Patients with the hepatitis C virus who receive a liver from a donorolder than age 60 do not experience a higher rate of transplantfailure, death, or recurrent disease in the following five years,according to a study published in the July issue of Archivesof Surgery.

The most common reason for liver transplants among adults in the UnitedStates is cirrhosis of the liver caused by the hepatitis C viralinfection. Though hospitals have been expanding requirements for donorsto increase the number of eligible organs, about 17,000 patients remainon the waiting list for a liver transplant. One criteria change hasbeen increasing donor age limits. “There are concerning reports,however, in recipients with hepatitis C virus that extended criteriadonors, particularly older donors, are associated with poorer outcome,especially with early and severe hepatitis C virus recurrence in thedonor graft,” note the authors.

To analyze the outcomes of liver transplants from donors of variousages, M.B. Majella Doyle, M.D. (Washington University School ofMedicine, St. Louis) and colleagues used data from 489 adult livertransplants performed between 1997 and 2007. Some of the patientsneeded a liver transplant due to hepatitis C (187 of 489 or 38.2%),while others presented a different indication for transplant (302 of489 or 61.8%).

Survival rates for patients with the hepatitis C virus were: 88.1%after one year, 78.3% after three years, and 69.2% after five years. Inthis group of hepatitis C virus-positive recipients, 85.6% of donorlivers were still functioning after one year, 75.6% after three years,and 65.6% after five years. Among patients with and without hepatitisC, the researchers did not find significant differences in rates ofsurvival and graft survival at one, three, or five years. The authorscaution, however, that, “Similar to other long-term transplant centers,we observed a negative effect from recurrent hepatitis C virus with atrend toward worsened long-term survival between years five and 10.”

Livers from donors who were age 60 and older were transplanted into 72patients - 24 (12.8%) with hepatitis C virus and 48 (15.9%) without thevirus. Patient and graft survival rates at one, three, and five yearsfor patients who received livers from donors age 60 and older were notsignificantly different than survival rates for patients who receivedorgans from younger donors. The researchers also found no difference insurvival rates if the donor was age 65 or older. These results suggestthat the practice of using livers from older donors is safe, accordingto the authors.

The researchers conclude that, “Overall patient and graft survival inhepatitis C virus-positive recipients is comparable with that inhepatitis C virus-negative patients, and there seems to be little, ifany, adverse effect on short- and medium-term follow-up with the use ofcarefully selected older donor grafts in recipients with hepatitis Cvirus…Data from this series suggest that the continued use ofselected older donors is a safe method of expanding the liver donorpool, even for hepatitis C-positive recipients.”

Liver Transplant for Hepatitis C Virus: Effect of Using OlderDonor Grafts on Short- and Medium-Term Survival
M. B. Majella Doyle; Christopher D. Anderson; Neeta Vachharajani;Jeffrey A. Lowell; Surendra Shenoy; Mauricio Lisker-Melman; KevinKorenblat; Jeffrey S. Crippin; William C. Chapman
Archives of Surgery (2008).143[7]: pp. 679- 685.
ClickHere to View Abstract

Written by: Peter M Crosta
Copyright: Medical News Today

The Alliance for Paired Donation (APD) announced that today marks the first anniversary of the world’s first NEAD (Never-Ending Altruistic Donor) chain, wherein Matt Jones, a then-28-year-old donor from Petoskey, Michigan sparked a chain of ten kidney transplants, with more on the way.

Building on the traditional method of paired exchanges, whereby kidney patients who have a willing but incompatible donor are matched with others in a similar situation, the Alliance uses altruistic (or “good Samaritan”) donors to begin a chain of transplants that can be performed in a step-wise fashion, rather than having to be performed simultaneously. Not only is this logistically easier, but it allows the recipient’s loved ones (including their incompatible donor) to be present for the transplant and recovery, before going on to give a kidney to someone else.

On July 18, 2007, Matt Jones of Petoskey traveled to Phoenix to donate a kidney to Barb Bunnell, a 53-year-old grandmother whose husband, Ron, wanted to donate but was incompatible. On July 26, Ron flew to Toledo, Ohio, where he donated a kidney to Angie Heckman, a 32-year-old woman who had been receiving kidney dialysis treatments three times a week for 11 years. The chain continued with Angie’s mom donating a kidney two months later, and there have now been ten people transplanted in five different states as a result of Matt’s initial gift.

Angie Heckman, the second recipient in the chain, recently traveled to Pittsburg for the Transplant Games, where she competed and won a bronze medal in racquetball. Matt and his new wife, Meghan, who celebrated their honeymoon at the Games, were on hand to participate in the 5k run. Matt also had the opportunity to present Angie with her bronze medal.

A reunion is planned for later this year, to celebrate both the donors and recipients of this first Never-Ending chain, as well as to honor all of those who have been part of the Alliance for Paired Donation program. In its first year of operations, the APD facilitated 19 transplants.

The Alliance for Paired Donation is headquartered in Toledo, Ohio. A 501 (c) 3 organization, the mission of the APD is to save lives by significantly shortening the waiting time for kidney patients through kidney paired donation. Learn more about the program by visiting http://www.paireddonation.org.

Donate Life America and the United Network for Organ Sharing (UNOS) are using the month of April to educate Americans about the number of lives that could be saved and improved through organ, eye and tissue transplants. Organizations, including Allsup, which represents people nationwide for Social Security Disability Insurance benefits, are helping raise awareness about the growing need.

The number of patients on the U.S. waiting list for organ transplants has grown at a steady rate, reaching 97,670 as of Dec. 31, 2007. In comparison, five years ago, there were 80,790 patients on the waiting list as of Dec. 31, 2002. And 10 years ago, there were 53,167 patients on the waiting list as of Dec. 31, 1997. The result is an increase of nearly 84 percent in 10 years.

In 2007, nearly 6,000 people died while on the waiting list, and more than 26,000 people received organ transplants. According to UNOS, the longest organ-specific waiting list is for kidney donations, with more than 75,000 people currently waiting for an organ transplant.

One method for meeting this need is encouraging donation sign-up at the state level. Many states provide simple methods for designating organ donation on drivers’ licenses or state identification cards. Donate Life America offers a directory with details by state online at http://www.donatelife.net.

“State donor registries play an essential role in the donation process by enabling an individual to make a decision that gives procurement agencies full authority to procure their organs and/or tissues upon their death,” said Sara Pace Jones, Donate Life America chairman. “These legally binding donation decisions are critical for the nearly 100,000 people who are on the National Waiting List for organ transplants and the many more awaiting cornea and tissue transplants to restore their lives and health.”

One misconception about organ transplants is that most recipients survive only a few years. According to Donate Life America, long-term survival is becoming more common. For example, a number of kidney recipients are living 30 years or longer after transplant. Recipients of other organs have survived more than 20 years after transplant.

Each day in the U.S., there are about 79 organ transplants taking place and an average of 132 people being added to the nation’s organ transplant waiting list.

Allsup is observing Donate Life Month with free posters available to hospitals, clinics and other community groups by calling Karen Hercules-Doerr at (800) 854-1418, ext. 5770.

Donate Life America

Surgeons at the The Johns Hopkins Hospital in Baltimore, Maryland, USA, have carried out the first simultaneous six-way kidney transplant operation involving six donors and six recipients that were paired using a “domino” system that relies on altruistic donation to facilitate better matching of recipients with volunteer donors.

The whole procedure, said to be the first six way transplant of its kind, was carried out last Saturday, 5th April, and took 10 hours, used six operating theatres and required nine surgical teams, involiving a total of 100 nurses, doctors and other medical and adminstration professionals.

According to a statement released by the hospital yesterday, all 12 patients are doing well.

The six-way “domino” procedure began when five of the recipients attended the hospital for evaluation, each with a willing donor (a relative or friend known to the recipient), but in each case, the donor’s tissue and blood type did not match the recipient’s.

It was only when a sixth volunteer donor was found, a so called “altruistic” donor who was prepared to donate a kidney to no particular recipient and whose blood and tissue type matched one of the recipients, that it then became possible to swap the pairs around so that each of the five recipients was better matched to receive a kidney from one of the donors, who was not necessarily a person they knew (ie not the donor they originally came forward with).

The kidney from the donor whose blood and tissue was least compatible with that of the five recipients was then available to donate to the first patient on the “waiting list” with a good match. Thus six well-matched donor-recipient pairs were created in a sort of “domino” effect with the last domino being the patient on the waiting list. (The “waiting list” was the United Network for Organ Sharing’s (UNOS) recipient list.)

In this kind of system, the more incompatible pairs that come forward, the greater the chance that better matched pairs can be created.

All six donor surgeries took place at the same time, after which the kidneys stayed in the same rooms, which were then sterilized before admitting the recipients and giving them their new kidneys.

Johns Hopkins said that each of the donors will now be monitored for the rest of his or her life to make sure the kidney they have left remains healthy. And the recipients will be monitored weekly for six weeks, then monthly, then gradually tapering off.

According to the hospital, the average life expectancy of a live donor kidney is around 18 to 20 years.

The transplant team at Johns Hopkins are the pioneers of the system where kidneys are exchanged among incompatible donor-recipient pairs. The procedure is called KPD, short for kidney paired donation.

The hospital were the first to carry out a KPD triple transplant in 2003, and two years later, in 2007, performed the first domino triple transplant and a year later, in 2007, the first domino five-way transplant.

Chief of the transplant division at Johns Hopkins Hospital, Dr Robert Montgomery, together with researchers from the hospital, presented a system for wider pairing of altruistic donors and incompatible recipients in a paper published in the Lancet last year. The intention was to substantially increase the number of organs available and to better serve the needs of donors and recipients.

Montgomery said that such a universal system obviates the inconsistencies of allocation systems where only a single patient benefits from an act of altruistic donation. It is often the case that the kidney from an altruistic donor goes either to someone at the top of the waiting list (regardless of predicted outcome or need), to a patient who is likely to live longer, or to someone in greatest need.

“With domino paired donation”, said Montgomery, “all three of these ethical tenets are satisfied.”

“The likelihood of a good outcome is increased by spreading the risk of recipient graft loss across more people. The neediest are served, since in many cases incompatible donor-recipient pools have a high proportion of patients who are hard to match,” he added.

“And fairness is served,” explained Montgomery, “because the last paired donor’s kidney in the chain is allocated to the next compatible patient on the deceased donor waiting list.”

Source: Johns Hopkins Medicine press release.

Written by: Catharine Paddock, PhD
Copyright: Medical News Today

The Department of Health announced the appointment of a new ‘transplant tsar’ to drive forward Government plans to increase the number of people who can benefit from an organ transplant.

On 16 January, Ministers accepted recommendations made by the Organ Donation Taskforce and agreed the necessary investment to increase by 50% in five years the number of donor organs available for transplantation.

To oversee delivery of this programme of work Transplant and Managing Director at UK Transplant, Mr Chris Rudge has been appointed as National Clinical Director for Transplant.

Ministers have also asked Prof Sir Bruce Keogh, NHS Medical Director at the Department of Health, to chair the implementation Group, which has a UK-wide remit, to support the new Clinical Director

Prof Sir Bruce Keogh, welcomed Mr Rudge to his new role. He said: “We are delighted that a clinician of Mr Rudge’s standing has agreed to work with us to drive forward implementation of the Organ Donation Taskforce recommendations and help achieve the significant increases in transplants that will benefit so many people.

Mr Rudge said:

“I feel privileged to be leading the day-to-day implementation of the Organ Donation Taskforce recommendations. Organ transplantation is one of medicine’s great success stories but tragically hundreds of people die in the UK every year because there are not enough organs. I am confident that we can make a real difference to peoples lives over the next three to five years and will be working to overcome the barriers to organ donation identified by the Taskforce and deliver the increase in transplants that is so desperately needed.’

Chris Rudge was appointed UK Transplant’s first Medical Director in 2001 to provide clinical leadership and has played a wide role in developing working relationships between UKT, the clinical transplant programmes in the UK and the critical care community. He was consultant transplant surgeon at Guy’s Hospital and then St Peter’s Hospital.

In 1995 he became Director of Transplantation at The Royal London Hospital, where he continues to spend one day a week.? Mr Rudge will be joining the Department of Health but at the same time he will continue to be responsible for the day to day running of UK Transplant until a permanent replacement is appointed.? His responsibilities also include liaising with those in the other UK Health Departments responsible for implementing the recommendations in their country.

Notes

1. Mr Rudge will undertake his role as National Clinical Director for Transplant on secondment to the Department of Health for three years. His work as National Clinical Director will begin shortly once transitional arrangements at UK Transplant are in place. As part of these arrangements, Lynda Hamlyn, the Chief Executive of NHS Blood and Transplant (NHSBT) will take responsibility for the implementation of the Taskforce recommendations that fall to NHSBT.

2. The Organ Donation Taskforce was established by the Government in 2007 to identify barriers to organ donation. The Taskforce was comprised of 20 members including patients, transplant surgeons, critical care specialists, donor transplant co-ordinators, NHS managers, the other Health Departments in the UK and? representatives from the media, clinical ethics, diversity issues and charities. In developing its recommendations the Taskforce consulted a number of experts, including those from Spain, USA and Australia.

3. The Taskforce was asked to identify barriers to organ donation, explore current issues that might have a bearing on donation rates, and recommend action to be taken to increase organ donation within current legal frameworks. Their Report published on 16 January contained 14 recommendations covering the need to invest in better donor identification and referral, better donor coordination and improved organ retrieval arrangements. The UK Government has committed ￡11m extra funding in 2008/08 to support implementation, and each of the other countries is committed to implementation.

4. The full Report of the taskforce- Organs for Transplants. A Report from the Organ Donation Taskforce, is available at http://www.dh.gov.uk

5. In September 2007, following the publication of the Chief Medical Officer’s annual report which recommended a move to presumed consent for organ donation, the Secretary of State for Health Alan Johnson asked the Taskforce to look at the issue of presumed consent as a second piece of work..? The issue of presumed consent was not included in the Report published on 16 January .? A separate report will follow in the summer.

6. Currently, more than 8,000 people in the UK need an organ transplant, rising by about 8% a year. At the end of March 2007, 7,219 patients were listed as actively waiting for a transplant. More information is available on http://www.uktransplant.org.uk

7. UK Transplant is the NHS organisation responsible for matching and allocating donated organs. It is part of NHS Blood and Transplant (NHSBT), a Special Health Authority within the NHS that manages the National Blood Service and transplants.? This part of its responsibilities covers the whole of the UK.

http://www.dh.gov.uk

Parents of pediatric liver transplant recipients report lower health-related quality of life for their children two years after the surgery, compared to reports from the parents of healthy children. However, reports of family dysfunction fall within the normal range. These findings are published in the April issue of Liver Transplantation. The article is also available online at Wiley Interscience (www.interscience.wiley.com ).

Children account for up to 15 percent of liver transplant recipients each year in the U.S. Their 10-year survival rate is nearly 80 percent, however, survival is not the only outcome of interest. Liver transplantation has long-term implications for a child’s health related quality of life (HRQOL), which includes physical health, mental health, social functioning, role functioning and general health perceptions.

Previous studies have attempted to measure the HRQOL of pediatric liver transplant recipients, but have been limited to single centers and have yielded mixed results. Researchers from the Studies of Pediatric Liver Transplantation (SPLIT) consortium, led by Estella Alonso of Children’s Memorial Hospital in Chicago, decided to conduct a multi-center analysis of HRQOL and family function for these young patients.

They included 102 pediatric liver transplant recipients from five centers in the United States. Sixty-seven were under 5 years old, while 35 were between 5 and 18 years of age. At about 2 years post transplant, the researchers asked the children’s parents to complete a questionnaire about their child’s quality of life, along with the Family Assessment Devise (FAD), assessing family function. They then compared the data to either a control population or a published healthy normative population.

On measures of HRQOL, the younger transplant recipients scored significantly lower in global health, general health perceptions and change in health, compared to the children in the control group. The older children scored significantly lower in physical health, general health, parental emotional impact, and disruption of family activities.

Interestingly, however, the mean scores of the FAD scales indicated no increase in family dysfunction. Twenty-five percent of the transplant families were within the unhealthy range, compared to 19 to 36 percent of non-clinical families reported in FAD validation studies.

“Future assessments of HRQOL in this population should include the perspective of the patient and both of their parents to yield the fullest understanding of their health status and adjustment to post-transplant medical care,” the authors conclude.

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Article: “Health related quality of life and family function following pediatric liver transplantation.” Alonso, Estella M.; Neighbors, Katie; Barton, Franca; McDiarmid, Sue; Dunn, Stephen P.; Mazariegos, George; Landgraf, Jeanne; Bucuvalas, John; SPLIT Research Group. Liver Transplantation; April 2008.

Source: Sean Wagner
Blackwell Publishing Ltd.

In an Open Letter to the Federal Drug Administrations (FDA), which appears in the April issue of the American Journal of Transplantation (AJT), the American Society of Transplantation (AST) and the American Society of Transplant Surgeons (ASTS) explain how FDA policy is thwarting the field of transplant medicine in the United States. Flavio Vincenti, MD, president of the AST and one of the letter’s authors, described the letter as an appeal to the FDA to reconsider its policy.

Vincenti maintains that FDA policy has:

— discouraged many transplant centers from participating in clinical trials of new transplant drugs

— driven American patients away from enrolling in clinical trials

— caused drug companies to seek patients outside the U.S. for clinical trials

— weakened clinical trial results of innovative transplant drugs

In summary, FDA policy mandates the use of immunosuppressive drugs in organ transplantation clinical trials (in the control arms) that are no longer the preferred regimen of drugs of transplant physicians. The letter can be reviewed by going to http://www.a-s-t.org.

About AST

The American Society of Transplantation (AST) was founded in 1982 and is an organization of more than 2,700 transplant professionals dedicated to improving patient care through the promotion of research, education, advocacy and organ donation. AST provides a forum for the exchange of knowledge, scientific information and expertise in the field of transplantation.

American Society of Transplantation
http://www.a-s-t.org

The University of Alberta Hospital (UAH) is one of only a few centers in Canada that perform living donor liver transplantation, a surgical procedure developed in the late 1980s that expands the organ donor pool. About 80 liver transplants are done a year in Alberta, 10 of those being living-donor.

All potential liver transplant donors are assessed based on considerations such as the size and composition of the liver and vascular and bile duct anatomy. Thanks to a review paper done at the University of Alberta radiologists at the University of Alberta Hospital are now using CT (Computed Tomography) imaging for living-donor liver transplantation. This technique shows relevant liver anatomy and, in particular, enhances high resolution imaging of the vital bile duct anatomy.

“CT scans provide a clear image of the important ducts we need to see,” said Dr. Gavin Low, a clinical fellow in the University of Alberta’s Faculty of Medicine and Dentistry and author of a recent study describing this process. In the past radiologists have only been using an MRI to scan possible donors for bile duct anatomy, but Low said that, “By using CT imaging the results are much more accurate and reliable for the surgeons.”

Right now possible donors are screened with both MRI and CT scans but Low says the hope is to one day only use CT imaging; adding, “All-in-one imaging will speed up the process and make living-donor evaluation more convenient for potential donors.”

As many as four patients are evaluated by CT imaging every month.

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Source: Carmen Leibel
University of Alberta

EBMT, the European Group for Blood and Marrow Transplantation, will host over 4,000 top scientists, physicians, nurses, caregivers, patients and their families, and others during its 5-day Annual Congress in Florence, Italy. This meeting is a forum for the scientific exchange between physicians, nurses, and data managers, as well as a place for families, patients and others to meet, network, and exchange their experiences. The Annual Congress is planned to enhance the crucial close interaction with the leaders of each discipline in a harmonious programme.

The 34th EBMT Annual Congress

This year’s Annual Congress is predicted to be an even bigger success than last year’s meeting in Lyon where EBMT welcomed over 3,600 delegates from more than 75 countries. This year’s Annual Congress in Florence from 30th March to 2nd April will also be the 24th Meeting of the EBMT Nurses Group, the 7th Meeting of the EBMT Data Management Group, and the 2nd Patient and Family Day.

The Congress has been carefully prepared to offer a scientifically productive and highly informative meeting with plenary sessions, educational sessions, workshops, lunch sessions and joint sessions covering all-important topics and presented by the top experts in the field. This year the two plenary sessions focus on rapidly changing issues: the evolution of Graft-versus-Host-Disease (GvHD) and a session on Cord Blood Transplantation. The combination of this scientific meeting with the nurses’, data managers’ and statisticians’ programmes highlights the multidisciplinary character of the EBMT Annual Congress.

The 2nd EBMT Patient & Family Day

The 2nd EBMT Patient & Family Day will take place in Florence on Saturday 29th March 2008. The EBMT Board decided to repeat this initiative based on the success of the first event in Lyon last year, in line with the Group’s goal of improving communication between EBMT professionals and patients. The programme will incorporate the suggestions and experience gained from the first exchanges with patients and families. It has been designed to explore both scientific trends and the special relationship which often exists between the clinical BMT personnel and patients and their families.

This information day will consist of two presentations, four plenary sessions and six workshops led by physicians, nurses, patients, donors and family members. The two presentations will be “Overview of transplant activity in Europe” and “Clinical evolution of GvHD”.

For more information on the Congress and to see the full schedule, please visit http://www.akm.ch/ebmt2008.

About the European Group for Blood and Marrow Transplantation

Bone marrow or stem cell transplantation is often the only curative treatment for different malignant diseases and is currently performed on more that 50,000 patients worldwide each year. The European Group for Blood and Marrow Transplantation (EBMT) as the leading non-profit, scientific society representing 530 transplant centres in and outside Europe, promotes all activity aiming to improve stem cell transplantation or cellular therapy. This includes registering all the activity relating to stem cell transplants with a view to improving treatment outcomes for patients. EBMT has set standards for indication and treatment for malignant and non-malignant diseases, along with running training programmes for continual professional development. These are continually audited and updated. EBMT is also responsible for accrediting the transplant centres based on their performance and data reporting.

European Group for Blood and Marrow Transplantation

Combination therapy of Prostacyclin, Sildenafil, and Bosentan helped a young male patient with severe portopulmonary hypertension improve enough to receive a liver transplant. It was also used post-transplant to help him maintain his health. These findings are published in the March issue of Liver Transplantation, a journal by John Wiley & Sons. The article is also available online at Wiley Interscience (http://www.interscience.wiley.com/).

Portopulmonary hypertension (PPHTN) is pulmonary arterial hypertension associated with liver disease or portal hypertension. Our knowledge about treatment options for this condition is limited by lack of randomized controlled trials, concerns about drug safety and the inability to reverse pulmonary disease. Liver transplant is an effective treatment for many patients with mild-to-moderate PPHTN characterized by a mean pulmonary artery pressure (mPAP) 50mmHg).

Researchers led by Mark Austin of King’s College Hospital describe a case study of a 26-year-old male patient who had severe refractory PPHTN and non-cirrhotic portal hypertension. He was treated with sequential, then combination, therapy of the vasodilators Iloprost, Sildenafil, and Bosentan. His condition improved dramatically, with his mPAP falling from 70 to 32mmHg. He underwent liver transplantation, and continued on the therapy for two years post-transplant, when his mPAP fell even further to 28mmHg. He currently continues on dual combination therapy of Sildenafil and Bosentan, and his doctors hope to eventually withdraw both agents.

“This is the first reported patient with severe PPHTN using this combination of vasodilator therapy as a bridge to liver transplantation and then as maintenance in the post-transplant phase. This regimen may enable liver transplantation in similar patients in the future, without long-term consequences,” the authors conclude.

An accompanying editorial by Karen Swanson of the Mayo Clinic writes, “It is easy to see why combination therapy may make sense as we do not yet have a means of determining which predominant mechanism is influencing which patient and, which medications might be most beneficial specifically in POPH.”

She laments the fact that POPH is excluded from every clinical trial involving pulmonary hypertension, especially given its prevalence, and worries about the cost of triple-drug therapy when we don’t even have good prospective data on individual drug therapy.

“Only by following multi-center prospective protocols in POPH will we ever have more meaningful answers to the ideal course of treatment in these patients,” she concludes. “Until then, we continue to extrapolate our thoughts from single center case reports and case series. Can we move on?”

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Article: “Safety and efficacy of combined use of Sildenafil, Bosentan and Iloprost before and after liver transplantation in severe portopulmonary hypertension.” Austin, Mark; McDougall, Neil; Wendon, Julia; Knisely, A.; Rela, Mohammed; Callender, Michael; Sizer, Elizabeth; Wilson, Carol; O’Grady, John; Heneghan, Michael A. Liver Transplantation; March 2008.

Editorial: “Treatment of portopulmonary hypertension - isn’t it time to move forward?” Swanson, Karen. Liver Transplantation; March 2008.

Source: Amy Molnar
Wiley-Blackwell