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Ethical considerations in lung re-transplantation. 肺再移植的伦理考量
IF 1.8 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-12-01 Epub Date: 2024-08-06 DOI: 10.1097/MOT.0000000000001171
Lynette A Lester, Valerie P Huang, Sean C Wightman, Graeme M Rosenberg

Purpose of review: Patients undergoing re-transplantation constitute a growing proportion of annual lung transplants. It is necessary to consider ethical considerations of re-transplantation in parallel with clinical progress.

Recent findings: Most clinical data demonstrate patients undergoing re-transplantation have worse survival outcomes; however, there is limited discussion of the ethical principles surrounding re-transplantation. Ethical guidance in re-transplantation trails clinical advancement.

Summary: The four-box model offers a valuable framework for assessing the ethical considerations in re-transplantation. This includes an analysis of medical indications, patient preferences, quality-of-life and contextual factors to support the ethical use of scarce donor lungs.

审查目的:在每年的肺移植手术中,接受再移植的患者所占比例越来越大。在临床进展的同时,有必要考虑再移植的伦理因素:大多数临床数据表明,接受再移植的患者存活率较低;然而,围绕再移植伦理原则的讨论却很有限。摘要:四箱模型为评估再移植中的伦理因素提供了一个有价值的框架。这包括对医学适应症、患者偏好、生活质量和环境因素的分析,以支持对稀缺供肺的伦理使用。
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引用次数: 0
Ethics of abortion in transplantation. 移植手术中堕胎的伦理问题。
IF 1.8 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-12-01 Epub Date: 2024-08-13 DOI: 10.1097/MOT.0000000000001172
Hector C Ramos, Allison Hill

Purpose of review: The controversial medical procedure of abortion is the subject of this article. It argues that for transplant patients, including recipients, abortion is ethical.

Recent findings: In June 2022, the United States Supreme Court overturned the long-standing decision of Roe v. Wade. This decision has led to a socio-legal environment where obtaining an abortion is impossible for some patients. However, the moral position relating to patients who have undergone transplants or are on a waiting list has been largely overlooked. End-stage renal, liver, and heart disease presents a hazardous situation for pregnancy, posing risks to both the fetus and the pregnant person. The abortion procedure is medically safer and allows a patient to proceed with a transplant. Limiting access to abortion or preventing it altogether will have a significant negative impact on transplant patients. The ethical analysis of abortion can be likened to compelling a relative or loved one of a transplant recipient to donate an organ to their family member or loved one.

Summary: This article emphasizes the importance of maintaining the legal availability of abortion for transplant patients. Allowing abortions in transplant patients upholds ethical parity, as seen in the analogous situation of live organ donation.

审查目的:本文的主题是备受争议的人工流产医疗程序。文章认为,对于移植患者(包括受者)而言,堕胎是合乎道德的:2022 年 6 月,美国最高法院推翻了罗伊诉韦德案的长期裁决。这一判决导致社会法律环境中一些患者无法进行人工流产。然而,与已接受移植手术或正在等待移植的患者有关的道德立场却在很大程度上被忽视了。终末期肾病、肝病和心脏病给怀孕带来危险,对胎儿和孕妇都有风险。人工流产手术在医学上更为安全,患者可以继续进行移植手术。限制人工流产或完全禁止人工流产将对移植患者产生严重的负面影响。对堕胎的伦理分析可以比作强迫移植受者的亲属或爱人向其家人或爱人捐献器官。摘要:本文强调了维持移植患者合法堕胎的重要性。正如活体器官捐献的类比情况一样,允许移植患者堕胎维护了伦理平等。
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引用次数: 0
Update on the immunological mechanisms of primary graft dysfunction and chronic lung allograft dysfunction. 原发性移植物功能障碍和慢性肺异体移植功能障碍的最新免疫学机制。
IF 1.8 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-12-01 Epub Date: 2024-10-16 DOI: 10.1097/MOT.0000000000001175
Jong Cheol Jeong, Andrew E Gelman, Anita S Chong

Purpose of review: Primary graft dysfunction (PGD) and chronic lung allograft dysfunction (CLAD) are the leading causes of graft loss in lung transplant recipients. The development of mouse lung transplant models has allowed for the genetic dissection of cellular and molecular pathways that prevent graft survival. This review provides an overview into recent mechanistic insights into PGD and CLAD.

Recent findings: Mouse orthotopic lung transplant models and investigations of human lung transplant recipeints have revealed new molecular and cellular targets that promote PGD and CLAD. Donor and recipient-derived innate immune cells promote PGD and CLAD. PGD is driven by communication between classical monocytes and tissue-resident nonclassical monocytes activating alveolar macrophages to release chemokines that recruit neutrophils. Products of cell damage trigger neutrophil NET release, which together with NK cells, antibodies and complement, that further promote PGD. The development of CLAD involves circuits that activate B cells, CD8 + T cells, classical monocytes, and eosinophils.

Summary: Effective targeted management of PGD and CLAD in lung transplant recipient to improve their long-term outcome remains a critical unmet need. Current mechanistic studies and therapeutic studies in mouse models and humans identify new possibilities for prevention and treatment.

审查目的:原发性移植物功能障碍(PGD)和慢性肺移植功能障碍(CLAD)是肺移植受者移植物丧失的主要原因。小鼠肺移植模型的开发使人们能够从遗传学角度剖析阻碍移植物存活的细胞和分子途径。本综述概述了最近对PGD和CLAD的机理认识:小鼠正位肺移植模型和人类肺移植配方的研究揭示了促进 PGD 和 CLAD 的新分子和细胞靶点。供体和受体衍生的先天性免疫细胞促进了PGD和CLAD。PGD是由经典单核细胞和组织驻留的非经典单核细胞之间的交流驱动的,这些单核细胞激活肺泡巨噬细胞释放趋化因子,从而招募中性粒细胞。细胞损伤产物触发中性粒细胞 NET 释放,NET 与 NK 细胞、抗体和补体一起进一步促进 PGD。CLAD的发展涉及激活B细胞、CD8+ T细胞、经典单核细胞和嗜酸性粒细胞的回路。摘要:对肺移植受者的PGD和CLAD进行有效的靶向治疗,以改善其长期预后,仍是一项尚未满足的关键需求。目前在小鼠模型和人体中进行的机理研究和治疗研究为预防和治疗提供了新的可能性。
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引用次数: 0
Interdisciplinary crosstalk for enduring and future challenges in lung transplantation. 跨学科协作,应对肺移植领域的持久挑战和未来挑战。
IF 1.8 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-12-01 Epub Date: 2024-11-07 DOI: 10.1097/MOT.0000000000001182
Norihisa Shigemura
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引用次数: 0
Establishing an upper extremity transplantation program: lessons learnt over 12 years. 建立上肢移植项目:12 年来的经验教训。
IF 1.8 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-12-01 Epub Date: 2024-10-04 DOI: 10.1097/MOT.0000000000001181
Kevin J Zuo, Alessandra Zaccardelli, Simon G Talbot

Purpose of review: As one of the early hand transplant programs in the world, we are often asked to educate other programs on the lessons we have learned and on how to set up a successful hand transplantation program.

Recent findings: Two decades of global experience with vascularized composite allotransplantation (VCA) of the upper limb have demonstrated improved functional outcomes and quality of life for carefully screened patients. Despite initial reticence about VCA, over 30 patients in the USA have benefited from hand transplantation, with around 80% long-term successes. We have experience with four bilateral upper extremity patients who have undergone bilateral upper extremity allotransplants. This review article highlights our personal experience and lessons with respect to VCA team assembly, logistics, patient selection, perioperative planning, the operative procedure, and postoperative management.

Summary: Continual learning and critical evaluation are crucial to maintaining a successful upper extremity VCA program. This will ensure that patients who stand to benefit most from this life-enhancing procedure are identified and are others optimized to achieve the best possible outcomes.

回顾的目的:作为世界上早期的手移植项目之一,我们经常被要求向其他项目介绍我们的经验教训以及如何建立一个成功的手移植项目:上肢血管化复合体异体移植(VCA)二十年的全球经验表明,经过仔细筛选的患者的功能效果和生活质量都得到了改善。尽管最初人们对血管化复合肢体移植持保留态度,但美国已有30多名患者从手部移植中受益,其中约80%的患者获得了长期成功。我们有四位接受过双侧上肢同种异体移植手术的患者。这篇综述文章重点介绍了我们在上肢同种异体移植团队组建、后勤、患者选择、围手术期计划、手术过程和术后管理等方面的个人经验和教训。摘要:持续学习和严格评估对于保持上肢同种异体移植项目的成功至关重要。总结:持续学习和批判性评估对维持成功的上肢动静脉联合术至关重要,这将确保能从这一改善生命的手术中获益最多的患者被识别出来,并对其他患者进行优化,以获得尽可能好的治疗效果。
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引用次数: 0
Grasping time - longevity of vascularized composite allografts. 抓取时间--血管化复合异体移植物的寿命。
IF 1.8 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-12-01 Epub Date: 2024-10-23 DOI: 10.1097/MOT.0000000000001177
Franka Messner, Claudia Sardu, Palmina Petruzzo

Purpose of review: Despite significant advancements in the field of vascularized composite allotransplantation, challenges, particularly regarding the long-term viability and functionality of vascularized composite allotransplantation (VCA) grafts, persist. This paper provides a review of the current literature on the longevity of VCA grafts, focusing on factors influencing graft survival, immunological considerations and clinical outcomes.

Recent findings: Longevity of VCA grafts is influenced by a variety of peri- and postoperative factors including cold ischemia time, human leukocyte antigen matching, environmental exposure, psychosocial factors, adherence, immunosuppression, and complications. Due to the limited number of VCA transplants performed and heterogenous reporting, direct correlation of single factors with VCA outcomes remains inconclusive. Indirect evidence, however, supports their importance. High immunosuppressive burden, frequent occurrence of acute and accumulating cases of chronic rejection remain a significant challenge of the field.

Summary: Insights gained from this review aim to inform clinical practice and guide future research endeavors with the goal of ameliorating outcomes after VCA transplantation and facilitate wider use of VCA grafts for restoration of tissue defects.

综述的目的:尽管血管化复合异体移植领域取得了重大进展,但挑战依然存在,尤其是血管化复合异体移植(VCA)移植物的长期存活率和功能。本文综述了目前有关血管化复合异体移植移植物寿命的文献,重点关注影响移植物存活的因素、免疫学考虑因素和临床结果:VCA移植物的寿命受多种围手术期和术后因素的影响,包括冷缺血时间、人类白细胞抗原匹配、环境暴露、社会心理因素、依从性、免疫抑制和并发症。由于进行的 VCA 移植数量有限,且报告内容不一,单一因素与 VCA 结果的直接相关性仍无定论。不过,间接证据证明了这些因素的重要性。高免疫抑制负担、频繁发生的急性和累积性慢性排斥反应病例仍是该领域面临的重大挑战。总结:本综述旨在为临床实践提供参考,并指导未来的研究工作,以改善 VCA 移植后的预后,促进 VCA 移植物在修复组织缺损方面的广泛应用。
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引用次数: 0
Tracheal transplantation: lessons learned that may apply to lung transplantation. 气管移植:可用于肺移植的经验教训。
IF 1.8 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-12-01 Epub Date: 2024-10-09 DOI: 10.1097/MOT.0000000000001180
Eric M Genden, Ya-Wen Chen

Purpose of review: The purpose of this review is to explore the lessons learned from experimental and human tracheal transplantation to determine if this information may be applied to lung transplantation.

Recent findings: Experimental work in animal models and the recent human tracheal transplantation suggests that a robust tracheal vascular supply prevents anastomotic complications. Further, this work demonstrates that tracheal allografts undergo a progressive chimerism as recipient epithelium repopulates the allograft. In contrast to most vascularized composite allografts such as hand and face transplantation that experience high rates of rejection, the tracheal allograft did not demonstrate rejection. This may suggest that tissue chimerism plays a role in evading immune-mediated allograft rejection.

Summary: While anastomotic complications and chronic allograft rejection are the most common complications related to lung transplantation, the findings associated with tracheal transplantation may have implications for both reducing complications associated with lung transplantation.

综述目的:本综述旨在探讨从实验和人体气管移植中吸取的经验教训,以确定这些信息是否可应用于肺移植:动物模型的实验工作和最近的人体气管移植表明,强大的气管血管供应可预防吻合并发症。此外,这项工作还表明,随着受体上皮细胞重新填充异体移植物,气管异体移植物会逐渐发生嵌合。与大多数血管化复合异体移植物(如手部和面部移植)的高排斥率不同,气管异体移植物没有出现排斥反应。小结:吻合口并发症和慢性异体移植排斥反应是肺移植最常见的并发症,而气管移植的相关研究结果可能对减少肺移植并发症有一定意义。
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引用次数: 0
The current state of tolerance induction in vascularized composite allotransplantation. 血管化复合异体移植的耐受诱导现状。
IF 1.8 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-12-01 Epub Date: 2024-09-20 DOI: 10.1097/MOT.0000000000001176
Caitlin M Blades, Christene A Huang, David W Mathes

Purpose of review: Significant advancements have been made in the field of vascularized composite allotransplantation (VCA); however, like solid organ transplantation, bypassing the recipient's immune response remains a significant obstacle to long-term allograft survival. Therefore, strategies to overcome acute and chronic rejection and minimize immunosuppressive therapy are crucial for the future of VCA. This review highlights recent attempts to induce tolerance in VCA and discusses key findings through a clinical lens.

Recent findings: Promising VCA tolerance protocols are being investigated, with five recent studies illustrating various successes. These preclinical approaches demonstrate a correlation between the presence of donor-derived T cells and VCA tolerance, the importance of using clinically available reagents within preclinical protocols, and the ability to induce sustained tolerance through nonmyeloablative methods. Furthermore, environmental factors, such as NB-UVB light are being investigated for their immunomodulation properties and may influence VCA graft rejection.

Summary: To widen the scope of VCA, minimization of immunosuppression is needed. Overall, tolerance induction protocols should have a low-toxicity level, minimally invasive induction therapies, and utilize short-term immunosuppressive medications. By examining the milestones of recent studies, researchers can gain new technical approaches to immune modulation and make data-driven amendments to tolerance protocols in preparation for clinical translation.

综述目的:血管化复合异体移植(VCA)领域取得了重大进展;然而,与实体器官移植一样,绕过受体的免疫反应仍然是异体移植长期存活的重大障碍。因此,克服急性和慢性排斥反应并尽量减少免疫抑制治疗的策略对 VCA 的未来至关重要。本综述重点介绍了最近在诱导 VCA 耐受方面所做的尝试,并从临床角度讨论了主要发现:目前正在研究前景看好的 VCA 耐受方案,最近的五项研究表明取得了各种成功。这些临床前方法证明了供体源性 T 细胞的存在与 VCA 耐受之间的相关性、在临床前方案中使用临床可用试剂的重要性,以及通过非髓鞘消融方法诱导持续耐受的能力。此外,目前正在研究环境因素(如 NB-UVB 光)的免疫调节特性,这些因素可能会影响 VCA 移植排斥反应。总体而言,耐受诱导方案应具有低毒性、微创诱导疗法和使用短期免疫抑制药物。通过研究近期研究的里程碑,研究人员可以获得新的免疫调节技术方法,并根据数据对耐受方案进行修正,为临床转化做好准备。
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引用次数: 0
Vascular changes in vascularized composite allotransplantation. 血管化复合异体移植中的血管变化。
IF 1.8 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-12-01 Epub Date: 2024-11-01 DOI: 10.1097/MOT.0000000000001184
Ethan Y Song, Brooke E Barrow, Linda C Cendales

Purpose of review: Allograft vasculopathy in vascularized composite allografts (VCA) remains understudied. This review explores the vascular changes in VCA, focused on recent literature.

Recent findings: Allograft vasculopathy in VCA generally includes progressive concentric myointimal thickening and luminal narrowing of arterial vessels through endothelial deterioration and proliferation of smooth muscle cells. Microvascular changes are also noted, with thrombosis and lumen narrowing in microvessels of the skin even in the absence of large vessel vasculopathy. Histopathologic reports of skin containing VCA rejection document arteriosclerosis in deep vessels that are not always reflected in skin punch biopsies. The first revision of the Banff VCA scoring system 2022 was developed to include vascular changes in VCA. The scoring system for chronic changes and antibody mediated rejection continues to be under development.

Summary: The study of vascular changes in VCA continues to progress. Important data and advances in experimental and clinical VCA have been reported and continue to take place. Challenges ahead include capture of clinical data that will evolve beyond transient report forms and approaching on the problem of graft failure well grounded in sound scientific methodology.

审查目的:血管化复合异体移植物(VCA)的血管病变仍未得到充分研究。这篇综述探讨了 VCA 的血管变化,重点关注最新文献:VCA中的同种异体移植血管病变通常包括通过内皮退化和平滑肌细胞增殖导致的动脉血管同心肌膜增厚和管腔狭窄。微血管也会发生变化,即使没有大血管病变,皮肤微血管也会出现血栓形成和管腔狭窄。含有 VCA 排斥反应的皮肤组织病理学报告显示,深层血管的动脉硬化并不总是能在皮肤打孔活检中反映出来。班夫 VCA 评分系统 2022 的首次修订版将 VCA 的血管变化纳入其中。慢性变化和抗体介导的排斥反应的评分系统仍在开发中。VCA 实验和临床方面的重要数据和进展已被报道,并将继续进行。未来的挑战包括获取临床数据,使其超越短暂的报告形式,并以健全的科学方法论为基础,解决移植失败的问题。
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引用次数: 0
Collaborative care models in adult congenital heart disease transplant. 成人先天性心脏病移植中的协作护理模式。
IF 1.8 4区 医学 Q3 TRANSPLANTATION Pub Date : 2024-12-01 Epub Date: 2024-09-16 DOI: 10.1097/MOT.0000000000001173
Katherine Kearney, Michael McDonald, Lucy Roche

Purpose of review: While multidisciplinary collaboration is a tenant of quality heart failure care and critical to the success of transplant programs, this essay challenges the temptation to shoehorn adult congenital heart disease (ACHD) patients into preexisting processes and paradigms. We explore the development of more relevant models, purposefully designed to improve ACHD transplant volumes and outcomes.

Recent findings: Globally, the rapid acceleration of ACHD patients living with and dying from HF stands in stark contrast to their access to transplant. Inferior early outcomes after ACHD transplant remain an undeniable barrier. And yet while all large registry datasets attest to this statistic, a few centers have achieved results comparable to those in acquired heart disease. This despite increases in both ACHD candidate complexity and referrals for Fontan Circulatory Failure. Perhaps something in their approach to care delivery is key?.

Summary: Alone, neither ACHD nor transplant programs can provide optimal management of HF in ACHD. A siloed approach is similarly inadequate. Building new ACHD-HF-Transplant teams, centered on the patient and supplemented by ad hoc expert partnerships, is an exciting approach that can improve outcomes, create a high-quality training environment, and in our experience, is a truly rewarding way of working together.

综述目的:多学科协作是优质心力衰竭护理的基石,也是移植项目取得成功的关键,但本文对将成人先天性心脏病(ACHD)患者塞入现有流程和模式的诱惑提出了质疑。我们探讨了更多相关模式的发展,这些模式旨在提高成人先天性心脏病移植的数量和效果:在全球范围内,因心房颤动而存活和死亡的 ACHD 患者人数急剧增加,这与他们获得移植的机会形成了鲜明对比。ACHD 移植后早期疗效不佳仍是一个不可否认的障碍。然而,尽管所有大型登记数据集都证明了这一统计数字,但只有少数中心取得了与获得性心脏病相当的结果。尽管ACHD候选者的复杂性和Fontan循环衰竭的转诊量都在增加,但情况依然如此。小结:单靠ACHD或移植项目都无法对ACHD患者的高血压进行最佳管理。各自为政的方法同样是不够的。建立新的 ACHD-HF- 移植团队,以患者为中心,辅以特别的专家合作关系,是一种令人兴奋的方法,可以改善治疗效果,创造高质量的培训环境,而且根据我们的经验,这是一种真正有益的合作方式。
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引用次数: 0
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Current Opinion in Organ Transplantation
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