Cross-over transplantation; a new national program for living kidney donations

In the Netherlands, cross-over kidney transplantation has been introduced as an extra option in the living kidney donation programme. In cross-over transplantation, patients who cannot be given their own partner's kidney for immunological reasons are given a kidney from the partner of another patient in exchange for a kidney from their own partner. There is no difference in the medical indications and contraindications between direct and indirect living donation. There are no ethical obstacles since the net gain for the two couples is no different from that of direct living kidney donation and because the exchange takes place on the basis of equality. One should be aware that the extra possibilities may result in more psychological pressure on potential donors. It is important that the donation procedures start at the same moment and that the wishes of patients and donors for anonymity be preserved. A successful cross-over kidney transplantation programme requires a large pool of donors and patients. Therefore, this has been organised in a national programme. The Dutch Transplantation Foundation is responsible for the allocation of cross-over kidneys. Organ trade will thus be impossible. The seven Dutch centres for kidney transplantation have developed a protocol.     

Liver transplantation of living donor adult-to-adult

End-stage liver disease is being treated by liver transplantation since more than 20 years. Despite social and legislative efforts, the number of cadaveric organs suitable for liver transplantation has not grown to match the surplus of patients with end-stage liver disease. With the growing discrepancy between donors and recipients, the median waiting time for liver transplantation has increased dramatically. As a result, the number of patients who die while waiting is increasing. To attempt to meet the growing needs of recipients, surgeons are developing innovative techniques to increase the number of donated livers. These include: split liver transplantation and transplantation of a part of the liver from living donors. This review will focus on adult-to-adult transplantation of the right lobe from a living donor.     

经裁剪供体肺的临床应用研究

目的 观察经裁剪供体肺用于同种异体肺移植的临床效果.方法 回顾性分析4例采用经裁剪供体肺用于同种异体肺移植的临床资料.例1供体肺部分上叶切除后施行左单肺移植并同期行右肺减容术,例2供体肺部分上叶切除后施行右单肺移植,例3供体肺双上叶部分切除后施行序贯式双肺移植,例4切除供体肺右下叶后施行序贯式双肺移植.结果 经裁剪的供体肺均能够顺利工作并渡过围手术期.例1及例2术后移植肺未出现明显并发症并生存;例3术后第5天再次出现短期漏气,经闭式引流而治愈,术后第32天死于曲霉感染导致的呼吸道大出血;例4术后恢复尚顺利,但术后2个月因重症病毒性肺炎死亡.结论 经裁剪供体肺可以用于临床肺移植.     

Surgical aspects of pediatric liver transplantation. Living donor liver transplant program in Hungary

Because of the long waiting time for pediatric liver transplantation, new techniques of liver transplantation were invented. Split and living-donor related liver transplantation are common today and the Kaplan-Meier (3 years) overall survival is over 80%. By splitting the liver, two recipients can be transplanted. In general, the left lobe is used for the pediatric, the right lobe for the adult recipient. There are a lot of combinations depending on the donor and recipient weight. The accepted liver volume is approx. 1% of the recipient body weight. The results of the Hungarian pediatric program improve, 27 transplantations were done using 14 partial liver grafts and living donor program was started. Using strict protocols and improving surgical skills, the overall pediatric survival was over 80% in the last 5 years.     

Living donor liver transplantation: the historical and cultural basis of policy decisions and ongoing ethical questions

Adult-to-adult living donor liver transplantation (LDLT) is in a state of flux. Technical innovations and demand have outpaced internal and external regulatory efforts. This has led to a wide array of centers performing LDLT for a variety of indications without clear evidence on the risks to the donor or recipient or the system as a whole. The birth from necessity of LDLT in Asia has led to the extrapolation of the technique in America and Europe that has not been sufficiently studied in the appropriate populations. While there is a clear benefit in some patients, the appropriate donors and recipients have not been defined. Regulatory and ethical consideration should be focused on minimizing acceptable risk in donors and recipients and expanding the investigation into the costs and outcomes of this challenging procedure. The recently funded adult-to-adult living donor liver transplantation cohort sponsored by the National Institutes of Health aims to answer some of these questions over the next five years.     

经裁剪供体肺的临床应用研究

目的 观察经裁剪供体肺用于同种异体肺移植的临床效果.方法 回顾性分析4例采用经裁剪供体肺用于同种异体肺移植的临床资料.例1供体肺部分上叶切除后施行左单肺移植并同期行右肺减容术,例2供体肺部分上叶切除后施行右单肺移植,例3供体肺双上叶部分切除后施行序贯式双肺移植,例4切除供体肺右下叶后施行序贯式双肺移植.结果 经裁剪的供体肺均能够顺利工作并渡过围手术期.例1及例2术后移植肺未出现明显并发症并生存;例3术后第5天再次出现短期漏气,经闭式引流而治愈,术后第32天死于曲霉感染导致的呼吸道大出血;例4术后恢复尚顺利,但术后2个月因重症病毒性肺炎死亡.结论 经裁剪供体肺可以用于临床肺移植.     

Donor nephrectomy: less fatigue and better quality of life following laparoscopic kidney removal compared with an open procedure by mini-incision: blind randomised study

OBJECTIVE: Determining possible differences in living donor nephrectomy procedures: laparoscopy against mini-incision concerning discomfort to the donor and the maintenance of good graft function. DESIGN: Blind randomized study. METHOD: In two university medical centres, one hundred living kidney donors were randomly assigned to either total laparoscopic donor nephrectomy or mini-incision muscle-splitting open donor nephrectomy. Primary outcome was physical fatigue measured with the 'Multidimensional Fatigue Inventory' (MFI-20) during one-year follow-up. Secondary outcomes were physical function measured with the 'Short form-36' questionnaire, postoperative hospital stay, amount of pain, operating times and graft and patient survival. RESULTS: Donors who underwent laparoscopy experienced less fatigue (difference: -1.3; 95% CI: -2.4 - (-0.1)) and physical function was better (difference: 6.2; 95% CI: 2.0-10.3) during one-year follow-up. Those donors who underwent laparoscopy required less morphine (16 mg versus 25 mg; p = 0.005) and the duration of hospital stay was shorter (3 versus 4 days; p = 0.003). The laparoscopic procedure resulted in a longer operation time (221 versus 164 min; p < 0.001) a longer first warm ischaemia time (6 versus 3 min; p < 0.001) and less blood loss (100 versus 240 ml; p < 0.001). Recipient renal function and one-year graft survival rates did not differ. The number of preoperative and postoperative complications did not differ significantly between both surgery techniques. Conversions did not occur. CONCLUSION: Donor nephrectomy through laparoscopy led to less fatigue and a better quality of life compared with the open procedure. The safety factors for donors and recipients were comparable for both techniques. Laparoscopic donor nephrectomy is therefore the better surgical choice for kidney donor programmes with living donors.     

Liver transplantation from a living donor: necessity or an alternative?

Liver transplantations using a part of the liver from a living donor are already being performed around the world. The main arguments for performing such transplantations are the shortage of brain-dead donors and the consequently high mortality rate of patients on the waiting list for a liver transplantation. The disadvantages of this option are the mortality and morbidity risk for the living donor. The shortage of brain-dead donors could also be resolved by the implementation of special techniques such as split-liver and domino-liver transplantations or by using compromised and non-heart-beating donors. Furthermore, measures should be taken to reduce the shortage of brain-dead donors in the Netherlands. If such actions do not lead to an increase in the number of brain-dead donors and a willingness to restrict the indications for transplantation is not forthcoming then donation for liver transplantation by living donors is inevitable. Such a program should satisfy certain conditions and have the requisite medical-ethical and public support.     

Eurotransplant--new possibility for the Hungarian transplantation

The year 2010 was a milestone in the history of transplantation in Hungary. The State Secretary for Health Issues announced a program in order to solve the serious problems of organ transplantation: 1) to increase waiting lists, 2) to raise donor numbers, 3) to establish a lung transplant program in the country, 4) to promote education and increase the knowledge base regarding transplantation for the public and the medical profession, and finally, 5) to begin negotiations for Hungary to join Eurotransplant. Joining Eurotransplant has been a priority of the transplant community. Finally, this year saw the Budapest Transplant Center perform 20% of their kidney transplants from living donors, up from a 5% frequency historically, an operation which is available in all four centers from this year.     

Advantages of living donor kidney transplantation; possibilities in the national transplantation program

The review paper summarizes the advantages of the living donor kidney transplantation aiming that this kind of activity should get more support in Hungary. It is a general phenomenon overall the world, that there is no more possibility to increase the number of cadaver transplantations, and the outcome of them is also worsening because of the accumulation of aged patients with long time period of dialysis treatment. The paper points out the better results of living donor kidney transplantation underlining that the kidney long term survival, in general, is 10% over the cadaver kidney survival with significant less complication. The indication of living related and unrelated donor kidney transplantation is reported and the harmless of donor kidney removal demonstrated. An important part of the review contains the ethical, legal and social issue of the living donation, moreover, its economical benefit. It shows that in certain countries the living donation becomes in the forefront of the transplantation activity, which demonstrates from statistical point of view the overall benefit in comparison to cadaver transplantation. Based on the experience of those countries, which are performing this type of transplantation for a long time ago recommendation is given what should be the methodology to increase the activity in this field of transplantation.     

Zum Stand der Lebendorganspende

In the Federal Republic of Germany the number of living organ donations is increasing. In 2001, 382 (16, 3%) kidney transplantations and 95 (12,5%) liver transplantations have been carried out by using organs or tissue of living donors. Graft survival in kidney transplantation is 91% for living related donation and 89% for living unrelated donation compared to 75% for cadaveric donation after a five year follow-up period. Detailed medical examinations of the donor and the recipient are an absolute prerequisite for organ donation. In Germany, living donation must be performed according to the criteria given in the Transplantation Act.     

Criteria for selecting organ donors and recipients

As there is a world-wide shortage of organs for transplantation, the selection of the patients is more defined by the availability of transplantable organs than by the medical condition of the potential recipient. This shortage of cadaveric organs is mainly responsible for the use of living donors. With HLA identical sibling donors the results are better than with cadaveric organs, but the ethical problems are usually underestimated. For the parent-to-child donation, the HLA compatibility is less than what could be achieved with well-matched cadaveric donors. The use of genetically unrelated donors is unacceptable from the ethical as well as from the medical point of view. The short- and long-term risk of donation has been insufficiently documented. The experience with the introduction of an opting-out legislation in Belgium in 1987 demonstrates that the shortage of cadaveric organs can be overcome. Harmonization of the legislation is, however, necessary so as to achieve comparable organ retrieval rates between countries participating in organ-exchange organisations.     

Lung transplantation in Hungary (1996-2011)

The 15 years history of lung transplantation in Hungary shows the medical, political and social characteristics of this period. The barely determined, open-ended legal, financial and ethical framework of transplantation has stayed nowadays in the same position. The Hungarian State Audit Office has also noted these problems. Joining of Hungary to Eurotransplant will beneficially influence the whole procedure.     

'New pathways to organ donation'; a recommendation of the Dutch Health Council

Despite recent efforts at improvement, the current status of postmortem organ donation in the Netherlands is a reason for serious concern. The waiting lists for all organ transplantations are increasing in length. The Dutch Health Council was asked by the Minister of Health to report on any available alternative sources of donor organs, focusing especially on donation from living donors and postmortem donors in whom the heart is no longer beating. Kidney donation by living relatives is a well-known procedure that has been performed since 1950. Since HLA-matching is now less important due to new immunosuppressive regimens, transplants from unrelated living volunteers are also possible with good results. Live donation from emotionally involved persons should be encouraged. In case of ABO incompatibility, donors could be exchanged via the organ exchange institution. Live donation of liver segments by an adult to benefit a child recipient is justified. In case of an adult recipient this should be performed only under exceptional circumstances. Live donation of lung lobes and segments of intestine is still in a developmental phase. Postmortem donation of kidneys and livers from donors in whom the heart is no longer beating should also be encouraged. Donation of the lungs and pancreas from these donors is still an experimental procedure.     

供精人工授精技术的伦理思考

伴随着精子冷冻技术的进步以及精子库的成立,供精人工授精技术日趋成熟,造福了许多不育症夫妇,但同时也带来一系列伦理方面的争论。当下的伦理争论热点主要集中在精液来源、捐精次数的限制、供精者年龄的限定、跨国供精人工授精、受者的选择权、供受者匿名及子代知情权等6个方面。通过对比国内外现行法律法规,结合目前社会现象,对上述伦理问题进行剖析和探讨,进而提出相应的观点和建议：精液来源应根据供者身体状况而非身份地位选择;捐精次数可适当提高;供精者年龄区间可适当下调;跨国供精人工授精尚不具备运行基础;受者的选择权应谨慎对待;供受者匿名制度应继续坚持。     

Liver transplantation with a living donor: the first 3 cases in Rotterdam

Liver transplantation with a part of the liver from a healthy living donor can be life saving for selected patients with end-stage liver failure. The experiences with the first 3 adult patients in the Netherlands were as follows. The first patient was a 56-year-old man with primary sclerosing cholangitis, who received half of the liver from his 53-year-old sister. Postoperatively, the donor developed a urinary tract infection, which was treated with antibiotics. The recipient developed fever and paralytic ileus 6 days after transplantation. Relaparotomy revealed minimal bile leakage from the cut surface of the liver, which was corrected with a suture. Three years after donation, both donor and recipient were doing well. The second patient was a 63-year-old man with hepatic cirrhosis due to hepatitis B, recurrent bleeding from varices, and hepatocellular carcinoma. The carcinoma was treated percutaneously with radiofrequency ablation. He was given a liver transplant from his 28-year-old son. The donor later developed transient ileus and mild liver function disorders. The recipient developed a bacterial infection of the ascites, which was treated with antibiotics, and later Candida-oesophagitis and a herpes simplex infection, which were also treated successfully. More than 2 years after donation and transplantation, both donor and recipient were in good condition. The third patient was a 42-year-old man with a chronic hepatitis B virus infection and 2 hepatocellular carcinomas. The donor was his 34-year-old sister-in-law. The recipient developed prolonged jaundice due to stenosis at the site of the bile duct anastomosis, for which a stent was placed. He was discharged in good condition but died 11 months later of cerebral metastases. One year after the procedure, the donor was doing well. The Rotterdam liver transplantation programme with living donors demonstrates that excellent results can be accomplished with minimal risk for the donor.     

Evaluation of the living kidney donor

Currently, due to the deficit of cadaveric tissues available for transplantation and due to the long waiting list for a kidney transplant, there is a clear tendency towards living donor kidney transplantations. Most donors are genetically related. Living donation should be considered a gift of extraordinary value, and should be made easy whenever a suitable donor is available. Worldwide, the number of patients on the waiting lists for a kidney transplantation has increased, in the last decades. Renal transplantation with living donor kidneys, is currently considered the best treatment for patients with end stage renal failure, due to the improved short and long-term survival benefits over dialysis treatment. Since considerable difference exist between countries in the evaluation and selection criteria for kidney donors, especially in selected patients such as older donors and those with associated comorbid conditions, it is necessary to discuss and establish minimal selection criteria for this cases. A common trend includes a complete clinical record, laboratory and radiologic evaluation which are described in detail in this paper. We also discuss the increasing acceptance of older kidney donors as well as the acceptance of individuals with comorbidities (such as obesity, hypertension, hyperglucemia, lithiasis and cancer) that were previously considered as not eligible for kidney donation.     

全胸腔镜肺叶切除术治疗非小细胞肺癌

目的：探讨全胸腔镜下肺叶切除术的安全性和可靠性及手术方法。方法：2005年10月-2011年6月笔者所在医院共实行全胸腔镜下肺叶切除术60例,手术通过胸部3个小切口全程非直视下完成,均为解剖性肺叶切除,同时施行淋巴结清扫;施行左肺上叶切除13例,左肺下叶切除16例,右肺上叶切除17例,右肺中叶切除5例,右肺下叶切除9例。结果：中转开胸2例。余手术均在全胸腔镜下顺利完成,手术时间150～245min,平均160min;术中平均失血量150ml;术后引流量100～420ml,平均135ml;住院日7～15d,平均10d。随访1～24个月,全部生存良好。结论：全胸腔镜下肺叶切除是一种安全、有效、更加微创的术式,适于经过选择的非小细胞肺癌。