This article explores current developments and continuing dilemmas in heart transplantation. Statistical trends such as the increased number of candidates and the increased waiting time are described. Recent developments in implantable ventricular assist device technology and the perioperative use of nitric oxide are also highlighted. In addition, advances in patient management from pretransplant care to long-term follow-up are presented, and alternatives to heart transplantation in current use and for the future are explored.
CONTEXT:Kidney preservation has been performed by either ice (static) or machine pulsatile perfusion. Ice storage is simple, with only 1 methodology. Machine perfusion, on the other hand, is accomplished using multiple methodologies. This article delineates the different methodologies of pumping centers throughout the country.OBJECTIVE:Pulsatile machine perfusion is again being viewed as the preservation method of choice for kidneys from non-heart-beating cadaver donors and cadaver kidneys from marginal donors. To develop indices to predict the viability of cadaver kidneys for transplant, a review of the organ procurement organizations, specific perfusion techniques, and a comparison of the delayed graft function and graft survival rates were considered.METHODS:A survey, asking for specifics on perfusion parameters, pulsatile machine perfusion experience, and criteria for perfusion implementation and graft survival results, was mailed to all organ procurement organizations in the United States.RESULTS:Of the 44 centers that responded to the survey, 12 used pulsatile machine perfusion (11 used the Waters perfusion machine), 6 pumped marginal cadaver kidneys, and the remaining 6 pumped all cadaver kidneys. Minimum perfusion criteria, pulse rates, perfusate composition, pressures, renal resistance, and renal pressure and flow were considered. Vasodilators and other machine additives were used to improve flow. The variance in each center's number of cadaver kidneys pumped each year, as well as the differences in pump times, was noted.CONCLUSION:Twelve centers use pulsatile machine perfusion. A variety of techniques are used to perform pulsatile machine perfusion, but 11 of 12 have less delayed graft function than those programs employing ice storage preservation.
Since its inception 12 years ago, a large, independent OPO experienced a 631% growth in the number of organ donors. These increases in organ recovery were achieved initially through successful mergers, and later, following the mergers, through focused management, OPO organizational development, and hospital marketing and system development. The cumulative percentage increases beginning in 1987 resulted in the OPO achieving 27.2 donors per million population. In 1996 a system of routine notification of all hospital deaths was implemented and a 24-hour communications center was operated. After 3 full years of routine notification, 73% of all deaths were called to the OPO, resulting in the following increases: total referrals, 691%; organ referrals, 41%; organ donors, 16%; bone donors, 149%; skin donors, 123%; and heart valve donors, 78%. The 16% increase in organ donors was twice the national growth rate and significantly more than the 2% growth experienced by the OPO in the year preceding the implementation of routine notification. The OPO has demonstrated sustained growth over the past decade in a time when erosion of donor recovery levels is always a possibility and frequently a reality for many OPOs.
Currently, more than 64,000 people are awaiting transplants in the United States. Transplant coordinators must do everything possible to ensure that viable organs from consented donors are transplanted. To evaluate donors and organ function, transplant coordinators rely on a multitude of diagnostic tests to determine donor organ suitability. How reliable are the results of these tests? The following case study presents an incident in which diagnostic test results were not accurate; as a result, transplant centers deferred what turned out to be a normal, atraumatic organ. The end result was that this organ was placed, but only after actual visualization in the operating room and the granting of full waivers to the transplanting center.
Lung and heart-lung transplantation was first undertaken in Australia in the late 1980s and early 1990s. Although detailed data are available on Australian lung transplantation outcomes, little data are available regarding the utilization of donated lungs. This study examines donated lung utilization rates and considers various factors that may affect these rates. Australian donation and transplantation data were analyzed for the years 1989 through 1997. Results showed that 24% of overall donors were lung donors. The percentage of donors from whom at least 1 lung was transplanted increased from 6% in 1989 to 36% in 1997. Heart-lung transplantation rates changed little (2%-9%), whereas bilateral lung transplantation increased from 1% to 23% of donors. Single-lung donors accounted for 32% of lung donors in 1997. Uniform basic donor criteria and management guidelines, simple allocation mechanisms, and cooperative retrieval have evolved during this time. Close collaboration at the time of donation between units, coordinators, and ICUs has allowed early retrieval from well-managed donors.
The high success rate of HLA-identical sibling transplants and our previous experience with steroid-free immunosuppressive regimens and cyclosporine withdrawal prompted us to evaluate the safety and efficacy of monotherapy with azathioprine in 12 HLA-identical kidney transplant recipients with a serum creatinine concentration less than 176.8 mumol/L, a 1-way stimulatory index less than 2.0 in a post-transplant mixed lymphocyte culture, and a demonstrated tolerance of a minimum azathioprine dose of 1.0 mg/kg per day without leukopenia. Eleven of 12 patients were successfully converted to azathioprine monotherapy without a significant change in serum creatinine concentration for as long as 76 months. Benefits of steroid and cyclosporine withdrawal included a significant reduction in mean systolic and diastolic blood pressure, number of blood pressure medications, total serum cholesterol, and glycohemoglobin in diabetic subjects. Our results suggest that azathioprine monotherapy is safe and effective in a select group of HLA-identical sibling transplants, but these benefits must be carefully balanced against an associated risk of precipitating acute allograft rejection.
Over-the-counter medications are becoming increasingly available to the general public. One of the issues facing clinicians working with transplant recipients is how to advise patients regarding management of symptoms associated with common ailments. Minimal literature is available to assist the transplant coordinators in this process. This article describes the usual immunosuppressants prescribed for transplant recipients and the over-the-counter medications used to manage these symptoms, and provides recommendations for over-the-counter medications with the least side effects.
Kidney transplantation has become a reasonable treatment option for selected patients aged 60 years or older, and a number of different immunosuppressive drug protocols have been described. This article concerns 230 recipients who were aged 60 years or older and who were undergoing kidney-only transplantation at the University of Pittsburgh between January 1990 and April 1997. All recipients were treated with a tacrolimus-based immunosuppression regimen. The median follow-up was 31.5 months (range, 1-86). The 1-, 3-, and 5-year actuarial patient survival rates were 90%, 83%, and 76%, respectively. There were 42 (19%) deaths, cardiovascular disease (50%) and infection (38%) being the main causes. Death with a functioning kidney occurred in 28 (67%) patients. The 1-, 3-, and 5-year actuarial graft survival rates were 84%, 74%, and 64%, respectively. The delayed graft function rate was 33%. Rejection was seen in 57 (25%) elderly patients. The mean serum creatinine was 2.6 +/- 2.7 mg/dL and the serum urea nitrogen was 35 +/- 22 mg/dL. The mean tacrolimus level was 8.5 +/- 3.8 ng/mL. These results suggest that renal transplantation in older recipients under tacrolimus-based immunosuppression is associated with reasonable outcomes, and can be offered to appropriately selected patients.
Ethical issues in pediatric heart transplantation are encountered daily in the work of the transplant coordinator. Issues such as use of resources in a just world, less-than-ideal candidates, and informed consent are challenges to the transplant professional. This article explores those issues using the language of ethics to analyze the conflicts they present. Resolutions will not necessarily be offered, as there are no simple answers.
Context Despite its pivotal nature, until the early 1990s the role of medical examiners, coroners, and justices of the peace was largely ignored in discussions of the critical shortage of organs for transplantation in the United States. These officials have the right to determine, from a medico-legal perspective, whether a deceased person can be an organ donor. Thus, they play an important role in the donation process. Using a principles-based ethical framework, this article examines the problem of nonrecovery of life-saving organs for transplantation in the United States because a medical examiner or other official denies recovery. Objective The goals of organ donation and the collection of forensic evidence are not mutually exclusive. An analysis of the ethical principles and obligations of beneficence, respect for autonomy, and justice reveals that medical examiners and other officials could probably, after appropriate review, release all cases under their jurisdiction for organ donation. Conclusion Medical examiners, coroners, and justices of the peace could assume a leadership role, working together on public policy with medical, social, and legal groups, spearheading efforts to stop the loss of organs due to official denials, up to and including state and federal regulation and legislation. Beyond their professional obligations, as agents of a social institution, medical examiners and other officials have the more general ethical responsibility of promoting the public health and welfare and of reinforcing societal consensus that transplantation is a social good which should be optimized through formal and informal activities.
The question of patient nonadherence has always been an important factor in determining candidate suitability for organ transplantation. Data that explore the association of financial problems and posttransplant medication nonadherence are limited. Findings suggest that medication nonadherence was more likely to occur when recipients did not have insurance coverage and had to rely on Medicaid or indigent drug programs. Our center developed a formalized program within the outpatient pharmacy, including a full-time medication counselor who helped recipients secure resources to pay for pre- and posttransplant medications. To determine whether the availability of posttransplant medications could reduce medication nonadherence, we conducted a survey with 50 consecutive liver transplant recipients in the outpatient clinic. Nonadherence rates were significantly reduced from 25% to 10% ( P<.01) compared with recipients who had been transplanted before the development of our drug program. These results suggest that optimum medication adherence can be obtained when recipients are provided guidance in securing their necessary medications without financial restriction.
The Questionnaire on Prolonging and Shortening Life was developed to assess the views of medical personnel regarding brain death, organ procurement policies, and related issues. The questionnaire was completed by 189 transplant physicians, 197 clinical coordinators, 150 medical students, and 70 nursing students. Ninety-five percent supported the so-called dead donor rule. What this rule means in practice appeared unclear among the population. More than 60% supported procuring organs from anencephalic and "higher brain-dead" patients, although patients in both groups are not dead by current legal standards. Performance on items relating to so-called non-heart-beating organ donation suggested that 75% of the group do not support non-heart-beating organ donation without assurance that the donors are brain-dead before procurement begins. Given that current recommendations to increase organ donation look to non-heart-beating organ donation rather than to anencephalic patients and those in a persistent vegetative state, these findings suggest that further ethical discussion and analysis are urgently needed.
Although heart transplantation has become recognized as a viable option for the treatment of incorrectable heart disease in infants and children, its application becomes less clear in infants with potentially serious neurologic impairment. The following case study illustrates one transplant team's approach to decision making in the case of an infant born with a chromosomal deletion syndrome.
Xenotransplantation is a potentially promising but exceedingly complex issue. It is critical that this subject be discussed within and outside the transplant community. The need for an expanded organ supply is urgent, but the scientific and ethical positions are complex. This article reviews the current status of xenotransplantation, including the potential benefits and risks; discusses multiple ethical issues; and makes recommendations for the transplant coordinator.
