Orthotopic liver transplantation following heart transplantation]

Heart transplantation was performed in a 24-year-old man suffering from dilated cardiomyopathy who was also infected with hepatitis B virus and had not yet seroconverted. Most likely due to the immunosuppression, the hepatitis exacerbated and soon led to hepatic dystrophy and precoma. In this phase of congruent rejection of the heart transplant, liver transplantation was performed. During the procedure the patient had stable circulatory parameters and a reduced cardiac output. The heart rate and cardiac output stabilized after release of the anastomosis of the hepatic vessels. The patient survived for 6 months and died at home with signs of a myocardial infarction.     

ABO incompatible renal transplantation following lung transplantation

We present management strategies utilised for the first case of an urgent live-donor ABO incompatible B blood group renal transplant, in a patient with a prior A blood group lung transplant for cystic fibrosis. Three years on, renal function is excellent and stable, whilst lung function has improved.     

Lung transplantation after hematopoietic stem cell transplantation

Whitson BA, Shelstad RC, Hertz MI, Kelly RF, D’Cunha J, Shumway SJ. Lung transplantation after hematopoietic stem cell transplantation.
Clin Transplant 2011 DOI: 10.1111/j.1399‐0012.2011.01482.x.
© 2011 John Wiley & Sons A/S. Abstract: Introduction: Pulmonary insufficiency following bone marrow transplant (BMT) is common and has significant associated mortality. Lung transplantation (LTX) is the only viable treatment for patients with end‐stage pulmonary disease, but LTX after BMT is an uncommon event given the medical candidacy of the potential recipients. We sought to evaluate the short‐ and long‐term outcomes of LTX in BMT recipients. Methods: We performed a retrospective evaluation of our institution’s longitudinal LTX and BMT databases. Demographic and outcomes variables were collected. Results: We identified 639 LTX from January 1, 1988, through December 31, 2009, and 5525 BMT from program inception, March 21, 1974, through December 31, 2009. From the cross‐referenced cohort, we identified four patients who had BMT followed by LTX. Our series was composed of two men and two women, with a mean age of 32.3 yr (range, 20–59 yr). Single LTX were performed in two recipients (50%). All patients had significant and expected morbidities related to their transplant immunosuppression. Three patients (75%) required cardiopulmonary bypass at the time of LTX. The two recipients who underwent bilateral LTX required open chest management and subsequent tracheostomy. All patients are still alive at follow‐up (range, 19–119 months, median 39.5). Conclusion: Our study demonstrates that LTX in the setting of BMT is a high‐risk operation with the potential for a tumultuous perioperative course. Despite this, good outcomes and survival are obtainable in carefully selected patients. Selection factors include clinically stable patients without active sepsis and preoperative optimization of nutrition in anticipation of a prolonged recovery. An experienced multidisciplinary team approach and a protocol‐driven management plan are paramount for successful outcomes in this challenging population.     

Combined pancreas kidney transplantation after isolated kidney transplantation

Simultaneous pancreas kidney transplantation (SPK) is an established therapy for type 1 diabetics with end stage or preterminal renal disease. SPK is superior to isolated kidney transplantation (KTX) in diabetic patients. Even pancreas-re-transplantations are more common in these patients now, mostly after SPK. But Experience with SPK after KTX is rare. Between 1994 and 2003 six Re-SPK 4.5 to 8.5 years after KTX were performed in our department. Average age of the recipients was 40.5 years. They had been suffering from diabetes for an average of 29.3 years. Four recipients were on dialysis again, whereas two had preterminal renal insufficiency. Pancreas transplants were drained through the bladder (n = 1) or into the small intestine (n = 5) with systemic venous anastomosis. After a median observation period of 28 months (8 to 99 months) all six recipients are insulin free. One patient lost his kidney graft due to severe acute rejection. Therefore kidney graft survival is 83 %. Four acute rejections (66 %) were observed in 4 patients. Only one rejection was treated successfully by steroids. Two rejections could be stopped with antibodies. 3 patients had infections in the early postoperative period (sinusitis, urinary tract infection, wound infection). Even after KTX with graft failure, diabetic patients suffering from renal disease can be re-transplanted successfully with SPK.     

Cardiopulmonary transplantation

The Registry of the International Society for Heart and Lung Transplantation reported 108,034 adult recipients of deceased donor heart transplants between January 1992 and June 2018. The 37th annual adult lung transplant report submitted data to the ISHLT TTX Registry on 67,493 adult recipients of deceased donor transplants between January 1, 1992 and June 30, 2018. In recent years more than 5000 heart transplants and approximately 4000 lung transplants have been performed annually across 388 centres worldwide. Heart transplantation is a proven surgical option for selected patients with advanced heart failure refractory to surgical or medical management. Lung transplantation is the definitive treatment for end-stage lung disease in patients who have failed medical therapy. More than 90% of adult patients presenting for heart transplantation have dilated cardiomyopathy or ischaemic cardiomyopathy. Anaesthetic principles for heart transplantation comprise full monitoring, including transoesophageal echocardiography, cardiostable anaesthesia and cardiac support with assessment and treatment of pulmonary vascular hypertension. Median survival after cardiac transplantation is 11.9 years. Lung transplantation includes single-lung, double-lung, bilateral sequential single-lung, heart–lung and lobar transplantation. The most common indication, representing more than one-third of all transplant recipients, is chronic obstructive pulmonary disease. Donor criteria have become more liberal and lung transplants may involve cardiopulmonary bypass. Pre-bypass air trapping can compromise cardiac function. Postoperative ventilation management should be guided by pH, not P_aCO₂. Thoracic epidural analgesia provides optimal pain relief without respiratory depression. Five-year survival after lung transplantation is approximately 65%.     

Heart transplantation

Heart transplantation is the definitive treatment for selected patients with end-stage heart failure refractory to medical, interventional and surgical treatment. However, due to limited number of donor organs, most patients wait a long time for heart transplantation and a significant proportion die or become unsuitable for transplantation while waiting. Although post-transplant survival outcomes continue improving, a fifth of recipients die within 1 year after transplantation. In addition, recipients face constant threats from infection, rejection, malignancy and chronic allograft vasculopathy. Therefore, it is imperative to increase donor heart utilization to reduce waiting list mortality, and maintain allograft quality during transportation and optimize post-transplant care to improve outcomes. This review summarizes the process of heart transplantation from recipient and donor selection and matching to post-transplant management with a focus on the surgical aspects, and highlights the recent advancement, including donation after circulatory death programme, mechanical circulatory support, and ex-vivo heart perfusion.     

Hepatocyte transplantation

Numerous laboratory studies have shown that hepatocyte transplantation may serve as an alternative to organ transplantation for patients with life-threatening liver disease. Because of the successes of experimental hepatocyte transplantation, institutions have attempted to use this therapy in the clinic for the treatment of a variety of hepatic diseases. Unfortunately, unequivocal evidence of transplanted human hepatocyte function has been obtained in only one patient with Crigler-Najjar syndrome type I, and, even then, the amount of bilirubin-UGT enzyme activity derived from the transplanted cells was not sufficient to eliminate the patient's eventual need for organ transplantation. A roadmap for improving patient outcome following hepatocyte transplantation can be obtained by a re-examination of previous animal research. A better understanding of the factors that allow hepatocyte integration and survival in the liver and spleen is needed to help reduce the need for repeated cell infusions and multiple donors. Although clinical evidence of hepatocyte function can be used to indicate function of transplanted hepatocytes, definitive histologic evidence is difficult to obtain. In order to assess whether rejection is taking place in a timely fashion, a reliable way of detecting donor hepatocytes will be needed. The most important issue affecting transplantation, however, relates to donor availability. Alternatives to the transplantation of allogeneic human hepatocytes include transplantation of hepatocytes derived from fetal, adult or embryonic stem cells, engineered immortalized cells, or hepatocytes derived from other animal species.     

Bone transplantation

Summary According to one principle of surgery, the transplantation of vital tissue is the best method of reconstructing a defect. Because of absent immunologic reactions, high osteogenic potency, and preserved stability, transplantation of autogenous bone shows the best results. Necrosis of transplanted bone, leading inevitibly to absorption and remodeling of the graft, can be avoided if microsurgically vascularized autogenous bone segments are transferred. Disadvantages are the low availability and the necessity of additional operations. As an alternative, deep-frozen allogeneic bone is used. However, this kind of bone shows delayed incorporation based on cellular and humoral immune reactions, and it is also installed into the host bed after overcoming the immune barrier. The risk of microbiological contamination or transmission of unrecognized germs such as HIV is a cause of great expense in bone banking techniques. If one succeeds in reducing (a) the immunologic defense reaction and (b) the risk of infection by sterilization or disinfection without damaging the osteoinductive proteins of bone matrix, the rate of complications can be lowered. Demineralized bone matrix can be used if biomechanical stability is not required. Its ability to induce osteogenesis without a major immune reaction or the risk of transmitting diseases justifies its clinical application. Further intensive research in these areas is unavoidable.

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Zusammenfassung Ein Grundprinzip der Chirurgie lautet, daß die Übertragung von vitalem Gewebe die beste Methode zur Rekonstruktion eines Defekts darstellt. Aufgrund fehlender Immunreaktionen, hoher osteogenetischer Potenz und erhaltener Stabilität können daher mit der Transplantation autogenen Knochens die besten Ergehnisse erzielt werden. Die Nekrose des transplantierten Knochens, die unweigerlich zu Resorption und Umbau führen, kann umgangen werden, wenn mikrochirurgisch-vasklarisierte, autogene Knochensegmente Anwendung finden. Nachteile autogener Transplantate bestehen in ihrer geringen Verfügbarkeit und der Notwendigkeit zusätzlicher Operationen. Alternativ wird daher tiefgefrorener allogener Knochen verwendet. Nach Überwindung der Immunschranke, basierend auf zellu lären und humoralen Immunreaktionen, wird dieser wenn auch verzögert in das Wirtslager eingebaut. Die Gefahr der mikrobiologischen Kontamination und das Risiko einer Übertragung nicht erkannter Keime, insbesondere HIV, bedingen einen hohen Aufwand der Knochenbanktechnik. Gelingt es, durch geeignete Verfahren (a) die immunologische Abwehr und (b) durch Desinfektion oder Sterilisation die Infektionsgefahr zu reduzieren, ohne die osteoinduktiven Proteine der Knochenmatrix zu zerstören, kann die heute noch hohe Komplikationsrate gesenkt werden. Demineralisierte Knochenmatrix stellt deshalb eine Alternative als Knochenersatz dar. Ihre osteogenetischen Eigenschaften bei fast vollständigem Fehlen einer Immunreaktion oder der Gefahr, eine Infektionskrankheit zu übertragen, rechtfertigen ihren Einsatz in der Klinik. Weitere intensive Forschung auf diesen Gebieten bleibt jedoch unverzichtbar.

     

Heart transplantation

We review the contemporary management of end-stage heart disease with cardiac transplantation and the use of ventricular assist devices. When indicated, cardiac transplantation remains the gold standard therapy for end-stage heart disease. The outcome of transplantation is dependent upon the entirety of the transplantation process which consists of recipient factors, donor factors, organ retrieval, organ preservation, implantation and long-term management of transplant-related complications such as infection, rejection, malignancy and immunosuppression. However, despite best efforts a number of patients will die every year on the transplant waiting list. This is primarily due to a shortage of donors. In the recent years we have developed strategies to increase the number of organs, quality of donors and developed ways to support decompensated patients until a suitable organ has become available. The latter is known as bridging to transplantation. The most recent and promising development in this field has been in heart procurement. The traditional mode of preservation and transport of hearts on ice has been replaced by a sophisticated, device assisted organ care system (OCS). This probably reduces the ischaemic burden, permits longer cross-clamp times and may significantly increase the number of donor organs.     

Chondrocyte transplantation

The transplantation of chondrocytes as a treatment to repair defects and degeneration in hyaline articular cartilage is being tested in numerous laboratory and clinical settings. This has included transplanting chondrocytes grown in tissue culture that were procured from non-weight-bearing areas of the affected joint to transplanting allografts with living chondrocytes in their intact cartilaginous matrix. Reported success with transplanting host and donor chondrocytes has varied and widespread application of these techniques still awaits more definitive studies. The clinician needs more evidence that the transplanted chondrocytes maintain their viability and that they synthesize the appropriate extracellular matrix. This new matrix needs to reproduce the functional, mechanical, and long-term wear properties of the native articular cartilage. Chondrocyte transplantation also merits further monitoring for possible delayed immunogenicity or for any signs of neoplastic potential. This exciting technology and its potential application to damaged and degenerated articular cartilage remains a stimulus to encourage further scientific work. Duplicating the unique and complex interrelations of the chondrocytes, matrix, and various bioactive factors is still some years away from general patient care.     

Pancreatic transplantation

Pancreas transplantation is the only treatment of Type I diabetes that consistently establishes an insulin-independent, normoglycemic state. Currently long-term insulin-independence is achieved in > 80% of recipients of pancreas grafts placed simultaneous with the kidney and in > 70% of recipients of a pancreas after a kidney and non-uremic recipients of a pancreas alone. The penalty is immunosuppression, already obligatory for a kidney recipient, but the benefits are improved quality of life and the effect that perfect control of glycemia can have on secondary complications of diabetes.