Successful Example of How to Implement and Develop a Deceased Organ Donation System in the Caribbean Region: Five-Year Experience of the SEUSA Program in Trinidad and Tobago.

BACKGROUND: The SEUSA program, the Donation and Transplantation Institute foundation consultancy program, was implemented in Trinidad and Tobago (T&T) in 2010 with the support of the National Organ Transplant Unit (NOTU) and the Ministry of Health of T&T. METHODS: The SEUSA program included (1) diagnosis of the current situation using the ODDS (Organ Donation Diagnostic Surveys); (2) creation of a human resources structure through Transplant Procurement Management (TPM); (3) detection of all brain and cardiac deaths in the hospitals implementing the DAS (Decease Alert System); (4) in-hospital awareness based on the EODS (Essentials in Organ Donation); and (5) external hospital audits. Additionally continued monitoring is performed. RESULTS: Thus far, thanks to implementation of the SEUSA program in Trinidad and Tobago 175, healthcare professionals have been exposed to training programs in the organ donation field. The Living Kidney Program was reinforced and the structure of the Deceased Donation (DD) network was defined. Since 2010, 485 potential organ donors have been detected, and 9 have become actual organ donors; 74 patients have received a kidney transplant (59 from living and 15 from deceased donors). CONCLUSIONS: This project results demonstrate that the application of the SEUSA program is an efficient methodology to develop DD programs that increase and consolidate transplant programs in the Caribbean region.

Autotrasplante renal en hipertensión renovascular secundaria a aneurisma de arteria renal / Renal autotransplantation in renovascular hypertension secondary to renal artery aneurysm

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[Renal xenotransplant. Acute vascular rejection]. / Xenotrasplante renal. El rechazo vascular agudo.

INTRODUCTION AND OBJECTIVES: Organ transplant is nowadays a usual and succesful practice, although with limited application due to the lack of organs. Yearly thousands of patients get access to the waiting list and finally will death while they are waiting for an organ. In the U.S.A., 2005 waiting list for kidneys, heart, liver lung and pancreas was around 94.419. Number of transplants performed was 27.966 and died patients while waiting for an organ, 41.392 (1). Pig xenotransplant is one of the possibilities to ameliorate the lack of organs for transplant. Arrangement of pigs with different genetic modifications generated great expectatives on the use of these organs in clinics. Although preclinical experimental studies with kidneys reached prolonged survivals, these are really insufficient to go on with the clinical appliance. Hyperacute rejection produces destruction of the organ immediately. This problem could be pharmacologically precluded in xeno-transplant. However, acute rejection or vascular rejection usually produces the lost of the implant. New inmunosuppresive schedules delay significantly rejection, but not definitively. Xenotransplant as a therapeutic option introduces important scientific problems, as well as ethical and social. This paper reports a summary of our experience in renal xenotransplant and the management of acute rejection. MATERIAL AND METHODS: Twenty xenotransplants from transgenic pig (hDAF) as donor to babuine as receptor. Average weight of the animals ranged 11.4-75 kgrs and babuines 10-26 kg. Xenograft average weight ranged 39-160 grs. Implant was performed to aorta and cava. Four inmunosupressive schedules were used. RESULTS: Average survival was 7-9 days. Final Histological findings are described. Changes observed were secondary to acute tubular necrosis mixed with changes due to acute rejection. Three grafts were lost due to technical major problems. CONCLUSIONS: Although we have observed some promising results, xenotransplant is a very difficult problem to solve in the long-term. A lot of research is still needed-.

Xenotrasplante renal. El rechazo vascular agudo / Renal xenotransplant. Acute vascular rejection

Introducción y objetivos: El trasplante de órganos es hoy una práctica habitual y de éxito, pero de aplicación limitada, debido a la insuficiencia de órganos. Anualmente miles de pacientes en lista de espera fallecen, esperando un órgano. En EEUU en el 2005 la lista de espera para trasplantes de órganos, riñón, corazón, hígado, pulmón, páncreas era de 94.419. El número de trasplantes realizados fue de 27.966 y el de fallecidos esperando un órgano 41.392. (1) El xenotrasplante de órganos de cerdo es una de las esperanzas para aliviar la falta de órganos para el trasplante. La disponibilidad de cerdos con distintas modificaciones genéticas, creó grandes expectativas sobre una pronta utilización clínica de los mismos, sin embargo, aunque los estudios experimentales preclínicos con el riñón han alcanzado supervivencias prolongadas, estas son insuficientes para dar el paso a la fase clínica. El rechazo hiperagudo (RH) con destrucción del órgano de forma inmediata, habitual en el trasplante de órganos entre especies distintas filogenéticamente (trasplante discordante) puede en la actualidad ser evitado sin embargo, la aparición de un posterior rechazo humoral agudo (RHA) también llamado rechazo vascular agudo (RVA) o xenorechazo agudo retardado, da lugar al fracaso del xenotrasplante. La utilización de distintas pautas de inmunosupresión han conseguido retrasar de forma significativa este rechazo, pero no lo previenen de forma sistemática. El xenotrasplante como opción terapéutica plantea importantes problemas científicos, éticos y sociales. En este artículo exponemos un resumen de nuestra experiencia en xenotrasplante renal y comentamos los problemas del RVA. Material y método: Se han practicado 20 xenotrasplantes renales de cerdo transgénico hDAF (donante) a babuino (receptor). El peso de los cerdos osciló entre 11,400 y 75 kg. y el de los babuinos entre 10 y 26,500 kg. El peso del xenoinjerto, riñón del cerdo, osciló entre 39 y 160 g. Resultados: La supervivencia media de los animales estuvo entre 7-9 días. El estudio histológico final de los injertos mostró cambios secundarios a necrosis tubular aguda mezclados con alteraciones propias de rechazo agudo. Tres injertos se perdieron por problemas técnicos mayores. Conclusiones: Aunque hemos observado resultados prometedores, el xenotrasplante es una cuestión de gran dificultad, especialmente a largo plazo. Se precisa aún en la actualidad de mucha actividad investigadora en este campo

Introduction and objectives: Organ transplant is nowadays a usual and succesful practice, although with limited application due to the lack of organs. Yearly thousands of patients get access to the waiting list and finally will death while they are waiting for an organ. In USA, 2005 waiting list for kidneys, heart, liver lung and pancreas was around 94.419. Number of transplants performed was 27.966 and died patients while waiting for an organ, 41.392 (1). Pig xenotransplant is one of the possibilities to ameliorate the lack of organs for transplant. Arrangement of pigs with different genetic modifications generated great expectatives on the use of these organs in clinics. Although preclinical experimental studies with kidneys reached prolonged survivals, these are really insufficient to go on with the clinical appliance. Hyperacute rejection produces destruction of the organ immediately. This problem could be pharmacologically precluded in xenotransplant. However, acute rejection or vascular rejection usually produces the lost of the implant. New inmunosuppresive schedules delay significantly rejection, but not definitively. Xenotransplant as a therapeutic option introduces important scientific problems, as well as ethical and social. This paper reports a summary of our experience in renal xenotransplant and the management of acute rejection. Material and methods: Twenty xenotransplants from transgenic pig (hDAF) as donor to babuine as receptor. Average weight of the animals ranged 11.4-75 kgrs and babuines 10-26 kg. Xenograft average weight ranged 39-160 grs. Implant was performed to aorta and cava. Four inmunosupressive schedules were used. Results: Average survival was 7-9 days. Final Histological findings are described. Changes observed were secondary to acute tubular necrosis mixed with changes due to acute rejection. Three grafts were lost due to technical major problems. Conclusions: Although we have observed some promising results, xenotransplant is a very difficult problem to solve in the long-term. A lot of research is still needed

[Renal xenotransplantation from hDAF pig to baboon. Experience and review]. / Xenotrasplante renal cerdo hDAF-babuino. Experiencia y revisión.

UNLABELLED: The renal xenotransplant could be the solution on the demand of organs for transplantation. We present here our experience and review the actual status of the xenotransplant. METHODS: We have done 20 xenotransplants from transgenic pig h DAF to baboons, with four protocols of immunosuppression. All the hosts were treated with GAS 914. Group A: Cyclophosphamide, Cyclosporine, Mycophenolate, and Steroids (n = 10). Group B: Cyclophosphamide, Cyclosporine, FTY 720, and Steroids (n = 3). Group C: Basiliximab, Cyclosporine, Mycophenolate, and Steroids (n = 3). Group D: Basiliximab, FTY 720, Everolymus, and Steroids (n = 4). RESULTS: The duration of the xenografts ranged between 1 and 31 days. The function of the xenografts in relation to the type of immunosuppression were not significantly different: A) 7 days, B) 8 days, C) 8 days, and D) 9 days. CONCLUSIONS: 1. The cold ischemic time of the graft, has influence in the initial function of the kidneys but not in the evolution and duration of the graft. 2. The hyperacute rejection has been overcome with the utilization of transgenic pigs. The graft failure was due to acute humoral rejection that was not aborted by the actual inmunosupressors. 3. It is necessary to develop new immunosuppression protocols, through new knowledge of their pharmacology and the physiology of the xenografts, and at the same time it is important to avoid the potential risk of transmission of animal infections.

Liver transplantation from maastricht category 2 non-heart-beating donors: a source to increase the donor pool?

INTRODUCTION: The demand for liver transplantation has increasingly exceeded the supply of cadaver donor organs. Non-heart-beating donors (NHBDs) may be an alternative to increase the cadaver donor pool. The outcome of 20 liver transplants from Maastricht category 2 NHBD was compared with that of 40 liver transplants from heart-beating donors (HBDs). After unsuccessful cardiopulmonary resuscitation (CPR), cardiopulmonary support with simultaneous application of chest and abdominal compression (CPS; n = 6) or cardiopulmonary bypass (CPB; n = 14) was used to maintain the donors. RESULTS: At a minimum follow-up of 2 years, actuarial patient and graft survival rates with livers from Maastricht category 2 NHBD were 80% and 55%, respectively. Transplantation of organs from these donors was associated with a significantly higher incidence of primary nonfunction, biliary complications, and more severe initial liver dysfunction compared with organs from HBDs. The graft survival rates was 83% for livers from NHBDs preserved with CPS and 42% in those maintained with CPB.

[Vascular prosthesis in kidney transplantation]. / Prótesis vasculares en el transplante renal.

OBJECTIVE: Three cases of kidney transplantation that required a vascular prosthesis are described and the literature reviewed. METHODS: Of 920 cases of kidney transplantation, 3 required a vascular prosthesis to repair the aortoiliac vessels. One patient with severe atherosclerotic disease had an aorto-bifemoral prosthesis (Gore-Tex) six months before renal transplantation and the other two patients required a vascular prosthesis to repair iliac artery lesions discovered during transplantation. RESULTS: The initial surgical results were satisfactory. No complications arising from the vascular prosthesis were observed. Two patients have a functioning renal graft, but the third patient developed acute tubular necrosis and tubulo-interstitial rejection and died from acute pulmonary edema. CONCLUSION: The importance of the preoperative cardiovascular evaluation in patients undergoing kidney transplantation is underscored. Some patients may require a vascular prosthesis. We should therefore be familiar with the prosthetic materials and the surgical techniques, which are not particularly difficult, and optimum results can be achieved. In patients with both end-stage renal disease and severe aortoiliac atherosclerotic disease, the controversy remains whether aortoiliac repair and kidney transplantation should be done simultaneously or in two stages.

[Urinary lithiasis in transplanted kidney]. / Litiasis urinaria en riñón trasplantado.

OBJECTIVE: We reviewed the records of patients submitted to renal transplantation at our institution to determine the incidence and risk factors for calculus formation in these patients. METHODS: Of 794 functioning renal grafts that had been transplanted from January, 1981 to May, 1996, 16 patients (2%), 9 males and 7 females, had upper urinary tract calculi post-transplantation. All 16 patients had received kidneys from cadaver donors. Three had donor graft lithiasis. The calculi were located predominantly in the calyces, at multiple sites in 7 patients and the mean size was 8.3 mm. The composition of the calculi was predominantly uric acid. Four patients who developed sudden obstructive anuria with elevated serum creatinine, underwent percutaneous drainage. RESULTS: All patients had one or more stone-predisposing factors, such as obstructive uropathy, recurrent urinary tract infection or metabolic abnormalities (predominantly hyperuricosuria). Five patients passed their stones spontaneously, 7 patients with uric acid stones were treated with urinary alkalinization, two patients underwent open pyelolithotomy, one underwent percutaneous nephrolithotomy and one patient with a small asymptomatic caliceal stone was managed conservatively (watchful waiting). During long-term follow-up (mean 69 months), 4 patients lost the real graft [only one case was related to urinary calculi (primary hyperoxaluria)] and 4 patients had recurrent calculi. CONCLUSION: Urinary lithiasis after renal transplantation is a relatively uncommon complication. A multifactorial etiology for calculus formation has been observed. The predisposing factors and composition of the calculi, but not frequency, are identical to those of non-transplant patients. A variety of methods are used to treat posttransplant calculi. The least invasive treatment available should be utilized according to the likelihood of recurrence and the need to preserve renal function. With adequate treatment and prophylaxis, posttransplant urolithiasis does not appear to affect graft function.

[Kidney transplantation with pediatric grafts. Technique and results]. / Trasplante renal con injertos pediátricos. Técnica y resultados.

OBJECTIVES: To demonstrate the viability of grafts from pediatric donors transplanted into adult recipients and to analyze new approaches. METHODS: The present series comprised 40 renal transplants in adults utilizing grafts from pediatric donors aged three years or less. A single renal unit was transplanted into each recipient in most of the cases in which grafts from pediatric donors over one year old (n: 26) were used. When the donor was less than one year old and in 3 cases aged over one year (n: 14), both renal units were transplanted en bloc (4 patients) or sequentially (10 patients) into each recipient. RESULTS: Graft survival rate was 58% at 29 months' mean follow-up (range 5-67) when a single unit was transplanted, 50% at 51 months' mean follow-up (range 49-53) when both renal units were transplanted en bloc and 70% at 22 months' mean follow-up (8-26) when both both renal units were transplanted sequentially. Most of the grafts that were lost were due to problems arising from vascular thrombosis; the incidence of failed grafts from immunological causes was very low. No technical problems were encountered and the urological complications were minimal. Only one case of bladder fistula was observed. CONCLUSIONS: Kidney grafts from pediatric donors of any age are viable for transplantation into adults. In the light of current technological and pharmacological developments, we believe that both renal units should be transplanted into the same recipient-preferably sequentially-if the donor is less than a year old. A single renal unit can be used if the donor is over one year old.

[Kidney transplants from asystolic donors]. / Trasplante de riñón procedente de donantes en asistolia.

Review of our experience on renal transplantation with graft from removal in asystole. We have performed 31 transplantations of kidneys removed while in asystole, 25 of which were treated only with cardiocompression and assisted ventilation as support measures, the average asystole time being 45 minutes. Two donors were treated by in situ cold perfusion of the abdominal organs (time of asystole, 70 and 218 minutes). One patient was maintained with body cooling by cardiopulmonary by-pass for 90 minutes. Graft survival at three months was 77%, with a delay in the initial function of 70%, secondary to acute tubular necrosis, this being the only parameter in which a significant difference is observed when comparing them to those from a control group of 50 transplant performed over the same interval. No significant differences were seen at one year with regard to either graft survival or the recipients in both groups.

[Kidney transplant with pediatric grafts from donors under a year old. The implantation technics]. / Trasplante renal con injertos pediátricos menores de un año. Técnicas de implantación.

Although the number of renal transplants performed in our country is high, it is far surpassed by the number of patients with end-stage chronic renal failure awaiting transplantation. The foregoing has led to the use of grafts from donors aged less than one year. Our series of 6 renal transplants in adults using grafts from these donors are presented. Both kidneys were transplanted in all cases, but two different techniques were utilized. The kidneys were transplanted "en bloc" in 4 cases and sequentially into the right iliac fossa in 2 cases. In 2 of the cases submitted to "en bloc" transplantation, the grafts never functioned and were lost due to venous thrombosis. The remaining cases (2 "en bloc" and 2 sequential) are functioning well at 6 to 20 months follow-up, with no vascular or urinary complication. In our view, the kidneys from pediatric donors less than one year old are an acceptable alternative for transplantation into adult patients using the classical "en bloc" or the sequential technique, although in certain aspects the latter may offer more advantages over the former.

[Spontaneous rupture of transplanted kidney. Experience with 500 transplants]. / Rotura renal espontánea de injerto. Experiencia en 500 trasplantes.

We reviewed a series of 500 transplants and found 21 (4.1%) cases of graft rupture. All the renal grafts had been harvested from cadavers. Hemodialysis was required in 18 (85%), acute rejection developed in 12 and acute tubular necrosis in 12 (3 were related to percutaneous maneuvers for biopsy or PCN). All cases developed acute pain and oligoanuria. No significant difference was observed relative to ischemia time or HLA typing. Concerning immunosuppression and graft rupture, a significant difference was observed for the group that received low dose CsA combined with triple therapy (3 rupture grafts, 14.2%) versus the high dose CsA and steroid treated group (11 ruptured grafts, 52.3%), p < 0.01. Twenty grafts had ruptured within the first 15 days following transplantation and one at 8 months. Graft removal was warranted in 8 (38%) and conservative surgery in 12 (57%). Two grafts (16%) were lost and 1 patient (4.7%) died without undergoing surgery. Graft rupture is a severe complication that warrants immediate surgical management. Conservative surgery is a valid alternative in those cases with a viable graft.

[Echo-guided biopsy in renal transplant]. / Biopsia ecodirigida en el trasplante renal.

A prospective study of 64 biopsies was undertaken to determine the efficacy of ultrasound-guided biopsy of renal grafts. All the biopsies were performed using real-time ultrasound guidance and a Tru-Cut biopsy needle. Sixty-two (97%) of the biopsies were diagnostic; a total of 85 punctions (mean 1.3) were performed. Forty-seven (73.4%) biopsies contained cortical issue, 15 (23.4%) cortical and medullary, and 2 (3.2%) medullary tissue alone. Mild hematuria was observed in 8 (12%) and there were no major complications. Four of the 8 cases (50%) with hematuria required dialysis, while the remaining 4 (50%) did not (p > 0.05). Concerning the type of tissue obtained and the complications, 5 (62.5%) of the patients whose biopsies contained medullary tissue presented complication (p < 0.05) ascribable to the depth of the punction. The mean number of biopsy punctions with hematuria was 1.5 (p < 0.05). In our view, ultrasound-guided biopsy is a highly effective technique for obtaining valid biopsy specimens of the renal graft, which reduces the risk of complications in this percutaneous procedure.

[Iatrogenic invagination of the ureteral mucosa in renal transplantation]. / Invaginación iatrogénica de mucosa ureteral en trasplante renal.

A case of antegrade invagination of the ureteral mucosa is described. This iatrogenic complication of endourology resulted from percutaneous dilatation with teflon catheters of a stricture in the ureter of a renal graft transplanted 4 years earlier. Definitive correction was by open surgery, which achieved good results.

[Renal transplantectomy]. / Trasplantectomia renal.

During the first ten years (1981-1990) of our organ transplantation program a total of 395 Renal Transplants (RTx) have been carried out in our Unit, 90 of which in 88 patients had to be subsequently transplantectomized. In 32 of them the reason was acute rejection (35%) including 7 renal rhexis, and in 30 chronic rejection (33%) (1 rhexis). There were 22 (24%) (1 rhexis) vascular complications leading to such procedure. The technique was chosen mainly depending on the amount of time elapsed between transplantation and transplantectomy, performing 47 subcapsular and 43 extracapsular manoeuvres. The complications developed were 7 (7.7%), mostly haemorrhagic. Our attitude when faced with non-functioning grafts due to chronic rejection is the complete withdrawal of immunosuppression performing transplantectomy only in the event of arterial hypertension or in the presence of symptoms of acute rejection overimposition.

[Ureteral stenosis. Endo-urologic treatment (dilatation). Experience with 43 cases]. / Estenosis ureteral. Tratamiento endourológico (dilatación). Experiencia en 43 casos.

Stricture of the ureter has been traditionally treated by open surgical techniques that occasionally had to be performed not without risk to the patient owing to the presence of septic and associated uremic conditions that invariably had a negative influence on the outcome. With the advent of endourological techniques in the last decade, much has been published on endoscopic treatment of the different areas of the urinary tract. One of the fields where important developments have taken place is that relative to endourological treatment of ureteric strictures. Since we started our therapeutic protocol for our patients in 1983 to date, we have treated 43 patients by dilatation. Patient follow up ranging from 6 months to 6 1/2 years (mean follow up greater than 30 months) revealed good results were achieved in 76.74%. The complications have been scant, mortality nil, and patients have been able to resume social and occupational activities early. All the foregoing prompt us to consider this therapeutic modality as the treatment of choice.