplantation. All recipients were maintained on immunosuppressive therapy during pregnancy, except one mother who refused immunosuppression and experienced transplant rejection. Hypertension was the most frequent complication during pregnancy: in 23% of kidney transplantated mothers and in one out of nine liver transplant recipients. The only malformation observed in the newborns was the dislocation of the hip in the child of a kidney transplant recipient.     

Risk of colorectal neoplasia in patients with solid organ transplantation

The incidence of colorectal adenomas and advanced neoplasia in the transplant population has not been well characterized. The aim of this study was to determine whether or not there was an increased incidence of colorectal adenomas and advanced neoplasia in solid organ transplantation (SOT) recipients compared with an average-risk population. We reviewed 360 patients with solid organ transplants who underwent colonoscopy between February 1995 and July 2008, and 360 age- and gender-matched patients in an average-risk population. The mean duration from transplantation to colonoscopy in the SOT group was 40.4 ± 34.0 months. Ninety-three (25.8%) adenomas were detected in the SOT group, while 98 (27.2%) adenomas were detected in the control group (p = 0.763). There was a statistically significant difference (p < 0.0001) in the number of patients with advanced neoplasia in the SOT group (24 patients [6.7%]) compared with the control group (3 patients [0.8%]). The independent risk factors of advanced neoplasia were old age (odds ratio [OR], 1.067; 95% CI, 1.019-1.118) and transplantation (OR, 6.069; 95% CI, 1.455-25.314). In summary, there was a significant increase in the incidence of advanced colorectal neoplasia in SOT recipients. The reason for this finding is unclear, and studies with a larger number of patients are needed to further evaluate this group.     

Psychosocial and behavioral selection criteria for solid organ transplantation

An evidence-based selection process for organ transplantation may be a valuable approach to improve posttransplant outcomes. This paper reviews state-of-the-art psychosocial and behavioral selection criteria and assesses their validity in view of predicting outcomes after transplantation. Psychosocial factors addressed are psychiatric disorders, mental retardation, irreversible cognitive dysfunction, and lack of social support. Behavioral selection criteria discussed are alcoholism, smoking, drug abuse, and obesity. This review reveals that the evidence concerning these selection criteria in scarce. There is a definite need for more longitudinal research to strengthen the scientific basis of the psychosocial and behavioral dimension of transplantation.     

Clinical glycopeptide-resistant enterococci isolated from patients after solid organ transplantation

The aim of this study was to confirm the identification and resistance to vancomycin and teicoplanin of nosocomial enterococcal strains using molecular biology methods. Glycopeptide-resistant enterococci (GRE) strains were isolated from clinical specimens of hospitalized patients. Bacterial identification was performed in an automatic ATB Expression system (bioMérieux SA). Susceptibility to glycopeptides was determined by the disc diffusion method and Etest (AB BIODISK, Sweden). We performed polymerase chain reactions (PCR) for Enterococcus faecium and E. faecalis identification and van genes detection. Fifteen GRE strains were cultured over 2 years (2003-2004). Fourteen isolates were highly resistant to vancomycin (MIC range, 128->256 mg/L) and teicoplanin (MIC range, 32->256 mg/L). Twelve strains harbored van A gene (Van A phenotype). Seven isolates were identified as E. faecium and seven as E. faecalis by the multiplex-PCR method. One strain-E. casseliflavus-showed low resistance to vancomycin (MIC 8 mg/L) with retained susceptibility to teicoplanin (MIC 4 mg/L). It harbored the van C2/C3 gene and was identified as the Van C2/C3 phenotype. GRE strains were more often isolated from hospitalized patients in Poland. Constant monitoring by reliable microbiological methods has become necessary to prevent the spread of these strains in the hospital environment.     

The immunology of solid organ transplantation

Solid organ transplantation has progressed dramatically over the last 50 years. However, rejection still remains one of the barriers to successful transplantation. Immunological processes underlying the mechanisms of rejection are well described and numerous pharmacological agents exist to help suppress a recipient's immune system in order to prolong graft survival. Furthermore, clinician decisions and actions during both the work-up of a potential transplant recipient and in the perioperative phase can impact upon the immunological status of an individual and the likelihood of successful solid organ transplantation. In this article we aim to describe the key processes involved in solid organ immunology and their relevance in anaesthetic practice.     

The immunology of solid organ transplantation

Solid organ transplantation has progressed dramatically over the last 50 years; however, rejection still remains one of the barriers to successful transplantation. Immunological processes underlying the mechanisms of rejection are well described and numerous pharmacological agents exist to help suppress a recipient's immune system in order to prolong graft survival. Furthermore, clinician decisions and actions during both the work-up of a potential transplant recipient and in the perioperative phase can impact upon the immunological status of an individual and the likelihood of successful solid organ transplantation. In this article we aim to describe the key processes involved in solid organ immunology and their relevance in anaesthetic practice.