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الجامعة السورية الخاصة كلية الطب البشري قسم الجراحة

الجامعة السورية الخاصة كلية الطب البشري قسم الجراحة. Principle of Transplantation M.A.Kubtan , MD - FRCS. LEARNING OBJECTIVES. The main indications for organ transplantation The surgical principles of organ implantation The causes of graft dysfunction

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الجامعة السورية الخاصة كلية الطب البشري قسم الجراحة

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  1. الجامعة السورية الخاصةكلية الطب البشريقسم الجراحة Principle of Transplantation M.A.Kubtan , MD - FRCS M.A.Kubtan

  2. LEARNING OBJECTIVES • The main indications for organ transplantation • The surgical principles of organ implantation • The causes of graft dysfunction • The likely outcomes after transplantation • The immunological basis of allograft rejection • The principles of immunosuppressive therapy • The side effects of non-specific immunosuppression • The major issues concerning organ donation M.A.Kubtan

  3. Definitions • Allograft: an organ or tissue transplanted from one individual to another • Xenograft: a graft performed between different species • Orthotopicgraft: a graft placed in its normal anatomical site • Heterotopic graft: a graft placed in a site different from that where the organ is normally located • Alloantigen: transplant antigen • Alloantibody: transplant antibody • HLA: human leucocyte antigen, the main trigger of graft rejection M.A.Kubtan

  4. GRAFT REJECTION ABO blood group antigens Permissible transplants are: • group O donor to group O, A, B or AB recipient; • group A donor to group A or AB recipient; • group B donor to group B or AB recipient; • group AB donor to group AB recipient. There is no need to take account of Rhesus antigen compatibility. M.A.Kubtan

  5. HLA antigens • Are the most common cause of graft rejection • Their physiological function is to act as antigen recognition units • Are highly polymorphic (amino acid sequence differs widely between individuals) • HLA-A, -B (class I) and -DR (class II) are the most important in organ transplantation • Anti-HLA antibodies may cause hyperacute rejection M.A.Kubtan

  6. Types of graft rejection Hyperacute • Immediate graft destruction due to ABO or pre-formed anti-HLA antibodies. • Characterisedby intravascular thrombosis Acute • Occurs during the first 6 months • T-cell dependent, characterised by mononuclear cell infiltration • Usually reversible Chronic • Occurs after the first 6 months • Most common cause of graft failure • Non-immune factors may contribute to pathogenesis • Characterisedby myo-intimal proliferation in graft arteries leading to ischaemia and fibrosis M.A.Kubtan

  7. Staging of transplantation in surgical practice • Urgent Transplantation . • Planned Transplantation . M.A.Kubtan

  8. Requirements • Recognized Transplantation Center . • Bank of Information . • Transplantation Team : • Immunologist . • Hematologist . • Transplant Surgeon : Gen/Vascular / special e experience . • Double operating theater . • Trained operating nursing staff . • Donor . • Recipient patient . • Postoperative care unit . • Post transplantation outpatients clinic . • IMMUNOSUPPRESSIVE THERAPY. M.A.Kubtan

  9. Overcoming the shortage of organs for transplantation • Maximizing heart-beating deceased donation • Use of marginal heart-beating deceased donors • Use of non-heart-beating donors • Use of split-liver transplantation • Increased living donor kidney (and liver) transplantation M.A.Kubtan

  10. Clinical testing for brainstem death • Absence of cranial nerve reflexes . • Absence of motor response . • Absence of spontaneous respiration . M.A.Kubtan

  11. Absence of cranial nerve reflexes Two physicians should be involved ( Neurosurgeon & Intensive care specialist ) . The treating physician should not be included . • Pupillary reflex • Corneal reflex • Pharyngeal (gag) and tracheal (cough) reflex • Oculovestibular (caloric) reflex M.A.Kubtan

  12. Absence of motor response • The absence of a motor response to painful stimuli applied to the head/face and the absence of a motor response within the cranial nerve distribution to adequate stimulation of any somatic area is an indicator of brainstem death • The presence of spinal reflexes does not preclude brainstem death . M.A.Kubtan

  13. Absence of spontaneous respiration • After pre-ventilation with 100% oxygen for at least 5 min, the patient is disconnected from the ventilator for 10 min to confirm absence of respiratory effort, during which time the arterial Pco2 level should be > 8 kPa (60 mmHg) to ensure adequate respiratory stimulation. • To prevent hypoxia during the apnoeic period, oxygen (6 l min-1) is delivered via an endotracheal catheter M.A.Kubtan

  14. Factors determining organ function after transplantation • Donor characteristics . • Procurement-related factors . • Recipient-related factors . M.A.Kubtan

  15. Donor characteristics • Extremes of age . • Presence of pre-existing disease in the transplanted organ . • Hemodynamic and metabolic instability . M.A.Kubtan

  16. Procurement-related factors • Warm ischemic time . • Type of preservation solution . • Cold ischemic time Recipient-related factors . M.A.Kubtan

  17. Recipient-related factors • Technical factors relating to implantation • Hemodynamic and metabolic stability • Immunological factors • Presence of drugs that impair transplant function M.A.Kubtan

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