脑死亡器官捐献单中心经验（附26例报告）

目的总结脑死亡器官捐献单中心经验。方法回顾性分析2006年3月至2012年6月解放军第181中心医院全军肾移植与透析治疗中心完成的脑死亡器官捐献与移植案例。结果共完成脑死亡器官捐献26例,进而完成52例肾移植和8例肝移植,移植器官功能均良好。其中48例肾移植受者总存活率92．2％,移植肾总存活率83．7％。结论脑死亡器官捐献是器官移植重要的器官来源,但在我国尚处于起步阶段,进一步发展需取决于相关法律法规的制定以及捐献者、受者、医疗机构的权责是否得到明确和保证。     

脑死亡的研究进展

本文综述了脑死亡的概念、诊断标准及其鉴别诊断和辅助检查。     

脑死亡与器官移植

传统的死亡概念是心脏和肺丧失功能，由于心肺功能的停止是容易观察到的，所以判定是否死亡比较容易取得一致。不过，最近３０年来，传统的死亡观念遇到了挑战，一方面是由于复苏抢救设备的出现，使人工维持心肺功能成为可能，心跳、呼吸停止才算是死亡的观念受到质疑；另一方面，大量的资料表明，当脑干受到广泛而不可恢复的损伤时，即使人工维持的心肺功能非常好，也不能真正挽救生命，而只是在延迟心肺的死亡过程。诊断脑死亡的所有病人的心脏迟早要停止跳动〔１〕。因此从中枢神经系统角度来定义死亡就越来越受到重视，这样不仅可以减少…     

脑死亡的研究进展

本文综述了脑死亡的概念、诊断标准及其鉴别诊断和辅助检查。     

我国大陆肝移植与脑死亡立法进展

我国是肝病大国,各种肝病发展至终末期均会导致正常肝功能的丧失,国内外普遍认为肝移植是治疗各种终末期肝病使患者重新获得正常肝功能的最佳选择.近年来我国肝移植取得快速发展,各种相关技术均已比较成熟,但肝脏来源作为一个瓶颈问题始终没有得到妥善解决,而采取脑死亡标准并立法加以规范是解决该问题的一个有效途径.我国的脑死亡标准仍没有法律依据,从而影响了可用于移植的肝脏来源,进而限制肝移植的发展.制定规范的脑死亡标准并对其立法规范必定能对增加器官来源给予极大帮助,促进肝移植的健康规范发展.     

脑死亡供体器官研究进展△

目的探讨脑死亡供体器官相关研究进展。方法采用文献复习的方法,对研究脑死亡供体器官研究的相关文献加以综述。结果脑死亡产生的一系列病理生理改变,如血流动力学、内分泌、代谢、炎症反应等,对供体器官质量、免疫活性以及移植后移植物长期生存率均有显著影响,虽然国内外学者对其研究甚多,但具体机理仍未完全阐明。结论脑死亡供体病理生理改变对移植物预后具有重要影响,需要深入研究。     

脑死亡对供体心脏损伤的研究进展

早期原发性移植物衰竭是心脏移植患者早期死亡的重要因素,而应用脑死亡供体是引起早期原发性移植物衰竭的重要因素。急性脑死亡后可引起供体血流动力学的剧烈改变以及循环中生化指标的紊乱,并造成心肌形态学上的损伤。本文就急性脑死亡后机体各系统出现的变化及造成心肌损伤的研究进行综述。     

脑死亡状态对大鼠肝脏损伤的影响

目的　探讨大鼠脑死亡状态与肝脏损伤之间的关系。方法　将 50只大鼠随机分为空白对照组 (C)、低血压状态假手术组 (E1 )、脑死亡实验组 (E2 )。各组动物分别于辅助呼吸 1、3h采血检测丙氨酸氨基转移酶 (ALT)、天冬氨酸氨基转移酶 (AST)及透明质酸 (HA)、内皮素 1 (ET 1 ) ,辅助呼吸 4h取肝组织行形态学检查。结果　 1、3h血清ALT、AST以及HA、ET 1水平E2组较C、E1组显著升高 (P <0 .0 5) ;E2组中 3h较 1h显著升高 (P <0 .0 5)。电镜下E2组大鼠肝脏Kuffer细胞明显活化 ,肝窦内皮细胞与基质部分脱落、肝窦内皮窗孔扩大 ;C、E1组Kuffer细胞活化不明显 ,内皮细胞基本完整。结论　大鼠脑死亡状态能明显导致肝实质细胞与非实质细胞损伤     

改良大鼠渐进性脑死亡模型的制作

目的 总结制作大鼠渐进性脑死亡模型的技巧并改良此模型的制作方法.方法 对经典Pratschke术式的麻醉、插管、颅内加压、脑死亡判断等环节进行探讨,建立Wistar大鼠的渐进性脑死亡模型.结果 所有动物在诱导脑死亡过程中均出现较一致的血压变化规律:诱导后期平均动脉压开始急剧升高,于颅内加压后(11±2)min时达到峰值(190±15)mm Hg,其后血压急剧下降,(20±3)min时达到谷值(70±16)mm Hg,与诱导前平均动脉压(110±18)mm Hg比较,其峰值和谷值差异均具有统计学意义(P＜0.05).共诱导40例大鼠脑死亡,37例能成功维持正常血压达6 h,手术成功率92.5%(37/40).结论 与经典Pratschke术式比较,该术式降低难度,提高手术成功率,是一种较稳定、可靠的大鼠脑死亡模型.     

脑死亡对猪肝脏免疫原性的影响

目的观察脑死亡对猪肝脏免疫原性的影响。方法健康猪12头,随机分为2组:对照组6头,仅行麻醉维持24h;脑死亡组6头,建立猪脑死亡模型并维持脑死亡状态24h。脑死亡后(对照组持续麻醉后)6、12、24h取血标本及开腹取同一部位肝组织,利用ELISA法检测血清肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)水平变化,实时荧光定量PCR法观察肝组织细胞间黏附分子-1(ICAM-1)、单核细胞趋化蛋白-1(MCP-1)mRNA变化,免疫组织化学法观察肝组织主要组织相容性复合体Ⅱ(MHC-Ⅱ)表达变化。结果各时间点脑死亡组血清TNF-α、IL-6水平、肝组织ICAM-1、MCP-1mRNA转录水平及肝组织MHC-Ⅱ表达水平均较对照组高,两者相比差异有统计学意义(P<0.05)。结论脑死亡状态增加了肝组织的免疫原性。可能潜在增加了移植后供肝的免疫损伤及排斥反应发生率。     

Brain Death and Its Influence on the Lungs of the Donor: How Is It Prevented?

The need for lung grafts is currently greater than ever. Unfortunately, the availability of grafts is insufficient for this demand. So we are forced to request organs for transplantation in the “waste bin.” One possible solution to this problem may be the use of grafts from brain-dead patients. Sadly brain death is followed by devastating hemodynamic, inflammatory, and neurohumoral reactions in the potential donor which not only inflict direct damage, but also induce activation of the immune system which can cause rejection or even graft failure. Therefore, various groups have examined measures to prevent this outcome. In this review, we attempt to reconstruct the events that follow brain death, suggesting an algorithm to prevent a brain-dead patient's lungs from further damage. Finally, we are proposing potential measures of graft's protection of further investigation.     

Brain Death: Knowledge of Future Brazilian Physicians

Background

Thousands of people die on the waiting list for transplants. The shortage of organs and tissues for transplantation is considered a serious global problem. Brain death (BD) is the main source of organs for transplantations.

Academia Eurasiana Neurochirurgica Brain Death

Conclusions Brain death (or cerebral death) means definitive cessation of all neural functions above the spinal cord, thus implying the irreversible loss of all cerebral and brain stem functions.Spinal cord activity may persist after brain death-priapism, persistence of myotatic reflexes- for a few minutes and this spinal activity may be responsible for coarse limb movements after life-support machines have been turned off.The preservation of these spinal reflexes reinforces the advice to allow only responsible doctors to assist at the declaration of death of the patient.     

Brain Death Impairs Pancreatic Microcirculation

Brain death (BD) influences the quality of donor grafts in transplantation. To evaluate the impact of BD on pancreas grafts, we investigated the influence of BD on the microcirculation and histology of the pancreas in a rat model of explosive BD. A group of Wistar rats (n=7), rendered brain dead by inflating an intracranially inserted Fogarty catheter was compared with controls (CO) using intravital epifluorescence-microscopy over 4 h after BD induction; functional capillary density (FCD), leukocyte adherence (AL) in post-capillary venules, histology and pancreatic enzymes were investigated. Four hours after BD, FCD decreased (333 +/- 11 vs. baseline 444 cm/cm2 +/- 5 SEM; p<0.01) and showed lower values than CO (388 +/- 9 p<0.01). In BD, AL was increased (628 cells/mm2 +/- 110 SEM vs. baseline 123 +/- 32, and vs. CO 180 +/- 33; p<0.001). BD caused increased histological damage (CO 1.6 score-points +/- 0.7 SD vs. BD 8.3 +/- 7.1; p<0.05). Amylase was higher in BD (p<0.05) but did not reach pathological values. We show for the first time that BD causes relevant changes in pancreatic microcirculation, histology and leukocyte endothelial interaction which might have a serious impact on the function of grafts. New strategies for preventing this damage are therefore highly desirable in order to improve the outcome of pancreas transplantation.     

Brain Death and Donor Heart Dysfunction: Implications in Cardiac Transplantation

Abstract   Aim: In this article, the hemodynamic, humoral, and immunological perturbations following brain death (BD) are going to be discussed in a stepwise manner. Materials and Methods: BD produces derangements in cardiac function, through a not-yet-well-explained mechanism. Using literature review, we attempted to delineate the "pathophysiology" involved. Results: A severe a-adrenergic stimulation following catecholamine storm results in conditions such that the pulmonary capillary pressure is massively increased. Furthermore, cytokine up-regulation, endothelial expression molecules, and neutrophil infiltration produce tissue damage. The end result reflects myocardial necrosis due to reduction of the calcium ATPase activity that leads to myocyte calcium overload and cell death. Conclusions: Delineation of the mechanisms responsible for donor heart dysfunction (DHD) would be presented. Furthermore, an attempt would be made to apply this knowledge into the clinical practice in order to increase the suitability of donor hearts for transplantation. (J Card Surg 2010;25:98-106)     

Our Brain Death and Organ Donation Experience: Over 12 Years

PurposeNowadays, as the number of patients waiting for organ transplant is increasing, it is important to diagnose brain death in intensive care units and to provide good donor care. We aimed to share our experience of donor care with the diagnosis of brain death in our clinic.Material and methodOne hundred and fifty-one patients diagnosed in our clinic with brain death between June 2006 to 2018 were studied retrospectively.FindingsThe mean age of the 151 patients was 46.6 (1–89) years. Fifty-seven (37.7%) of the 151 patients’ families accepted donation. Ten out of 57 patients could not be organ donors for medical reasons. Eighty-four kidneys, 7 hearts, and 40 livers were transplanted to the patients. When the diagnosis at admission to the intensive care unit was examined, it was found that the most common diagnosis was intracranial hemorrhage (36.8%), followed by head trauma (21.05%), drowning in water (3.5%), and firearm injury (3.5%). The apnea test was applied to all cases, but 17 patients could not complete the apnea test. In order to support the diagnosis of brain death, in 63% of patients (n = 95) radiological methods were performed. Cranial computed tomography angiography was performed as a radiological method. All cases were found to have received at least 1 inotropic support. We used dopamine in 41 patients, noradrenaline in 36 patients, dobutamine in 8 patients, and adrenaline in 3 patients. During the 12 months when the organ transplant coordinator was not on duty, there were no organ donors. It is important to maintain an organ and tissue transplant coordinator and an intensive care unit team for organ donation.ConclusionIn order to increase the cadaver donor pool, it is necessary to increase the number of brain death diagnoses and decrease the rate of family rejection. Therefore, patients with poor neurologic prognosis should be carefully monitored for brain death. Successful family discussions by an experienced and trained organ transplant coordinator should try to increase donation rates by emphasizing the importance of organ donation and the fact that brain death is a real death.     

Brain Death Determination in Israel: The First Two Years Experience Following Changes to the Brain Death Law—Opportunities and Challenges

To increase support for the concept of brain death, changes accommodating requirements of the religious authorities were made to the Brain Death Act in Israel. These included (1) considering patient wishes regarding brain death determination (BDD); (2) mandatory performance of apnea and ancillary testing; (3) establishment of an accreditation committee and (4) requirement for physician training courses. We describe the first 2 years experience following implementation (2010–2011). During 2010, the number of BDD decreased from 21.9/million population (during the years 2007–2009) to 16.0 (p < 0.001). Reasons included family resistance to brain death testing (27 cases), inability to perform apnea testing (7) and logistic problems related to ancillary testing (26 cases). The number of physicians available to declare brain death also decreased (210 vs. 102). During 2011, BDDs increased to 20.5/million following the introduction of radionuclide angiography as an ancillary test; other reasons for nondetermination persisted (family resistance 26 cases, inability to perform apnea testing 10 cases). Instead of increasing opportunities, many obstacles were encountered following the changes to the Brain Death Act. Although some of these challenges have been met, longer term follow‐up is required to assess their complete impact.     

Portrayal of Brain Death in Film and Television

We sought to evaluate whether television and cinematic coverage of brain death is educational or misleading. We identified 24 accessible productions that addressed brain death using the archives of the Paley Center for Media (160 000 titles) and the Internet Movie Database (3.7 million titles). Productions were reviewed by two board‐certified neurologists. Although 19 characters were pronounced brain dead, no productions demonstrated a complete examination to assess for brain death (6 included an assessment for coma, 9 included an evaluation of at least 1 brainstem reflex, but none included an assessment of every brainstem reflex, and 2 included an apnea test). Subjectively, both authors believed only a small fraction of productions (13% A.L., 13% J.W.) provided the public a complete and accurate understanding of brain death. Organ donation was addressed in 17 productions (71%), but both reviewers felt that the discussions about organ donation were professional in a paucity of productions (9% for A.L., 27% for J.W.). Because television and movies serve as a key source for public education, the quality of productions that feature brain death must be improved.