Progress in Transplantation

Gene induction, cytokine production, and programmed neuronal and myocardial cell death are concerns that have entered the areas of donor evaluation and care over the past several years. Following ischemic or traumatic brain injury and the evolution of brain death, a large number of proteins (cytokines) are produced as part of a regional inflammatory response. These cytokines and related compounds appear to contribute to programmed death (apoptosis) of individual cells and the severe cardiac and hemodynamic changes often encountered during donor care. In addition, these cytokines and related compounds may sensitize donor organs so that a faster and more severe form of rejection occurs in the recipient. Although no directed therapy for these cytokine effects is presently available, the organ procurement coordinator should be aware of these issues and concerns as new treatment options evolve in the near future.

The need for transplantable organs continues to far outweigh the number of organs available for transplantation through donation. To date, many avenues for expanding the donor pool have been explored, including Non—Heart-beating donor protocols and the expansion of acceptable criteria. This case study reviews the successful procurement of a liver and kidney from a 72-year-old Non—Heart-beating donor.

Procurement professionals disagree on the necessity for matching donation requestors with donor families by race or ethnicity in order to increase donation rates. However, reports from minority requestors indicate that displays of cultural sensitivity during donation discussions may affect both the discussions and family decisions. In donation discussions with African Americans, Asians, American Indians, and Hispanic people from traditional cultures, requestors should consider factors such as which family representatives to include, cultural familiarity with specific diseases necessitating transplants, forms of address, concepts of time, methods of decision making and communicating refusal, and families' previous experience with the hospital and the American society as a whole.

The increasing cultural diversity in modern society creates difficulties in cross-cultural ethical decision making for healthcare workers. Nurses need to be sensitive and knowledgeable about the cultural background of individual patients. Acknowledging an individual's cultural background and considering the characteristics of different cultures when planning the patient's care may facilitate the process of ethical decision making.

Reversible myocardial dysfunction is known to occur in patients with cerebrovascular accidents and brain death. Several mechanisms for transient myocardial dysfunction have been proposed, including increased sympathetic activity, hormone depletion, and a reduction in coronary perfusion pressure. The relative importance of each of these mechanisms remains controversial. We report the case of a 19-year-old man who suffered traumatic brain death associated with reversible myocardial dysfunction despite elevated cardiac enzymes. Myocardial recovery occurred after correcting his hemodynamic instability and hypothermia emphasizing the importance of normalization of coronary perfusion pressure and core body temperature. The mechanisms for reversible myocardial dysfunction and their implications for heart transplantation following traumatic brain death are reviewed. A diagnostic strategy is proposed that would allow early recognition of reversible myocardial dysfunction in brain-dead patients.

Liver transplantation offers a lifesaving treatment for individuals with terminal disease. An extended waiting period may contribute to anxiety and undermine overall health status, jeopardizing the patient's opportunity for successful transplantation. The purpose of this grounded theory qualitative study was to discover how individuals experience life and health resources during the wait for a liver transplant. In-depth interviews, conducted with 12 adults who had awaited liver transplantation for more than a year, were transcribed verbatim and analyzed using grounded theory methods. The findings portrayed the transplant waiting period to be a process of experiencing confinement, disciplining the self, and ultimately letting go and surrendering one's self to accept available, accessible, and appropriate resources for health. Resources for life and health used by the participants included: following instructions, presenting self positively, seeking information and support, controlling symptoms, using distraction and denial, changing attitudes, setting and achieving new goals, isolating oneself and entrusting oneself to another. The findings suggest the importance of increasing supportive, health-oriented care aimed at promoting resources for everyday living and health during the transplant waiting period.

Lung transplantation is an accepted therapy for children with end-stage lung disease. One-year lung transplant survival rates of 86% have been reported by the United Network for Organ Sharing. Allograft rejection is a common cause of death following transplantation. Extracorporeal photopheresis is a novel therapy used to treat solid-organ rejection; this therapy involves separating the leukocyte-rich fraction from whole blood, treating with psoralen and ultraviolet light A exposure. The objective of therapy is to reverse progressive and persistent rejection. Working collaboratively with an institution that offers extracorporeal photopheresis may provide an alternative or additional therapy in the management of ongoing rejection following solid-organ transplantation.

The limited number of organs and tissues available for transplantation in Venezuela and the need to improve outcomes for patients with life-threatening end-stage organ failure or inadequate quality of life resulted in the development and implementation of an organ and tissue procurement system by the Venezuelan National Transplant Organization. This procurement system, a 24-hour, nationwide, free phone service for detection of potential organ donors, connects callers with transplant coordinators. The on-call coordinator supervises family approach as well as maintenance, transport, and allocation of the organs and tissues. During a period of 21 months, the phone service received 1191 calls (713 requesting information to become a voluntary donor, 207 requesting information about donation and transplantation, and 271 reporting potential donors). Of the potential donors, 74% were men and 67% were aged between 11 and 40 years, and most came from hospital intensive care units, emergency departments, and trauma shock units. The main causes of death were trauma and stroke. Reasons why donation was not accomplished included early cardiorespiratory arrest and denied consent. In conclusion, establishing the procurement system resulted in an increase in the detection, referral, and maintenance of potential donors; doubling of the number of donors per million population; and an increase in the number of cadaveric transplants.