Awaiting Organ Transplantation Research Articles

The MGH Guide to Psychiatry in Primary Care

I approached the review of this paperback with a smattering of trepidation. Since such handbooks frequently are obsequious reiterations of the DSM, overrun with obfuscation and tenuous usefulness (much like this introduction), I was pleasantly surprised with the utility and breadth of this volume. The book consists of 78 concisely and readably written chapters averaging 8 pages each. Individual topics are “co authored by a primary care professional and a psychiatrist,” and this formula appears to be an effective one. Every chapter clearly identifies and defines key terms, criteria for diagnosis, and approach to treatment. Given the relative brevity of each chapter, several suggested readings are appended to aid the interested party in further study. Topics addressed include the expected approaches to the depressed patient and the anxious patient, but quickly branch off to explore items like smoking cessation, fatigue, headaches, chronic steroid use, and PMS. These frequently encountered problems, while widely understood to have psychiatric aspects, often receive short shrift in similar handbooks. The editors go on to include sections on less common scenarios, providing excellent “quick studies” to aid in patient management. Among others, approaches to the patient who has been sexually assaulted, who is awaiting organ transplantation, or who has celebrity status are all standouts. A healthy dose of pharmacotherapeutics rounds out this selection. The book is not without fault. There is some variability between chapters—some are written in skeleton outline format, while others are in a more friendly, yet still succinct prose. More troubling is that, although the book has a 1998 publication date, several recent (but not novel) chemotherapeutic agents and treatment strategies are glaringly absent, even from cursory mention. Finally, while a few chapters may feel a bit wanting, one should approach the guide not as a comprehensive text, but rather as a handy, focused review that ably directs further study when indicated. When used in this manner, this book deserves a place on every physician's bookshelf.

Double adult renal allografts

D espite renewed efforts l’ocused on education of the public on the great disparity between the number of organ donors relative to the number of patients awaiting organ transplantation in the United States, the gap continues to increase. Currently, there are over 50,000 patient registrations on the United Network for Organ Sharing (UNOS) waiting list. Thirty-four thousand seven hundred sixty-six patients are awaiting kidney transplantation. It is estimated that 10 patients die each day awaiting transplantation. In 1996, there were 5,411 cadaveric organ donors. Although the waiting list size has increased approximately 20% per year, the cadaveric organ donor pool has only increased 4% per year. Median waiting times have nearly doubled for all organs in the last 6 years. From 1988 to 1995, cadaveric donors in the 18-34 age group decreased from 41% to 29%. During the same time period, the percentage of older donors (50 years) doubled from 12% to 24% and likely will continue to increase in prevalence as the population ages. Innovative strategies to compensate for this major constraint to kidney transplantation provided the impetus to conduct a protocol for the use of kidneys from older donors with suboptimal nephron mass, kidneys that otherwise might not have been used for transplantation. The protocol was initiated in 1994 and entailed the simultaneous transplantation of both kidneys from a single donor into a recipient. The background for this novel approach was based on several elegant

The Use of Kidneys from Living Donors With Renal Vascular Disease: Expanding the Donor Pool

Purpose The disparity between the number of patients awaiting organ transplantation and the number of available donor organs continues to increase. We report the outcomes of transplantation using kidneys from living donors who had unilateral renovascular disease. Materials and Methods We identified 5 living donors who had unilateral renovascular disease, including saccular renal artery aneurysms, an arteriovenous malformation, localized atherosclerosis and fibromuscular renal artery stenosis. Each donor was normotensive and asymptomatic, and had otherwise normal renal function. Results In each case the abnormal kidney was removed, the lesion was repaired ex vivo and the kidney was successfully transplanted without complication in the donor or recipient. Each recipient had a serum creatinine of less than 2 mg./dl. and each donor remained normotensive with stable renal function at up to 3 years of followup. Conclusions Kidneys from living donors with renovascular disease can be transplanted safely provided that careful selection, informed consent and a normal remaining kidney are ensured.

REASONS FOR RESISTANCE TO ORGAN DONATION.

Over 16,000 patients have died while awaiting organ transplantation during the past eight years. But, despite an intense national educational campaign,

Psychiatric interview and psychometric predictors of cardiac transplant survival.

This study prospectively investigated the relation between pretransplant assessment of psychiatric diagnosis, coping skills, and social support and outcome measures of survival and health care utilization. Ninety-four heart transplant patients underwent structured interviews and completed a battery of self-report psychometric tests assessing coping style, health status, and psychosocial supports. Follow-up that ranged from 9 to 56 months after transplant produced a group of 63 survivors and 31 nonsurvivors, who were found to be comparable in terms of pretransplant cardiac status and severity of illness. Survival analysis showed that dimensional psychometric measures of coping and social support based on patient self-assessment were the best significant predictors of survival. Considered separately, interview-determined ratings of social support and pretransplant compliance with treatment regimens were also potential predictors. Formal DSM-III-R diagnoses were related specifically to posttransplant hospital utilization (axis I diagnoses) and posttransplant health behavior (axis II diagnoses). The data demonstrate the value of multifaceted assessment, since psychiatric diagnosis, coping style, and psychosocial support may contribute differently to prediction of such aspects of outcome as mortality and health care utilization.

Acid treatment of lymphocytes selectively decreases the expression of HLA class I antigens: a method to confirm that a positive clinical crossmatch test was due to class I antibodies

A rapid and reliable method for eliminating HLA class I antigens from the surface of lymphocytes without damaging the cells is described. Lymphocytes were exposed to an acid solution (pH 3.0) which selectively destroys the antigenicity of HLA class I antigens. Alloantisera containing multispecific HLA class I antibodies reacted with phosphate-buffered saline (PBS)-treated, but not with acid-treated, lymphocytes. Specificity controls included: antibodies against HLA class II antigens and CD3, CD4, CD8; markers expressed on T cells and CD19, CD22; markers expressed on B cells. No change in lymphocyte reactivity to any of these surface antigens or to autoantibodies was observed. The viability of acid-treated lymphocytes was regularly around 90%. We propose that acid-treated lymphocytes are suitable targets for determination of the sole presence of class I antibodies in crossmatch sera of patients awaiting organ transplants.

Five years' experience at one centre with protein A immunoadsorption in patients with deleterious allo/autoantibodies (anti-HLA antibodies, autoimmune bleeding disorders) and post-transplant patients relapsing with focal glomerular sclerosis.

Protein A is extracted from a strain of Staphylococcus aureus and binds specifically to the constant domains of immunoglobulins and possibly to fibronectin. It has already been shown that concentrations of all IgG isotypes (except IgG3) are efficiently decreased by immunoadsorption (IA) on protein A linked to sepharose beads. This system has been developed by Cobe-Excorim Co. to either remove IgG in some instances where they wil be harmful, i.e. allo- and autoantibodies inducing pathological conditions (autoimmune diseases, haematological disorders with allo/autoantibodies, anti-HLA antibodies in sensitized patients awaiting organ transplantation) or treat several immunological diseases with unknown pathogenesis. In our unit, 20 patients with high titres of anti-HLA panel-reactive antibodies, four patients with haematological disorders (haemophilia with anti-VIII antibodies and Glanzmann diseases) and three patients with post-transplant focal glomerular sclerosis (FGS) underwent IA over the past 5 years. Infectious complications were not observed after IA and the procedure was always well tolerated. In spite of the use of adjunctive immunosuppressive therapy with prednisone and cyclophosphamide, and although the reduction in serum IgG was close to 90%, the de novo synthesis of allo- and autoantibodies was important after IA procedures. In the cases of removal of anti-HLA antibodies, patients with a pre-IA antibody titre which was > 1:128 clearly did not benefit from the technique and other immunological criteria were not predictive of efficacy. Fourteen patients were transplanted, four with a well-matched kidney with both pre- and post-IA negative cross-matching, and 10 with a positive historical cross-match with the donor.(ABSTRACT TRUNCATED AT 250 WORDS)

An enzyme-linked immunosorbent assay (ELISA) for the detection of serum IgA against Candida albicans mannan

An enzyme-linked immunosorbent assay (ELISA) is described for measuring serum IgA against highly purified preparations of the Candida albicans immunodominant surface carbohydrate, mannan. Optimal assay conditions are presented for the test to be run in less than four hours. The assay is reliable and easy to use in the diagnostic laboratory with an intraassay variation of less than 10%. Blood donors showed a wide variation of serum levels. Two groups of patients awaiting organ transplants, with a high degree of mucosal colonization by Candida species, showed significantly higher levels of serum IgA against the mannan as compared to the blood donors. This test is proposed to be a useful tool in the surveillance of Candida colonization as one of the factors predisposing for infection in both immunocompetent and immunocompromised patients.

Ethical, psychosocial, and public policy implications of procuring organs from non-heart-beating cadaver donors

A SHORTAGE of transplantable organs is a constant and frustrating reality. With continued progress in organ transplantation, the demand for transplants, and thus the need for organs, has increased markedly. The result is an increasing shortage of organs and longer waiting lists for transplantation. As of May 7, 1993, there were 31 303 people awaiting organ transplants (Dave Lohrey, United Network for Organ Sharing Data Base, oral communication, May 7,1993). One third of patients awaiting liver or heart transplants currently will die awaiting an organ, while patients awaiting renal transplants must tolerate a less acceptable quality of life undergoing dialysis.1 Most organs come from patients who have been declared dead by neurological criteria—ie, they have irreversibly lost all brain function and their bodies are being maintained on ventilators in intensive care units. They are commonly referred to as heart-beating cadaver donors (HBCDs) because their hearts are beating at the

Ethical, Psychosocial, and Public Policy Implications of Procuring Organs From Non—Heart-Beating Cadaver Donors

A SHORTAGE of transplantable organs is a constant and frustrating reality. With continued progress in organ transplantation, the demand for transplants, and thus the need for organs, has increased markedly. The result is an increasing shortage of organs and longer waiting lists for transplantation. As of May 7, 1993, there were 31 303 people awaiting organ transplants (Dave Lohrey, United Network for Organ Sharing Data Base, oral communication, May 7,1993). One third of patients awaiting liver or heart transplants currently will die awaiting an organ, while patients awaiting renal transplants must tolerate a less acceptable quality of life undergoing dialysis.¹ Most organs come from patients who have been declared dead by neurological criteria—ie, they have irreversibly lost all brain function and their bodies are being maintained on ventilators in intensive care units. They are commonly referred to as heart-beating cadaver donors (HBCDs) because their hearts are beating at the

Safety and efficacy of preoperative donation of blood for autologous use by patients with end-stage heart or lung disease who are awaiting organ transplantation.

Many patients are, perhaps inappropriately, denied the benefits of autologous blood transfusion, because they are thought to be too ill to donate blood safely. The safety and efficacy of autologous blood donation by selected patients with end-stage heart or lung disease who are awaiting organ transplantation were studied to determine if even these critically ill patients could be suitable candidates for autologous blood donation. Seventy-two adults awaiting heart or lung transplantation were evaluated for autologous blood donation in a hospital-based blood collection facility. Phlebotomy was performed if the patient met the required medical eligibility protocol, and if he or she consented to participate. Units of blood were separated into packed red cells and plasma and stored in a frozen state. Of 48 heart transplant candidates, 31 (65%) were each able to donate 1 to 8 units of blood. The median number of exposures to allogeneic components was 1 for patients who donated and 7 for nondonors (p = 0.0141). Among patients who donated, 54 percent required allogeneic components, as compared to 88 percent of nondonors (p = 0.0968). Of 24 lung transplant candidates, 15 (63%) made 1 to 6 donations each. The median number of exposures to allogeneic components was 0 for donors and 2 for nondonors (p = 0.1871), but only 45 percent of donors required allogeneic components, as compared to 100 percent of nondonors (p = 0.0418). No serious complications during or following phlebotomy were observed. It is concluded that autologous blood donation by patients with end-stage heart or lung disease may be safe.(ABSTRACT TRUNCATED AT 250 WORDS)

Life or death. The issue of payment in cadaveric organ donation

IN 1989, 1878 people died while awaiting organ transplantation. Public awareness programs, professional education, and legislation have not increased organ donation; the motive for consent in organ donation remains altruism. I shall argue that because of an ever larger number of patients listed as candidates for lifesaving organs, the policy of a death benefit payment to motivate families of potential organ donors should be studied. A death benefit of $1000 paid through organ procurement organizations would not necessarily be coercive. Laws now prohibiting organ brokerage and assuring fair organ allocation would continue unchanged. A death benefit payment may most favorably affect the socially disenfranchised through increased organ transplantation in minority populations. Because so many salvageable lives are now lost, only because organs cannot be obtained, pilot programs to determine the impact of death benefit payment to the enabling (consenting) next-of-kin should be initiated. If organ recovery increases sufficiently, a nationwide

Identifying and managing the potential transplant donor in the emergency department

Emergency physicians, often the first physician to see a potential organ donor, are in a position to identify and appropriately manage them. There is a large discrepancy between the number of patients awaiting organ transplant and the number of organs available. Approximately 13,000 patients suffering from chronic, irreversible renal failure are being treated by dialysis, while only 2,400 patients receive kidney transplants each year. Patients with irreversible loss of brain function, as defined by the Ad Hoc Committee of Harvard University Faculty, are most suitable for organ donation. The evaluation and management of potential organ donors in the emergency department are described, along with contraindications. A procedure for obtaining consent from next of kin is discussed.