[The definition of death and organ retrieval: a persisting philosophical controversy]. / La définition de la mort et le prélèvement d'organes: une controverse philosophique persistante.

Since the publication of the recommendations of the ad hoc committee of the Harvard Medical School to examine the definition of brain death in 1968, philosophical discussions concerning the licit character of organ retrieval in brain dead patients never ceased. The present paper summarizes the main arguments of supporters and opponents of this procedure.

[Serendipity, beneficial error, and chance in the development of kidney transplantation]. / Le hasard, l'erreur profitable, la chance dans le développement de la transplantation renale.

Serendipity played an essential role in two major developments of organ transplantation: the method of continuous hypothermic perfusion of the kidney and the introduction of ciclosporin in the clinical setting. An erroneous reasoning lead to the creation of an efficient preservation fluid: Collins's solution. However, these investigations would have failed without the open-mindedness and the tenacity of the clinicians.

[Ethics of organ retrieval after controlled cardiac arrest]. / Ethique du prélèvement d'organes après arrêt cardiaque planifié.

The article tells the evolution of the terminology concerning non heart beating donors during the two last decades and describes summarily the procedure of organ retrieval after controlled cardiac arrest. We then consider the various ethical problems created by this practice. We discuss in detail therapeutic withdrawal, the treatment of the donor during the agonal period, death certification, the doctor's conflict of interests, the presence of the family at the time of death, the quality of the organs and organ retrieval after euthanasia.

Some historical notes on the diagnosis of death--the emergence of the brain death concept.

This paper demonstrates that discussions about the diagnosis of death and the meaning of states of suspended animation existed long before the publication of the Harvard criteria in 1968. The surgeons who started retrieving kidneys from heart beating cadavers have been accused to redefine death in order to obtain high quality organs. In fact, they were not aware of modifying a definition. They did not view death as a philosophical concept but considered that it was a biological phenomenon of which brain death was merely a new expression resulting from the development of resuscitation and intensive care procedures.

[The evaluation of medical treatments in the course of ages: from antiquity to the first randomized controlled trial]. / L'evaluation des traitements médicaux au cours des ages: de l'antiquité au premier essai randomisé contrôlé.

This paper describes the chief landmarks in the slow development of therapeutic research from antiquity to the first randomized controlled trial.

[Christian religions and organ transplantation]. / Religions chrétiennes et transplantation d'organes.

The present paper describes the position of catholic, protestant and orthodox Churches concerning the various aspects of organ retrieval and transplantation. The official position of the catholic Church, defined by the pope favors these activities if they respond to strict rules. The absence of magisterium in the protestant and orthodox Churches causes sometimes divergent opinions among the members of the clergy. However, there are convergences between the three religions. Theologians who are in favour of organ transplantation promote organ donation but consider that it is not mandatory. They do not admit the principle of presumed consent and organ commerce is expressly forbidden.

[Experience about more than 2000 renal transplantations at the university of Brussels]. / A propos de 2000 greffes rénales a l'U.L.B.: le parcours d'un patient transplanté rénal en 2007.

Since 1965, more than 2000 renal transplantations (including more than 100 living-donor transplantations) have been performed at the University of Brussels. An end-stage renal disease patient candidate to renal transplantation will be therefore followed from his enrolment on the waiting list to the long-term post-transplant period. Improvement in the outcome of renal transplantation is achieved due to better knowledge in many fields of medicine, such as immunology, infectious disease, metabolic diseases (hyperlipemia, diabetes mellitus), pharmacology, use of immunosuppressive regimen, a more adequate cardiovascular prevention and treatment. If the best results were achieved with kidneys from living donors, the graft survival rate at the University of Brussels was nearly 80% for the last period (2000-2006). Unfortunately, renal transplantation cannot cure certain comorbid conditions and even may promote them: infectious diseases, neoplasia, metabolic disorders (e.a diabetes mellitus, hyperlipemia). Many efforts have to be done to develop less toxic and more immune selective therapeutic strategies. Living donation and extension of the pool of cadaveric donors will reduce the length of time spent on the waiting list and will significantly impact on mortality and morbidity after kidney transplantation.

[Placebo and placebo effects (second part) : ethical aspects]. / Placebo et effet placebo (deuxième partie) : aspects éthiques.

The use of placebo is controversial. It is generally accepted when no treatment exists for the disease under study but a polemic persists when a therapy is already regularly applied by medical practitioners. The paper cites and comments on the publications of national and international institutions (Belgian Medical Board, World Medical Association, Council for International Organizations of Medical Sciences) on this topic. The pros and cons about the use of placebo in clinical research are presented. Each protocol, with or without placebo has to abide by the general principles of medical ethics whose requirements may sometimes be contradictory. In these circumstances, the investigators must find a compromise acceptable morally and scientifically and submit it to ethics committees which have to decide about the validity of their arguments.

[Evidence based surgery: ethical and methodological aspects]. / La chirurgie factuelle: aspects ethiques et méthodologiques.

Recently, it has been said that surgical clinical research was of poor quality because there are few randomized controlled trials in this area. This type of experimental protocol comes up against many difficulties in surgery and may induce a conflict between scientific requirements and ethical principles. Improving the quality of observational studies with simple measures may palliate the problem. Moreover, keeping national or international registries provides very useful informations.

[The enigma of the renal allografts performed in man in the early 1950s]. / L'enigme des allogreffes rénales réalisées chez l'homme au début des années 1950.

In the early 1950s, a few renal allografts were performed without immunosuppression in man. The paper describes these attempts and tries to explain the behavior of the medical doctors who undertook these human experimentations taking into account their personality, the knowledge at that time and the absence of treatment for end stage chronic renal failure.

[Placebo and placebo effects (first part): definition, clinical aspects, mechanisms]. / Placebo et effet placebo (première partie): définition, aspects cliniques, mécanismes.

There are many papers devoted to placebo and placebo effects. The present article tries to provide a precise definition of these concepts and to take stock of our knowledge on this topic. Considering that most of the publications dealing with this phenomon are of poor scientific quality, some authors deny its existence. However recent findings in neuroscience show that it is a reality and explain its mechanisms.

Sclerosing peritonitis: report of three cases.

Sclerosing peritonitis is a dramatic complication of continuous ambulatory peritoneal dialysis and chronic peritoneal inflammation. Both visceral and parietal surfaces of the peritoneal cavity are involved. A thickened peritoneum encloses the small intestine in a "cocoon" formation which often leads to intestinal occlusion. CT scan may help obtaining an early diagnosis but diagnosis is often established with some delay or even at the time of laparotomy. Our report describes three cases of this uncommon peritoneal fibrosis syndrome which caused intestinal obstruction requiring surgical intervention.

Persistent hyperparathyroidism requiring surgical treatment after kidney transplantation.

There are not many publications describing long-term follow-up of persistent hyperparathyroidism requiring surgical treatment after kidney transplantation (PHSKT). In some patients adenomas, rather than multiglandular disease, have been incriminated as the cause of PHSKT. We reviewed the charts of 45 patients followed for 12 to 146 months (median 45 months) after parathyroidectomy for PHSKT. We compared them with (1) those of 951 patients receiving a kidney graft during the same period but not submitted to parathyroidectomy or (2) 90 matched controls selected from this cohort to determine the characteristics of PHSKT patients. The duration of pretransplant dialysis was significantly longer in PHSKT patients than in controls (5.78 +/- 0.41 vs. 3.41 +/- 0.24 years; p < 0.0001). A total of 166 glands were removed or biopsied. Except for one questionable case, no true adenoma was observed even when only one gland was enlarged. The outcome of surgery was not influenced by the technique (subtotal parathyroidectomy versus total parathyroidectomy and autografting) but depended on the amount of resected parathyroid tissue: no failures and 4 cases of hypoparathyroidism in 34 cases with no missing gland at cervical exploration; 3 failures and no permanent hypoparathyroidism in 11 cases with one or two missing glands. Excision of the enlarged glands only was sufficient to cure the patient. No recurrence was observed. Our results suggest that single gland enlargement in PHSKT results in most cases from different rates of involution of the parathyroids after successful kidney transplantation. When fewer than four glands are discovered, resection of all visible glands with or without grafting corrects hypercalcemia in more than 70% of the cases.

Long-term results of subcutaneous parathyroid grafts in uremic patients.

HYPOTHESIS: Parathyroid glands are normally surrounded (entirely or partially) by fatty tissue. Subcutaneous parathyroid grafts are thus located in a normal environment. Therefore, we postulated that the late results of subcutaneous implantation of parathyroid tissue in uremic patients should be at least as good as those reported for intramuscular grafting. We also challenged the idea that the recurrence rate of renal hyperparathyroidism after surgery depended solely on the type of hyperplasia (diffuse vs nodular) observed in the implanted tissue. DESIGN: A retrospective study of a series of patients without loss to follow-up. SETTING: A university hospital and 9 affiliated dialysis units. PATIENTS AND INTERVENTIONS: Fifty-nine patients (33 women and 26 men) operated on for renal hyperparathyroidism underwent the resection of at least 4 parathyroid glands followed by presternal subcutaneous implantation of parathyroid tissue. They were followed up for 12 to 130 months (median, 38 months). MAIN OUTCOME MEASURES: Failure of treatment, recurrence of disease, and hypoparathyroidism. RESULTS: During the study period, 9 patients had to undergo another operation: 2 (3%) for persistent hyperparathyroidism due to a fifth ectopic gland and 7 (12%) for recurrence of hyperparathyroidism resulting from hypertrophy of the subcutaneous grafts. Four patients received a kidney transplant. The prevalence of hypoparathyroidism (intact parathyroid hormone serum level <1.6 pmol/L with a normal or low serum calcium concentration) was 14% (8 of 59 patients), and the curve representing the distribution of intact parathyroid hormone serum concentrations among operated on patients was shifted to the left when compared with the curve of patients who underwent hemodialysis and who had no indication for parathyroid surgery. In this latter group, the peak of the curve was situated between 1 and 2 times the upper normal limit, while it was in the normal range 12 to 130 months after total parathyroidectomy and subcutaneous parathyroid autotransplantation. No relation was observed between the recurrence rate of the disease and the histological characteristics of the parathyroid grafts. Also, their function was not influenced by the presence or absence of aluminum deposits in bone biopsy specimens that were obtained at the time of cervical exploration. CONCLUSIONS: The late results of total parathyroidectomy and presternal subcutaneous grafting compare favorably with the published data on other surgical techniques proposed for the treatment of renal hyperparathyroidism. The ease with which the hypertrophied grafts are removed when the disease recurs warrants further use of this procedure.

[What degree of freedom is there for living donors?]. / Quel degré de liberté y a-t-il pour un donneur vivant?

The shortage of cadaveric donors has induced a renewed interest in living kidney donation. This paper describes the legal, religious and ethical factors which ensure or restrict the autonomy of the potential donor. We conclude that it is possible with appropriate measures to protect his freedom of choice.