How Did the War Affect Organ Transplantation in Syria?

Since 2011, the Syrian conflict has destroyed much of the country's infrastructure. The deteriorating humanitarian situation has involved health workers and facilities. In 2010, before the war, 385 kidney transplants were performed in Syria. This number declined to 154 in 2013 (60% less) before increasing to 251 transplants in 2018, which is still 35% less than the number of transplants performed before the war. In addition, the number of operational kidney transplant centers has decreased from 8 in 2010, distributed over 3 cities, to only 4 in 2013, all located in Damascus, which increased to 6 centers in 2019. Interestingly, with regard to type of living donor, the percentage of unrelated kidney donors has decreased by 20% for unclear reasons. Another alarming statistic is that more than 50% of kidney transplant physicians and surgeons are no longer practicing transplant medicine in their centers, either because they have left the country or because their centers had become nonoperational. Since the war, free and timely provision of immunosuppressive drugs for all patients in all provinces has been a leading challenge for health authorities and transplant patients. This difficulty has led to adverse medical consequences for patients. A project to initiate liver transplant came to a halt because of complex reasons but mainly because foreign trainers could not visit Syria. Although the autologous bone marrow transplant program had slowed until recently, it has become more active, involving both autologous and allogeneic transplants. The deceased-donor program is still not available in Syria; the war has just reinforced the many reasons that prevented the start of this program before the conflict. The commitment of transplant teams despite these large challenges continues to be extraordinary. The Syrian conflict has affected all aspects of organ transplant, paralyzing new projects and negatively affecting existing programs.

Risk of adverse maternal and fetal outcomes during pregnancy in living kidney donors: A matched cohort study.

BACKGROUND: We examined the risk of adverse pregnancy outcomes in primiparous kidney donors compared to matched controls. METHODS: Fifty-nine women with a history of kidney donation prior to their first pregnancy with normal renal function and no history of kidney disease, diabetes or chronic hypertension were matched 1:4 by age (within 2 years) and race to women with two kidneys using data from an integrated healthcare delivery system. Adverse pregnancy outcomes were defined as preterm delivery (delivery <37 weeks), delivery via cesarean section, gestational hypertension, preeclampsia/eclampsia, gestational diabetes, length of stay in the hospital >3 days, infant death/transfer to acute facility and low birthweight (<2500 g). RESULTS: Living kidney donors did not have a higher risk of adverse outcomes compared to matched controls. There was a trend toward an increased risk of preeclampsia/eclampsia in kidney donors but it did not reach statistical significance (Odds ratio [OR]: 2.96, 95% CI: 0.98-8.94, P = 0.06). However, in kidney donors ≤30 years of age, there was a fourfold increased risk of preeclampsia/eclampsia (OR: 4.09, 95% CI: 1.07-15.59, P = 0.04). CONCLUSION: Overall, the risk of pregnancy-associated complications following kidney donation is small but potential female kidney donors should be counseled on the possible increased risk of preeclampsia.

Expanding renal transplantation organ donor pool in Nigeria.

Kidney transplantation is the gold standard for end-stage renal disease. All over the world there are several challenges preventing sufficient organ donation to meet the growing needs of patients on the waiting list. One major challenge which is common to most countries is the shortage of organs from willing living donors. Many countries, especially, the developed countries, have devised several models of expanding their donor pools to meet the growing needs of patients on the waiting list. Nigeria, a developing country has very low kidney transplantation rate even though some progress have been made in making the procedure feasible in about a dozen hospitals in Nigeria. One very major challenge has been the shortage of donor organ supply. This paper intends to proffer suggestions on how to expand the organ donor pool in Nigeria.

Análisis de los resultados a largo plazo del trasplante hepático de donante vivo en adulto / Analysis of the long-term results of living donor liver transplantation in adults

Introducción: El trasplante hepático de donante vivo (THDV) es una alternativa al trasplante convencional dados sus excelentes resultados. El objetivo de este trabajo es la evaluación de los resultados a largo plazo en los receptores de THDV. Métodos: Cien receptores consecutivos de THDV del Hospital Clínic de Barcelona desde marzo de 2000 hasta octubre de 2015. La indicación principal de trasplante fue hepatopatía terminal (58%) seguido de hepatocarcinoma (41%). Los injertos consistieron en un 95% del hígado derecho del donante y en un 5% del izquierdo. Resultados: Tras una mediana de seguimiento de 65,5 meses, la supervivencia global a uno, 3 y 5 años de los pacientes y de los injertos fue del 93%, 80% y 74% y del 90%, 76% y 71% respectivamente, con una tasa de retrasplante global del 9%. La complicación a largo plazo más frecuente fue una estenosis biliar (40%), con un tiempo medio de aparición de 13,5±12 meses, que comportó repetidos ingresos y una media de 1,9±2 abordajes endoscópicos y 3,5±3 abordajes radiológicos por paciente. El tratamiento definitivo fue dilatación radiológica en un 40% de los casos, intervención quirúrgica en un 22,5% y retrasplante en un 7,5%. Conclusiones: Dados los resultados a largo plazo, el THDV se confirma como una alternativa al trasplante convencional. Sin embargo, la alta tasa de complicaciones biliares tardías conlleva repetidos ingresos y tratamientos invasivos que, si bien no comprometen la supervivencia, pueden afectar la calidad de vida del paciente (AU)

Introduction: Living donor liver transplantation (LDLT) is an alternative to conventional transplantation given its excellent results. The aim of this study is to evaluate long-term outcomes in LDLT recipients. Methods: 100 consecutive THDV recipients from the Hospital Clínic of Barcelona from March 2000 to October 2015 were included. The main indication for transplantation was end-stage liver disease (58%) followed by hepatocellular carcinoma (41%). 95% of grafts consisted of the right liver of the donor and the 5% of the left liver. Results: After a median follow-up of 65.5 months, patient and graft survival at 1, 3, and 5 years was 93%, 80% and 74% and 90%, 76%, and 71%, respectively. The overall re-transplant rate was 9%. The most common long-term complication was biliary stenosis (40%) with an average time of onset of 13.5±12 months, with repeated admissions and an average of 1.9±2 endoscopic procedures and 3.5±3 Radiological procedures per patient. The definitive treatment was radiological dilation in 40% of cases, surgical intervention in 22.5% and re-transplantation in 7.5%. Conclusions: Given the long-term results, LDLT is confirmed as an alternative to conventional transplantation. However, the high rate of late biliary complications involves repeated admissions and invasive treatments that, while not compromising survival, can affect the patient's quality of life (AU)

Vouchers for Future Kidney Transplants to Overcome "Chronological Incompatibility" Between Living Donors and Recipients.

BACKGROUND: The waiting list for kidney transplantation is long. The creation of "vouchers" for future kidney transplants enables living donation to occur when optimal for the donor and transplantation to occur later, when and if needed by the recipient. METHODS: The donation of a kidney at a time that is optimal for the donor generates a "voucher" that only a specified recipient may redeem later when needed. The voucher provides the recipient with priority in being matched with a living donor from the end of a future transplantation chain. Besides its use in persons of advancing age with a limited window for donation, vouchers remove a disincentive to kidney donation, namely, a reluctance to donate now lest one's family member should need a transplant in the future. RESULTS: We describe the first three voucher cases, in which advancing age might otherwise have deprived the donors the opportunity to provide a kidney to a family member. These 3 voucher donations functioned in a nondirected fashion and triggered 25 transplants through kidney paired donation across the United States. CONCLUSIONS: The provision of a voucher to potential recipients whose need for a transplant makes them "chronologically incompatible" with their donors may increase the number of living donor transplants.

Lessons Learned From Review of a Single Center Experience With 500 Consecutive Liver Transplants in a Region With Insufficient Deceased-Donor Support.

OBJECTIVES: We present here the outcomes of our first 500 liver transplants and discuss the lessons learned during this time. MATERIALS AND METHODS: We retrospectively analyzed the first 500 consecutive transplants within the listing criteria of the United Network for Organ Sharing, with recipients and donors with minimum 1-year follow-up. Patient survival and donor complications were analyzed for 31 liver transplant recipients with hepatocellular carcinoma beyond the Milan criteria who had transplant performed during the same time. RESULTS: Between August 2006 and March 2013, there were 519 liver transplants performed in 500 patients (365 adult, 135 pediatric). There were 394 living-donor and 125 deceased-donor liver transplants. In addition, 31 adult liver transplants were performed in patients with hepatocellular carcinoma beyond Milan criteria (22 living-donor and 9 deceased-donor transplants). The main cause of chronic liver failure was biliary atresia in pediatric patients (30.4%) and chronic hepatitis B infection in adults (35.6%). The complication rate for primary nonfunction was 3.8%, overall biliary complications 24.0% (significantly higher after adult living-donor liver transplant, 30.3%), hepatic artery thrombosis 1.6%, portal vein thrombosis 3.0%, retransplant 3.8%, acute cellular rejection 29.6%, and bacterial infection 39.4%. Overall 1-, 3-, and 5-year patient survival rates in the first 500 consecutive transplants performed on recipients within United Network for Organ Sharing listing criteria were 87.8%, 85.0%, and 78.6%; for hepatocellular carcinoma patients beyond the Milan criteria, survival rates were 71.9%, 52.5%, and 38.2%. CONCLUSIONS: In regions without a sufficient number of deceased donors, living-donor liver transplant, with its associated problems, is the only alternative to deceased-donor liver transplant. Liver transplant requires teamwork, with all players working well together for a successful outcome. The important keys to success in liver transplant include decision-making, timing, surgical skills, experience, and close follow-up.

[Liver transplantation with living donor : current aspects, perspectives and significance in Germany]. / Lebertransplantation mit Lebendspende : Aktuelles, Perspektiven und Stellenwert in Deutschland.

More than 20 years ago living donor liver transplantation was introduced into clinical practice. Specifics of this method were developed initially for children and later on for adults particularly in regions where a liver transplantation program using deceased donors was not readily available. The most sensitive aspect of living donation, namely the danger to a healthy relative in order to perform the transplantation is immanent in the system and, thus, it is definitively a secondary option as compared to deceased organ donation. Following worldwide initial euphoria the numbers have markedly decreased in the western world since the start of the new millennium. In Asian countries in particular, much work has been done to optimize the procedure so that the donor safety and the outcome quality for the recipient have been impressively demonstrated in large patient populations. There is still a severe donor organ shortage and the option to allocate an optimal (partial) organ on an individual basis by living donation has given new impact to the discussion about a further rise in the profile of living donations here as well. The new version of the German transplantation legislation implemented in summer 2012 requires a number of conditions with respect to insurance for living donors. The current state and perspectives are presented here.

Outcomes of overseas kidney transplantation in chronic haemodialysis patients in Taiwan.

AIM: Overseas kidney transplantation has often been reported to have unsatisfactory outcomes. This study aims to compare post-transplantation outcomes between overseas and domestic kidney transplant (KT) recipients in Taiwan. METHODS: The Taiwanese National Health Insurance Research Database was used to identify 310 domestic and 643 overseas KT recipients, who survived for longer than 1 month after the transplantation, in a cohort of 45,453 chronic haemodialysis patients in 1997-2002. Cox proportional hazards models were used to assess risks of mortality and graft failure. RESULTS: The 1, 3 and 5 year survival rates for domestic KT recipients were 96.5%, 93.3% and 91.6%, respectively, while those for overseas KT recipients were 94.9%, 87.9% and 77.1%, respectively (P = 0.015). For the overseas group, those who received a KT before 2001 had significantly higher hazard ratios of mortality and graft failure (2.85 and 1.71, respectively). However, for those receiving a KT in 2001-2002, no significant outcome difference could be found between overseas and domestic recipients. CONCLUSION: The risk disparity between overseas and domestic KT recipients is mainly attributable to when the transplantation was performed. In attempting to dissuade potential recipients from organ trafficking, merely emphasizing the previously acknowledged poor outcomes no longer suffices as a valid reason.

Living donor liver transplantation.

PURPOSE OF REVIEW: The widening gap between the growing number of liver transplant candidates and the supply of deceased donor organs became a strong motivation for the development of living donor liver transplantation (LDLT). LDLT has gone through its developmental phase and become an established life-saving procedure. RECENT FINDINGS: Despite the challenging nature of the technique of LDLT, there have been continuous innovations. A better understanding of complex surgical anatomy and physiologic differences of partial hepatic allografts has helped to avoid graft congestion, small-for-size syndrome, or graft hypoperfusion from portal flow steal. LDLT for patients with high Model for End-Stage Liver Disease score can achieve comparable results with deceased donor liver transplantation (DDLT). Size limitation of partial grafts can be overcome with dual grafts. The extended application of LDLT for hepatocellular carcinoma beyond Milan criteria seems feasible but at the cost of slightly compromised survival. More information has become available for prospective donors about the consequences of living liver donation in terms of psychosocial impact. SUMMARY: Although LDLT is still evolving, it has become the most effective alternative to DDLT. Proven or potential benefit of LDLT include the superior quality of the allograft despite the smaller size, selection of proper timing for transplantation and a reduced waiting time, which prevents waiting list mortality.

National Kidney Registry: 213 transplants in three years.

Since its establishment in 2008, the National Kidney Registry has facilitated 213 kidney transplants between unrelated living donors and recipients at 28 transplant centers. Rapid innovations in matching strategies, advanced computer technologies, good communication and an evolving understanding of the processes at participating transplant centers and histocompatibility laboratories are among the factors driving the success of the NKR. Virtual cross match accuracy has improved from 43% to 91% as a result of changes to the HLA typing requirements for potential donors and improved mechanisms to list unacceptable HLA antigens for sensitized patients. A uniform financial agreement among participating centers eliminated a major roadblock to facilitate unbalanced donor kidney exchanges among centers. The NKR transplanted 64% of the patients registered since 2008 and the average waiting time for those transplanted in 2010 was 11 months.

Transplantation ethics from the Islamic point of view.

Organ transplantation has been transformed from an experimental procedure at Western academic centers to an increasingly common procedure in private and public hospitals throughout the world. Attendant with advancements in organ harvesting, preservation, and transplantation come moral issues. Islam is a holistic religion that takes into account social affairs of man as well as spiritual ones. Islam has a long history of ethics literature including the subgenre of medical ethics. Historical considerations are discussed as to why Muslim thinkers were late to consider contemporary medical issues such as organ donation. Islam respects life and values the needs of the living over the dead, thus allowing organ donation to be considered in certain circumstances. The sources of Islamic law are discussed in brief in order for non-Muslims to appreciate how the parameters of organ transplantation are derived. The Islamic viewpoint, both Shiite and Sunni, is examined in relation to organ donation and its various sources. The advantages and disadvantages of brain dead and cadaveric donation is reviewed with technical and ethical considerations. The Islamic concept of brain death, informed and proxy consent are also discussed. We discuss the concept of rewarded donation as a way to alleviate the current shortage of organs available for transplantation and consider secular and religious support for such a program. Suggestions are made for greater discussion and exchange of ideas between secular and religious thinkers in the Islamic world and between the Islamic world and secular Western countries.