A new MEFV gene mutation in an Iranian patient with familial Mediterranean fever.

Familial mediterranean fever (FMF) is an inherited autoinflammatory disorder characterized by recurrent episodes of fever and painful inflammation involving the intra-abdominal organs, the lungs and the joints, which is highly prevalent in specific ethnic groups including the Iranians. We report a 12-year-old boy from Iran, with a clinical history of recurrent fever. Based on the suggestive clinical data, mutational analysis revealed the presence of the novel c.1945C>T heterozygous variant in exon 10, which leads to a leucine to phenylalanine change at position 649 of the protein. The mutation was inherited from the mother. This novel mutation lies in exon 10 of the MEFV gene, which encodes for a domain called B30.2-SPRY, located in the C-terminal region of the pyrin protein and contains the most frequent mutations associated with FMF. The present report expands the spectrum of MEFV gene mutations associated with FMF. The uniqueness of this study, compared with other published case reports, consists in the new mutation found in the MEFV gene. In fact, new mutations in this gene are of high interest, in order to better understand the role of this gene in autoinflammation.

9q31.1q31.3 deletion in two patients with similar clinical features: a newly recognized microdeletion syndrome?

Interstitial deletions of the long arm of chromosome 9 are rare and most patients have been detected by conventional cytogenetic techniques. Disparities in size and localization are large and no consistent region of overlap has been delineated. We report two similar de novo deletions of 6.3 Mb involving the 9q31.1q31.3 region, identified in two monozygotic twins and one unrelated patient through array-CGH analysis. By cloning the deletion breakpoints, we could show that these deletions are not mediated by segmental duplications. The patients displayed a distinct clinical phenotype characterized by mild intellectual disability, short stature with high body mass index, thick hair, arched eyebrows, flat profile with broad chin and mild prognathism, broad, and slightly overhanging tip of the nose, short neck with cervical gibbus. The twin patients developed a metabolic syndrome (type 2 diabetes, hypercholesterolemia, vascular hypertension) during the third decade of life. Although long-term follow-up and collection of additional patients will be needed to obtain a better definition of the phenotype, our findings characterize a previously undescribed syndromic disorder associated with haploinsufficiency of the chromosome 9q31.1q31.3 region.

MR Brain Screening in ADPKD Patients : To Screen or not to Screen?

BACKGROUND: Adult polycystic kidney disease (ADPKD) still represents a major cause of renal failure and intracranial aneurisms (IA) have a higher prevalence in ADPKD than in the general population. Current guidelines suggest performing brain MRI only in the subjects with a positive familiar history of IAs or subarachnoid hemorrhage (SAH). This is a retrospective case-control analysis to evaluate the usefulness of a MR screening program in ADPKD patients. METHODS: We retrospectively analyzed all ADPKD patients followed in our outpatient clinic between 2016 and 2019 who underwent a brain MRI screening. We evaluated the presence of IAs and others brain abnormalities and compared our results with a non-ADPKD population (n = 300). We performed univariate and multivariate regression analysis to evaluate if general and demographic features, laboratory findings, clinical parameters and genetic test results correlated with IAs or other brain abnormalities presence. RESULTS: Among the patients evaluated 17 out of 156 (13.6%) ADPKD patients had IAs, compared to 16 out of 300 (5.3%) non-ADPKD controls (p < 0.005). Considering ADPKD patients presenting IAs, 12 (70.6%) had no family history for IAs or SAH. Genetic analysis was available for 97 patients: in the sub-population with IAs, 13 (76.5%) presented a PKD1 mutation and none a PKD2 mutation. We found that arachnoid cysts (AC) (p < 0.001) and arterial anatomical variants (p < 0.04) were significantly more frequent in ADPKD patients. CONCLUSION: In our population ADPKD patients showed a higher prevalence of IAs, AC and arterial variants compared to non-ADPKD. Most of the IAs were found in patients presenting a PKD1 mutation. We found a significant number of alterations even in those patients without a family history of IAs or SAH. The practice of submitting only patients with familial IAs or kidney transplantation candidates to MRI scan should be re-evaluated.

Intracranial Arterial Tortuosity in Marfan Syndrome and Loeys-Dietz Syndrome: Tortuosity Index Evaluation Is Useful in the Differential Diagnosis.

BACKGROUND AND PURPOSE: The association of arterial tortuosity and connective tissue diseases is widely reported in the literature, but only a few studies were based on a quantitative evaluation of this arterial phenotype, and none of the latter examined the intracranial vasculature. The aim of this study was to evaluate the degree of intracranial arterial tortuosity in patients with Marfan syndrome and those with Loeys-Dietz syndrome, and to assess its usefulness in the differential diagnosis. MATERIALS AND METHODS: We performed a retrospective analysis of 68 patients with genetically confirmed Marfan syndrome (n = 36) or Loeys-Dietz syndrome (n = 32), who underwent at least 1 MRA of the brain at our institution. Fifty-two controls were randomly selected among patients who presented with headache and without any known comorbidity. Tortuosity indexes of 4 intracranial arterial segments were measured on a 3D volume-rendered angiogram by using the following formula: [Formula: see text]. RESULTS: Both Marfan syndrome and Loeys-Dietz syndrome showed a significantly higher tortuosity index compared with controls in all examined vessels. The tortuosity index of the vertebrobasilar system showed an excellent interrater reliability (intraclass correlation coefficient, 0.99) and was the strongest independent predictor of Loeys-Dietz syndrome in patients with connective tissue disease (P = .002), with a 97% specificity for this pathology when its value was > 60. CONCLUSIONS: The tortuosity index of intracranial arteries is an easily calculated and highly reproducible measure, which shows a high specificity for Marfan syndrome and Loeys-Dietz syndrome and may be useful in differentiating these 2 entities.

Loss of chemokine SDF-1alpha-mediated CXCR4 signalling and receptor internalization in human hepatoma cell line HepG2.

Expression of the chemokine stromal cell-derived factor-1alpha (SDF-1alpha) is absent from many carcinomas, including hepatomas. We note an early signalling defect in the hepatocellular carcinoma (HCC) cell line HepG2 that expresses the CXCR4 receptor and binds biotin-labelled SDF, but fails to stimulate downstream signalling events after engagement with SDF. In HepG2, the SDF/CXCR4 interaction did not result in calcium influx, phosphorylation and internalization of CXCR4, nor in a rapid phosphorylation of p44/42 MAP kinase. There were no CXCR4 mutations in the second chemokine binding loop or C terminal phosphorylation and internalization domains. The downstream signalling machinery in HepG2 appears to be intact since transfection of wild-type CXCR4 restored functional responsiveness. We conclude that HepG2 is unresponsive to SDF stimulation because of a defect located after receptor binding but before the activation of the signalling cascade. A hypothetical blocking molecule could hinder receptor internalization or CXCR4 signalling.

Increased monocyte TNF-alpha message stability contributes to trauma patients' increased TNF production.

Post-trauma elevation of tumor necrosis factor alpha (TNF-alpha) appears to be critical in mediating many symptoms of systemic inflammatory response syndrome (SIRS), resulting in late mortality. Although increased monocyte (mphi) TNF-alpha production plays a pivotal role in this TNF-alpha elevation, the molecular mechanisms leading to increased mphi TNF-alpha production have yet to be elucidated. We demonstrate that, although TNF-alpha mRNA levels are increased in all trauma patients' mphi, which produce elevated levels of TNF-alpha protein, in the majority of patients, these increased TNF-alpha mRNA levels are under normal transcriptional and posttranscriptional control. Consequently, the increased TNF-alpha production by these patients' mphi is probably due to preactivation of these mphi by trauma-released mediators. However, a small minority of patients, whose mortality rate was 57%, produce TNF-alpha of primarily the membrane-associated type. The mphi TNF-alpha mRNA accumulation of these patients in response to in vitro stimulation is significantly augmented. All of these patients experienced SIRS. In this subset of patients' mphi, TNF-alpha mRNA stability was aberrantly increased. Such an increase in TNF-alpha mRNA stability could lead to devastatingly prolonged production of TNF-alpha protein. This demonstration of increased TNF-alpha mRNA stability in post-trauma mphi represents a novel correlation of elevated membrane-associated TNF-alpha protein, increased mortality, and a mechanism for this occurrence.

Differential tumor necrosis factor production by human monocyte subsets.

The human monocyte (M phi subset rosetting with anti RH-coated human erythrocytes via high-affinity, 72 kD receptors (FcRI+), contains the PGE2-producing immunosuppressive subpopulation, while the non-rosetting M phi subset (FcRI-) is the major plasminogen activator-producing and antigen-presenting M phi. This study gives additional evidence for the functional disparity of the FcRI- and FcRI+ M phi subsets. We are demonstrating that the normal human M phi subset isolated by rosetting via the FcRI receptor (FcRI+) produces greater quantities of tumor necrosis factor (TNF) than the non-rosetting (FcRI-) M phi. TNF production by the FcRI+ M phi subset is greater than that of the FcRI- M phi subset whether secreted (P less than .001) or cell-associated (P less than .001) TNF is assessed. The rosetting M phi subset that expresses high densities of FcRI (FcRI+) produced the majority of normal human peripheral blood M phi TNF whether the stimulation was an interferon gamma (IFN gamma) prime followed by MDP or followed by interleukin-2 (IL-2). The Fc rosetting technique itself resulted in some TNF induction in the FcRI+ M phi subset accounting for some of the increased TNF production of this subset. However, increasing the stimulation level of the FcRI very-low-density (FcRI-) M phi subset did not induce it to produce TNF levels equivalent to the moderately stimulated FcRI+ M phi subset. These data, therefore, imply that only stimulation through the type I Fc gamma receptor can augment or induce TNF activity. The difference in the M phi subset's TNF response remained even after the FcRI- M phi subset received a 2.5-fold increase in stimulation with the classical M phi induction regimen of IFN gamma plus bacterial cell wall product. Although stimulation of the FcRI+ M phi subset via crosslinking of their FcRI receptors might represent a unique TNF stimulation pathway, this stimulation does not occur in the low-density FcRI (FcRI-) M phi subset, again indicating functional disparity between these subsets. Greater TNF production by the FcRI+ M phi subset was induced concomitant to elevation of its prostaglandin E2 production. Since both TNF and PGE2 are increased in some patient groups, a pathological shift in the FcRI+ versus FcRI- M phi ratio in these patients coupled to the functional differences in FcRI+ and FcRI- M phi subsets could be one mechanism for the development of immunoincompetence.

Usher syndrome: an effective sequencing approach to establish a genetic and clinical diagnosis.

Usher syndrome is an autosomal recessive disorder characterized by retinitis pigmentosa, sensorineural hearing loss and, in some cases, vestibular dysfunction. The disorder is clinically and genetically heterogeneous and, to date, mutations in 11 genes have been described. This finding makes difficult to get a precise molecular diagnosis and offer patients accurate genetic counselling. To overcome this problem and to increase our knowledge of the molecular basis of Usher syndrome, we designed a targeted resequencing custom panel. In a first validation step a series of 16 Italian patients with known molecular diagnosis were analysed and 31 out of 32 alleles were detected (97% of accuracy). After this step, 31 patients without a molecular diagnosis were enrolled in the study. Three out of them with an uncertain Usher diagnosis were excluded. One causative allele was detected in 24 out 28 patients (86%) while the presence of both causative alleles characterized 19 patients out 28 (68%). Sixteen novel and 27 known alleles were found in the following genes: USH2A (50%), MYO7A (7%), CDH23 (11%), PCDH15 (7%) and USH1G (2%). Overall, on the 44 patients the protocol was able to characterize 74 alleles out of 88 (84%). These results suggest that our panel is an effective approach for the genetic diagnosis of Usher syndrome leading to: 1) an accurate molecular diagnosis, 2) better genetic counselling, 3) more precise molecular epidemiology data fundamental for future interventional plans.

Clinical and genetic heterogeneity in autosomal recessive nemaline myopathy.

Autosomal recessive nemaline (rod) myopathy is clinically and genetically heterogeneous. A clinically distinct, typical form, with onset in infancy and a non-progressive or slowly progressive course, has been assigned to a region on chromosome 2q22 harbouring the nebulin gene Mutations have now been found in this gene, confirming its causative role. The gene for slow tropomyosin TPM3 on chromosome 1q21, previously found to cause a dominantly inherited form, has recently been found to be homozygously mutated in one severe consanguineous case. Here we wished to determine the degree of genetic homogeneity or heterogeneity of autosomal recessive nemaline myopathy by linkage analysis of 45 families from 10 countries. Forty-one of the families showed linkage results compatible with linkage to markers in the nebulin region, the highest combined lod scores at zero recombination being 14.13 for the marker D2S2236. We found no indication of genetic heterogeneity for the typical form of nemaline myopathy. In four families with more severe forms of nemaline myopathy, however, linkage to both the nebulin and the TPM3 locus was excluded. Our results indicate that at least three genetic loci exist for autosomal recessive nemaline myopathy. Studies of additional families are needed to localise the as yet unknown causative genes, and to fully elucidate genotype-phenotype correlations.

Induction and regulation of monocyte procoagulant activity.

Monocyte (MO) procoagulant activity (PCA) is induced by various stimuli including allogeneic stimulation, immunocomplexes, and bacterial products. Antigen-antibody complex stimulation therefore represents a pathway for MO PCA induction. Activation of MO PCA has been demonstrated in immunocomplex disease and could represent a major pathology in transplanted immunocomplex disease patients. Stimulation of monocytes via their FcRI receptor has been demonstrated to induce TNF and PGE2. This report demonstrates that stimulation of the high-density FcRI receptor-bearing (FcRI+) MO by resetting with anti-Rh coated erythrocytes also induces significant PCA levels (P less than 0.001). Muramyl dipeptide (MDP), a Gram-positive bacterial cell wall analogue, further increased PCA levels in the FcRI stimulated MO subpopulation (P less than 0.003). Although increased PCA levels were also induced in the FcRI- MO subpopulation by MDP (P less than 0.003), the FcRI+ MO responded with much greater levels of PCA and PGE2 (P less than 0.001). Greater PCA levels in the FcRI-positive MO subpopulation may indicate that stimulation of MO through their FcRI represents a different pathway from allogenic PCA activation, which can be augmented by subsequent bacterial challenge. A novel inhibitory effect of IL-4 on MO PCA induction is also demonstrated. IL-4 downregulated MO PCA levels either after isolation stimulation (55 +/- 19%), FcRI stimulation (57 +/- 12%), or FcRI plus MDP stimulation (60 +/- 13%). PCA and PGE2 levels were concomitantly downregulated by IL-4 both in the FcRI-stimulated, FcRI+ and in the MDP-stimulated FcRI- MO subpopulations. Since indomethacin blocked MDP induced MO PGE2 production without affecting MO PCA levels, PGE2 production is not required for FcRI-stimulated PCA induction.

Generation of tissue factor by patient monocytes: correlation to thromboembolic complications.

Thromboembolic complications are often a common pathological consequence of severe soft tissue trauma. Recent demonstration that monocytes (M0) produce tissue factor (TF) has led to the suggestion that these TF producing M0 might play a role in coagulopathy. We have previously demonstrated that trauma patients with splenectomy develop aberrant monocyte function and this patient group is also known to be at high risk of hypercoagulability episodes. This paper is an initial report on the use of M0 TF as an indicator of and/or correlated to clotting episodes. Monocytes isolated form the Ficoll-Hypaque purified mononuclear cells of 46 normal individuals, 17 trauma patients and 6 surgical controls were assayed at 3 day post-injury intervals for their levels of TF activity. Changes in monocyte TF activity were correlated to increases in the fractional catabolic rate (FCR) of 125 I-fibrinogen. Trauma patients were retrospectively divided into those whose FcR was elevated to a level indicative of coagulopathy and those whose FCR levels were not associated with coagulation abnormalities. All trauma patients who exhibited significantly increased FCR experienced thromboembolic episodes and had monocytes whose TF activity was increased an average of 300% (mean = 47 units vs mean = 12 units) over surgical controls. These increase in monocyte TF activity occurred at 6-13 days post injury and preceded clinical manifestation of coagulopathy by 4-6 days. The increased monocyte TF activity demonstrated in this study was significantly correlated to detection of pathologically increased FCR (R = 0.850) and compared to other indices of hypercoagulability.

Continued tumor necrosis factor receptor expression by trauma patients' monocytes (Mphi) despite TNF alpha secretion.

In investigating various mechanisms for continued elevated tumor necrosis factor alpha (TNF alpha) production in trauma patients' monocytes (Mphi), we examined TNF receptor (TNFR) levels on the patients' Mphi as a possible altered pathway leading to continued autocrine TNF alpha stimulation. Mphi TNFR synthesis and shedding are both increased as TNF alpha protein production increases. In fatal meningococcal infections, TNFR shedding fails to pace TNF alpha production. Here, isolated normal and trauma patients' Mphi (injury severity score greater than 30), were examined by flow cytometry using phycoerythrin-labeled TNF alpha to detect increased or decreased TNFR expression concomitant to Mphi production of secreted TNF alpha (as measured in the LM bioassay). Immunoaberrant patients (mitogen proliferation depressed) had reduction in detectable TNF alpha binding by their TNFR, while Mphi from immunocompetent (normal mitogen response) trauma patients' Mphi had a TNFR expression intensity comparable to normals' Mphi. Upon in vitro stimulation of TNF alpha (IFN gamma + muramyl dipeptide) normals' and immunocompetent patients' MO TNFR expression is decreased for the entire 18 h period during which secreted TNF alpha is produced, but immunoaberrant trauma patients' Mphi increased their TNFR expression, while concomitantly producing both secreted and cell-associated TNF alpha protein. Patients' Mphi with highly elevated TNF alpha levels are still expressing high levels of TNFR and capable of auto-stimulating TNF alpha production. This elevated TNFR expression could be due to reduced shedding, overproduction of TNFR, or both.

Elevated IL-8 production by trauma patients' monocytes is associated with elevated secretion of TNF alpha.

IL-8 is a recently described chemokine that increases polymorphonuclear neutrophil infiltration and has been implicated in inflammatory pathology. This study assesses monocyte (M phi) interleukin-8 (IL-8) levels in severe trauma patients (injury severity score > 16) who have elevated levels of M phi cell-associated tumor necrosis factor alpha (TNF alpha), a major marker for systemic inflammatory response syndrome after injury. We demonstrate elevated (p = .0007) levels of M phi IL-8 only in those trauma patients who also have increased (p = .0001) M phi-secreted TNF alpha whereas the patients having normal M phi-secreted TNF alpha levels have normal or even decreased M phi IL-8 production. There is no association between M phi IL-8 production and cell-associated TNF alpha levels. M phi induction by Fc gamma RI cross-linking, a common induction pathway in trauma patients' M phi that increases the production of both cell-associated and secreted TNF alpha, can also increase (p = .0022) M phi IL-8 levels. Therefore, post-trauma elevation of M phi IL-8 levels may be associated with increased secreted TNF alpha resulting from, at least in part, Fc gamma RI cross-linking stimulation in vivo.

A membrane TNF-alpha/TNFR ratio correlates to MODS score and mortality.

This study hypothesizes that post-trauma elevated membrane-associated tumor necrosis factor-alpha (mTNF) and decreased TNF receptor shedding may be more related to development of multiple organ dysfunction syndrome (MODS) than elevated secreted TNF-alpha. We also address several of the possible reasons for the previous conflicting reports in studies correlating trauma patients sera TNF-alpha levels to their clinical outcome. These are 1) the lack of an objective quantitative score of clinical illness severity, 2) the lack of multiple TNF-alpha measurements in one patient to allow for trend analysis, 3) the lack of analysis of membrane-associated as well as secreted TNF-alpha levels, 4) the lack of concomitant analysis of soluble TNF-alpha receptors which may bind TNF-alpha in the serum, and 5) the possible requirement for more than one dysfunction in monocyte (M phi) TNF-alpha production and regulation to initiate pathology. Here, the MODS score was used to quantitate patients' illness severity over the length of their intensive care unit (ICU) stay. Patients' and normals' monocytes (stimulated and unstimulated) were assessed for production of secreted as well as membrane-associated TNF-alpha (sTNF and mTNF) and for shed p75 TNF-alpha receptor (TNFR) levels. These parameters of M phi TNF-alpha production and regulation were correlated to the MODS score as an indicator of clinical outcome. There was no correlation between sTNF and MODS score (p = .9025). There was a correlation between increased mTNF (p = .057) or decreased TNFR shedding (p = .0021) to increased MODS, but this lacked specificity. However, when the stimulated M phi production of mTNF and TNFR are expressed as the mTNF/TNFR ratio, an increased ratio correlates with high specificity to development of organ failure (p = .0002). These data indicate that a dual deregulation in M phi TNF-alpha production reflects increasing mTNF-alpha levels concomitant to decreased M phi shedding of neutralizing TNFR and correlates with the development of MODS.

In vivo assessment of anticoagulation.

All methods of assessing anticoagulation rely on in vitro techniques. Although these may reflect the clotting tendency in a specimen of blood accurately, they do not necessarily indicate the effectiveness of the anticoagulant in the body where stasis, acidosis, catecholamines, endotoxin, and exposed collagen may alter the coagulability of blood locally. We have utilized autologous 125I-labelled fibrinogen to assess fibrinogen half-life in normal subjects and in patients with clotting complications before and after the administration of anticoagulants. Fibrinogen half-life has varied from normal (104 hours) to markedly abbreviated (13 hours) in patients apparently fully anticoagulated, utilizing standard laboratory parameters. Although there are many potential causes of the shortening of fibrinogen half-life, including fibrinogenolysis and extravascular losses into the interstitial space and wounds, we have been able to establish whether the disappearance of the radioactive-labelled fibrinogen is due to these causes or to clotting by increasing the levels of anticoagulation. Plateauing of fibrinogen half-life values despite increased doses of heparin, or return of the half-life to normal, indicates full anticoagulation. This has permitted determination and administration of the theoretically optimal dose of heparin. In situations involving life-threatening clotting complications, such as massive pulmonary embolism, the use of 125I-labelled fibrinogen provides a means for controlling anticoagulant therapy in a rational fashion by this technique of assessing clotting.

Mitogen-activated protein kinases signal inhibition of apoptosis in lipopolysaccharide-stimulated neutrophils.

BACKGROUND: Neutrophil (PMN) apoptosis is critical to the resolution of infection and the limitation of inflammation. Bacterial endotoxin (lipopolysaccharide [LPS]) inhibits PMN apoptosis and activates the p38 mitogen-activated protein kinase (MAPK) signal cascade. The role of p38 and other MAPKs (ERK and SAPK/JNK) in regulating PMN apoptosis after LPS stimulation is unknown. We hypothesize that MAPK activation by LPS signals inhibition of PMN apoptosis. METHODS: PMNs were isolated from the blood of healthy human volunteers and incubated with PD98059 (ERK inhibitor), SB203580 (p38 inhibitor), or 0.1% dimethyl sulfoxide (vehicle) for 1 hour before treatment with LPS (0, 10, or 1000 ng/mL). Neutrophil MAPK activation was determined by Western blot analysis for phosphorylated p38, ERK, and SAPK/JNK. Apoptosis was quantified by flow cytometry with use of propidium iodide and annexin V. RESULTS: LPS inhibited PMN apoptosis and activated p38 and ERK in a dose- and time-dependent fashion. SAPK/JNK was not activated by LPS. Treatment of cells with ERK inhibitor before LPS stimulation abrogated LPS signaled inhibition of PMN apoptosis. Conversely, p38 inhibition with SB203580 augmented inhibition of apoptosis by LPS. CONCLUSIONS: These data demonstrate opposing roles of MAPKs in mediating PMN apoptosis after LPS stimulation. We conclude that LPS signal transduction by ERK inhibits PMN apoptosis while activation of p38 promotes apoptosis.

Mechanisms of altered monocyte prostaglandin E2 production in severely injured patients.

Monocytes from immunosuppressed trauma (11 patients) and burn (12 patients) patients stimulated with muramyl dipeptide, a potent prostaglandin E2 (PGE2) secretagogue, showed twofold greater PGE2 production compared with normal controls or immunocompetent patients. Monocyte plasminogen activator production was markedly depressed and inversely correlated to patients' monocyte hyper PGE2 production. Levels of the PGE2-producing monocyte subset (selected as high-affinity Fc+ receptors) were progressively elevated after injury in immunosuppressed patients, reaching 65% to 80% of the total monocyte population (39% for normal controls). Although early T-suppressor (Ts) lymphocytes did not augment monocyte PGE2 secretion, Ts lymphocytes that appeared late (greater than 12 days after injury), during chronic infection, acted as monocyte PGE2 secretagogues. Posttraumatic increases in monocyte sensitivity to PGE2 secretagogues augmented the numbers of PGE2-secreting monocytes, and the appearance of Ts lymphocytes with PGE2 secretagogue activity may be responsible for elevated monocyte PGE2 production in immunosuppressed trauma patients.

Procuring organs from a non-heart-beating cadaver: a case report.

Organ transplantation is an accepted therapy for major organ failure, but it depends on the availability of viable organs. Most organs transplanted in the U.S. come from either "brain-dead" or living related donors. Recently organ procurement from patients pronounced dead using cardiopulmonary criteria, so-called "non-heart-beating cadaver donors" (NHBCDs), has been reconsidered. In May 1992, the University of Pittsburgh Medical Center (UPMC) enacted a new, complicated policy for procuring organs from NHBCDs after the elective removal of life support. Seventeen months later only one patient has become a NHBCD. This article describes her case and the results of interviews with the health care team and the patient's family. The case and interviews are discussed in relation to several of the ethical concerns previously raised about the policy, including potential conflicts of interest, the definition of cardiopulmonary death, and a possible net decrease in organ donation. The conclusion is reached that organ procurement from non-heart-beating cadavers is feasible and may be desirable both for the patient's family and the health care providers.