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  1. Home
  2. Books
  3. Organ Transplantation
  • Cited by 6
Publisher:
Cambridge University Press
Online publication date:
September 2011
Print publication year:
2011
Online ISBN:
9780511994876
DOI:
https://doi.org/10.1017/CBO9780511994876
Subjects:
Anesthesia, Intensive Care, Pain Management, Medicine, Surgery
Information

Book description

Organ Transplantation: A Clinical Guide covers all aspects of transplantation in both adult and pediatric patients. Cardiac, lung, liver, kidney, pancreas and small bowel transplantation are discussed in detail, as well as emerging areas such as face and pancreatic islet cell transplantation. For each organ, chapters cover basic science of transplantation, recipient selection, the transplant procedure, anesthetic and post-operative care, and long-term follow-up and management of complications. Important issues in donor selection and management are also discussed, including recruitment and allocation of potential donor organs and expanding the donor pool. Summary tables and illustrations enhance the text, and long-term outcome data are provided where available. Written by expert transplant surgeons, anesthetists and physicians, Organ Transplantation: A Clinical Guide is an invaluable multidisciplinary resource for any clinician involved in transplantation, providing in-depth knowledge of specialist areas of transplantation and covering the full range of management strategies.

Reviews

'… provides an excellent overview of modern transplantation medicine. The increasing number of organ recipients and their improved longevity means that many more non-specialists will need to be aware of the considerations in such patients. As such, this book is particularly suitable for the general physician or intensivist. Similarly, with the growth in donation after circulatory death, healthcare professionals working with patients at the end of life will find this book valuable reading. The strength of this book is the breadth of its coverage coupled with an accessible level of detail.'

Dr Julia Wendon - Senior Lecturer in Hepatology/Intensive Care Medicine, Kings College London, and Clinical Director of Intensive Care, Kings College Hospital, London

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Contents

Page 2 of 3

Contents
  • Chapter 18 - Postoperative care and early complications
    pp 145-154
  • View abstract

    Summary

    Donor to recipient matching is based primarily on ABO blood group compatibility. Median sternotomy is the standard approach for heart transplantation. Although the surgical technique of heart transplantation is simple, there are certain specific circumstances in which the operation can be technically demanding and require careful planning to get the best outcome. Ventricular assist devices (VADs) are more commonly used as a bridge to transplantation, and many patients wait for heart transplantation with a functioning VAD or are listed for urgent procedure due to VAD-related complications. Heart-lung transplantation and domino heart transplantation have largely been superseded by bilateral sequential lung transplantation. Heterotopic transplantation allows much more leniency on the donor and recipient mismatching. Careful consideration should be given to the adequacy of cardiac output in maintaining oxygen delivery to the tissues, bleeding, collections, pneumothorax, and position of the monitoring lines.
  • Chapter 19 - Long-term management and outcomes
    pp 155-163
  • View abstract

    Summary

    Heart transplantation is considered emergency surgery, and there is often little time for extensive evaluation in the immediate preoperative period. This chapter covers the preoperative considerations and reviews the intraoperative management of heart transplant patients. Patients with severe heart failure are often on many drugs, including diuretics, angiotensin-converting enzyme (ACE) inhibitors and calcium antagonists. Many of these drugs interact with anesthesia and should be taken into account. Following pre-anaesthetic assessment, induction of anesthesia should be performed after placement of essential monitoring. Initial pharmacological support is required during the period of weaning from cardiopulmonary bypass (CPB), and this initial management is described with ongoing support and choice of agent. After CPB, the transesophageal echocardiography (TEE) should focus on the ventricular function. Finally, there should be a careful and thorough handover to the team taking over the patient's care following transfer to the intensive care unit.
  • Chapter 20 - Pediatric lung transplantation
    pp 164-172
  • View abstract

    Summary

    In the immediate postoperative period, close attention must be paid to hemodynamic stability by focusing on preventing right ventricular failure and maintaining chronotropic competence. Preoperative support of the recipient circulation by mechanical assist devices appears to significantly increase the risk of post-transplantation primary graft failure. Primary cardiac allograft failure accounts for 40 percentage of mortality within 30 days of heart transplantation (HT). Following HT, the use of intraoperative and peri-operative corticosteroids remains the mainstay of early therapy. Monitoring of therapeutic drug levels is important but there is some controversy in how best to monitor the target levels of calcineurin inhibitors (CNIs). Early after transplantation, particularly in the first 3 months when the risk of rejection is highest, invasive biopsies are recommended at decreasing intervals. Close vigilance for re-emergence of circulating antibodies is needed, and newer approaches using complement inhibitors or intensive B-cell modulating drugs such as bortezomib are being studied.
  • Chapter 21 - Recipient selection
    pp 173-181
  • View abstract

    Summary

    Heart transplantation has excellent long-term survival, with 50% of patients living 10 years, and significant improvement in quality of life. Various factors contribute to increased early graft failure and morality, including changing donor and recipient profiles in recent years. Changes in recent years that have improved very long-term survival include modern immunosuppression, statin use, systematic post-transplant care/surveillance, and better management of renal dysfunction. The long-term complications following heart transplantation are similar to those of other organ transplants and include vasculopathy and complications of immunosuppressants. Coronary artery vasculopathy (CAV) is a leading cause of graft failure. The incidences of various metabolic syndrome risk factors including hypertension, obesity, diabetes mellitus, and hyperlipidemia are increasingly seen after heart transplantation. Acute and chronic renal failures are common after heart transplantation. Malignancy is a major cause of late morbidity and mortality after heart transplantation. Involvement of psychological and psychiatric support is important following heart transplantation.
  • Chapter 22 - Living donor liver transplantation
    pp 182-189
  • View abstract

    Summary

    Heart transplantation remains the only realistic therapeutic option for children with end-stage heart disease. The main indication for transplantation in children is severe heart failure (HF) associated with impaired function of the systemic ventricle. Extensive evidence supports the use of cardiopulmonary exercise testing to select patients with increased short-term mortality who should be offered transplantation. Transplantation for congenital heart disease illustrates best many of the peculiarities of heart transplant in the pediatric age group. The assessment of pulmonary vascular resistance (PVR) is particularly crucial in order to reduce the rate of right HF post-transplant, but it can be technically difficult, particularly in congenital heart disease. Maintenance therapy is commonly a combination of a calcineurin inhibitor (CNI) and cell cycle inhibitor. A problem in pediatric transplantation is the presence of pre-existing human leukocyte antigen (HLA) antibodies, which have been linked to increased hyperacute, cellular, and humoral rejection and increased mortality posttransplant.
  • Chapter 23 - Surgical procedure
    pp 190-198
  • View abstract

    Summary

    This chapter focuses on how to select patients who will gain maximum benefit from lung transplantation (LT). It outlines the general considerations and exclusions pertaining to all potential recipients and focuses on disease specific guidance for the major recipient groups: chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), idiopathic pulmonary fibrosis (IPF), and idiopathic pulmonary arterial hypertension (IPAH). Pulmonary infections with highly resistant bacteria have been shown to have poorer outcomes in comparison with non-infected patients. The presence of fungus in the native lungs can cause problems after LT and needs careful assessment in each individual. The presence of comorbidities outside of the failing respiratory system is important considerations that can impact patient outcomes. COPD accounts for approximately 40% of LTs performed, with CF and IPF accounting for 20% each. In the current era there remains a critical shortage of donor organs, and thus unfortunately, recipient selection remains extremely important.
  • Chapter 25 - Long-term management and outcomes
    pp 212-219
  • View abstract

    Summary

    Bilateral living donor lung transplantation in which two healthy donors donate their right or left lower lobes is an alternative to cadaveric transplantation. The most common procedure involves a right lower lobectomy from a larger donor and a left lower lobectomy from a smaller donor. Potential donors should be competent, willing to donate free of coercion, medically and psychosocially suitable, and fully informed of risks, benefits, and alternative treatment available to the recipient. All recipients should fulfill the criteria for conventional cadaveric transplantation. Due to possible serious complications in the donor lobectomy, living donor lobar lung transplantation (LDLLT) should be reserved for critically ill patients who are unlikely to survive the long wait for cadaveric lungs. Postoperative immunosuppression usually consists of triple-drug therapy with cyclosporine (CyA), azathioprine (AZA) and corticosteroids without induction. LDLLT may be associated with a lower incidence of Bronchiolitis obliterans syndrome (BOS), especially in pediatric patients.
  • Chapter 26 - Pediatric liver transplantation
    pp 220-230
  • View abstract

    Summary

    Bilateral lung transplantation (BLT) has evolved into a routine procedure and is the most frequently performed method. Traditionally single lung transplantation (SLT) has been the procedure of choice in patients with non-infective end-stage lung disease such as chronic obstructive pulmonary disorder (COPD) and idiopathic pulmonary fibrosis (IPF). Most common incisions for SLT are the posterolateral thoracotomy, anterolateral thoracotomy and median sternotomy, which are usually used if cardiopulmonary bypass (CPB) has to be employed. The preferred surgical incision for BLT is a bilateral transverse thoracotomy joint across the middle, best known as a clamshell incision. Cannulation for CPB is achieved using the ascending aorta and both the inferior vena cava (IVC) and superior vena cava (SVC) with tapes around for sealed occlusion. After intensive animal research and clinical experience gained from kidney and liver donation, the technique of lung donation after cardiac death (DCD) has been established successfully in recent years.
  • Chapter Chapter 27 - Recipient selection
    pp 231-237
  • View abstract

    Summary

    Thoracic epidural analgesia should be considered in all cases, but may be most safely sited postoperatively. In addition to the usual anesthetic issues of aspiration risk, airway assessment, comorbidities, medications, and adverse reactions, assessment on the day of surgery focuses on the current illness state and amount of deterioration since investigations were performed, as the patient's physical state may be significantly worse than investigations may suggest. Mandatory monitoring includes five-lead electrocardiography, pulse goniometry, invasive measurement of arterial, central venous, and pulmonary artery (PA) pressures; urine output via an indwelling catheter, temperature, oceanography, pyrometer and anesthetic agent gas analysis. Maintenance of anesthesia by protocol infusion, inhalational anesthetic agent, or both has been described. Most patients with end-stage parenchyma lung disease can get symptomatic improvement with single lung transplantation (SLT). Primary graft dysfunction (PGD) is a devastating complication akin to acute lung injury due to the transplantation process.
  • Chapter 28 - Sensitization of kidney transplant recipients
    pp 238-247
  • View abstract

    Summary

    This chapter focuses on postoperative fluid management and early complications of lung transplantation (LT). Patients with emphysema who undergo single LT (SLT) require special attention to airway pressures and the compliance difference between the allograft and the native lung. Postoperative antimicrobial coverage should be modified if pathogens are identified in the sputum of the donor that is not already covered by the recipient-specific regimen. Postoperative hemodynamic instability has been common in patients with underlying pulmonary hypertension. Maintaining optimal nutrition in the postoperative period is essential and may improve operative outcomes. Early complications of LT can be classified into four categories: complications of the surgery itself, re-implantation response and primary graft dysfunction (PGD), immunologic complications including rejection, and organ-specific complications of the immunosuppressive agents. Standard therapy is recommended in the early post-transplant setting, although a focal structural abnormality may require surgical removal if it becomes the source of recurrent infection.
  • Chapter 29 - Live donor kidney donation
    pp 248-252
  • View abstract

    Summary

    This chapter presents a commentary on the lung-specific complications following transplantation and this should be used to drive the investigation plan and management. Shared care protocols with effective communication should be organized in patients who live at a distance from the transplant center to ensure that local follow-up includes monitoring of the lung function and imaging. Acute rejection can be identified on lung biopsies obtained via transbronchial biopsy (TBBx) at fiberoptic bronchoscopy. Many transplant centers perform regular bronchoscopy and TBBx in addition to spirometry in the first year to enable early diagnosis and treatment of asymptomatic rejection, with the aim of preserving graft function and protecting against bronchiolitis obliterans syndrome (BOS). Recently the importance of detecting early, subclinical BOS before irreversible fibroproliferative disease has become established has been recognized, and a new stage of BOS 0-p has been added.
  • Chapter Chapter 30 - Surgical procedure
    pp 253-257
  • View abstract

    Summary

    This chapter addresses aspects of lung transplantation (LT) that are unique to infants, children, and adolescents. The primary diagnoses leading to LT in the pediatric age group are cystic fibrosis (CF) and pulmonary hypertension, either idiopathic or related to congenital heart disease. The main difference in surgical technique relates to the increased use of bypass. The vast majority of pediatric LT recipients receive two lungs; for those with CF and other suppurative diseases, the decision is based on the infection risk. Transbronchial biopsies (TBBx) are also more challenging in pediatrics, particularly in infants and toddlers. Graft failure and infection are important causes of death in the first year after transplant. In pediatrics, as few centers perform enough transplants each year to adequately power outcome studies, uniform treatment strategies and multi-center collaborations helps to identify strategies for earlier diagnosis and allow assessment of treatment efficacy.
  • Chapter 31 - Peri-operative care and early complications
    pp 258-264
  • View abstract

    Summary

    A stringent process of selection of appropriate candidates for liver transplantation is necessary for a number of reasons. This chapter discusses deceased organ transplantation in adults. In liver transplant practice, a distinction needs to be made between the process of selection of appropriate candidates for transplant, which is the main focus of the chapter, and that of organ allocation for those candidates who have been placed on the waiting list for the procedure. Both of these processes are underpinned by similar considerations with respect to the relevant clinical end points and ethical standpoints. The practice of candidate selection and organ allocation is predicated on two fundamental ethical principles: justice (or equity) and utility. Most liver transplant programs have adopted the Milan criteria for selecting patients with hepatocellular carcinoma (HCC) for transplantation. Rarely, patients with heart and liver failure will be considered for combined heart-liver or heart-lung-liver transplant.
  • Chapter 33 - Pediatric kidney transplantation
    pp 278-285
  • View abstract

    Summary

    Careful selection of both donor and recipient is crucial in preventing donor complications and optimizing recipient outcomes. Hepatocellular carcinoma (HCC) patients usually have less portal hypertension and lower chemical Model for End-Stage Liver Disease (MELD) scores. Donor selection criteria vary slightly among different programs. Donor safety is the primary concern; therefore, the ideal graft is the one that leaves a donor a future liver remnant (FLR) above 35% and at the same time provides a graft with an adequate size with respect to the recipient. Despite donor safety being of paramount importance in living donor liver transplantation (LDLT), finite morbidity and mortality rates has been reported worldwide. Intraoperative hemodynamic studies are emerging in recent years as a tool to guide implantation technique and in low modulation. The severity of liver disease and recipient status along with severe portal hypertension also affects the risk of small-for-size syndrome (SFSS).
  • Chapter 34 - Pancreatic transplantation
    pp 286-294
  • View abstract

    Summary

    A successful liver transplant requires a number of procedures, including donor hepatectomy, preparation of the donor liver, recipient hepatectomy, and implantation of the liver graft. A midline laparotomy and sternotomy are performed and can be extended using transverse abdominal incisions to maximize surgical access. Preparation of the liver for transplantation is usually performed following a period of efficient cooling in an ice box and transportation to the recipient center. The hepatectomy begins with division of the left triangular ligament, falciform ligament, and lesser omentum before moving to the hilum. The greatest challenge when performing the portal venous anastomosis is the presence of portal vein thrombosis (PVT), which was originally an absolute contraindication to liver transplantation, but is now part of standard practice. Reperfusion of the liver is often the most dangerous part of the transplant procedure, and close communication between surgeon and anesthetist is crucial.
  • Chapter 35 - Pancreatic islet transplantation
    pp 295-302
  • View abstract

    Summary

    This chapter outlines the pathophysiology of liver disease as it affects patient selection and management in the peri-operative period and key aspects of anesthetic, surgical, and early postoperative care. The most important early complications are primary non-function, hepatic artery thrombosis, and bleeding. Pulmonary hypertension is seen in up to 20% of adult liver transplant candidates and is usually identified by transthoracic echocardiography. Full multi-system assessment should be performed before listing for transplantation, and the patient reviewed when a donor liver becomes available. Management of liver transplant recipients between transplantation and discharge is usually undertaken by a multi-disciplinary team that includes intensivists, hepatologists, and transplant surgeons. Most liver recipients are transferred to the intensive care unit (ICU) for postoperative care. Sepsis is common after transplant and is frequently associated with liver dysfunction. Culture results from the donor and targeted antimicrobial treatment should be considered in recipients with unusual presentations of sepsis.
  • Chapter 36 - Intestinal transplantation
    pp 303-312
  • View abstract

    Summary

    The most common causes of death after the first year following liver transplantation are recurrent and de novo malignancy, return of the original liver disease in the graft, sepsis, cardiovascular disease, and chronic rejection. Review frequency varies between centers and depends partly on patient morbidity. The aim of follow-up is to screen for graft dysfunction and the late complications of liver transplantation. Complications of immune suppression may be related to the original etiology or unrelated and similar to other organs. Azathioprine (AZA) or mycophenolate mofetil (MMF) are often used as long-term maintenance immunosuppression. Up to 45% of liver transplant recipients have metabolic syndrome that includes excessive weight gain, hypertension, diabetes, and hyperlipidemia. Biliary stricture and incisional hernia are the most common late surgical complications after liver transplantation. Psychosocial health should be considered as an important facet in the long-term management of liver transplant recipient.
  • Chapter 37 - Composite tissue allotransplantation
    pp 313-319
  • Face transplantation
  • View abstract

    Summary

    Liver transplantation (LT) is the accepted treatment for a wide variety of liver diseases in children. Some children develop hepatorenal or hepatopulmonary syndrome, which often reverses after LT. Acute liver failure (ALF) is rare in children, but is associated with significant mortality. Donor liver grafts for children are most commonly obtained from donation after brain death (DBD) donors. Split LT provides two grafts from a single donor, the left lateral segment for a child and the right lobe for an adult. Tacrolimus (TAC) is now the preferred agent for maintenance immunosuppression in pediatric LT. Immunosuppression generally requires the use of steroids, which are rapidly weaned or withdrawn in the majority of children. Common causes for retransplantation are hepatic artery thrombosis (HAT), primary graft dysfunction (PGD), chronic rejection and biliary complications. Health-related quality of life (HRQOL) assesses markers of overall well-being and functional outcomes, including physical, psychological, and social functions.
  • Chapter 38 - Hematopoietic stem cell transplantation
    pp 320-329
  • View abstract

    Summary

    The preoperative evaluation of kidney transplant candidates involves transplant surgeons, nephrologists, mental health professionals, social workers, dieticians, financial coordinators, and transplant coordinators. There are several absolute and relative contraindications to kidney transplantation. Immunologic evaluation begins with a thorough history of potential antigen exposure, including prior transplantation of any kind, blood product transfusion, and, in female candidates, prior pregnancy. Cardiovascular disease is the leading cause of death, and therefore graft loss, in the first year post transplant. Depending on the malignancy, a disease-free period of between 2 and 5 years is generally accepted as adequate. As the transplanted kidney usually drains into the native lower urinary tract, underlying urologic disease can affect the transplant outcome. In the future, diabetes management via islet cell transplantation, coupled with kidney transplantation, may be considered. A multi-disciplinary approach considering cognitive and other psychosocial factors is necessary to ensure successful transplantation.
  • Chapter 40 - UK and European service – legal and operational framework
    pp 335-346
  • View abstract

    Summary

    This chapter considers the importance of recipient sensitization with particular reference to renal transplantation. It considers the clinical relevance of both human leukocyte antigen (HLA) and non-HLA antibodies in graft outcomes. Measurement of panel-reactive antibodies (PRA) by complement-dependent cytotoxicity cross-match (CDC) has been largely replaced by more sensitive and less cumbersome solid-phase assays, which report a calculated PRA or population-reactive antibodies. Factors relating to donor, recipient, and locally available resources play a role in the final decision regarding what constitutes an acceptable level of risk and how it is managed. Virtual cross-match has applications in pretransplant risk assessment and can assist with the process of organ allocation. The accuracy of immunological risk assessment has improved the options available for the successful transplantation of highly sensitized recipients has increased. The options include paired-donation programs, acceptable mismatch programs, and desensitization. In HLAi transplants, donor-specific antibody (DSA) levels are monitored using solid-phase assays.
  • Chapter 41 - US transplant service – legal and operational framework
    pp 347-354
  • View abstract

    Summary

    For a patient with end-stage renal disease, the best option is a living donor transplant. The major concern about living donor transplantation is the risk to the donor. The donor operation is a major procedure that is associated with morbidity, mortality, and the potential for adverse long-term consequences, secondary to living with a single kidney. The surgical risks for laparoscopic and open nephrectomy are similar. The most common causes of death have been pulmonary embolism, bleeding, and infection. Living donors report a similar or better quality of life, as compared with the general population. Risk factors for less positive quality of life after donation have also been identified, including poor donor or recipient physical outcome, a negative personal donor-recipient relationship, and financial hardship. Population studies have shown that smoking, obesity, hypertension, and elevated blood glucose levels are associated with an increased risk of proteinuria and kidney disease.
  • Chapter 42 - Conclusions
    pp 355-356
  • View abstract

    Summary

    The most common surgical approach used for cadaveric donor nephrectomy is the en bloc technique through a large abdominal incision. Transplantation using organs from cadaveric donors is always performed with the over-riding need to minimize the cold ischemic time of the organ. There are a number of techniques for anastomosing the ureter to the bladder. These include the Leadbetter-Politano or a direct vesico-ureteric anastomosis. Many patients with renal failure have significant atherosclerosis, with calcification resulting in noncompressible solid arteries that cannot be clamped. Careful preoperative assessment by computed tomography scanning should allow identification of calcified arteries before listing for transplantation. The preferred donor procedure is a laparoscopic nephrectomy, with mobilization of the kidney assisted by the use of a hand port, usually through a small infra-umbilical midline incision through which the kidney is removed. Late vascular complications are usually stenosis of the arterial anastomosis.

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