Progress in Transplantation

In order to increase the supply of transplantable organs, an increasing number of organ procurement organizations are adopting policies regarding donations from Non—Heart-beating donors. Few centers, however, actually recover and transplant these organs. This article reviews a case in which kidneys and livers imported from out of state were successfully recovered from a Non—Heart-beating donor and transplanted. In addition, the article demonstrates how cooperation and flexibility in transplant personnel can increase the number of organs transplanted from a Non—Heart-beating donor.

The purpose of this study was to explore the relationship between family stress, family coping, social support, perception of stress, and family adaptation from the mother's perspective during the pretransplant period in the context of the Double ABC-X Model of Family Adaptation. The process of seeking a transplant for a child is very stressful, and before interventions can be developed, clinicians need to understand how aspects of family life are affected. Twenty-nine mothers whose children were being evaluated for a liver transplant constituted the sample for this exploratory study. Higher family strains, fewer coping skills, and higher perception of stress were related to more unhealthy family adaptation during the pretransplant phase. Data point to the need for close evaluation not only for the child's needs but for the family's needs as the family begins the process of seeking a transplant for the child.

Abnormal serum concentrations of electrolytes, hormones, and glucose are common throughout donor care. The organ procurement coordinator must properly interpret and plan treatment for these changes to prevent intracellular dysfunction in donor organs. This article describes abnormalities in magnesium, phosphorous, calcium, sodium, potassium, and glucose levels; polyuria; and thyroid and pituitary changes. Their potential consequences are discussed, and recommendations for treatment options are presented.

An abnormal blood pH may cause the loss of donor organs through harmful physiological consequences. The organ procurement coordinator must correctly analyze the acid-base abnormality and treat its cause while normalizing the blood pH. We recommend that treatment of acidemia or alkalemia be first directed toward changing parameters on the mechanical ventilator, using the Paco₂ to modify blood pH. Thereafter, hydrochloric acid or sodium bicarbonate may be administered to correct the calculated metabolic acid-base deficit. The types of acidosis or alkalosis, dead space effect during mechanical ventilation, base excess, base deficit, and the appropriate evaluation of blood lactate are also discussed as related to the correction of the acid-base status throughout donor care.

Although organ transplantation following brain death has progressed in the West, it has lagged far behind in Japan, following the first such case in 1968. As effective immunosuppressants made transplantation a better option, Japanese patients increasingly sought treatment overseas. Japanese physician groups studied issues related to transplantation but did not succeed in making brain-dead donor transplants available to patients, and the matter was referred to the government. However, transplant medicine was still marked by controversy, and as political pressure was applied the controversy deepened, splintering public opinion. At the same time, transplant groups continued working to establish structures to allow transplantation to proceed. Public awareness and knowledge of brain death grew, and acceptance widened. Eventually, legislation was passed in June 1997 that allowed organ donations from some brain-dead donors. The law is restrictive, and such organ transplants in Japan are still limited.

Eight female lung transplant recipients, all of whom became pregnant after transplant, were reported to the National Transplantation Pregnancy Registry from US transplant centers. Outcomes of the 8 pregnancies were 4 live births, 3 therapeutic abortions, and 1 spontaneous abortion. Three of the 4 newborns were premature, with low birth weight (<2500 grams). Rejection during pregnancy occurred in 3 pregnancies (38%). All 8 transplant recipients reported at least 1 complication during pregnancy, including shortness of breath, rejection, and infection. Two of the 4 deliveries were by cesarean section. At follow-up, all children were developing well with no residual problems. Female lung transplant recipients may face higher risks during pregnancy than other solid organ transplant recipients.

Many patients undergo a full transplant evaluation and are rejected for transplant on the basis of the test results. Some of these patients could be identified earlier in the evaluation process, thus reducing the cost of undergoing a full evaluation. Subjects in this study were 117 patients who had undergone a heart transplant evaluation over a 6-month period. The rates of acceptance, rejection, deferral, and those deferred and later listed were monitored: 53% were accepted, 17.1% rejected, 18.8% deferred, and a further 11.1% were deferred and then later listed. Of the group that was rejected, 45% were rejected on the basis of the cardiopulmonary exercise test and deemed too well for transplant. Other reasons for patients being rejected were obesity, psychological or social issues, and as a result of other diagnostic testing. The transplant evaluation process can be modified so that the cardiopulmonary exercise test is performed first, which would reduce the ultimate cost of a transplant evaluation from $11330 to $680. The cardiopulmonary exercise test has become an intrinsic part of the cardiac evaluation process and is a strong indicator of a patient's suitability for transplant.