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Living Donor TranspLanTaTion Living Donor TranspLanTaTion Edited by Henkie p. Tan Thomas E. Starzl Transplantation Institute Pittsburgh, Pennsylvania, USA amadeo Marcos Thomas E. Starzl Transplantation Institute Pittsburgh, Pennsylvania, USA ron shapiro Thomas E. Starzl Transplantation Institute Pittsburgh, Pennsylvania, USA CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2008 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Version Date: 20130325 International Standard Book Number-13: 978-1-4822-0782-8 (eBook - PDF) This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal respon- sibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not neces- sarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the drug companies’ printed instructions, and their websites, before administering any of the drugs recommended in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ulti- mately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or uti- lized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopy- ing, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright.com (http:// www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com To our families for their love and support. To our live donors for their altruistic acts. To our recipients for their courage and faith in us. To Dr. Starzl for providing challenges, inspiration, and a vision. Preface Living Donor Transplantation discusses all aspects of living donor solid organ and cellular t ransplantation in current clinical practice, including kidney, liver, pancreas, lung, small bowel, islet, and hematopoietic stem cell transplantation. Each organ/cell-specific chapter includes sections on the medical evaluation, technical aspects of the operation, and donor and recipient outcomes. Special topics also include the history of living donor organ transplantation, the psychosocial aspects of donation and the transplant process, anesthetic management, preven- tion and control of infections, pregnancy in transplant recipients, the financial impact of living donation, transplantation tolerance, transplantation for malignancy, the ethics of paid living donation (pro and con), and living donor transplantation in pediatric recipients. This book describes in detail the state of the art and practice of live donor organ trans- plantation. Although many of the chapters are from the Thomas E. Starzl Transplantation Institute at the University of Pittsburgh, it represents a broad-based attempt to present, as clearly as possible, a comprehensive guide to the practice of live donor organ transplantation and includes important contributions from many other transplant centers in the United States. Chapters 1 to 3 are introductory overviews. Chapter 1 is a discussion of the history of living donor organ transplantation by Dr. Thomas E. Starzl, the “father” of modern transplan- tation and winner of both the Medawar Prize and the National Medal of Science. Chapter 2 examines the psychosocial aspects of living organ donation and the transplant process, empha- sizing the well-being of donors both before and after transplantation. Chapter 3 describes the general medical evaluation of the living donor. Chapters 4 to 13 are specific to living donor kidney transplantation. Chapter 4 focuses on issues related to the medical evaluation of live kidney donors. Chapter 5 is about the different technical aspects of live donor nephrectomy. This extensive chapter covers open, minimal inci- sional open, laparoscopic, hand-assisted laparoscopic, and robotically hand-assisted laparoscopic donor nephrectomy techniques. Chapters 6 and 7 consider the perioperative and long-term risks to the live kidney donors. These chapters also present a live donor nephrectomy complica- tion classification scheme. Chapter 8 is a discussion of the long-term outcomes for live kidney donors by Dr. Arthur Matas of the University of Minnesota, examining the long-term conse- quences of living with a single kidney (survival, renal function, cardiovascular disease, p roteinuria, risk factors of end-stage renal disease, and quality of life) and the limitations of the current data. Chapter 9 covers donor and recipient outcomes after laparoscopic live donor nephrectomy. Chapter 10, by Drs. Lloyd Ratner and R. John Crew of Columbia Presbyterian Hospital in New York, reviews immunologically incompatible living donor kidney transplants in the highly sensitized, positive crossmatch, and ABO-incompatible recipients. In Chapter 11, Drs. Dorry Segev, Robert Montgomery, and colleague at Johns Hopkins in Baltimore, Maryland, focus on expanding live donor renal transplantation through paired and nondirected donation. Chapter 12 discusses a limited experience with living donor kidney transplantation in HIV- positive recipients. Chapter 13 examines pediatric living donor renal transplantation. Chapters 14 to 20 are specific to living donor liver transplantation. Chapter 14 analyzes issues related to the evaluation of the live liver donor and recipient. Chapter 15 investigates the technical aspects of live donor hepatectomy. Chapter 16 explores live liver donor outcomes. Chapter 17 is a discussion of recipient outcomes after living donor liver transplantation by Drs. James Pomposelli, Elizabeth Pomfret, and Roger Jenkins of the Lahey Clinic. Chapter 18 describes recipient outcomes from the Pittsburgh experience with alemtuzumab preconditioning and tacrolimus monotherapy. Chapter 19 focuses on pediatric living-donor liver transplantation. Chapter 20 examines living donor liver transplantation for hepatocellular carcinoma. vi Preface A discussion of live donor pancreas transplantation by Drs. Miguel Tan, Raja Kandaswamy, Rainer Gruessner, and David Sutherland of the University of Minnesota is undertaken in Chapter 21. This chapter spotlights the preoperative donor evaluation, operative technique (including hand-assisted laparoscopic donor distal pancreatectomy), the recipient operation, and donor and recipient outcomes. Chapter 22 is an examination of living-donor islet cell transplantation by Drs. Emamaullee and J. Shapiro of the University of Alberta, Edmonton, Canada. This chapter describes the evaluation of the live donor and recipient, technical aspects of the islet transplantation proce- dure, and donor and recipient outcomes. Chapter 23 is a discussion of living lobar lung transplantation by Drs. Mark Barr and Vaughn Starnes of the University of Southern California. It covers evaluation, technical aspects, and donor and recipient outcomes. In Chapters 24 to 26, Dr. Luca Cicalese and colleague of the University of Massachusetts discuss live-donor small intestinal transplantation. Chapter 24 reviews specific issues related to the donor and recipient evaluation. Chapter 25 analyzes the surgical technique, and Chapter 26 examines donor and recipient outcomes. A discussion of hematopoietic stem cell transplantation by Dr. Andrew Yeager and c olleagues from the Arizona Cancer Center takes place in Chapters 27 to 29. Chapter 27 investi- gates the collection, processing, and infusion of adult hematopoietic stem cells (bone marrow and peripheral blood stem cells). Chapter 28 is an examination of the applications and outcomes of autologous and allogeneic hematopoietic stem cell transplantation, and Chapter 29 is a discussion of umbilical cord blood cell transplantation. Chapters 30 to 36 are special topics related to living donor organ transplantation. Chapter 30 examines anesthetic management for living donor organ transplantation. Chapter 31 focuses on the management of infections in living donor transplant recipients. Chapter 32 is a discussion of pregnancy after living donor organ transplantation by Drs. Vincent Armenti and colleagues of the National Transplantation Pregnancy Registry. Chapter 33 covers the financial impact of living donor organ transplantation. Chapter 34 describes transplantation tolerance. In this chapter, the mechanisms of immunological tolerance and the barriers to its induction are depicted. Chapters 35 and 36 consider the ethics of paid living donation. The case for a regulated system of kidney sales is made by Dr. Arthur Matas, and the case against organ sales is taken up by Dr. Arthur Caplan of the University of Pennsylvania. Chapters 37 and 38 are sample live kidney- and liver-donor consent forms created by the editors at the Starzl Transplantation Institute. We hope that this book proves to be a useful guide for individuals interested in living donor transplantation. Henkie P. Tan Amadeo Marcos Ron Shapiro Acknowledgments This multiauthored book represents the work of many individuals. We would like to thank all the authors (and their families) who contributed their time and energy to produce the specific chapters of this book. As we all know, the care of transplant donors and recipients is possible only with the help and commitment of a large number of physician consultants, transplant coordinators, nurses, social workers, and other staff personnel. Specifically, we would like to thank Annie M. Smith, RN, CCTC, and Eileen Stanford, RN, BSN, our two very proud live kidney donors. We also thank Gerri James, RN, CCTC; Cindy Anderson, RN, CCRN, CCTC; Diane Connors RN, MPH; Linda Boig, RN, CCTC; Theresa Caponi, RN, CCTC; Deborah Good, RN, BSN, CCTC; Jareen Flohr, RN, BSN, CCTC; Shirley Grube, MSW, ACSW, BCD, LCSW, MPH; and many others who are part of the transplant teams at the Thomas E. Starzl Transplant Institute at the University of Pittsburgh. We would like to thank Dana Bigelow, development editor at Informa Healthcare, for her patience and guidance as well as Alan Kaplan, project editor at Informa Healthcare, and Paula Garber, editorial supervisor at the Egerton Group. Thanks also to Chris DiBiase for the cover illustrations. We would also like to thank Judy Canelos, M.A., Communications Specialist II, and Miranda G. Rosen, Web Editor/Medical Writer, for their help in proofreading and editing the manuscripts. Without their valued help and participation, this book could not have been com- pleted. We also want to thank Diana Smith, Administrative Assistant, for her help in preparing the manuscripts. Finally, we would like to thank our families, especially our wives (Robin, Cristina, and Mary), for their love and support; our live donors, for their altruistic acts; our recipients, for their courage and faith in us; and Dr. Thomas E. Starzl, for providing challenges, inspiration, and a vision. Contents Preface …. v Acknowledgments …. vii Contributors …. xiii Part I: Overview 1. Live-Donor Organ Transplantation: Then and Now 1 Thomas E. Starzl and Amadeo Marcos 2. Psychosocial Aspects of Living Organ Donation 7 Mary Amanda Dew, Galen E. Switzer, Andrea F. DiMartini, Larissa Myaskovsky, and Megan Crowley-Matoka 3. General Medical Evaluation of the Living Donor 27 Jerry McCauley, Thomas Shaw-Stiffel, and Henkie P. Tan Part II: Living-Donor Kidney Transplantation 4. Evaluation: Specific Issues for Living-Donor Kidney Transplantation 33 Mark Unruh, Christine Wu, Henkie P. Tan, and Jerry McCauley 5. Technical Aspects of Live-Donor Nephrectomy 49 Amit Basu, Ron Shapiro, John L. Falcone, and Henkie P. Tan 6. Perioperative Donor Risk 69 Henkie P. Tan, Zebulon Z. Spector, and Ron Shapiro 7. Long-Term Risks of Living Donation 77 Connie L. Davis 8. Long-Term Outcomes for the Donor 87 Arthur J. Matas and Hassan Ibrahim 9. Donor and Recipient Outcomes After Laparoscopic Live-Donor Nephrectomy 101 Henkie P. Tan, David J. Kaczorowski, Amit Basu, Joseph Donaldson, and Ron Shapiro 10. Immunologically Incompatible Renal Transplants: Highly Sensitized Recipients, Positive Crossmatches, and ABO Blood Group Incompatibility 113 Lloyd E. Ratner and R. John Crew 11. Expanding Live-Donor Renal Transplantation Through Paired and Nondirected Donation 125 Dorry L. Segev, Sommer E. Gentry, Henkie P. Tan, and Robert A. Montgomery 12. Living-Donor Renal Transplantation in HIV Positive Recipients 137 Henkie P. Tan, David J. Kaczorowski, Amadeo Marcos, and Ron Shapiro x Contents 13. Pediatric Living-Donor Kidney Transplantation 149 Vivek Sharma, Ron Shapiro, Demetrius Ellis, and Henkie P. Tan Part III: Living-Donor Liver Transplantation 14. Evaluation: Specific Issues 159 Vladimir Bogin, Henkie P. Tan, Amadeo Marcos, and Thomas Shaw-Stiffel 15. Technical Aspects of Live-Donor Hepatectomy 169 Vivek Sharma, Henkie P. Tan, J. Wallis Marsh, and Amadeo Marcos 16. Donor Outcomes 185 Henkie P. Tan, Abigail E. Martin, Arman Kilac, Roberto Lopez, and Amadeo Marcos 17. Recipient Outcomes After Living-Donor Liver Transplantation 197 James J. Pomposelli, Elizabeth A. Pomfret, and Roger L. Jenkins 18. Adult Recipient Outcomes: The Pittsburgh Experience with Alemtuzumab Preconditioning and Tacrolimus Monotherapy—Two-Year Outcomes 207 Henkie P. Tan, Kusum Tom, Ngoc L. Thai, Paulo Fontes, Michael DeVera, Joseph Donaldson, Igor Dvorchik, and Amadeo Marcos 19. Pediatric Living-Donor Liver Transplantation 217 Kyle Soltys, Geoffrey Bond, Rakesh Sindhi, Henkie P. Tan, Amadeo Marcos, and George V. Mazariegos 20. Living-Donor Liver Transplantation for Hepatocellular Carcinoma 227 J. Wallis Marsh, Matthew P. Holtzman, and Igor Dvorchik Part IV: Living-Donor Pancreas Transplantation 21. Living-Donor Pancreas Transplantation 235 Miguel Tan, Raja Kandaswamy, David E. R. Sutherland, and Rainer W. G. Gruessner Part V: Living-Donor Islet-Cell Transplantation 22. Islet-Cell Transplant: Evaluation, Technical Aspects, and Donor and Recipient Outcomes 245 Juliet A. Emamaullee and A. M. James Shapiro Part VI: Living-Donor Lung Transplantation 23. Living Lobar-Lung Transplantation 259 Mark L. Barr and Vaughn A. Starnes Part VII: Living-Donor Intestinal Transplantation 24. Intestinal Transplantation from Living Donors: Specific Issues and Donor/Recipient Evaluation 269 Luca Cicalese 25. Living-Donor Intestinal Transplantation: Surgical Technique 281 Luca Cicalese 26. Living-Donor Intestinal Transplantation: Clinical Outcomes 297 Luca Cicalese and Shimul A. Shah Contents xi Part VIII: Hematopoietic Stem-Cell Transplantation 27. Collection, Processing, and Infusion of Adult Hematopoietic Stem Cells (Bone Marrow and Peripheral Blood Stem Cells) 309 Leslie A. Andritsos, Candace Paprocki, and Andrew M. Yeager 28. Applications and Outcomes of Autologous and Allogeneic Hematopoietic Stem-Cell Transplantation 319 Gregory Gerstner, Jennifer Christian, and Andrew M. Yeager 29. Umbilical-Cord Blood-Cell Transplantation 329 Michael L. Graham, Martin Andreansky, and Andrew M. Yeager Part IX: Special Topics in Living-Donor Transplantation 30. Anesthesia for Living-Donor Transplantation 341 Raymond M. Planinsic 31. Management of Infections in Living-Donor Transplant Recipients 363 Fernanda P. Silveira and David L. Paterson 32. Pregnancy After Living-Donor Transplantation 379 Vincent T. Armenti, Michael J. Moritz, and John M. Davison 33. Financial Impact of Living-Donor Organ Transplantation 395 Liise K. Kayler, Abigail E. Martin, and Henkie P. Tan 34. Transplantation Tolerance 405 Fadi G. Lakkis 35. Ethics of Paid Living-Unrelated Donation: The Case for a Regulated System of Kidney Sales 417 Arthur J. Matas 36. Do No Harm: The Case Against Organ Sales from Living Persons 431 Arthur L. Caplan Part X: Sample Consent Forms to Living Kidney and Liver Donation 37. Consent to Living Kidney Donation 435 Henkie P. Tan, Amadeo Marcos, and Ron Shapiro 38. Consent to Living Partial-Liver Donation 441 Henkie P. Tan, Ron Shapiro, and Amadeo Marcos Index …. 449

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