RESUMEN
In this review, we identify important challenges facing physicians responsible for renal and cardiac transplantation in children based on a review of the contemporary medical literature. Regarding pediatric renal transplantation, we discuss the challenge of antibody-mediated rejection, focusing on both acute and chronic antibody-mediated rejection. We review new diagnostic approaches to antibody-mediated rejection, such as panel-reactive antibodies, donor-specific cross-matching, antibody assays, risk assessment and diagnosis of antibody-mediated rejection, the pathology of antibody-mediated rejection, the issue of ABO incompatibility in renal transplantation, new therapies for antibody-mediated rejection, inhibiting of residual antibodies, the suppression or depletion of B-cells, genetic approaches to treating acute antibody-mediated rejection, and identifying future translational research directions in kidney transplantation in children. Regarding pediatric cardiac transplantation, we discuss the mechanisms of cardiac transplant rejection, including the role of endomyocardial biopsy in detecting graft rejection and the role of biomarkers in detecting cardiac graft rejection, including biomarkers of inflammation, cardiomyocyte injury, or stress. We review cardiac allograft vasculopathy. We also address the role of genetic analyses, including genome-wide association studies, gene expression profiling using entities such as AlloMap®, and adenosine triphosphate release as a measure of immune function using the Cylex® ImmuKnow™ cell function assay. Finally, we identify future translational research directions in heart transplantation in children.
Asunto(s)
Rechazo de Injerto , Trasplante de Corazón/efectos adversos , Trasplante de Riñón/efectos adversos , Investigación Biomédica Traslacional , Anticuerpos/inmunología , Biomarcadores/sangre , Niño , Perfilación de la Expresión Génica/métodos , Glomeruloesclerosis Focal y Segmentaria/patología , Rechazo de Injerto/genética , Rechazo de Injerto/inmunología , Rechazo de Injerto/patología , Rechazo de Injerto/terapia , Prueba de Histocompatibilidad , Humanos , Medición de Riesgo , Tolerancia al TrasplanteRESUMEN
In this review, we identify important challenges facing physicians responsible for renal and cardiac transplantation in children based on a review of the contemporary medical literature. Regarding pediatric renal transplantation, we discuss the challenge of antibody-mediated rejection, focusing on both acute and chronic antibody-mediated rejection. We review new diagnostic approaches to antibody-mediated rejection, such as panel-reactive antibodies, donor-specific cross-matching, antibody assays, risk assessment and diagnosis of antibody-mediated rejection, the pathology of antibody-mediated rejection, the issue of ABO incompatibility in renal transplantation, new therapies for antibody-mediated rejection, inhibiting of residual antibodies, the suppression or depletion of B-cells, genetic approaches to treating acute antibody-mediated rejection, and identifying future translational research directions in kidney transplantation in children. Regarding pediatric cardiac transplantation, we discuss the mechanisms of cardiac transplant rejection, including the role of endomyocardial biopsy in detecting graft rejection and the role of biomarkers in detecting cardiac graft rejection, including biomarkers of inflammation, cardiomyocyte injury, or stress. We review cardiac allograft vasculopathy. We also address the role of genetic analyses, including genome-wide association studies, gene expression profiling using entities such as AlloMap®, and adenosine triphosphate release as a measure of immune function using the Cylex® ImmuKnow™ cell function assay. Finally, we identify future translational research directions in heart transplantation in children.
Asunto(s)
Niño , Humanos , Rechazo de Injerto , Trasplante de Corazón/efectos adversos , Trasplante de Riñón/efectos adversos , Investigación Biomédica Traslacional , Anticuerpos/inmunología , Biomarcadores/sangre , Perfilación de la Expresión Génica/métodos , Glomeruloesclerosis Focal y Segmentaria/patología , Rechazo de Injerto/genética , Rechazo de Injerto/inmunología , Rechazo de Injerto/patología , Rechazo de Injerto/terapia , Prueba de Histocompatibilidad , Medición de Riesgo , Tolerancia al TrasplanteRESUMEN
Lung transplantation is currently considered an established treatment for some advanced lung diseases. The beginning of experimental lung transplantation dates back to the 1940's when the Soviet Vladimir P. Demikhov performed the first lung transplants in animals. Two decades later, James Hardy performed the first lung transplant in humans. Unfortunately, the beginning of clinical lung transplantation was hampered by technical complications and the excessive toxicity of immunosuppressive drugs. Improvement in the surgical technique along with the development of more effective and less toxic immunosuppressive drugs has led to a better outcome in lunt transplant recipients. Donor selection and management before organ procurement play a key role in the receptor's outcome. Due to the shortage of donors, some institutions are using more liberal selection criteria, reporting satisfactory outcomes. The approach of the lung and heart-lung transplant patient is multidisciplinary and includes the cardiothoracic transplant surgeon, pulmonologist, anesthesiologist, and intensivist, among others. Herein, we review some relevant historical aspects and recent advances in the management of lung transplant recipients, including indications and contraindications, evaluation of donors and recipients, surgical techniques and peripost-operative care.
Asunto(s)
Trasplante de Pulmón , Adulto , Factores de Edad , Anciano , Animales , Canadá , Contraindicaciones , Selección de Donante , Trasplante de Corazón-Pulmón , Historia del Siglo XX , Humanos , Hipertensión Pulmonar/cirugía , Inmunosupresores/efectos adversos , Inmunosupresores/uso terapéutico , Donadores Vivos , Trasplante de Pulmón/efectos adversos , Trasplante de Pulmón/historia , Trasplante de Pulmón/métodos , Trasplante de Pulmón/mortalidad , México , Persona de Mediana Edad , Grupo de Atención al Paciente , Cuidados Posoperatorios , Complicaciones Posoperatorias , Enfermedad Pulmonar Obstructiva Crónica/cirugía , Fibrosis Pulmonar/cirugía , Donantes de Tejidos , Obtención de Tejidos y Órganos , U.R.S.S. , Estados UnidosRESUMEN
Actualmente el trasplante pulmonar es considerado como tratamiento definitivo para algunas enfermedades pulmonares avanzadas. Los primeros trasplantes pulmonares experimentales en animales fueron realizados en los años 1940s por el soviético Vladimir P. Demikhov. Sin embargo, pasaron aproximadamente dos décadas antes de que se realizara el primer trasplante pulmonar en humanos por el doctor James Hardy. Desafortunadamente los inicios clínicos del trasplante pulmonar no fueron muy exitosos debido a complicaciones quirúrgicas y efectos secundarios de los fármacos inmunosupresores. Gracias al mejoramiento de la técnica quirúrgica y al desarrollo de fármacos inmunosupresores más efectivos y menos tóxicos, la morbimortalidad ha disminuido significativamente. La selección y el cuidado del donador antes de la procuración de los órganos juegan un papel primordial en los resultados en el receptor. Debido a la escasez de donadores, algunas instituciones están utilizando criterios de selección más liberales con resultados satisfactorios. El manejo del paciente con trasplante pulmonar o del bloque cardiopulmonar requiere de un enfoque multidisciplinario que incluye al cirujano de trasplantes cardiotorácicos, al neumólogo, al anestesiólogo y al intensivista entre otros. En este artículo revisamos aspectos históricos y avances recientes en el manejo de estos pacientes incluyendo indicaciones y contraindicaciones, evaluación y cuidado del donador y del receptor, técnica quirúrgica y manejo peri- y posoperatorio.
Lung transplantation is currently considered an established treatment for some advanced lung diseases. The beginning of experimental lung transplantation dates back to the 1940's when the Soviet Vladimir P. Demikhov performed the first lung transplants in animals. Two decades later, James Hardy performed the first lung transplant in humans. Unfortunately, the beginning of clinical lung transplantation was hampered by technical complications and the excessive toxicity of immunosuppressive drugs. Improvement in the surgical technique along with the development of more effective and less toxic immunosuppressive drugs has led to a better outcome in lunt transplant recipients. Donor selection and management before organ procurement play a key role in the receptor's outcome. Due to the shortage of donors, some institutions are using more liberal selection criteria, reporting satisfactory outcomes. The approach of the lung and heart-lung transplant patient is multidisciplinary and includes the cardiothoracic transplant surgeon, pulmonologist, anesthesiologist, and intensivist, among others. Herein, we review some relevant historical aspects and recent advances in the management of lung transplant recipients, including indications and contraindications, evaluation of donors and recipients, surgical techniques and peripost-operative care.
Asunto(s)
Humanos , Animales , Adulto , Persona de Mediana Edad , Historia del Siglo XX , Trasplante de Pulmón , Factores de Edad , Canadá , Selección de Donante , Enfermedad Pulmonar Obstructiva Crónica/cirugía , Fibrosis Pulmonar/cirugía , Trasplante de Corazón-Pulmón , Hipertensión Pulmonar/cirugía , Inmunosupresores/efectos adversos , Inmunosupresores/uso terapéutico , Donadores Vivos , México , Grupo de Atención al Paciente , Cuidados Posoperatorios , Complicaciones Posoperatorias , Obtención de Tejidos y Órganos , Donantes de Tejidos , Estados Unidos , U.R.S.S.RESUMEN
We have recently described the Novel Left Ventricular Assist Systems (Novel LVAS) I and II, which avoid cannulation of cardiac chambers and synchronize pumping with the patient's electrocardiogram. We now describe the drive system in more detail. The drive unit is an air-driven pulsatile system. The driver's parameters can be programmed. This electro-pneumatic unit contains 3 modules. A remarkable feature of the driver system is that it contains 2 pneumatic units that alternate in their function every 15 minutes. This prevents overheating and component fatigue or failure, and it enables the use of smaller units. If one of the units fails, an alarm will warn of the problem, and the other will continue indefinitely. This LVAS is synchronized with the patient's ECG, which enables it to eject the stroke volume during diastole and in this way to act as a chronic counterpulsator. We have designed the Novel LVAS to operate at a low-frequency rate. This fact, together with the electrocardiographic synchronization, offers the best prospect for myocardial recovery in patients who are also receiving beta-adrenergic blocking agents. This dual therapy will help adjust heart rate to pump frequency.