This study reviews the clinical outcome of the 132 orthotopic heart transplantations performed at our institute from 1984 through 1991 and focuses on the pathology of those patients who died. The study comprised 124 adults (mean age, 45.6 +/- 0.9 years) and eight children. Twenty-six adult and one pediatric deaths occurred. Operative mortality (within 30 days) was 10.6%, with 84.8% of patients surviving to discharge. Actuarial probabilities of survival at 1 and 5 years were 84% +/- 3% and 71% +/- 6%, respectively. Of the 27 deaths, six (22.2%) occurred in the operating room (from hemorrhage, graft failure, and hyperacute rejection); 14 (51.9%) occurred in-hospital after surgery (from sepsis, rejection, cytomegalovirus disease, or myocardial infarct), and seven (25.9%) occurred after discharge (from rejection and/or recurrent coronary artery disease). Two groups of patients were at higher risk: patients in cardiogenic shock requiring pretransplantation mechanical support, with in-hospital mortality of 39.1%; and patients with previous valve replacement who were taking oral anticoagulants, with intraoperative mortality of 50.0%. Pathologic examination revealed occasional instances of unsuspected coronary artery disease in the donor hearts with more than 50% stenoses of the left anterior descending coronary arteries in three of 21 (14.3%) of cases. Complications of the transplantation or related therapeutic procedures were common among those who died. The complications ranged from functionally insignificant anatomic curiosities to life-threatening problems. These complications are tabulated and shown.
CORR reports that 21,451 transplants have been performed from 1981-1996. Approximately 78% of these have been kidney transplantations. Survival statistics revealed that progress has been made to improve both patient and graft survival, particularly during the period between 1991-1996. Consequently, the number of patients being followed with a functioning transplant increased to 11,645. There has been a rise in the number of kidney transplants, which is largely attributed to an increase in the number of living donors. Data also revealed that there was increasing acceptance of elderly patients, who were not transplant candidates, into dialysis programs. Furthermore, the percentage of the number of patients alive with functioning kidney transplants to the total number of patients with ESRD increased from 41% in 1981 to 46% in 1996. Non-renal transplant activity has increased in the recent past. Overall, 5-year patient and graft survival was about 70%. This improvement in survival was associated with a reduction in 30-, 60- and 90-day mortality. The organ donation rate has increased slightly from 13.9 donors per million population in 1994 to 14.1 in 1996. The majority of Canadian donors were multi-organ donors, while fewer were kidney, liver, heart or lung-specific donors only. The proportion of female donors has increased. The number of patients waiting for transplants continues to increase. Approximately 3,072 patients are on waiting lists; the majority are for kidney transplants. As the increase in the number of donors does not match the increasing numbers of transplants needed, this suggests that greater efforts are necessary to reduce this difference.
Scandiatransplant is the Nordic organ exchange organization having existed for almost 40 years. With close collaboration between transplant centers in the Nordic countries, it has been valuable to ensure the optimal usage of available organs. The heart is the most often exchanged organ within the collaboration. It has been decided to create a priority for hyperimmunized kidney patients for compulsory exchange of organs from deceased donors. The age of the deceased organ donors has changed from younger to older donors. The evaluation of deceased kidney transplantations and deceased liver transplantations from 1995 to 2007 is shown for 4 countries. Iceland by itself is performing living donor kidney transplantations with great intensity. Scandiatransplant will make efforts to present more data than just transplantation to yield a more complete picture of organ transplantation.
To evaluate the demand for organs for transplantation and to recommend a reorganization of transplantation services in Quebec.
Province of Quebec, 1988 to 1992.
All patients on waiting lists for organ transplantation and patients who received transplants registered in national data banks.
The actual annual demand for organ transplantation and the rate of transplantations performed.
The rates of heart transplantation were lower than the actual annual demand, which resulted in many patients dying while awaiting transplantation. The actual annual demand for heart transplantation decreased during the last 5 years from 10.9 per million people in 1987 to 6.7 in 1992. The rates of heart transplantation in Quebec were higher than the Canadian average. The actual demand for lung transplantation was only 2.9 per million people on average in 1992. Demand for liver transplantation increased annually, reaching 8.6 per million in 1992. The rate of transplantation increased likewise but remained insufficient. The demand for kidney transplantation reached 27.2 per million people in 1992, and the transplantation rate was 17.8.
Taking into account the actual demand for and supply of organ transplantation, to insure high-quality service and to control costs associated with organ transplantation, we recommend that the present system in Quebec be reorganized so that transplantations are performed in 12 centres: 7 for kidney transplantation, 2 for hearts, 2 for livers and 1 for lungs.
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The aim of this study was to assess knowledge, attitudes, and proficiency in relation to organ donation among staff members of intensive care units (ICUs) in donor hospitals, and possibly identify areas for improvement. The investigation was carried out as a collaboration between the transplant center and appointed key persons in all 17 ICUs in 15 hospitals in northern Denmark. A total of 1168 structured questionnaires were distributed to the health care professionals in the ICUs in the region; 689 were returned, giving a response rate of 59%. In general, there is a positive attitude among health care professionals toward organ donation. However, a considerable fraction of 11% declares to be against organ donation. Only 49% of the ICU health care professionals are willing to donate their own organs after death. By comparison, 74% of the general Danish population are willing to donate organs after death. Doctors are more positive toward organ donation than the nursing staff. Thus, 95% of the doctors are positive to organ donation compared to 81% of the nurses; 70% of the doctors will donate own organs after death compared to 45% of the nurses. Further, the survey demonstrates as expected a significant lack of experience in organ donation. Our data show a considerable need for more education and training, especially on how to inform and support the donor relatives and how to identify potential donors. The survey also discloses a substantial need for information regarding the results of transplantation.
The annual number of cadaveric organ donors in Norway increased from an average of 12.4 per million inhabitants per year in the period 1985-88 to 13.1 in the period 1989-92. An increase to 20 organ donors per million per year is required to meet the anticipated need for organs. The donation rates differ greatly between health regions. Possible strategies to increase the organ donation rate are discussed.
The annual number of cadaveric organ donors increased from 13.1 per million inhabitants in the period 1989-92 to 15.8 in the period 1993-96. Multiple organ harvesting was performed in 68% of the donors. There are significant differences in donation rate between health regions. An increase to 20 organ donors per year per million inhabitants is required to meet the anticipated need for organs. Strategies to increase organ donation are discussed.
While the field of islet transplantation has evolved over the past 30 years and exponential progress and increase in clinical activity has occurred during the past 5 years, it is clear that major challenges still remain, particularly in understanding why islet function seems to decay over time. High one-year rates of insulin independence, and high 5-year rates of partial islet function (with C-peptide secretion and protection from hypoglycemia) are now routine. Improved control of glycated HbA1c and reduced risk of recurrent hypoglycemia are benefits of islet transplantation irrespective of the status of insulin independence. If complete and sustained freedom from insulin is the primary objective, it is clear that whole pancreas transplantation still offers far superior metabolic reserve. However, the less interventional nature of islet infusion and avoidance of major surgery are advantages of islet transplantation over whole pancreas strategies. While the anti-rejection drugs available today may have had an acceptable safety profile in most islet transplant recipients, the drug-related and dose-limiting side effects have proved to be a challenge in some patients. Current islet-alone transplantation requires lifelong immunosuppression and is limited to patients with recurrent severe hypoglycemia and severe labile diabetes. More effective treatments are needed to control both acute rejection and recurrent autoimmunity. Remarkable opportunities lie ahead for improved islet survival, better engraftment and the possibility of expansion of islet mass both in culture and possibly within the patient after transplantation. Living-donor islet transplantation offers one option to expand the available donor supply, but remains controversial because of the potential for diabetes induction or other morbidities in a healthy donor. The development of less toxic immunosuppression and perhaps immunological tolerance will one day also have a huge impact on this field. Alternative tissue sources from either xenogenic sources or stem cells will ultimately solve the challenge of limited donor supply.