Selection of patients for cardiac transplantation

In order to appropriately allocate the precious resource of donor organs for cardiac transplantation, one must adequately assess the prognosis of the prospective recipient with or without transplantation. This requires knowledge of the natural history of heart failure as well as those parameters by which it is evaluated. It also requires knowledge of those factors that make patients appropriate versus inappropriate surgical candidates. This article approaches both these necessary areas of patient evaluation.     

Selection and management of patients for cardiac transplantation

Each month in the United States, approximately 170 patients undergo cardiac transplantation and 300 new candidates are listed. Provision of alternative therapies, identification of the patients who truly have no other option, and management of those candidates until transplantation is performed has created a challenging area of investigation. The results of heart failure trials conducted in populations with milder heart failure may not always extend to advanced heart failure, to which some prognostic and therapeutic principles are unique. Many patients with low ejection fractions and a history of severe heart-failure symptoms can nonetheless enjoy quality of life and survival equivalent to those of patients who have received transplants. Improvements in our ability to design optimal medical therapy and to identify risk factors for early mortality will allow many patients with advanced heart failure to defer or avoid transplantation, and enable the majority of candidates to remain stable until transplantation can be performed.     

Selection of patients for liver transplantation

Liver transplantation is now available world-wide. It plays an important role in the treatment of irreversible acute and chronic liver disease (CLD). Selection of patients for liver transplantation is subject to many factors including economic, cultural, availability of donor organs and degree of illness. This article looks at seven general considerations for receipients of liver transplantation. As well, disease-specific criteria are investigated and include such areas as cirrhosis due to chronic hepatitis B virus (HBV), hepatitis C virus (HCV) positive cirrhosis, fulminant hepatic failure (FHF), malignancy, alcoholic liver disease (ALD), metabolic conditions and Budd–Chiari syndrome. If hepatic transplantation surivival rates were to approach 95%, the relative risk ratio between transplantation and conservative therapy would increase. At present an 80% 1–5 year survival rate following transplantation should be expected.     

Outcome of patients referred for cardiac transplantation

The outcome of 1,102 patients referred for cardiac transplantation at five centers participating in the National Heart Transplantation Study was examined. Using medical and referral records, patients were tracked from date of referral until they were rejected as transplantation candidates or received a transplant. Overall, 34.6% of all patients referred were eventually accepted for transplantation but, of these, 71.9% underwent the procedure. Of those patients accepted but not undergoing the procedure, the vast majority (58.8%) died awaiting a donor heart; another 30.8% later refused the procedure. Very few patients (2.1%) who were accepted for transplantation were deselected as possible candidates because of improved health status. The number of patients awaiting transplantation at all centers was found to be small at the time of study. The results of the analyses revealed major differences among centers in evaluation procedures, proportion of patients accepted and number of patients receiving a transplant. For example, one center performed transplantation on only 50.0% of all patients it accepted, while another did so in more than 81.0% of such patients. It is concluded that both patient selection and donor supply will remain significant determinants of the outcome of patients referred for cardiac transplantation.     

Selection of patients with parenchymal cirrhosis for hepatic transplantation

The aim of our study was to design simple and practical quantitative scores or indices suitable for deciding a pre-liver transplantation work-up in patients with parenchymal cirrhosis. A Pugh score (combining five variables) superior to 8 or a p value inferior to 0.7 of a logistic regression equation containing only two variables (score of ascites and result of 14C aminopyrine breath test) were found to be highly effective for making this decision.     

Selection of patients with cystic fibrosis for lung transplantation

Lung transplantation is the most aggressive therapy available for end-stage lung disease from cystic fibrosis (CF). A new predictive survival model of CF uses demographic, FEV1, nutritional, microbiologic, and acute exacerbation data to produce precise estimates of 5-year survival. The model improves the ability to select patients most likely to have survival benefit from transplantation. We discuss potential application of the survival model to four distinct groups of patients with CF: (1) candidates for cadaveric transplantation, (2) potential living donor recipients, (3) patients infected with multiply-resistant organisms such as Burkholderia cepacia, and (4) patients critically ill and dependent on mechanical ventilation. Measuring the impact of transplantation on quality of life remains a difficult task, and further studies are needed to determine whether lung-transplantation-derived survival benefit implies quality-of-life benefit. However, judicious use of the survival model to select patients for transplantation is likely to improve survival outcomes.     

Bridging patients to cardiac transplantation

Potential recipients of heart transplants have the most advanced form of congestive heart failure, in which standard therapy fails to maintain clinical stability. In the absence of guidelines derived from evidence obtained in clinical trials, caring for these patients becomes a challenge. A successful approach requires the proper coordination of surgical and nonsurgical strategies, including revascularization and valvular surgery as well as mechanical ventricular support and medical strategies. Intensive medical therapy is the most commonly used approach for prolonged bridging to transplantation. Although carefully individualized regimens are necessary to achieve desired goals, most centers adopt a fairly standardized approach involving vasodilators, diuretics, and inotropic support. Bridging patients with cardiac decompensation to transplantation presents a major therapeutic challenge. Appropriate strategies will maximize patients' chances that the bridge from decompensation to transplantation remains intact. (c)2000 by CHF, Inc.     

Selection of patients for liver transplantation in 1997 and beyond

Liver transplantation is now accepted as the standard surgical-medical treatment for end-stage liver disease, as well as replacement therapy for certain inborn errors of metabolism. While improvements in surgical methods and new immunosuppressive agents have improved survival, there remains a chronic shortage of available donor organs. This article offers guidelines for the physician, discussing indications for liver transplantation, controversial selection issues, contraindications, and finally, the future of liver transplantation.     

Selection of patients for bone marrow transplantation in severe aplastic anemia

Despite androgens and intensive supportive care, satisfactory survival in severe aplastic anemia remains at 20% or less. Histocompatible bone marrow transplantation can restore normal hematopoiesis in approximately 40% of similarly severe individuals. Delay of transplantation for 3 wk after diagnosis allows time for proper evaluation and for many spontaneous recoveries. Further delay increases risks of fatal complications and decreases chances for successful transplantation while the incidence of spontaneous remission declines. When available, early histocompatible bone marrow transplantation may be the treatment of choice for severe aplastic anemia.     

Selection of diabetic patients for islet transplantation. A single-center experience

OBJECTIVE: Since the Edmonton protocol, islet transplantation (IT) offers the prospect of adequate glycemic control with no major surgical risk. In our single-center experience of IT, we studied the recruitment of eligible diabetic patients. METHODS: Between 1998 and 2002, we screened 79 diabetic patients that were divided into 2 groups according to their renal status: 41 were not receiving dialysis (ND) while 38 were receiving ongoing dialysis (D). RESULTS: In the ND group, 20 patients initiated the contact with our team, 8 patients were recruited during hospitalization for very poor glycemic imbalance, and 13 were referred by their diabetologist. 14/41 (34%) patients were ineligible for IT either because of very good glycemic balance, detectable C-peptide (C-p), kidney or liver problems, or plans for future pregnancy. 16/41 (39%) did not wish to proceed, 7 of whom were more interested by a pump. 11/41 (27%) were eligible, among which 8 are currently being assessed, 1 is on the waiting list and 2 have been transplanted. In the D group, 17/38 (45%) had a detectable C-p and received a kidney graft alone. Among the remaining 21 C-p negative diabetic patients, 3 were not eligible for kidney transplantation mainly for psychological reasons, and 4 were enlisted for kidney+pancreas transplantation. The remaining 14 C-p negative patients were kidney-transplanted. Among them, 6 were not eligible for IT, mainly for lack of motivation, slightly positive C-p stimulation tests, obesity, cancer, or increased creatininemia. The remaining 8/14 C-p negative kidney-engrafted patients were enlisted for IT. 3 had secondary failure with the pre-Edmonton immunosuppressive (IS) protocol. Five have been transplanted with the Edmonton-like IS regimen. CONCLUSION: Twenty-five per cent of the 79 patients for whom islet transplantation was considered underwent pregraft assessment and 12% (10 patients, 8 kidney-transplanted and 2 islet alone) of the 79 have been transplanted. The main eligibility criteria were undetectable Cpeptide, normal kidney function, average weight, glycemic imbalance, hypoglycemia unawareness, and glycemic brittleness.     

Oral treatment with enoximone in patients referred for cardiac transplantation.

A prospective, uncontrolled, open ended study was performed to assess the effect of treatment with oral enoximone therapy in patients with end stage cardiac failure unresponsive to conventional treatment. The primary objective of treatment, hospital discharge, was achieved in 27 of 35 patients studied. Baseline haemodynamics were obtained in 21 patients. The mean cardiac index of patients who improved by one or more grades (New York Heart Association) was 2.1 litres/min while, in those who had less improvement, the mean cardiac index was 1.5 l/min (P less than 0.01). The average duration of treatment was 13 weeks, treatment being discontinued in 25 patients within twelve weeks. The main reasons for discontinuation were side effects (n = 11), and progressive cardiac failure (n = 7). The prognosis of patients in whom therapy was discontinued was very poor, only 5 of 28 being discharged from hospital without cardiac transplantation. Sudden death was uncommon (1/13), and Holter monitoring in 17 showed no aggravation of ventricular arrhythmias. Oral treatment with enoximone is a useful adjunct in the treatment of end stage cardiac failure.