Adult living donor liver transplantation: living donation of the right liver lobe

Background Adult living donor liver transplantation (LDLT) has become a routine treatment option for patients waiting for liver transplantation. In European and North American countries, LDLT for adult recipients is mainly performed with right lobe grafts. Indications, when compared to deceased donor liver transplantation, are controversial. Materials and methods In our institution, patients suffering from hepatocellular carcinoma in cirrhosis, non-resectable hilar cholangiocarcinoma, viral hepatitis associated cirrhosis, as well as cholestatic liver and biliary disease are considered good candidates for LDLT. Results In this overview, donor evaluation, graft selection, and the donor operation with special regard to operative techniques and strategies are discussed. For visualization, a 5-min video sequence of the standard donor operation as performed in our institution is attached. Conclusion Given the ongoing shortage of donor organs, adult LDLT has become a routine treatment option for patients waiting for liver transplantation. The associated inevitable risk for the healthy donor, however, remains ethically controversial. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Association Between Waiting Times for Kidney Transplantation and Rates of Live Donation

A deceased donor (DD) allocation system incorporating net life survival benefit has been proposed. In this system, many kidneys will be shifted to younger recipients, thereby decreasing their waiting times. The goal of this study was to determine the potential effects of altering waiting times on the likelihood of live donor kidney transplantation (LDKT). We analyzed 93,727 waiting list candidates to determine the association of various patient factors with likelihood of LDKT. The proportion of patients receiving LDKT was compared by the median DD waiting time at that patient's transplant center for someone of that patient's age category and race. LDKT was consistently higher as waiting times became longer. After adjusting for all other factors associated with likelihood of LDKT, waiting time remained a significant, independent predictor. Patients with the longest DD waiting times had 2.3-fold higher odds of LDKT (95% CI 2.11-2.58, p < 0.001). In planning the new DD allocation policy, we must account for resulting alterations in LDKT. It is possible that shifting DD kidneys to younger recipients may decrease LDKT or shift it to older recipients, net effects not consistent with the goal of net life survival benefit.     

Effect of Population Aging on the International Organ Donation Rates and the Effectiveness of the Donation Process

This study analyzed the effect of population aging on organ donation for transplants in 43 countries and on the effectiveness of the donation process by comparing the results between Spain and the United States. The percentage of the population aged 65 or over accounted for 33% of the difference in the donation rates between the countries and for 91% of the variation in the rates after age adjustment. However, the level of aging of the Spanish (16.5%) and American (12.3%) populations failed to account for the percentages of deceased donors 65 or over (28% vs. 10%), due to the different age-specific donation rates, much higher in Spain above 50 years. These differences lead to a higher effectiveness of the process in the United States (3.1 transplanted organs per donor vs. 2.5 in Spain), though at lower rates of transplant per million population (73 vs. 87). We conclude that older populations have a greater donation potential as donation rates are strongly associated with population aging. It should therefore be mandatory to adjust donation rates for age before making comparisons. Additionally, effectiveness decreases with older donors, so age should be considered when establishing standards relating to organ donation and effectiveness of the process.     

Liver and intestine transplantation

The most significant development in liver transplantation in the USA over the past year was the full implementation of the MELD- and PELD-based allocation policy in March 2002, which shifted emphasis from waiting time within broad medical urgency status to prioritization by risk of waiting list death. The implementation of this system has led to a decrease in pretransplant mortality without increasing post-transplant mortality, despite a higher severity of illness at the time of transplant.
The trend over the last few years of rapidly increasing numbers of adult living donor liver transplants was reversed in 2002 by a decline of more than 30% in the number of these procedures. In 2002, a greater percentage of women received livers from living donors (43%) than deceased donors (34%), possibly because of size considerations.
From 1993 to 2001, the waiting list increased more than sixfold, from 2902 patients to 18 047 patients. For the first time since 1993, the waiting list size decreased in 2002, dropping 6% to 16 974 candidates. The percentage of temporarily inactive liver candidates also increased from 2001, thus the net decrease in the active waiting list for 2002 was 12%. This may reflect a trend toward less pre-emptive listing practices under MELD.
Intestine transplantation remains a low-volume procedure limited to a few transplant centers and is still accompanied by significant pre- and post-transplantation risks. As this procedure matures, its application may increase to include recipients at an earlier stage of their disease with better likelihood of success.     

广州地区围产儿脏器重量及大小测量的研究

目的　探讨广州地区围产儿脏器重量及大小的发育规律 .方法　选择 6 2 5例胎龄准确的单胎 ,除外明显浸软、IUGR、水肿儿、巨大胎、有胸腹水者 ,新生儿除外先天性心脏病及有明显疾病的脏器 .根据胎龄分为 6组 ,分别测量围产儿体重、身长和各脏器重量、长度 .进行统计分析 .结果　胰腺、肺发育最早 ,肾脏与肺发育最快 ,出生后脑增长最少而胰腺增长最快 ,肠变异最大等规律 .结论　围产儿脏器资料用于围产儿病理研究有一定意义     

What should we do with donated embryos that may be genetically affected?

The ethical and legal issues arising from genetic screening in embryo donation are discussed in relation to two recent cases where embryos with uncertain genetic health were offered for donation.     

Organ specific apoptosis following polymicrobial intraperitoneal infection

Background Leukocyte apoptosis allows safe removal of potentially harmful cells and facilitates resolution of inflammation. We hypothesized that the number of apoptotic cells changes in a disproportionate fashion in parenchymal organs in response to intra-abdominal infection. Materials and methods The percentage of apoptotic cells in the liver, spleen, lung, and peripheral blood was evaluated following cecal ligation and puncture (CLP) in mice. Tissue myeloperoxidase (MPO) levels were measured as an index of neutrophil extravasation. Results Liver & spleen MPO continually increased, while lung MPO remained low after CLP. In parallel to the increase in MPO, liver & spleen apoptosis continually increased throughout the 9-day follow-up period, whereas lung apoptosis remained unchanged. Conclusions The distribution of apoptotic cells during intraperitoneal infection occurs in an organ specific manner, with significant increases in the spleen and liver. This distribution likely reflected the clearance of apoptotic cells as the inflammatory focus became contained. Supported by the American Association for the Surgery of Trauma, John H. Davis Research Scholarship, and by the Veterans Administration Merit Review Project 0005. Received 7 October 2005; returned for revision 22 November 2005; accepted by G. Wallace 23 December 2005     

A report on 100 cycles of oocyte donation; factors affecting the outcome

Eighty-two patients had 100 cycles of oocyte donation from 68 donors resulting in 27 clinical pregnancies. The source of donated oocytes was 42 fertile volunteers and 26 patients from the assisted conception programme. The pregnancy rate was significantly higher when intra-Fallopian transfer was performed (36%; 21/59), compared with intrauterine transfer (15%; 6/41). The pregnancy rate following fresh gamete/embryo transfer (39%; 15/39) was slightly higher than for frozen embryo transfer (20%; 12/61). The age of the recipient significantly affected the pregnancy rate. The pregnancy rate was 50% in the 25-29 years age group and steadily dropped to 9.7% in the 45-49 age group. The pregnancy rate in patients with primary ovarian failure (50%; 8/16) was significantly higher than in patients with secondary ovarian failure (18%; 9/50). The pregnancy rate was significantly greater when parous donors (33%; 23/69) were used compared with non-parous donors (13%; 4/31). The number of gametes/embryos transferred significantly affected the pregnancy rate regardless of the treatment used. If one or two gametes/embryos were transferred, the pregnancy rate was 11% compared with 33% if three to four embryos were transferred. The age of the donors did not affect the pregnancy rate. The majority of the donors were under the age of 35 years. The best results (50% per cycle) were therefore achieved using gametes from parous donors and transferring three to four oocytes fresh to the Fallopian tubes of a young recipient.     

Embryo donation: attitudes toward donation procedures and factors predicting willingness to donate

BACKGROUND: The aim of the study was to assess infertile couples' attitudes toward the procedures of embryo donation (ED) and to identify factors predicting interest in donation. METHODS: Fifty-one couples who had received IVF treatment and had subsequently had embryos cryopreserved for >3 years were located and sent written information about the procedures for ED and possible implications of donation. A total of 49 couples agreed to participate in the study with 36 women and 31 men subsequently returning questionnaires describing their reasons for not claiming unused embryos and attitudes towards ED. RESULTS: Patients were supportive of donor screening procedures, but less comfortable sharing non-identifying information. Comfort levels declined as information became increasingly personal. Support for unconditional (i.e. the donation of embryos without conditions attached) and conditional (i.e. where couples could limit the donation of their embryos to persons/couples according to their preferences) models of donation was highly polarized and a substantial minority expressed strong opposition to each model. Willingness to donate was associated with greater comfort about disclosing personal information, a desire to know the outcome of donation and willingness to have future contact with a child, but not with current family size. CONCLUSIONS: Comfort in sharing information with a recipient couple is more important than acceptance of screening procedures, or attainment of family size goals in predicting willingness to donate embryos. Offering the option of conditional donation could increase the acceptability of ED for some patients.     

Egg-sharing in assisted conception: ethical and practical considerations

The present acute shortage of eggs for donation cannot be overcomeunless adequate guidelines are set to alleviate the anxietiesregarding payments, in cash or kind, to donors. The currentHuman Fertilisation and Embryology Authority (HFEA) guidelinesdo not allow direct payment to donors but accept the provisionof lower cost or free in-vitro fertilization (IVF) treatmentto women in recognition of oocyte donation to anonymous recipients.Egg-sharing achieved in this way enables two infertile couplesto benefit from a single surgical procedure. However, the practicalguidelines related to this approach are ill-defined at the presenttime leading to some justifiable uncertainty. A pilot studywas therefore undertaken in order to establish the place ofegg-sharing in an assisted conception programme. The currentHFEA guidelines on medical screening of patients, counselling,age and rigid anonymity between the donor and recipient werefollowed. The study involved 55 women (25 donors and 30 recipients)in 73 treatment cycles involving fresh and frozen-thawed embryos.Donors were previous IVF patients who, regardless of their abilityto pay, shared their eggs equally with matched anonymous recipients.They paid only for their consultations and tests right up tothe point of being matched with a recipient The sole recipientpaid the cost applicable in egg donation of a single egg collection,although both received embryo transfers. The results indicatethat although the recipients were older than the donors (41.4± 0.9 versus 31.6 ± 0.5 years), and there wasno difference in the mean number of eggs allocated, the percentagefertilization rates, or the mean number of embryos transferred,there were more births per patient amongst recipients than amongstdonors (30 versus 20%). We conclude that providing the donorsare selected carefully, this scheme whereby a sub-fertile donorhelps a sub-fertile recipient is a very constructive way ofsolving the problem of the shortage of eggs for donation. Thereare also the advantages of including a group of women who wouldotherwise be denied treatment Problems related to ‘patientcoercion’ can, in our view, be fully overcome by the applicationof strict common-sense safeguards. The ideal of pure altruismis not without its medical and moral risk. The success of egg-sharingdepends on shared interests and a degree of altruism betweenthe donor, the recipient and the centre. The current HFEA guidelinesshould be applauded for enabling a highly effective conceptof mutual help to develop.