Donación de órganos tras muerte inesperada por criterios circulatorios / Organ Donation after unexpected death determined by circulatory criteria

Objetivos: analizar los programas de uDCDD (uncontroller Donorsalter Circulatoty Determination of Death), que han sufrido modificaciones en sus nomenclaturas y definiciones, explorándolas posibles causas. Revisar las recomendaciones internacionales sobre los programas de uDCDD y las cláusulas emanadas de la Conferencia de Maastricht, para verificar el nivel de seguimiento por los programas de uDCDD activos en España, Francia y Estados Unidos. Analizar las modificaciones propuestas para que dichos programas sean acordes a los conocimientos científicos, al buen hacer profesional, a la ética ya la legislación, respetando el espíritu y los principios consensuados internacionalmente en materia de donación de órganos. Metodología: revisión bibliográfica referente a las actuales recomendaciones en reanimación centrada en el manejo de las paradas cardiorrespiratoria (PCR) de causa potencialmente reversible, identificando las técnicas y tratamientos que se están empleando de forma internacional. Se utilizaron las bases de datos: PubMed, CINAHL, CUIDEN y Biblioteca Cochrane. Se incluyeron artículos en inglés, francés y español hasta 2012.Se sistematizaron las variables: perfil de pacientes que se beneficia de las medidas no convencionales de RCP, técnicas y tratamientos aplicados y porcentaje de supervivencia sin déficit neurológico (Cerebral Peformance Categrories Scale,CPC). Asimismo, se efectuó una revisión de los programas de (..) (AU)

Objectives: to analyze programs for uDCDD (Uncontrolled Donation after Cardiac Determination of Death), which have undergone modifications in their nomenclatures and definitions, exploring their likely causes. To review international recommendations about uDCDD programs, and clauses issued by the Maastricht Conference, in order to assess their level of enforcement by uDCDD programs active in Spain, France and the United States. To analyze those modifications put forward so that said programs are in accordance with scientific knowledge, good professional practice, ethics and legislation, while respecting the spirit and the principles reached by international consensus regarding organ donations. Methodology: bibliographic review regarding current recommendations on resuscitation, focused on management of cardiorespiratory arrest (CRA) with a potentially reversible cause, identifying those techniques and treatments which are being used at an international level. The following databases were used: PubMed, CINAHL, CUIDEN and Cochrane Library. Their view included articles in English, French and Spanish until2012. The following variables were systematized: patient profile which benefits with non-conventional CRA measures, techniques and treatments implemented, and rate of survival without neurological deficit (Cerebral Performance Categories Scale,CPC). At the same time, a review was conducted for uDCDD programs in Spain, France and the United States, analyzing these (..) (AU)

Clinical outcomes of combined anterior and posterior spinal fusion for dystrophic thoracolumbar spinal deformities of neurofibromatosis-1: fate of nonvascularized anterior fibular strut grafts.

STUDY DESIGN: Retrospective study. OBJECTIVE: To analyze the clinical outcomes of anterior and posterior spinal fusion (APSF) using a fibular strut autograft (FSAG) and to investigate the morphological changes in the reconstructed spinal column of dystrophic deformities in neurofibromatosis (NF)-1. SUMMARY OF BACKGROUND DATA: APSF is desirable for dystrophic deformities in NF-1 with more than 50° of dystrophic kyphosis. There are few reports regarding the clinical outcomes of APSF in which the morphological changes over time of the anterior strut graft have been investigated. METHODS: The clinical and radiographic outcomes of APSF with FSAG were investigated in 10 consecutive patients with dystrophic deformity in NF-1. For qualitative and quantitative analyses, the chronological changes in the FSAG configuration, length, and diameter were evaluated. RESULTS: The mean follow-up period was 9 years, 9 months (range, 1-30 years). Graft bone erosion and postoperative curve progression were not observed in any patient. In quantitative analyses of the anterior strut, the mean ratio of the latest and immediately postoperative FSAG lengths was 0.98 (0.93-1.09). The mean central/peripheral ratios of the FSAG diameter (central portion/[upper end + lower end]/2) were 1.02 (0.92-1.10) immediately after surgery, and 1.01 (0.92-1.07) at the latest follow-up, with no significant change between these 2 time points (P = 0.937). The mean preoperative cross-sectional area of the apical vertebral body and its mean virtual cross-sectional area at the final follow-up were 3.80 (1.83-5.43) and 4.87 (2.46-7.00) cm(2), respectively, with a significant difference between these 2 parameters (P = 0.0078). The mean final/preoperative ratio was 1.31 (1.10-1.43). CONCLUSION: APSF with FSAG for dystrophic deformity in NF-1 successfully reconstructed a reliable spinal column with a rich bone stock. The FSAG and surrounding vertebral bodies were free from postoperative erosion due to dystrophic changes and maintained their stability for a long time.

Evolving approaches of hematopoietic stem cell-based therapies to induce tolerance to organ transplants: the long road to tolerance.

The immunoregulatory properties of hematopoietic stem cells (HSCs) have been recognized for more than 60 years, beginning in 1945, when Owen reported that genetically disparate freemartin cattle sharing a common placenta were red blood cell chimeras. In 1953, Billingham, Brent, and Medawar demonstrated that murine neonatal chimeras prepared by infusion of donor-derived hematopoietic cells exhibited donor-specific tolerance to skin allografts. Various approaches using HSCs in organ transplantation have gradually brought closer to reality the dream of inducing donor-specific tolerance in organ transplant recipients. Several hurdles needed to be overcome, especially the risk of graft-versus-host disease (GVHD), the toxicity of ablative conditioning, and the need for close donor-recipient matching. For wide acceptance, HSC therapy must be safe and reproducible in mismatched donor-recipient combinations. Discoveries in other disciplines have often unexpectedly and synergistically contributed to progress in this area. This review presents a historic perspective of the quest for tolerance in organ transplantation, highlighting current clinical approaches.

Transplantation in the future.

Cellular transplantation to the brain and spinal cord remains a promising approach both for probing basic biological questions and as a potential therapy for neurological diseases. This chapter summarizes some of the main constraints that continue to limit general biological applications and, specifically, clinical applications. These constraints include the critical features of the successful donor cell as well as those of the receptive host tissue and organism. In addition, we explore future directions, with special emphasis on genetic engineering, combinations of novel cell types combined with trophic factors, and training of the host organism to improve the accurate integration of grafted cells. Some speculations are made regarding universal donor cells, but these advances will depend on additional basic work to bring this approach to the clinic. The convergence of advanced molecular and cellular methods together with improved methods of in vivo imaging adds to our optimism for significant advances in cellular transplantation in the near future.

Transplantation in the future.

Cellular transplantation to the brain and spinal cord remains a promising approach both for probing basic biological questions and as a potential therapy for neurological diseases. This chapter summarizes some of the main constraints that continue to limit general biological applications and, specifically, clinical applications. These constraints include the critical features of the successful donor cell as well as those of the receptive host tissue and organism. In addition, we explore future directions, with special emphasis on genetic engineering, combinations of novel cell types combined with trophic factors, and training of the host organism to improve the accurate integration of grafted cells. Some speculations are made regarding universal donor cells, but these advances will depend on additional basic work to bring this approach to the clinic. The convergence of advanced molecular and cellular methods together with improved methods of in vivo imaging adds to our optimism for significant advances in cellular transplantation in the near future.

The future of tissue-engineered organs for transplant? It's here!

The first-in-man bioengineered artificial tracheobronchial transplant consisting of a synthetic scaffold and autologous bone marrow-derived mesenchymal cells was recently reported. Extensive evaluation of the patient before and after transplant provides some insight into the potential mechanisms of stem cell mobilization and tracheal tissue regeneration.

Injectable hydroxyapatite cement patch as an on-lay graft for the sellar reconstructions following endoscopic endonasal approach.

BACKGROUND: Skull base reconstruction after endoscopic endonasal resection of a variety of skull base lesions remains challenging because of some lethal complications such as cerebrospinal fluid (CSF) leaks. We investigated the outcomes of hydroxyapatite (HA) cement patch as on-lay graft for skull base defects following endoscopic endonasal approach (EEA). METHODS: We analyzed 53 consecutive patients who underwent sellar reconstruction using HA cement following EEA at our institution between July 2009 and March 2011. Patients were composed of 23 men and 30 women with a mean age of 47 years, ranging from 10 to 72 years. Among these patients, 29 patients (54.7%) experienced intraoperative CSF leaks with high-output, 10 patients (18.9%) underwent CSF leaks with low output, and 14 patients (26.4%) experienced no intraoperative CSF leak. Mean follow-up period for clinical outcomes was 8.6 months (range, 3-22 months). RESULTS: We performed injectable HA patch as on-lay graft over fascia lata for the skull base defects. Routine lumbar CSF drainage was not performed postoperatively in any patients since the introduction of HA. During the follow-up period, three of 53 patients (5.6%) demonstrated meningitis associated with postoperative CSF leaks and underwent re-do reconstruction surgery. There was no allergic symptoms associated with HA cement. At an outpatient clinic, the defects were found to be covered with surrounding nasal mucosa at an average of 14 weeks (range, 3-28 weeks). CONCLUSIONS: The use of HA cement as an on-lay patch for the reconstruction of sellar defect demonstrated a low incidence of CSF leaks with minimal complications. HA cement may be an alternative option for repair of CSF leaks following EEA.

Bioengineering heart muscle: a paradigm for regenerative medicine.

The idea of extending the lifetime of our organs is as old as humankind, fueled by major advances in organ transplantation, novel drugs, and medical devices. However, true regeneration of human tissue has become increasingly plausible only in recent years. The human heart has always been a focus of such efforts, given its notorious inability to repair itself following injury or disease. We discuss here the emerging bioengineering approaches to regeneration of heart muscle as a paradigm for regenerative medicine. Our focus is on biologically inspired strategies for heart regeneration, knowledge gained thus far about how to make a "perfect" heart graft, and the challenges that remain to be addressed for tissue-engineered heart regeneration to become a clinical reality. We emphasize the need for interdisciplinary research and training, as recent progress in the field is largely being made at the interfaces between cardiology, stem cell science, and bioengineering.

Long-term in vivo regeneration of peripheral nerves through bioengineered nerve grafts.

Although autologous nerve graft is still the first choice strategy in nerve reconstruction, it has the severe disadvantage of the sacrifice of a functional nerve. Cell transplantation in a bioartificial conduit is an alternative strategy to improve nerve regeneration. Nerve fibrin conduits were seeded with various cell types: primary Schwann cells (SC), SC-like differentiated bone marrow-derived mesenchymal stem cells (dMSC), SC-like differentiated adipose-derived stem cells (dASC). Two further control groups were fibrin conduits without cells and autografts. Conduits were used to bridge a 1 cm rat sciatic nerve gap in a long term experiment (16 weeks). Functional and morphological properties of regenerated nerves were investigated. A reduction in muscle atrophy was observed in the autograft and in all cell-seeded groups, when compared with the empty fibrin conduits. SC showed significant improvement in axon myelination and average fiber diameter of the regenerated nerves. dASC were the most effective cell population in terms of improvement of axonal and fiber diameter, evoked potentials at the level of the gastrocnemius muscle and regeneration of motoneurons, similar to the autografts. Given these results and other advantages of adipose derived stem cells such as ease of harvest and relative abundance, dASC could be a clinically translatable route towards new methods to enhance peripheral nerve repair.

The AJT report: news and issues that affect organ and tissue transplantation.

Is individualized organ repair in our future? This month, "The AJT Report" explores warm ex vivo lung perfusion, and what it might mean for the future of organ transplantation.

Current status of hair restoration surgery.

Hair restoration has emerged as a subspecialty of aesthetic plastic surgery practiced by a wide range of doctors including plastic surgeons, general surgeons, dermatologists, and even general practitioners. As a current trend, most doctors practice "Ultrarefined follicular unit hair transplantation" in which the entire procedure is done precisely with minimal donor scar. In selected cases, Mega or even Giga sessions are now done with natural appearance and almost undetectable scar, in a single session with good density. This article is an attempt to review the history of hair restoration surgery, describe a novel technique currently practiced in our center, and summarize possible future innovations.

Tratamiento de hepatitis crónica C en un paciente con fibrosis quística en situación de pretrasplante pulmonar / Chronic hepatitis C treatment in a cystic fibrosis patient in the pulmonary pre-transplant stage

El tratamiento estándar de la hepatitis crónica C, interferón pegilado (INF-peg) y ribavirina (RBV), puede ser inadecuado o incluso estar contraindicado en algunos pacientes debido a sus limitaciones en cuanto a eficacia y efectos adversos. En pacientes con fibrosis quística infectados por el virus de la hepatitis C (VHC) el tratamiento antiviral podría aumentar las infecciones respiratorias con el consiguiente empeoramiento de la función pulmonar. Por contra, la infección por VHC podría desestimar a estos pacientes para un necesario trasplante pulmonar. Presentamos el caso de un varón con fibrosis quística diagnosticado de infección VHC durante su evaluación previa al trasplante pulmonar. El paciente fue tratado con INF-peg y RBV. A pesar del empeoramiento en la función pulmonar y numerosas infecciones respiratorias intercurrentes, logró completar el tratamiento y obtener respuesta viral sostenida, encontrándose actualmente en lista de espera(AU)

The standard treatment of chronic hepatitis C, pegylated interferon and ribavirin (pegI/R), has many limitations in both effectiveness and secondary effects, which makes it unsuitable or even contraindicated for some patients. In hepatitis C virus-infected cystic fibrosis patients this treatment could increase respiratory infections with subsequent pulmonary function deterioration. On the contrary, hepatitis C virus (HCV) infection may make lung transplant (LT) unfeasible. We present the case of a cystic fibrosisyoung man diagnosed with HCV infection during LT assessment who was treated with pegI/R. In spite of the lung function worsening and respiratory infections, he managed to complete treatment and even sustained virological response (SVR). At present he is on LT waiting list(AU)

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Organ transplantation in Switzerland: impact of the new transplant law on cold ischaemia time and organ transports.

BACKGROUND: On 1 July 2007 a new transplant law came into force in Switzerland. The principal item of this new law is the change from centre-oriented allocation to patient-oriented national allocation of organs. The aim of the present study is to assess the impact on cold ischaemia time (CIT) and transport requirements. METHODS: From 1 July 2006 to 30 June 2008 168 brain-dead donors were registered by Swisstransplant in Switzerland. Donors have been analysed in a retrospective cohort study design. Donor characteristics, transportation requirements and CIT were assessed from the Necroreport. RESULTS: 74 donors (44%) were allocated in the period before the introduction of the new law (period A) and 94 donors (56%) after the new law. Donor characteristics were similar. In period A, 114 organs (37.9%) were allocated within the procurement centre, compared to 54 organs (15.5%) in period B. Transport time for liver and kidney was remarkably longer in period B. Overall, CITs remained largely stable except for a significant increase of nearly 115 minutes in the liver graft median CIT (p <0.01). CONCLUSIONS: The new Swiss transplant law clearly entails an increase in the frequency of organ transports. Overall CIT is not affected. However, liver transplantation is afflicted by an increase in transports and CIT. This may affect mid-term outcome and should therefore be followed closely.

Preservación de órganos / Organ preservation

El mantenimiento de la viabilidad de los órganos desde su extracción hasta el trasplante es un factor crucial para la adecuada función y la supervivencia del injerto. En los últimos años, este proceso se ha convertido en un verdadero reto, ya que, como consecuencia de la escasez de donantes, se utilizan con mayor frecuencia donantes con criterios expandidos, en los que la funcionalidad del órgano está más afectada. El daño de los órganos ocurre principalmente como resultado de la lesión por isquemiareperfusión, en relación con las lesiones derivadas de la propia preservación. Para minimizar este daño se usan diferentes técnicas de preservación de los órganos, cuyo objetivo es optimizar la función del órgano una vez que se restablezca la perfusión. Por su extremada simpleza, la conservación en frío estática es el método de preservación más utilizado, ya que presenta una serie de ventajas, como su disponibilidad, casi universal, y su facilidad de transporte. Sin embargo, es cuestionable si este método es capaz de prevenir el deterioro de la calidad de los órganos del grupo de donantes con criterios expandidos. En este artículo se describen pormenorizadamente los métodos de preservación actuales, con especial énfasis en la utilización de las máquinas de perfusión continua (AU)

Maintaining organ viability from extraction to transplantation is crucial to ensure the function and survival of the graft. In recent years, maintaining organ viability has become more challenging because the shortage of donors has led to broader criteria for donor acceptability and consequently to organs with greater compromise. Organ damage occurs primarily as a result of ischemia-reperfusion injury, which is associated to additional damage from the preservation process. To minimize this damage, different techniques of organ preservation are used with the aim of optimizing organ function once perfusion is restored. Static cold storage is the most commonly used method of preservation because it is extremely simple, nearly universally available, and easy to transport. However, static cold storage may be unable to prevent the deterioration of the quality of organs from donors included under the broader criteria. In this article, we describe current preservation techniques; we place special emphasis on continuous machine perfusion (AU)

Moyamoya disease: a summary.

Moyamoya, meaning a "hazy puff of smoke" in Japanese, is a chronic, occlusive cerebrovascular disease involving bilateral stenosis or occlusion of the terminal portion of the internal carotid arteries (ICAs) and/or the proximal portions of the anterior cerebral arteries and middle cerebral arteries (MCAs). The Ministry of Health and Welfare of Japan has defined 4 types of moyamoya disease (MMD): ischemic, hemorrhagic, epileptic, and "other." The ischemic type has been shown to predominate in childhood, while the hemorrhagic type is more often observed in the adult population. The highest prevalence of MMD is found in Japan, with a higher female to male ratio. Studies have shown a possible genetic association of MMD linked to chromosome 17 in Japanese cases as well as in cases found in other demographics. During autopsy, intracerebral hematoma is found and most commonly serves as the major cause of death in patients with MMD. Moyamoya vessels at the base of the brain are composed of medium-sized or small muscular arteries emanating from the circle of Willis, mainly the intracranial portions of ICAs, anterior choroidal arteries, and posterior cerebral arteries, forming complex channels that connect with distal positions of the MCAs. Off of these channels are small tortuous and dilated vessels that penetrate into the base of the brain at the site of the thalamoperforate and lenticulostriate arteries. On angiography, there is the characteristic stenosis or occlusion bilaterally at the terminal portion of the ICAs as well as the moyamoya vessels at the base of the brain. Six angiographic stages have been described, from Stage 1, which reveals a narrowing of the carotid forks, to Stage 6, in which the moyamoya vessels disappear and collateral circulation is produced solely from the external carotid arteries. Cases with milder symptoms are usually treated conservatively; however, more severe symptomatic cases are treated using revascularization procedures. Surgical treatments are divided into 3 types: direct, indirect, and combined/other methods. Direct bypass includes superficial temporal artery-MCA bypass or use of other graft types. Indirect procedures bring in circulation to the intracranial regions by introducing newly developed vasculature from newly approximated tissues. These procedures may not be enough to prevent further ischemia; therefore, a combination of direct and indirect procedures is more suitable. This article will give a review of the epidemiology, natural history, pathology, pathophysiology, and diagnostic criteria, including imaging, and briefly describe the surgical treatment of MMD.