Transplantation of kidneys from pediatric cadaver donors to adult recipients

Pediatric donors (less than 12 years old) are a potentially important source of kidneys for adult recipients. Previous reports of decreased graft survival and increased complication rates have made surgeons wary of using such kidneys. In 64 kidneys from younger donors transplanted to adult recipients the delayed graft function rate (41 versus 42%), and 2 and 3-year graft survival rates (67 versus 72% and 61 versus 65%, respectively) were similar to those seen with kidneys from adult donors. Kidneys from donors 24 months old or less experienced an 80% rate of graft loss at 1 year. When these kidneys are excluded the 1-year graft survival rate was similar to kidneys from older and younger donors (70 versus 77%). Mean serum creatinine at 1 year was similar in both groups (155 +/- 21 versus 151 +/- 10). Pediatric kidneys except those obtained from donors 2 years old or less are suitable for adult recipients. However, kidneys from very young donors may be more appropriate to pediatric recipients.     

Heart and unilateral lung transplantation for cardiomyopathy with high pulmonary vascular resistance.

Heart and left lung (en bloc) transplantation was used as an approach to end-stage cardiomyopathy with very high pulmonary vascular resistance. This surgical method was applied to a 13-year-old girl who did very well initially, but died 5 months later of severe pulmonary and cardiac rejection. The pulmonary perfusion scintigraphy showed equalization of the blood flow in both lungs after 42 days, and complete reversal of the pulmonary vascular changes in the opposite lung was observed at autopsy.     

Transplantation tourism: high risk for the recipients

Yakupoglu YK, Ozden E, Dilek M, Demirbas A, Adibelli Z, Sarikaya S, Akpolat T. Transplantation tourism: high risk for the recipients.
Clin Transplant 2010: 24: 835–838. © 2009 John Wiley & Sons A/S. Abstract: Background: The shortage of donor organ supply is forcing patients with end‐stage renal disease to alternative searches. The aim of this study is to present the clinical and laboratory data of five patients who were transplanted in Egypt from paid living‐unrelated donors and followed at our institution. Methods: Five patients (four male, one female, mean age 51 yr) were included in this retrospective study. Results: All allografts still have good function with a mean serum creatinine level of 0.9 mg/dL. Surgical and medical problems were common such as wound infection (n = 3), evisceration (n = 2), deep vein thrombosis (n = 2), unexplained abdominal incision requiring removal of an abdominal surgical compress left in situ during previous surgery, placement of allograft on the side of an unrepaired indirect inguinal hernia and transplant pyelonephritis. Conclusion: Although recent developments increased success in renal transplantation, receiving a kidney from a paid living donor at a commercial transplant center still carries great risks for the recipient.     

Transplantation of liver grafts from older donors: impact on recipients with hepatitis C virus infection

INTRODUCTION: Older donor allografts are being accepted for liver transplantation (LTx) due to shortage of organs. Hepatitis C virus (HCV) infection-related disease is presently the most common indication of LT in the United States. We studied the impact of donor age on patient and graft survivals in patients with HCV infection. PATIENTS AND METHODS: One hundred fifty four consecutive HCV(+) LTx recipients (117 men, 37 women) were studied. The mean follow-up period was 41.0 +/- 30.2 months. The population was divided into four groups according to donor age: group I (< or =20 years); group II (21 to 40 years); group III (41 to 60 years); group IV (>60 years). RESULTS: Thirty-two (20.8%) patients died during follow-up and 16 patients (10.4%) required retransplantation. The actuarial 7-year patient survivals for groups I, II, III, and IV were 87.1%, 73.7%, 69.3%, and 68.5%, respectively (P = .4). Patient survivals for donor age groups III + IV (n = 95) and groups I + II (n = 59) were 68.9% and 77.2%, respectively (P = .19). The 7-year graft survivals for groups I, II, III, and IV were 82.7%, 71.8%, 65.8%, and 62.5%, respectively (P = .17). Graft survivals for groups III + IV and groups I + II were 58.4% and 76.2%, respectively (P = .03). CONCLUSION: Patient and graft survivals for HCV-positive liver transplant recipients in this study decreased progressively as the donor age increased. Patient and graft survivals were best for group I recipients. There were significant differences in graft survivals when recipients were grouped with a cutoff donor age of 40 years.     

Organs from donors with primary brain malignancy: the fate of cardiac allograft recipients

BACKGROUND: The phenomenon of malignancy transmission from donors with primary brain malignancy (PBM) which is relatively well documented in renal or liver transplant recipients, has not been analyzed in cardiac allograft recipients. METHODS: We reviewed the medical records of 32 cardiac allograft recipients who were transplanted with organs from donors suffering from primary brain malignancies from 1989 to 2003. RESULTS: No case of donor-transmitted malignancy has been reported with a mean follow-up of 80.6 months. CONCLUSIONS: In our experience as well as according to a review of the literature, the risk of tumor transmission from donors with primary brain malignancy to cardiac allograft recipients seems to be extremely low. In the context of the increased donor shortage, we recommend to accept all suitable cardiac allografts harvested from donors with primary brain malignancy provided there are no detectable remote metastases.     

Liver transplantation from living donors with Gilbert's syndrome is a safe procedure for both donors and recipients

Liver transplantation (LT) has become a favorable therapeutic option for patients with end‐stage liver diseases. Gilbert's syndrome (GS) is a benign condition characterized by intermittent mild jaundice due to unconjugated hyperbilirubinemia. It is not obvious whether living‐donor liver transplantation (LDLT) from a donor with GS could result in a normal outcome for both the recipient and the donor. We aimed to determine whether right lobe hepatectomy is a safe procedure for living donors with GS and LT recipients. Between September 2011 and March 2015, 305 LDLT procedures using right lobe grafts were performed at Atasehir Memorial Hospital, Istanbul, Turkey. Nineteen of 305 LT candidates who had been diagnosed with GS were included in the current study. After a 12‐h overnight fast, total and indirect bilirubin levels of donors and recipients were measured. The median follow‐up after transplant was 16 months (range 3–36 months). The median age of donors was 25 (range 20–55 yr). Four donors (21%) were female, and 15 donors (89%) were male. The median age of donors was 51 (range 23–68 yr). Eleven recipients (57%) were female, and 8 (43%) were male. The median preoperative total bilirubin level of donors was 1.69 mg/dL (range 1.26–2.43 mg/dL) (normal range <1.2 mg/dL). The median total bilirubin level of donors on postoperative day 7 was 1.04 mg/dL (range 0.71–3.23 mg/dL). As our study has included a large number of donors with GS, it produced reliable evidence that right lobe hepatectomy is a safe procedure for living donors with GS and LT recipients.     

婴儿供肾儿童肾移植四例临床分析

目的 探讨婴儿供肾儿童肾移植的临床效果.方法 回顾性分析4例婴儿供肾儿童肾移植的临床资料、手术方式、免疫抑制剂应用和随访情况.结果 术后随访2～14个月,所有受者均存活.1例术后发生肾功能延迟恢复,经腹膜透析治疗后恢复;1例出现尿漏,经再次手术后恢复;1例因移植肾动、静脉血栓形成而切除移植肾.3例受者移植肾功能恢复良好,末次随访时血肌酐分别为70 μumol/L、102 μmol/L和83 μmol/L.结论 婴儿供肾儿童肾移植短期效果尚可,有利于缓解供肾短缺情况,值得深入研究.     

Advising potential recipients on the use of organs from donors with primary central nervous system tumors

Deciding to use an organ from a donor with a primary central nervous system (CNS) tumor necessitates offsetting the risk of tumor transmission with the chances of survival if the patient waits for another offer of a transplant. Published data vary in the quoted risk of tumor transmission. We used data obtained by reviewing 246 UK recipients of organs taken from donors with CNS tumors and found no evidence of a difference in overall patient mortality for recipients of a kidney, liver, or cardiothoracic organ, compared with recipients of organs from donors without a CNS tumor. Recent publication of the UK experience of transplanting organs from CNS tumor donors found no transmission in 448 recipients of organs from 177 donors with a primary CNS tumor (Watson et al., Am J Transplant 2010; 10: 1437). This 0% transmission rate is associated with an upper 95% confidence interval limit of 1.5%. Using a series of assumptions of risk, we compared the risks of dying as a result of the transmission of a primary brain tumor with the risks of dying if not transplanted. On this basis, the use of kidneys from a donor with a primary CNS tumor provides a further 8 years of life over someone who waited for a donor who did not have a primary CNS tumor, in addition to the life years gained by the transplant itself. The benefits for the recipients of livers and cardiothoracic organs were less, but there was no disadvantage in the impact on life expectancy.     

Retrospective investigation of pulmonary resection in patients with high total pulmonary vascular resistance during preoperative unilateral pulmonary artery occlusion

Purpose  The aim of this study was to evaluate the indications for pulmonary resection (lobectomy) in patients with increased total pulmonary vascular resistance (TPVR) during a preoperative unilateral pulmonary artery occlusion (UPAO) test. According to our previous report, the feasibility of performing lobectomy in patients with a high risk of cardiopulmonary complications is determined on the basis of the increase in TPVR after 15 min of obstruction during the UPAO test (occluded TPVR). Methods  A total of 19 high-risk [occluded TPVR ≥700 dynes/s/cm⁻⁵/m² (dynes)] patients who underwent lobectomy or pneumonectomy were studied and a detailed analysis of postoperative cardiopulmonary complications was performed. The subjects were divided into four groups based on the occluded TPVR (700–799 dynes, 800–899 dynes, 900–999 dynes, or ≥1000 dynes) to compare the incidence of postoperative complications. Results  Two patients died after surgery. One of them had an occluded TPVR >1000 dynes and died 313 days after right upper lobectomy; the other had an occluded TPVR of 783 dynes and died 20 days after right pneumonectomy. Postoperative cardiopulmonary complications occurred in 6 of 19 patients (31.6%), and all three patients with an occluded TPVR ≥900 dynes developed cardiopulmonary complications. Conclusion  Limited surgery should be performed in patients with an occluded TPVR ≥900 dynes.     

Normalization of high pulmonary vascular resistance with LVAD support in heart transplantation candidates.

OBJECTIVE: Pulmonary hypertension (PH) and elevated pulmonary vascular resistance (PVR) lead to poor outcome after heart transplantation due to postoperative failure of the non-conditioned right ventricle. The role of continuous flow left ventricular assist device (LVAD) support in the reduction of elevated PVR was evaluated in a series of clinical implants. METHODS: Among 17 patients with terminal heart failure receiving a MicroMed DeBakey LVAD as bridge to transplant, there were six patients with pulmonary hypertension (mean systolic PAP 47 mmHg) and high PVR (398 dynes/cm5), previously not considered suitable for heart transplantation, who underwent serial right heart catheters during their LVAD support period. RESULTS: In these patients mean systolic pulmonary pressure dropped to 29 mmHg and PVR decreased to a mean 167 dynes/cm5 under LVAD support. Clinical improvement was significant in all patients. Four patients were successfully transplanted without major postoperative difficulties (mean duration 130 days support) and all are doing well to date. Post-transplant-PVR remained in the normal range in all transplanted patients. CONCLUSIONS: Elevated PVR and severe PH were both previously considered as contraindication for heart transplantation. A period of LVAD pumping leads to a progressive decrease of PVR and normalization of pulmonary pressures, making these patients amenable for heart transplantation. LVAD as bridge to heart transplantation is safe and highly beneficial for terminal heart failure patients with severe PH.     

Postoperative non-invasive assessment of pulmonary vascular resistance using Doppler echocardiography

Non-invasive monitoring of pulmonary vascular resistance (PVR) in postoperative cardiac surgery patients might be useful, particularly for management of pulmonary hypertension. For this purpose, we sought to assess Doppler echocardiography in the intensive care setting. In 73 patients, hemodynamics was measured using both, invasive gold standard (pulmonary artery catheter), and non-invasively by Doppler echocardiography. Four Doppler parameters: (1) tricuspid regurgitant velocity/time-velocity-integral of right ventricular outflow tract (TRV/VTI(RVOT)), (2) tricuspid annular systolic velocity (S'), (3) tricuspid annular strain, and (4) tricuspid annular strain rate, were compared with invasive PVR, using linear regression analysis and receiver-operating-characteristics. Patients without (n = 25, group 1) and patients with elevated left ventricular filling pressure (wedge pressure ≥ 15 mmHg, group 2, n = 48) were compared. Correlations were (1) R = 0.874, P < 0.0001, (2) R = -0.765, P < 0.0001, (3) R = 0.279, P = 0.009, (4) R = 0.378, P = 0.001. TRV/VTI(RVOT) showed prediction of PVR >300 dyn*s*/cm(5) (area-under-curve 0.975, cut-off 0.245, sensitivity 100%, specificity 91%). Strain correlated with PVR in group 2 patients only. TRV/VTI(RVOT) and tricuspid annular systolic velocity (S'), are useful for non-invasive monitoring of PVR in postoperative cardiac surgery patients with or without elevated left ventricular filling pressure. Strain may be used in patients with elevated filling pressure.     

Use of hearts transplanted from donors with atraumatic intracranial bleeds.

BACKGROUND: Donor atraumatic intracranial bleed (aICB) is associated with older age and may reflect a history of hypertension. Hearts from donors who died of aICB may be at increased risk for graft failure because of the associated catecholamine surge. We evaluated whether receiving a heart from a donor who had an aICB independently affected the outcome of transplantation. METHODS: We reviewed adult patients (>18 years) who underwent heart transplantation between July 1994 and December 1999. We excluded patients who received non-standard hearts (e.g., donor age >55 years). Group 1 received hearts from donors with aICB (n = 80), and Group 2 received hearts from donors who did not have aICB (n = 171). RESULTS: Recipient age, gender, United Network for Organ Sharing status, and indication for transplantation were similar for both groups. Donors in Group 1 were older (41 vs 26 years, p = 0.001), more commonly women (55% vs 20%, p = 0.001), and more often had history of hypertension (26% vs 2%, p = 0.001). Survival to discharge was 86% in Group 1 and 95% in Group 2. Actuarial 5-year survival was 72% for Group 1 and 81% for Group 2 (p = 0.52). Regression analysis showed that receiving a heart from a donor with aICB was a risk factor for early recipient mortality but not for long-term outcome (odds ratio = 3.25, p = 0.02, and hazard ratio = 1.16, p = 0.69, respectively). Donor aICB, female gender, and abnormal initial echocardiogram (global hypokinesia) were selected as clinically relevant independent risk factors for early mortality of the recipient, using a fitted multifactor logistic regression model (goodness-of-fit chi-square p value = 0.94). Donor age, accident-to-retrieval time interval, and borderline left ventricular hypertrophy did not significantly differ. Five-year freedom from transplant coronary artery disease in Group 1 was 74% (vs 80% in Group 2, p = 0.05). CONCLUSIONS: The trend observed in this series suggests that receiving a heart from a donor with aICB is a potential independent risk factor for early mortality after transplantation independent of age. Caution should be used when evaluating such donors, particularly when other risk factors such as female donor or depressed ejection fraction are present.