Current opinion in organ transplantation
-
Curr Opin Organ Transplant · Oct 2017
ReviewImmunosuppression maintenance in vascularized composite allotransplantation: what is just right?
Over the last two decades advances in vascularized composite allotransplantation have achieved clinically significant milestones. This review provides a synopsis for immunosuppressive maintenance therapy for VCA and discusses the nuances surrounding the determination of the right amount of immunosuppression in vascularized composite allotransplantation. ⋯ Examining conventional treatment protocols can lead to the development of novel immunosuppression concepts that will ultimately assist in favorably tilting the risk-benefit scale for these life-changing transplants.
-
Curr Opin Organ Transplant · Oct 2017
ReviewAdipose-derived cellular therapies in solid organ and vascularized-composite allotransplantation.
Controlling acute allograft rejection following vascularized composite allotransplantation requires strict adherence to courses of systemic immunosuppression. Discovering new methods to modulate the alloreactive immune response is essential for widespread application of vascularized composite allotransplantation. Here, we discuss how adipose-derived cellular therapies represent novel treatment options for immune modulation and tolerance induction in vascularized composite allotransplantation. ⋯ To date, most reports focus on adipose derived mesenchymal stem cells for immune modulation in transplantation despite their phenotypic plasticity and reliance upon culture expansion. Along with the capacity for immune modulation, the supplemental wound healing and vasculogenic properties of stromal vascular fraction, which are not shared by adipose derived mesenchymal stem cells, hint at the profound therapeutic impact stromal vascular fraction-derived treatments could have on controlling acute allograft rejection and tolerance induction in vascularized composite allotransplantation. Ongoing projects in the next few years will help design the best applications of these well tolerated and effective treatments that should reduce the risk/benefit ratio and allow more patients access to vascularized composite allotransplantation therapy.
-
Curr Opin Organ Transplant · Jun 2017
ReviewExtending normothermic regional perfusion to the thorax in donors after circulatory death.
Despite a significant increase in the utilization of donors after circulatory death (DCD), the number of organs recovered and their function are largely inferior to those from donors after brain death. This review summarizes recent advances in in-situ normothermic regional perfusion of DCD organs prior to procurement. ⋯ Thoraco-abdominal NRP may become the new gold standard for DCD organ retrieval. Further research and education are required to streamline logistics, define organ function markers and increase acceptance and utilization.
-
Curr Opin Organ Transplant · Jun 2017
ReviewDonation after circulatory death heart transplantation.
Despite continued expansion in the use of extended-criteria donor hearts following donation after brain death, there remains an unacceptable discrepancy between the supply of suitable donor hearts and the demand from increasing recipient numbers on transplant wait lists. Until recently, the additional approach of utilizing organs following donation after circulatory death (DCD) had not been possible for clinical heart transplantation in the modern era. This review describes relevant advances in translational research and provides an update on the favourable adoption of this donation pathway for clinical heart transplantation. ⋯ DCD heart transplantation is feasible with excellent early outcomes. In the face of continued and significant donor organ shortage and inevitable wait list attrition, the rejection of suitable DCD hearts, in jurisdictions permitting this donation pathway, is increasingly difficult to justify.
-
Curr Opin Organ Transplant · Oct 2016
ReviewDonor-specific antibodies and antibody-mediated rejection in vascularized composite allotransplantation.
The presence of donor-specific antibodies (DSA) increases the risk of graft failure. Although DSA characteristics, human leukocyte antigen class specificity, mean fluorescence intensity and immunoglobulin G subclasses, and their impact on the graft are quite well studied in solid organ transplants, very little information is known about their impact on vascularized composite allotransplantation (VCA). The aim of this review is to highlight recent publications regarding occurrence and effects of DSA, their follow-up and treatment in the field of VCA. ⋯ The functional outcome of reconstructive transplantation has clearly exceeded the results achieved with conventional surgical techniques. The recipients' immune response, particularly development of DSA and the long-term adherence, which is probably associated with the occurrence of chronic rejection, remain a challenge.