Transplantation Immunology.pdf - E-Lib FK UWKS

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Current Status of Renal <strong>Transplantation</strong> 7 are potential problems with this approach. Advances in surgical techniques and fiber-optic technology have enabled the introduction of laparoscopic (keyhole) live donor nephrectomy (LLDN) (32) in an attempt to reduce postoperative morbidity. Instrument access to the kidney is gained through four abdominal ports requiring 1- to 2-cm incisions each, and the donor kidney is then removed after mobilization through a 6-cm abdominal incision. Although no large randomized controlled trials have been performed, longterm graft function after LLDN is similar to that after open nephrectomy. Some studies have suggested that early graft function may be marginally delayed after LLDN (33,34). The laparoscopic approach requires a longer operative time (35), although this disadvantage is counterbalanced by improved cosmesis, shorter postoperative stay, reduced analgesic requirement, and earlier return to work (36). Morbidity is similar for the two approaches, although LLDN may leave the donor at long-term risk of small bowel obstruction from adhesions. Some centers offering LLDN have observed increases in donation rates (37), although it difficult to know whether LLDN per se is responsible for this. Although the number of living donor transplants in the United Kingdom is increasing (Fig. 1), it makes up only 21% of total kidney transplant activity (UKT 2003 data). This compares poorly with North America, Scandinavia, and Australia, all of which have higher rates of living donation. United Network for Organ Sharing data for 2001 showed, for the first time, that the number of living-donor kidney transplants in the United States exceeded the number of cadaveric transplants undertaken. There is, therefore, considerable scope for further increasing the living kidney donor rate in the United Kingdom. 3.3. Non-Heart-Beating Donors NHBDs are donors from whom organs are retrieved following declaration of death by conventional means, that is, irreversible cessation of circulatory and respiratory function. NHBDs were the main source of organs before the widespread acceptance of brainstem death criteria in the late 1970s but then declined markedly owing to less favorable results. In recent years, the use of NHBDs has increased in many centers in an attempt to offset the severe shortage of kidneys from cadaveric heart-beating donors. NHBDs can be separated into categories on the basis of their mode of death (38) (Table 3). Uncontrolled NHB donations (categories 1 and 2) occur in emergency settings, and because the process of seeking consent from relatives is often protracted, warm ischemic times must be minimized by inserting a double-balloon triple-lumen catheter via the femoral artery, allowing selective perfusion of the renal arteries with cooled organ-preservation solution (39). Controlled NHB donations (categories 3 and 4) are derived from critically ill patients who have died in an intensive care setting. This allows time for con-
8 Callaghan and Bradley Table 3 Maastricht Categories of Non-Heart-Beating Donors Maastricht category Description Location 1 Dead on arrival Outside hospital, emergency room 2 Unsuccessful Emergency room, resuscitation intensive care, general ward 3 Treatment withdrawn, Intensive care awaiting cardiac arrest 4 Cardiac arrest while Intensive care brainstem dead From ref. 38. sent to donation to be taken from relatives. Once medical intervention has been withdrawn and death has been declared by the medical staff, the transplant team waits a further 5–10 min before starting the organ-retrieval operation. The insertion of medical devices into uncontrolled NHBDs before consent has been obtained from the relatives raises ethical and legal questions (40). In the United Kingdom, the acceptance of this technique in potential uncontrolled donors has been achieved by discussions with the local ethics committee and by requesting the coroner’s permission before inserting a double-balloon triplelumen catheter (41). The principal concern relating to renal transplants from NHBDs is the higher rates of delayed graft function (DGF) and primary nonfunction (PNF) when compared to kidneys from cadaveric heart-beating donors (42,43). Careful donor selection may minimize PNF (44,45), and despite a higher incidence of DGF than after transplantation with kidneys from cadaveric heart-beating donors, the long-term survival of heart-beating and NHBD kidneys is very similar (43–45). Other trials report similar PNF rates between the two groups. Although DGF after transplantation of kidneys from cadaveric heart-beating donors may be associated with reduced long-term graft survival (46), the longterm graft survival of NHBD grafts appears comparable to cadaveric heartbeating grafts. There are significant logistical difficulties in instituting a NHBD program. Referrals of potential uncontrolled donors call for enthusiasm and dedication from accident and emergency department staff and a rapid response from the transplant team. Controlled NHBDs often require the surgical team and operating room nursing staff to wait for prolonged periods for the patient to develop asystole once ventilation has been discontinued.
Page 1 and 2: METHODS IN MOLECULAR BIOLOGY 333 T
Page 3 and 4: M E T H O D S I N M O L E C U L A R
Page 5 and 6: © 2006 Humana Press Inc. 999 River
Page 8 and 9: Contents Preface ..................
Page 10 and 11: Contributors PAUL J. R. BARTON •
Page 12 and 13: Current Status of Renal Transplanta
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Page 43 and 44: 30 Friend and Imber meaningful surv
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Page 49 and 50: 36 Friend and Imber inotrope use, c
Page 51 and 52: 38 Friend and Imber very experience
Page 53 and 54: 40 Friend and Imber 14. Auxiliary L
Page 55 and 56: 42 Friend and Imber subsequent isol
Page 57 and 58: 44 Friend and Imber 21. Heffron, T.
Page 59 and 60: 46 Friend and Imber 53. Saudubray,
Page 61 and 62: 48 Lakey et al. There are an estima
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Page 67 and 68: 54 Lakey et al. Fig. 1. Schematic v
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56 Lakey et al. Table 1 Effect of I
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58 Lakey et al. from suitable donor
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60 Lakey et al. mined by high-perfo
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62 Lakey et al. Fig. 3. (A) Mean po
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64 Lakey et al. Fig. 5. HbA1c at 3-
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66 Lakey et al. All patients enjoy
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68 Lakey et al. 6. Sirolimus-based
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70 Lakey et al. Fig. 7. Two-layer (
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72 Table 2 Human Islet Transplantat
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74 Lakey et al. 3.4. Single-Donor I
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76 Lakey et al. difficult to isolat
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78 Lakey et al. 4.2. Islet Transpla
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80 Lakey et al. Table 3 Major Targe
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82 Lakey et al. CD40L (anti-CD154)
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84 Lakey et al. as kidney, heart, o
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86 Lakey et al. 14. Despres, J. P.,
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88 Lakey et al. tion despite a weak
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90 Lakey et al. 77. Maffi, P., Bert
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92 Lakey et al. 108. Idezuki, Y., G
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94 Lakey et al. 138. http://www.imm
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96 Lakey et al. tory reaction trigg
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98 Lakey et al. 198. O’Neil, J. J
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100 Lakey et al. 232. Delves, P. J.
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102 Lakey et al. 259. Grewal, I. S.
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Status of Lung Transplantation 105
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Chronic Rejection in the Heart 131
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Direct and Indirect Allorecognition
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HLA Typing and Organ Transplantatio
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Gene Transfer to Solid Organs 175 8
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Gene Transfer to Solid Organs 177 t
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Gene Transfer to Solid Organs 181
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183 Adenovirs (Ad) Nonenveloped vir
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Gene Transfer to Solid Organs 185 t
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Gene Transfer to Solid Organs 187 A
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Gene Transfer to Solid Organs 189 c
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202 Collins Table 1 Advantages and
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204 Collins The advantage of these
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206 Collins have used liposomal del
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208 Table 2 Ligands Used for Recept
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210 Collins It must not be forgotte
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212 Collins Fig. 3. Receptor-mediat
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214 Collins Receptor-mediated polyl
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216 Collins there are, to date, mor
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218 Collins 29. Niculescu-Duvaz, D.
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220 Collins 59. Wolfert, M. A. and
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222 Collins 91. Simoes, S., Slepush
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224 Collins 122. Hart, S. L., Harbo
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Antibody Relevance After Transplant
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248 Graca and Waldmann 2. The Use o
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250 Graca and Waldmann Fig. 1. Indu
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252 Graca and Waldmann Despite this
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254 Graca and Waldmann transforming
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256 Graca and Waldmann The role of
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258 Graca and Waldmann Fig. 5. A re
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260 Graca and Waldmann 4. Kahan, B.
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262 Graca and Waldmann 35. Powrie,
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264 Graca and Waldmann 67. Annacker
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266 Graca and Waldmann 96. Bommired
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Immune Monitoring in Transplantatio
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283 Table 1 Current and Potential F
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Proteomics and Laser Microdissectio
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Real-Time PCR 305 14 Real-Time Quan
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Real-Time PCR 307 Table 1 Real-Time
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Real-Time PCR 309 Fig. 2. Determina
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Real-Time PCR 311 such as Applied B
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Real-Time PCR 313 Table 2 Compariso
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315 Fig. 4. Quantification of RNA u
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Real-Time PCR 317 correlate directl
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319 Table 4 Common Internal Control
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321 Table 5 Examples of Single-Nucl
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Real-Time PCR 323 3.2. Real-Time PC
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Real-Time PCR 325 3.3.2. Sources of
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Real-Time PCR 327 9. Barton, P. J.
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Real-Time PCR 329 40. Primer expres
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Organ Preservation 331 15 Organ Pre
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Organ Preservation 333 2. Managemen
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Organ Preservation 335 tal observat
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Organ Preservation 337 donors, depe
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Organ Preservation 339 Table 1 Lung
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Organ Preservation 341 obtained wit
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Organ Preservation 343 Fig. 2. Acti
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Organ Preservation 345 Fig. 3. Outl
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Organ Preservation 347 and related
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Organ Preservation 349 mic, ischemi
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Organ Preservation 351 While these
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Organ Preservation 353 experimental
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Organ Preservation 355 with inhaled
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Organ Preservation 357 cellular sol
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Organ Preservation 359 4. Rosengard
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Organ Preservation 361 35. Powner,
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Organ Preservation 363 64. Hendry,
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Organ Preservation 365 factor-media
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Organ Preservation 367 120. Bonser,
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Organ Preservation 369 150. Macdona
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Organ Preservation 371 180. Carbogn
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209. Szabo, G., Soos, P., Bahrle, S
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376 Hopkins the extent of cold isch
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378 Hopkins or sequential administr
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380 Hopkins Table 2 Current Availab
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382 Hopkins 2. Renal failure: acute
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384 Table 4 Comparison of Azathiopr
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386 Hopkins Table 6 Side-Effect Pro
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388 Hopkins baseline immunosuppress
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390 Hopkins supplement to maintenan
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392 Hopkins 3. Kauppinen, H., Soots
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394 Hopkins uline versus no inducti
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396 Hopkins 62. Mycophenolate Mofet
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398 Hopkins 89. Mentzer, R. M., Jah
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Experimental Models of Graft Arteri
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405 Fig. 1. Variation in GA severit
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