Transplant Medicine in China: Need for Transparency and International Scrutiny Remains.

Previous publications have described unethical organ procurement procedures in the People's Republic of China. International awareness and condemnation contributed to the announcement abolishing the procurement of organs from executed prisoners starting from January 2015. Eighteen months after the announcement, and aligned with the upcoming International Congress of the Transplantation Society in Hong Kong, this paper revisits the topic and discusses whether the declared reform has indeed been implemented. China has neither addressed nor included in the reform a pledge to end the procurement of organs from prisoners of conscience, nor has the government initiated any legislative amendments. Recent reports have discussed an implausible discrepancy of officially reported steady annual transplant numbers and a steep expansion of the transplant infrastructure in China. This paper expresses the viewpoint that, in the current context, it is not possible to verify the veracity of the announced changes, and it thus remains premature to include China as an ethical partner in the international transplant community. Until we have independent and objective evidence of a complete cessation of unethical organ procurement from prisoners, the medical community has a professional responsibility to maintain the academic embargo on Chinese transplant professionals.

Incentivizing Authorization for Deceased Organ Donation With Organ Allocation Priority: The First 5 Years.

The allocation system of donor organs for transplantation may affect their scarcity. In 2008, Israel's Parliament passed the Organ Transplantation Law, which grants priority on waiting lists for transplants to candidates who are first-degree relatives of deceased organ donors or who previously registered as organ donors themselves. Several public campaigns have advertised the existence of the law since November 2010. We evaluated the effect of the law using all deceased donation requests made in Israel during the period 1998-2015. We use logistic regression to compare the authorization rates of the donors' next of kin in the periods before (1998-2010) and after (2011-2015) the public was made aware of the law. The authorization rate for donation in the period after awareness was substantially higher (55.1% vs. 45.0%, odds ratio [OR] 1.43, p = 0.0003) and reached an all-time high rate of 60.2% in 2015. This increase was mainly due to an increase in the authorization rate of next of kin of unregistered donors (51.1% vs. 42.2%). We also found that the likelihood of next-of-kin authorization for donation was approximately twice as high when the deceased relative was a registered donor rather than unregistered (89.4% vs. 44.6%, OR 14.27, p < 0.0001). We concluded that the priority law is associated with an increased authorization rate for organ donation.

Non-ionizing radiofrequency electromagnetic waves traversing the head can be used to detect cerebrovascular autoregulation responses.

Monitoring changes in non-ionizing radiofrequency electromagnetic waves as they traverse the brain can detect the effects of stimuli employed in cerebrovascular autoregulation (CVA) tests on the brain, without contact and in real time. CVA is a physiological phenomenon of importance to health, used for diagnosis of a number of diseases of the brain with a vascular component. The technology described here is being developed for use in diagnosis of injuries and diseases of the brain in rural and economically underdeveloped parts of the world. A group of nine subjects participated in this pilot clinical evaluation of the technology. Substantial research remains to be done on correlating the measurements with physiology and anatomy.

Organ procurement from executed prisoners in China.

Organ procurement from executed prisoners in China is internationally condemned, yet this practice continues unabated in 2014. This is despite repeated announcements from Chinese authorities that constructive measures have been undertaken to conform to accepted ethical standards. While there is unanimous agreement on the unethical nature of using organs from executed prisoners, due to its limitations on voluntary and informed consent, there is insufficient coverage of forced organ procurement from prisoners of conscience without consent. Strategies to influence positive change in China over the last few decades have failed to bring this practice to an end. While organ donation and transplantation services in China have undergone considerable structural changes in the last few years, fundamental attempts to shift practice to ethically sourced organs have floundered. In this article, we discuss the organ trade in China, reflect upon organ procurement from executed prisoners (including both capital prisoners and prisoners of conscience) and provide an overview of contradictory Chinese efforts to halt forced organ procurement from executed prisoners. Finally, we highlight current actions being taken to address this issue and offer comprehensive recommendations to bring this ethically indefensible practice to an immediate end.

Preliminary marked increase in the national organ donation rate in Israel following implementation of a new organ transplantation law.

Israel's organ donation rate has always been among the lowest in Western countries. In 2008 two new laws relevant to organ transplantation were introduced. The Brain-Respiratory Death Law defines the precise circumstances and mechanisms to determine brain death. The Organ Transplantation Law bans reimbursing transplant tourism involving organ trade, grants prioritization in organ allocation to candidates who are registered donors and removes disincentives for living donation by providing modest insurance reimbursement and social supportive services. The preliminary impact of the gradual introduction and implementation of these laws has been witnessed in 2011. Compared to previous years, in 2011 there was a significant increase in the number of deceased organ donors directly related to an increase in organ donation rate (from 7.8 to 11.4 donors per million population), in parallel to a significant increase in the number of new registered donors. In addition the number of kidney transplantations from living donors significantly increased in parallel to a significant decrease in the number of kidney transplantations performed abroad (from 155 in 2006 to 35 in 2011). The new laws have significantly increased both deceased and living organ donation while sharply decreasing transplant tourism.

The use of executed prisoners as a source of organ transplants in China must stop.

Internationally accepted ethical standards are unequivocal in their prohibition of the use of organs recovered from executed prisoners: yet this practice continues in China despite indications that Ministry of Health officials intend to end this abhorrent practice. Recently published articles on this topic emphasize the medical complications that result from liver transplantation from executed 'donors' but scant attention is given to the source of the organs, raising concern that the transplant community may be becoming inured to unacceptable practice. Strategies to influence positive change in organ donation practice in China by the international transplant community are discussed. They include an absolutist policy whereby no clinical data from China is deemed acceptable until unacceptable donation practices end, and an incremental policy whereby clinical data is carefully evaluated for acceptability. The relative advantages and drawbacks of these strategies are discussed together with some practical suggestions for response available to individuals and the transplant community.

[Dynamic cardiomyoplasty].

The high prevalence of end-stage heart failure and its influence on the quality of life, force the medical community to seek effective therapeutic modalities. Heart transplantation is the accepted therapy for such patients, nevertheless, a significant percentage of patients do not reach transplantation due to the shortage of donors. Therefore, the establishment of surgical alternatives is very important. Dynamic cardiomyoplasty is accepted as an alternative to heart transplantation. In this technique skeletal muscle is wrapped around the heart and stimulated synchronously with the heart itself. We describe the present status of this procedure.

Hypotensive reactions associated with transfusion of bedside leukocyte-reduction filtered blood products in heart transplanted patients.

Severe hypotensive reactions that occur during transfusions of blood products to non-transplanted patients were recently linked to the use of bedside leukocyte-reduction filters, sometimes in association with angiotensin-converting enzyme (ACE) inhibitor treatment. We present the first report of such reactions in patients who underwent orthotopic heart transplantation. Fourteen (47%) of the 30 transfused patients experienced severe hypotensive reaction during filtered transfusion of at least 1 unit of blood product, with a total of 24 episodes. Eleven (79%) of these patients were treated pre-operatively with ACE inhibitors.

[Massive pulmonary embolism--summary of experiences with 13 patients].

Pulmonary embolism is a common event in hospitalized patients. In some cases it presents with hemodynamic collapse, indicating massive obliteration of the pulmonary vasculature and has a very grim prognosis; 2/3 of such patients die within 2 hours of onset of symptoms. We describe our experience in 13 patients with massive pulmonary embolism. An aggressive diagnostic and therapeutic approach, utilizing sophisticated imaging techniques, thrombolytic therapy and surgery, led to the survival of 8 of the patients. Our experience supports an aggressive approach in these seriously ill patients.

Prediction of mortality in patients awaiting cardiac transplantation: increased risk of sudden death in ischemic compared to idiopathic dilated cardiomyopathy.

A major problem in cardiac transplantation is the death of candidates due to the increasing shortage of donors and the consequent longer waiting periods. To determine whether clinical markers for death could be identified in these patients, 168 adult candidates with heart failure (NYHA class III and IV) listed between August 1987 and December 1989 were analyzed. There were 104 patients with ischemic cardiomyopathy (ISCM) and 64 with idiopathic dilated cardiomyopathy (IDCM). Transplantation was performed in 93 patients (55%). Actuarial 1 year survival was 61% in the ISCM group and 78% in the IDCM group (P = NS). Freedom from sudden death at one year was significantly lower in the ISCM group (73%) than in the IDCM group (96%) (P < 0.01). The rate of patients who did not die from terminal myocardial failure was 83% in the ISCM group and 81% in the IDCM group (P = NS). There were no significant differences between the two groups in right atrial, pulmonary artery, and pulmonary wedge pressures, transpulmonic pressure gradient, pulmonary vascular resistance, cardiac index, and ejection fraction. We conclude that candidates for cardiac transplantation with ISCM are at higher risk for sudden death during the first year on the waiting list than patients with IDCM. These results warrant consideration of aggressive arrhythmia control measures, including an automatic implantable defibrillator, to "bridge" these high risk patients to transplantation.

Aprotinin improves hemostasis after cardiopulmonary bypass better than single-donor platelet concentrate.

Platelet transfusion and aprotinin administration improve platelet function and clinical hemostasis after extracorporeal circulation. To compare two methods of improving postoperative hemostasis, we preoperatively randomized 40 patients undergoing various open heart procedures into two groups. Group A included 20 patients who, immediately after bypass, received single-donor plateletpheresis concentrates collected from ABO-compatible donors (Baxter Autopheresis-C System). They were compared with 20 patients who received high-dose aprotinin (6 x 10(6) KIU) before and during cardiopulmonary bypass (group B). Group A patients showed significantly higher platelet count after single-donor plateletpheresis concentrate transfusion (157 +/- 36 x 10(9)/L compared with 118 +/- 42 x 10(9)/L (p < 0.05). However, platelet aggregation on extracellular matrix was better in group B (3.4 +/- 0.7 versus 2.8 +/- 0.9; p < 0.05). Total 24-hour blood loss and exposure to homologous blood products were significantly less in group B (396 +/- 125 mL and 1.1 +/- 1.6 units compared with 617 +/- 233 mL and 5.4 +/- 3.4 units; p < 0.01). Despite higher platelet count in patients after single-donor plateletpheresis concentrates transfusion, hemostasis in patients receiving aprotinin is better due to improved platelet function.

Percutaneous balloon pericardiostomy for treatment of cardiac tamponade.

Percutaneous balloon pericardiostomy was performed in eight severely ill patients with malignancy (seven patients) and chronic renal failure (one patient). To investigate the feasibility of balloon pericardiostomy as a bedside procedure, echocardiography was used in addition to fluoroscopy in monitoring the procedure. The pericardium was entered from the standard subxiphoid site. An 18 to 25 mm, 3 or 4 cm long, balloon catheter, introduced over a stiff guidewire was inflated across the parietal pericardium. Creation of a pericardial opening was obtained in each of the eight patients. Bleeding from the needle entry site was the only complication observed in one patient. The balloon catheter could be localized by echocardiography only in 2/8 cases. Two patients died, 3 and 14 days after the procedure, from the primary disease; six patients were still alive at follow-up ranging from 32 to 342 days. No recurrence of cardiac tamponade was observed in any patient. Percutaneous balloon pericardiostomy is efficacious and safe in relieving pericardial tamponade and preventing its recurrence in severely ill patients. Fluoroscopy is needed to monitor the procedure. The value of echocardiography is limited for follow-up controls of pericardial effusion.

Irradiation of fresh whole blood for prevention of transfusion-associated graft-versus-host disease does not impair platelet function and clinical hemostasis after open heart surgery.

Since our previous studies suggested that the transfusion of 1 unit fresh whole blood (FWB) after cardiopulmonary bypass (CPB) using a bubble oxygenator may provide hemostatic benefit equivalent to 8-10 units of platelet concentrates, we have routinely used FWB at the termination of CPB. Two patients who received FWB and developed transfusion-associated graft-versus-host disease (TA-GVHD) prompted us to investigate the effect of irradiation of FWB on platelet and clinical hemostasis. Twenty-four patients were randomized to receive either 1 unit FWB (12 patients), or 1 unit irradiated FWB (IrFWB, 1,500 cGy,12 patients) after CPB. Platelet aggregation on extracellular matrix, studied by a scanning electron microscope and graded from 1 to 4 (from poor to excellent aggregation), was similar in both groups preoperatively [3.3 +/- 0.9 (FWB) and 3.5 +/- 0.5 (Ir FWB)], and at the end of CPB [1.8 +/- 1.2 (FWB) and 1.9 +/- 0.9 (IrFWB)]. Platelet aggregation was similar after transfusion of FWB (3.0 +/- 1.0) and after IrFWB (3.2 +/- 0.8), as was the increase in platelet count. Twenty-four hours total postoperative bleeding was similar (560 +/- 420 and 523 +/- 236 ml for FWB and IrFWB, respectively). We conclude that irradiation of FWB for prevention of TA-GVHD does not impair platelet aggregating capacity, and can be used when blood is donated by the patient's next of kin.