Attitudes of medical students about brain death and organ donation.

INTRODUCTION: There have been publications on the attitudes of the general Iranian population and health care personnel about brain death and organ donation; however, there is little information about such attitudes of medical students. In 2006, a survey was conducted in Tehran about the attitudes of medical students in a hospital with a transplantation program. MATERIAL AND METHODS: The general population, health care personnel, and medical students were surveyed, and data were extracted from interviews with 41 medical students. The survey included 35 items about attitudes toward brain death and organ transplantation. RESULTS: Nine students (22.0%) had ever seen a transplant recipient, and 7 (17.1%) had ever seen a brain-dead patient. Thirty-four students (82.9%) agreed with organ donation after brain death. Six students (14.6%) had received information through university lectures, and 40 (97.5%) perceived a need for further information about organ donation and brain death in the university curriculum. Nine students (22.0%) had an organ donor card. CONCLUSION: Most Iranian medical students have neither been exposed to brain death or organ recipients nor received appropriate information about organ donation and transplantation.

Issuing donor cards in a single center in Iran: results of the first 3 years.

INTRODUCTION: Issuing an organ donation card has become a goal for procurement units to solve the organ shortage. The number of issued cards is an index of the attitudes or even actions of communities toward brain-dead donations. In the present study, we have reported the characteristics of issuing organ donation cards in a single organ procurement unit in Iran. MATERIALS AND METHODS: This retrospective study used an organ donation willingness database for 3 years after launching the unit. We used the registration data of the first 3 years of its activity from August 1, 2005, to July 31, 2008. For each organ donation volunteer, we extracted demographic data, organs to be donated, and source of their knowledge about the organ donation card system. RESULTS: During the study period, donor cards were issued to 172,290 volunteers; a monthly mean of 4785 registries. Among the total volunteers, 54.2% were females: with 50.7% between 21 to 30 years, 35.2% with an educational level less than a high school diploma, and 35.7% introduced by their friends. The volunteers were more willing to donate heart, kidney, liver, lung, and tissue donations, respectively. Out of the total number of volunteers, 94.1% were willing to donate all organs. An increasing trend was seen in the donation cards issued during the study period. CONCLUSION: Following 3 years of activity, a single center has issued nearly 200,000 cards. The rate at which organ donor cards are issued is increasing, which puts emphasis on establishment of funding for other organ procurement units. This information may be useful to program the field of brain-dead donations in this country.

Organ retrieval from brain-dead patients by a single organ procurement center in Iran.

INTRODUCTION: The majority of transplantations depend solely on cadaveric organs. In recent years, special focus has been directed toward brain-dead patients in Iran, but it seems that there is limited information regarding the characteristics of cadaveric organ donation in our country. MATERIALS AND METHODS: This is a retrospective analysis of data of our Organ Procurement Unit (OPU), which is one of the most active organ procurement units in Iran. We incorporated the data on all organ donations from brain-dead patients between 2004 and 2008 into the present study. Demographic characteristics of the patients along with data regarding brain death and organ donation were extracted from already registered data on patients. RESULTS: Among 93 brain-dead patients registered in the database of the OPU, organs were retrieved from 85% (n = 79). Out of the 14 patients from whom no organ was retrieved, the cause for this failure was death before donation in 85% (n = 12). The numbers of donated organs varied between zero and six (mean +/- standard deviation = 3.1 +/- 1.7). The most donated organs in terms of frequency and count were: right kidney (n = 68; 73.1%), left kidney (n = 67; 72%), liver (n = 63; 67.7%), heart (n = 40; 43%), pancreas (n = 5; 5.4%), and lung (n = 4; 4.3%). DISCUSSION: The overall organ retrieval rate from brain-dead patients by this OPU was comparable to that of developed countries; however, we still believe we can improve this rate/scale.

Lung donation and causes behind its failure: a single-center experience.

INTRODUCTION: Brain-dead patients are almost the only source of organs for lung transplantation, and lungs fall within the area of the least harvested organs. As a result, maintaining the highest possible harvest rate is a must for the lung transplantation system. In the present study, the harvest rate of lungs and also the causes of failure to donate the lungs is reported for brain-dead patients in our organ procurement unit. MATERIALS AND METHODS: After going through the brain-death database at our organ procurement unit between 2004 and 2008, we included all 93 brain deaths in this hospital. The lung donation rate was reviewed to examined the causes for failure to donate lungs. RESULTS: From the total brain-dead patients registered in the database, only 4 (4.6%) patients donated their lungs. The causes of failure to donate a lung were not suitable lungs among 78 (83.8%) because they had an unacceptable oxygen challenge test results (<300 mm Hg). Another 11 patients had acceptable oxygen challenge test results, but donation failed in their case as well due to most frequently to pulmonary aspiration. CONCLUSION: In this center, only a small percentage of lungs are appropriate for harvest in brain-dead patients, because many patients' lungs do not meet the criteria with unacceptable oxygen challenge test results. Patients with proper test results may fail to donate lungs due to pulmonary aspiration. More aggressive care of the patients may have an important role in keeping them in good condition and helping to preserve the organs for harvest. For this purpose, further training of intensive care unit staff and physicians are among the suggested steps to enhance the quality of care, which in turn can maximize the lung harvest rate.

Kidney transplantation: is there any place for refugees?

There are more than 8 million refugees worldwide with the Middle East bearing the brunt. Socioeconomic factors are the major obstacles that refugees encounter when seeking health care in the host country. It, therefore, comes as no surprise that refugees are denied equal opportunities for one of the most sophisticated and expensive medical procedures in the world, kidney transplantation. With respect to transplantation, refugees are caught between a rock and a hard place: as recipients they have to single-handedly clear many hurdles on the arduous road to renal transplantation and as donors they are left unprotected against human organ trafficking. It should be the moral responsibility of the host country to provide this population with a support network. The ways and means of establishing this network should be defined locally; nevertheless, enabling refugees to receive a transplant is the most basic step, which should be followed by the provision of financial support and follow-up facilities in a concerted effort to ensure the continued function of the invaluable graft. It is also necessary that refugees be protected from being an organ reservoir on the black market. There are no precise regional or international data available on kidney transplantation in refugees; among the Middle East Society for Organ Transplantation countries, only Iran, Saudi Arabia, Pakistan, and Turkey have thus far provided data on their respective kidney transplantation regulations and models. Other countries in the region should follow suit and design models tailored to the local needs and conditions. What could, indubitably, be of enormous benefit in the long term is the establishment of an international committee on transplantation in refugees.

Which primary diagnosis has the highest in-hospital mortality rate for kidney recipients?

OBJECTIVES: Although "in-hospital mortality" for several post-renal transplantation complications has been reported in various studies, there is no single published single-center study that compares their hospital mortality rates. We sought to rank the primary diagnoses post-renal transplantation by means of in-hospital mortality. METHODS: We selected 404 consecutive rehospitalizations following kidney transplantation from 2003 to 2005. The causes of rehospitalization were categorized into infection, allograft rejection, surgical complication, cerebrovascular accidents (CVA), malignancy, medication complications, and miscellaneous. Fatality was defined as the relative frequency of death due to the same cause among all admissions. RESULTS: The mortality rate (MR) was 5.7%. From the 23 cases of death, 17 (74%) had a functioning kidney at the time of death. The MR was 40% for CVA, 14.3% for surgical complications, 11.1% for miscellaneous, 5.3% for drug complications, 7% for infections, and 4.8% for graft rejection (P=.002). No death was observed among cases with a diagnosis of malignancy or nephrolithiasis. Inpatient mortality was higher among those with more than one diagnosis at admission: 42.9% for more than two diagnosis, 7.1% for those with two diagnosis, and 4.2% for those with one diagnosis (P=.001). CONCLUSIONS: The in-patient mortality ranking is totally different from the ranking of causes of death in renal recipients. In other words, infection is the leading cause of death due to high incidence, and not high fatality. More rare complications, including CVA and surgical complications, are more often fatal.

Causes of rehospitalization after renal transplantation; does age of recipient matter?

BACKGROUND: This study assessed the causes and related factors of rehospitalization following renal transplantation among elderly compared with younger patients. METHODS: We reviewed the charts of 567 patients rehospitalized after kidney transplantation from 2000 to 2006. According to age at the time of transplantation, hospitalizations were divided into two groups: group 1 (age >or=50 years) and group II (age 20 to 50 years). Demographics, clinical findings, causes for rehospitalization, patient outcomes (recovery, graft loss, death), intensive care unit (ICU) admission, length of hospital stay, time interval from transplantation to rehospitalization, as well as hospital costs were compared between the two groups. RESULTS: One hundred eighty-five (32.6%) rehospitalizations were charted for group I, who showed a higher proportion of admissions due to infection (42.2% vs 29.8%, P=.004) and macrovascular disease (3.8% vs 1.0%, P=.027) compared with group II. ICU admission (8.8% vs 2.4%, P=.001), mortality (10.2% vs 3.6%, P=.008), and hospital charges (1610 +/- 933 vs 931 +/- 850 purchase power parity dollars, P=.001) were also seen more frequently in group I but displayed a lower frequency of admissions due to graft rejection (20% vs 34.3%, P=.001). CONCLUSION: Recipient age at the time of transplantation was a main factor affecting rehospitalization among our patients.

Prediction of inpatient survival and graft loss in rehospitalized kidney recipients.

INTRODUCTION: Despite a sizeable amount of research conducted hitherto into predictors of renal transplantation outcomes, there are scarce, data on predictors of in-hospital outcomes of post-kidney transplant rehospitalization. This study sought to provide a user-friendly prediction model for inpatient mortality and graft loss among rehospitalized kidney recipients. METHOD: This retrospective review of 424 consecutive kidney recipients rehospitalized after kidney transplantation between the years 2000 and 2005 used multiple logistic regression analysis to evaluate predictors of hospitalization outcomes. RESULTS: Multivariate analysis showed that age at admission, diabetes mellitus as the cause of end-stage renal disease (ESRD), admission due to cerebrovascular accident (CVA), surgical complications were predictors of in-hospital death; age at transplantation, surgical complications, and rejection were predictors of graft loss. Equation for prediction of in-hospital death was Logit(death) -0.304 * age at transplantation (year) + 0.284 age at admission (year) + 1.621 admission for surgical complication + 4.001 admission for CVA-ischemic heart disease + 2.312 diabetes as cause of ESRD. Equation for prediction of in-hospital death was Logit(graft loss) = 0.041 age at transplantation (year) + 1.184 admission for graft rejection + 1.798 admission for surgical complication. CONCLUSIONS: Our prediction equations, using simple demographic and clinical variables, estimated the probability of inpatient mortality and graft loss among re-hospitalized kidney recipients.

Anxiety and depression: a comparison between renal transplant recipients and hemodialysis patients.

BACKGROUND: Anxiety and depression are known causes of morbidity among patients with chronic illnesses. There is controversy whether hemodialysis or renal transplanted subjects have less severe anxiety or depression symptoms. We designed this study to evaluate these symptoms in the two groups of subjects. METHODS: In a case-control study performed in 2006, we randomly selected 32 transplant recipients and 39 hemodialysis patients. The two groups were matched for gender, age, marital status, educational background, and somatic comorbidities. Symptoms of anxiety and depression were compared between the groups using the Hospital Anxiety Depression Scale. RESULTS: Anxiety score was significantly lower among transplant recipients compared with hemodialysis patients (8.61 +/- 3.09 vs 10.41 +/- 2.77; P=.01). There was no significant difference between the two groups in the score for depression (P>.05). In transplant recipients, the severity of anxiety was higher among those with a history of graft rejection and those <35 years at the time of transplantation (P<.05). The severity of depressive symptoms was higher among subjects with lower educational status (P<.05). CONCLUSION: Depressive symptoms did not seem to improve after renal transplantation, which highlights the need for screening and appropriate treatment of depression. Transplant recipients with a history of rejection or a young age at the time of transplantation should receive more attention for psychiatric problems.

Outcome of living kidney transplant: pediatric in comparison to adults.

BACKGROUND: Renal transplantation is the most optimal way to manage children with end-stage renal disease. Despite its benefits, pediatric renal transplantation is a challenge for several transplantation centers in terms of achieving a satisfactory outcome. We sought to compare the long-term outcome of pediatric versus adult recipients who underwent renal transplantation. METHOD: We examined, 2631 recipients of a first kidney from a living donor between 1982 and 2002. The two groups were matched for immunosuppressive therapy and number of HLA mismatches. The patients were divided into a pediatric (n=301; age 18 years) to compare 5-year patient and graft survivals. RESULTS: The mean ages of the pediatric and adult groups were 40 +/- 13 and 14 +/- 13 years, respectively. The 5-year graft survival was lower among the pediatric versus the adult group (56% vs 68%; P=.015) with no difference in patient survival (88% vs 86%; P>.05). CONCLUSION: The poorer graft survival in pediatric transplantation may be due to the nature of pediatric transplantation, in terms of inconsistent adherence to medication regimens, worse side effects of medications, higher rate of graft rejection due to recurrent disease, and more intense immunoreactivity of children.

Impact of pregnancy on the outcome of kidney transplantation.

BACKGROUND: There is still controversy over whether pregnancy adversely affects renal transplantation outcomes. We, thus, compared two groups of kidney transplant recipients in terms of patient survival and allograft function: those who did versus did not conceive posttransplant. METHODS: This historical cohort study conducted between 1996 and 2002, divided female kidney transplant recipients of reproductive age into group I (n=86, at least one posttransplant pregnancy) and group II (n=125, no posttransplant pregnancy). The two groups were matched for age, cause of end-stage renal disease (ESRD), treatment protocol, and first creatinine (Cr). All patients received a first transplant and all had a Cr less than 1.5 mg/dL on entry into the study. The subjects were followed for 45.4 +/- 22.0 and 46.3 +/- 19.8 months, respectively (P>.05). Five-year patient and graft survivals and Cr were considered to be the main outcome measures. RESULTS: Mean (SD) age in groups I and II was 26.6 +/- 6.6 and 26.9 +/- 8.1 years, respectively (P>.05). Five-year patient and graft survival rates were not significantly different between the study groups. Of the women in group 1, only 9 (10.5%) subjects displayed elevated serum Cr levels (>1.5 mg/dL) at the end of follow-up, while the serum Cr levels in 35 (28%) group II patients were above 1.5 mg/dL (P=.024). CONCLUSION: Our results indicates pregnancy did not seem to adversely affect patient and graft survival among kidney transplant recipients. Renal transplantation in stable women of childbearing age should not be a contraindication to pregnancy.

Cyclosporine trough (C0) and 2-hour postdose (C2) levels: which one is a predictor of graft loss?

BACKGROUND: Compared with conventionally measured trough level (C0), cyclosporine 2-hour postdose (C2) concentrations show a better correlation with the area under the curve and acute graft rejection. OBJECTIVES: We evaluated the relationships of C0 and C2 with long-term graft survival among kidney transplant recipients. METHODS: In a case-control design, we selected 215 adult kidney recipients. Inclusion criteria were more than 18 years of age at transplantation and at least 6 months of follow-up. The case group consisted of patients with graft loss (n=17) and a control group, patients with functioning grafts (n=198). The C0 and C2 levels for the first 6 months posttransplantation, along with demographic and clinical data, were compared between the two groups using univariate analysis. P<.05 was considered to be significant. RESULTS: The mean age at transplantation was 40.5 +/- 16.5 years. The mean follow-up duration was 18 +/- 14 months. The mean C0 values for the case and control groups were 257.8 +/- 126.5 and 248.5 +/- 104.4 mumol/L, respectively (P>.05). The values for C2 were 712.7 +/- 273.2 and 886.2 +/- 266.9 mumol/L, respectively (P=.01). CONCLUSIONS: We observed that C2, but not C0, in the first 6 months posttransplantation were a predictor of long-term graft survival. The findings here in supported the results of other studies that have proposed cyclosporine concentration monitoring by C2 rather than C0 measurements.

Changing treatment protocol from azathioprine to mycophenolate mofetil: decrease in renal dysfunction, increase in infections.

INTRODUCTION: Immunosuppression for renal transplantation has shifted from azathioprine (AZA) regimens to those containing mycophenolate mofetil (MMF). This study investigated the impact of this change on the causes for rehospitalization as well as on graft and patient survival. METHODS: In this retrospective cohort study, we reviewed long-term patient and graft survivals as well as the causes of posttransplant admissions for 893 kidney recipients. Data on survival and readmissions were available for 811 subjects, who were divided to into the AZA cohort (n=289, transplantation between 1998 and 1999) and the MMF cohort (n=567, transplantation between 2000 and 2001). Survival, the cause for readmission, time interval between transplantation and readmission, intensive care unit (ICU) admission, mortality, and graft loss were compared between the two cohorts. RESULTS: Five-year patient and graft survival rates were 85% and 67% for the AZA cohort and 91% and 68% for the MMF cohort (P=.013). There were 202 (71%) and 371 (72%) readmissions registered for the AZA and MMF groups, respectively. In comparison with the AZA cohort, while readmissions secondary to graft rejection showed a significant decrease in the MMF cohort (62% vs 35%, P=.000), readmissions secondary to infections exhibited a significant increase (37% vs 50%, P=.002). A marginally significant increased mortality rate (2% vs 5%, P=.087) and ICU admission rate (3% vs 6%, P=.062) were also observed in the MMF cohort by comparison with the AZA cohort. CONCLUSION: The shift in the immunosuppression protocol from AZA to MMF, albeit advantageous in many instances, can sometimes undermine the outcome by giving rise to such complications as high infection rates.