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Conventional renal function markers are unable to measure renal allograft perfusion intraoperatively, leading to delayed recognition of initial allograft function. A handheld near-infrared spectroscopy (NIRS) device that can provide real-time assessment of renal allograft perfusion by quantifying regional tissue oxygen saturation levels (rSO2) was approved by the FDA. This pilot study evaluated the feasibility of intraoperative NIRS monitoring of allograft reperfusion in renal transplant recipients (RTR). Intraoperative renal allograft rSO2 and perfusion rates were measured in living (LDRT, n = 3) and deceased donor RTR (DDRT, n = 4) during the first 50 min post-reperfusion and correlated with renal function markers 30 days post-transplantation. Intraoperative renal allograft rSO2 for the DDRT group remained significantly lower than the LDRT group throughout the 50 min. Reperfusion rates were significantly faster in the LDRT group during the first 5 min post-reperfusion but remained stable thereafter in both groups. Intraoperative rSO2 were similar among the upper pole, renal hilum, and lower pole, and strongly correlated with allograft function and hemodynamic parameters up to 14 days post-transplantation. NIRS successfully detected differences in intraoperative renal allograft rSO2, warranting future studies to evaluate it as an objective method to measure ischemic injury and perfusion for the optimization of preservation/reperfusion protocols and early prediction of allograft function.

Purpose: Previous studies have shown that opportunities to diagnose chronic obstructive pulmonary disease (COPD) early are often missed in primary care. This retrospective study aimed to utilize secondary data from the United Kingdom (UK) healthcare system to understand the impact of early versus late diagnosis of COPD. Patients and Methods: Newly diagnosed COPD patients were identified in the UK Clinical Practice Research Database from 2011 to 2014. Patients whose 5-year medical data before diagnosis revealed [greater than or equal to]3 counts of eight indicators of early COPD were deemed as late-diagnosed, whereas others were deemed as early-diagnosed. We assessed patients' characteristics; time-to-first, risk, and rates of exacerbation; and healthcare resource utilization (COPD-related clinic visits, Accident and Emergency visits, and hospitalizations) in late- versus early-diagnosed patients. Results: Of 10,158 patients included in the study, 6783 (67%) were identified as late-diagnosed and 3375 (33%) as early-diagnosed. The median time-to-first exacerbation was shorter in late-diagnosed (14.5 months) versus early-diagnosed (29.0 months) patients, with a significant risk of exacerbation (hazard ratio 1.46 [95% confidence interval: 1.38-1.55]). Additionally, the exacerbation rate (per 100 person-years) over 3 years was higher in late (108.9) versus early (57.2) diagnosed patients. Late-diagnosed patients had a significantly higher rate of COPD hospitalizations (per 1000 patient years) compared with early-diagnosed patients during 2 and 3 years of follow-ups (P = 0.0165 and P < 0.0001, respectively). Conclusion: Results showed that a significant percentage of COPD patients in UK primary care are diagnosed late. A late COPD diagnosis is associated with a shorter time-to-first exacerbation and a higher rate and risk of exacerbations compared with early diagnosis. Additionally, late diagnosis of COPD is associated with a higher rate of COPD-related hospitalizations compared with early diagnosis. Keywords: chronic obstructive pulmonary disease, COPD, clinical practice research datalink, UK-CPRD, early diagnosis of COPD, late diagnosis of COPD, healthcare utilization

Technical aspects of the operation play an integral role in the success of kidney transplantation today. Similarly, advances in imaging techniques, along with developments in percutaneous and other minimally invasive techniques, have resulted in improved diagnosis and therapy for associated technical complications. In this chapter the operative procedure is reviewed, including preoperative considerations and components of the operation itself, such as back‐table preparation of the organ, incision and exposure, revascularization, urinary reconstruction, and closure. Evaluation and diagnosis of technical problems potentially affecting graft and patient outcome following kidney transplantation and therapeutic options to manage these complications are subsequently discussed.

Transplantation is one of the most visible and influential medical accomplishments of the twentieth century. Arising from technical advances occurring at the turn of the twentieth century and the mid‐century scientific observations of a small number of visionary investigators, the clinical practice of transplantation rapidly became interwoven into the fabric of clinical care, not only from a practical standpoint, but also as an example of the immense possibilities, and challenges, of advanced medical practice. The history of transplantation has been the subject of numerous books, and while its in‐depth treatment is not practical in this text, it is important to make evident the major contributions that brought the field to where it stands currently: a prime example of the power of science and medicine combined for a common good. This chapter will provide the reader with a reasonable orientation to the history of the field, and serve as an important introduction to the subject of organ transplantation in general.

The Lower and Shumway biatrial technique has been the gold standard for orthotopic heart transplantation for many years. However, anastomoses of donor and recipient atria using this technique created large atrial cavities with abnormal geometry. The loss of atrial anatomy led to post‐transplant complications such as mitral and tricuspid regurgitation, atrial septal aneurysm, atrial thrombus formation, and tachyarrhythmia. In attempts to preserve the right atrium, the bicaval implantation technique was developed. It preserves atrial contractility, sinus node function, and atrioventricular valve competence. While the most significant overall advance in heart transplantation since 1967 has been the advent of effective immunosuppression, the most notable evolution in the technique of heart transplantation has been the switch from biatrial to bicaval anastomoses of the vena cavae. Here we review the technical details of orthotopic heart transplantation and some special cases of heart transplantation.

Transplant recipients exhibit increased morbidity and mortality as a consequence of chronic exposure to immunosuppressive agents. The search for tools to tailor immunosuppressive therapy to the individual needs of transplant recipients is therefore an ongoing clinical and research priority in transplantation. Recent advances in cellular and molecular analytic technologies have allowed the identification of many biomarkers with potential relevance to applied immunology and transplantation. The development of these markers holds promise to improve patient care by facilitating personalized medicine in transplantation. Despite these burgeoning advances, existing means for monitoring of immunosuppressive therapies in the clinic continues to be almost exclusively based on pharmacokinetic markers, with little attention toward the individual pharmacodynamic effects of the drugs under study. A substantial effort by the transplant community in the form of adequately powered validation clinical trials is therefore still needed before biomarker‐based diagnostics becomes a reality in clinical organ transplantation.

Liver transplantation is a technically demanding procedure that leaves little room for error. The surgical techniques of liver transplantation have evolved dramatically over the past 30 years, with striking improvements in outcomes. These improvements have resulted from standardization of operative techniques and postoperative management, including clear communication between surgeons, anesthesiologists, and ancillary teams, as well as advances in anesthesia and critical care. Although liver transplantation is a long and complex surgical procedure, it nevertheless comprises a series of discrete steps that are detailed herein, each requiring satisfactory completion to assure a favorable outcome for the patient.

Non‐adherence remains a critical barrier to long‐term successful transplantation, particularly in childhood. Non‐adherence is most prevalent in the adolescent population. Research in this area is now identifying barriers to achieving adherence and clinical trials of interventions to improve adherence are underway. Unfortunately, non‐adherence remains a major cause of late graft loss and patient death. This chapter provides a comprehensive overview of non‐adherence and its consequences in the pediatric and young adult population of solid organ recipients.

The technique for intestinal transplantation has been increasingly refined and standardized over the past two decades. Intestinal transplantation can be performed through either a midline or bilateral subcostal incision. Successful implantation of the allograft requires proper positioning and judgment of the length of vascular structures. Mesenteric arterial and venous reconstruction is best performed in the setting of patients for whom the native bowel is removed at transplantation. This is usually encountered in patients suffering from motility disorders of the small bowel or enterocyte dysfunction. For short bowel syndrome patients, removal of diseased bowel and systemic vascular anastomosis is more commonly employed. The graft relies on infrarenal aortic inflow and outflow through the vena cava. Colonic transplantation including the small bowel requires proximal diverting ileostomy and a distal anastomosis. Rarely, a diseased foregut must be removed, requiring modified multivisceral transplantation. The proper surgical approaches to each of these procedures are detailed, and pitfalls and unique circumstances are explained.

De novo malignancies are a significant and well‐established major adverse consequence of chronic immunosuppression. Their occurrence tempers to some extent the success achieved in the last decades in terms of improvement of short‐term allograft and patient survival. This chapter covers the factors contributing to the development of post‐transplant malignancy. Besides the direct effects of chronic immunosuppression, numerous additional key risk factors contribute to post‐transplant cancer development. Characterization of these factors informs the main oncogenic and anti‐tumor immune mechanisms influencing the clinical risk, and might allow the development of primary preventive and early tumor detection strategies, and improve therapeutic intervention.