Progress in Transplantation

The integrative literature review has many benefits to the scholarly reviewer, including evaluating the strength of the scientific evidence, identifying gaps in current research, identifying the need for future research, bridging between related areas of work, identifying central issues in an area, generating a research question, identifying a theoretical or conceptual framework, and exploring which research methods have been used successfully. The 5-stage integrative review process includes (1) problem formulation, (2) data collection or literature search, (3) evaluation of data, (4) data analysis, and (5) interpretation and presentation of results. Maintaining scientific integrity while conducting an integrative research review involves careful consideration to threats to validity. Strategies to overcome these threats are reviewed. The integrative review methodology must involve detailed and thoughtful work, the outcome of which can be a significant contribution to a particular body of knowledge and, consequently, to practice and research.

Posttransplant hypertension is a major risk factor for cardiovascular disease and chronic renal allograft dysfunction. A significant number of transplant recipients suffer from posttransplant hypertension in part because of corticosteroid and calcineurin inhibitor use. Although the optimal blood pressure range and the antihypertensive agents of choice in the transplant population have not been determined, the guidelines for blood pressure control in the general population can be extrapolated to the transplant population. The choice of an antihypertensive regimen should be tailored on the basis of the individual patient's risk factors and comorbidities.

Recipients receiving heart transplants from 83 donors from 1995 to 2002 were analyzed to evaluate the effect of various donor factors on recipient outcomes. The 83 donors (13 women and 70 men; 2–51 years old) had cold ischemic times ranging between 55 and 287 minutes. Donor age, cause of death, inotropic support, and cold ischemic times of the hearts were compared to 1-year left ventricular ejection fraction, permanent pacemaker dependency, 30-day mortality, and 1-year survival in the recipients. Donors receiving low-dose inotropic support resulted in recipients with permanent pacemaker dependency in 14.8%, and 30-day mortality and 1-year survival rates of 7.4% and 70.3%, respectively. Donors not receiving inotropic support resulted in recipients with permanent pacemaker dependency in 3.5%, and 30-day mortality and 1-year survival of 3.5% and 83.9%, respectively. Cold ischemic times less than or equal to 120 minutes showed 30-day mortality and 1-year survival rates of 0% and 90.9%, respectively. Cold ischemic times equal to or more than 121 minutes showed 30-day mortality and 1-year survival rates of 8% and 76%, respectively. Increased donor age (P=.22) and cold ischemic time showed an increase in mortality without affecting mean ejection fraction in survivors. Use of inotropic support in donors (P=.95) showed an increase in mortality without affecting mean ejection fraction in survivors.

Increased use of expanded donors requires optimal organ perfusion to prevent graft damage. In this regard, pulmonary artery catheters have been advocated to monitor hemodynamic status. Cost, catheter placement, and inconsistent management preclude broad use of pulmonary artery catheters. Esophageal Doppler monitoring also monitors hemodynamic status and can be instituted in minutes by an organ procurement coordinator. Concomitant assessment of acid-base balance using base excess and/or anion gap can help determine resuscitation efficacy. Esophageal Doppler monitoring is described to help salvage 2 hemodynamically deteriorating donors. Anion gap and corrected base excess identified poor resuscitation status in both donors and normalized after improvement in hemodynamic status. Compared to pulmonary artery catheters, esophageal Doppler monitoring may provide a more accessible means to assess and improve hemodynamic status. Base deficit and/or anion gap may determine resuscitation efficacy by exposing acid-base imbalance resulting from poor tissue perfusion. The full efficacy of this approach remains to be determined.

Educating family members of transplant recipients has long been recognized as an important factor in preparation for organ transplantation. This preparation may help the family come to terms with potential complications, the possibility of extended hospitalization, and the psychological changes that their loved ones might experience. Although education of a spouse or essential others may take place, children of an organ recipient may be unintentionally overlooked in the teaching process. This article describes how an educational booklet for children of adults undergoing liver transplantaion was developed and introduced into a liver transplant unit.

More than 1600 Americans have received adult-to-adult living donor liver transplants. As the number of patients with end-stage liver disease is expected to grow significantly in the next 20 years due to hepatitis C infection, living donor liver transplantation has become a promising solution to the shortage of donor organs. The use of living donors provides organs in an environment of scarcity, allows patients to receive transplants when medically optimized, and produces liver segments with minimal ischemic damage. The donor complications most frequently cited in the medical literature include bile leaks and strictures, biloma, hepatic encephalopathy, wound infection, and pressure sores. In the wake of 2 donor deaths in the United States and subsequent media publicity, there have been new efforts by the transplant community to describe the risks and outcomes for donors, and establish safeguards to protect them from excessive pressure to donate.

After 4 decades of development, the American Gastroenterological Association in a medical position statement recently declared intestinal transplantation to be an acceptable therapy for patients suffering from intestinal failure. Improvements in surgical technique, immunosuppression, and treatment of rejection and infection have contributed to this advancement. Early referral and candidate selection have also been cited as key components to a successful transplantation. The evaluation period, including the referral process, is the cornerstone for this success. The purpose of this article is to present a detailed definition and analysis of the evaluation process. Criteria for listing with the United Network for Organ Sharing will also be discussed.

Patients suffering from intestinal failure present unique and difficult challenges to the transplant team. Augmenting the need for interdisciplinary teamwork is the higher incidence of death on the intestinal transplant waiting list. Successful management of this population requires an interdisciplinary approach at each stage of care, beginning with evaluation and continuing through discharge and lifetime management. A close relationship between patients, their caregivers, and all members of the transplant team is an essential component to successful lifetime management. Open communication between team members and unlimited accessibility to each other enables work flow to be managed efficiently, and enables the provision of optimal care. In this article, we describe the functions of the nonphysician clinical personnel needed to manage the intestinal transplant patient—beginning at the evaluation through lifetime follow-up care. The goal of each professional is the same: to restore the patient to the best quality of life possible.

Intestinal, combined liver-intestinal, and multivisceral transplantation are now considered the standard of care for children and adults with permanent intestinal failure. Early attempts at intestinal transplantation were discouraging because of the high incidence of technical complications, rejection, and infection. Advances in the field of transplantation, including the introduction of tacrolimus, improved surgical techniques, and improvements in postoperative care, have led to a renewed interest in intestinal transplantation since 1990. The most significant achievement, however, has been the effective control of rejection and life-threatening infections. This article focuses on the experience to date of innovative strategies that induce lymphocyte depletion and reduction in the incidence of rejection. In this setting, low-maintenance immunosuppression is clinically achievable with an acceptable rate of allograft rejection. Subsequently, the long-term complications of immunosuppression are significantly reduced with achievement of better long-term survival, and an overall improvement in the quality of life.

Intestinal transplantation is an accepted lifesaving option to treat appropriately selected patients with end-stage failure of the gastrointestinal tract. The evaluation of each candidate involves complex judgments. When to perform an isolated intestinal transplantation versus a combined transplantation with the liver and/or other organs often requires thoughtful considerations and an individualized approach. In addition, performing venous drainage of the isolated graft is potentially complex. We discuss the significant advances in surgical and medical decision making in the evaluation and management of patients with intestinal failure.