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Deceased organ donation Waqas Ali

Deceased organ donation

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Deceased organ donation overview

Deceased organ donationWaqas Ali

ObjectivesTo have a basic idea of solid organ transplantationTo know about Organ sources and donor typesTo know about brain death concept and controversies

Solid organ transplantationDefinition: Autograft: The transfer of a tissue or organ from one part of the body to another within the same person Allograft:The transfer of a tissue or organ from one individual to another individual.

Commonly transplanted organsCorneaKidneysSkinBone marrowHeart and heart valvesIntestineBoneLungLiverPancreas

Principles of transplantationTransplant immunologyThe immune system recognizes graft from someone else as foreign and triggers response via immune cells or substances they produce - cytokines and antibodies

Responses are via; recognition, amplification and memory

KeyStimulatesGives rise to+MemoryHelper T cellsAntigen-presenting cellHelper T cellEngulfed byAntigen (1st exposure)++++++Defend against extracellular pathogens/Transplant rejectionMemoryB cellsAntigen (2nd exposure)Plasma cellsB cellSecretedantibodiesHumoral (antibody-mediated) immune [email protected]

6Figure 43.16 An overview of the acquired immune response

Organ rejectionsRejection of transplanted organs is a bigger challenge than the technical expertise required to perform the surgery. It results mainly from HLA and ABO incompatibilityHyperacute: with in seconds to minutesAcute: In first six monthsChronic: After 6 monthsRejection is controlled by immunosuppression given asInductionMaintainanceRescue agents

Organ DonorsLiving-Relative-StrangerCadaver

Types of Living Donor TransplantsKidney (entire organ)Liver (segment)Lung (lobe)Intestine (portion)Pancreas (portion)After brain death (heart beating donor)KidneyHeartLiver LungsPancreasIntestineHeart valvesConnective tissueCadaver (non heart beating donor)After natural deathCorneaBoneSkin Blood vessels

Living vs decease transplantImproved graft survivalLess recipient morbidityEarly function and easier to manage Avoidance long waiting time for transplantLess aggressive immunosuppressive regimen

Relatively inferior graft survivalsMore immunogenicSurgery of recipient is unscheduledMore likely to need future retransplantWaiting time is more

Contra-indications for living donor

Mental diseaseDiseased organMorbidity and mortality riskABO incompatibility Cross matching incompatibilityTransmissible disease

CouncellingMay involve professional counselors/ psychotherapistAimed at preventing / minimizing possible complication Need for adherence to post-op maintenance medications Regular follow-up with thorough evaluationLife style modification; smoking, alcohol, sedentary life style, junks, excessive salt ingestion.

Informed consentLiving DonorEducationWillingly not for any financial reason or under duress Most undergo extensive screening medical psychologicalInvolve family Surgery and anesthetic complications

Informed consentDecease donorSome factors influencing refusal to consent by relatives;non-acceptance of brain death. Superstitions relating to being reborn with a missing organ A delay in funeral Lack of consensus within family members Fear of social criticism Dissatisfaction with the hospital staffReligious believes

Organ procurement

After removal, the organ is flushed with chilled organ preservation solution e.g University of Wisconsin(UW)


Non heart beating kidney donation

Ischemia durationWarm ischemic time ; time an organ remains at body temperature between which the blood supply is cut off before cold perfusion. (within 30min)Cold ischemic time ; the time between the chilling of the organ, after blood supply has been cut off and the time it is warmed by reconnection

Maximum and optimal cold storage times (approximate)Organ Optimal (hours )Safe maximum(hours) Kidney < 24 48Liver < 12 24Pancreas < 10 24Small intestine < 4 8Heart < 3 6Lung < 3 8

Assuming zero warm ischemic time and organs obtained from a non-marginal

Brain deathWhen brain injury is refractory to aggressive management and is considered nonsurvivable, with loss of consciousness and brain stem reflexes, a brain death protocol may be initiated to determine death according to neurological criteria

Brain death implicationsHeart-beating, brain-dead donors provide the majority of organs for transplant.1Extended times between terminal brain stem herniation, declaration of brain death, and organ recovery risk loss of organs because of refractory cardiopulmonary instabilityCost of intensive care1. United Network of Organ Sharing. 2012 data: spring regional meetings.

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Pathophysiology of Brain InjuryTerminal brain stem herniation is often the final stage in refractory brain injury caused by trauma, ischemia or infarction, hemorrhage, intracranial tumors, and infectious processes such as encephalitis and meningitisProgression of injury follows a rostral to caudal path

Clinical brain stem assessment

Confounding factors in brain deathspinal cord injury, movements in brain death (complex spinal reflexes, muscle fasciculations, ventilator autotriggering), therapeutic hypothermiatransient brain stem depression after cardiopulmonary arrest

Ethical concerns The World Health Organization argues that transplantations promote health, but the notion of transplantation tourism has the potential to violate human rights or exploit the poor

There is also a powerful opposing view, that trade in organs, if properly and effectively regulated to ensure that the seller is fully informed of all the consequences of donation, is a mutually beneficial transaction between two consenting adults, and that prohibiting it would itself be a violation of Articles 3 and 29 of the Universal Declaration of Human Rights.

History of Organ transplant

The Chinese physician Pien Chi'ao reportedly exchanged hearts between a man of strong spirit but weak will with one of a man of weak spirit but strong will in an attempt to achieve balance in each man.

Roman Catholic accounts report the third-century saints Damian and Cosmas as replacing the gangrenous leg of the Roman deacon Justinian with the leg of a recently deceased Ethiopian.

The first reasonable account is of the Indian surgeon Sushruta in the second century BC, who used autografted skin transplantation in nose reconstruction rhinoplasty.

Centuries later, the Italian surgeon performed successful skin autografts; he also failed consistently with allografts

the first successful human corneal transplant, a keratoplastic operation, was performed by Eduard Zirm in Austria in 1905.

Their skillful anastomosis operations, the new suturing techniques, laid the groundwork for later transplant surgery and won Carrel the 1912 Nobel Prize for Medicine or Physiology

Archibald McIndoe

carried on the work into World War II as reconstructive surgery

The first attempted human deceased-donor transplant was performed by the Ukrainian surgeon in the 1930s

Yu Yu Voronoy

the late 1940s Peter Medawar, working for the National Institute for Medica Research, improved the understanding of rejection.

On March 9th 1981 t the first successful heart-lung transplant took place at Stanford University Hospital. The head surgeon, Bruce Reitz, credited the patient's recovery to cyclosporine-A.

Timeline of successful transpants 1905: First successful cornea transplant by Eduard Zirm 1954: First successful kidney transplant by Joseph Murray (Boston, U.S.A.) 1966: First successful pancreas transplant by Richard Lillehei and William Kelly (Minnesota, U.S.A.) 1967: First successful liver transplant by Thomas Starzl (Denver, U.S.A.) 1967: First successful heart transplant by Christiaan Barnard (Cape Town, South Africa) 1970: First successful monkey head transplant by Robert White (Cleveland, U.S.A.) 1981: First successful heart/lung transplant by Bruce Reitz (Stanford, U.S.A.) 1983: First successful lung lobe transplant by Joel Cooper (Toronto, Canada) 1986: First successful double-lung transplant (Ann Harrison) by Joel Cooper (Toronto, Canada) 1987: First successful whole lung transplant by Joel Cooper (St. Louis, U.S.A.) 1995: First successful laparoscopic live-donor nephrectomy by Lloyd Ratner and Louis Kavoussi (Baltimore, U.S.A.) 1998: First successful live-donor partial pancreas transplant by David Sutherland (Minnesota, U.S.A.) 1998: First successful hand transplant (France) 2005: First successful partial face transplant (France) 2006: First successful penis transplant (China)

Thank youReferencesBrain Death: Assessment, Controversy, and Confounding Factors RICHARD B. ARBOUR, RN, MSN, CCRN, CNRN, CCNSLIVING DONOR KIDNEY TRANSPLANT Kelli Willard West, MSSW, APSW Living Donation Outreach EducatorPRINCIPLES INVOLVED IN ORGAN TRANSPLANT DR BASHIR YUNUS SURGERY DEPT. AKTH 19/1/15 Wikipedia and google