Transplantation
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Editorial Review
Whose consent matters? Controlled donation after cardiac death and premortem organ-preserving measures.
The goal of this overview is to discuss the ethics of premortem organ-protective measures with the aim of improving donation outcome for the recipient. A literature review was undertaken to find out which such measures were implemented in published articles on controlled donation after cardiac death. We reviewed studies on controlled human organ donation after cardiac death that were published in PUBMED and EMBASE between 2000 and 2010. ⋯ The authors conclude that premortem measures have the potential to instrumentalize the organ donor and that they should be restricted to cases in which the donor wish is known-directly, through a donor card, or through a surrogate decision maker-and specific consent to premortem procedures has been given. This specific consent should be required at least until the general public is aware that premortem measures may be performed. If potential donors were informed about premortem measures as part of a community information effort, for example, school curricula, and again when they signed their donor card, one might consider their consent to be truly informed and valid.
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Review
Immunological issues in clinical composite tissue allotransplantation: where do we stand today?
Composite tissue allografts are made of histogenetically different tissues and although skin seems to be the most antigenic of them, it is unknown whether the dominant immune response is really directed against the skin or we have insufficient information on the involvement of the other components of these allografts. The first clinical signs of acute rejection manifest on the skin and microscopically the earliest lesions consist in a dermal perivascular lymphocytic infiltrate, predominantly made of CD3+/CD4+ T cells. On the basis of the histological changes, a specific score (Banff score 2007) has been established to assess the severity of rejection. ⋯ The complications in composite tissue allotransplantation are similar to those usually reported after solid organ transplantation and have prompted different strategies to minimize the maintenance immunosuppression or to induce donor-specific tolerance. Furthermore, to what extent the immunosuppression can be tapered is unknown, as well as the influence of donor bone-marrow infusion in tolerance and chronic rejection. The increasing number of patients and the longer follow-up hopefully will allow answering these questions.