Chapter 56
- Organ Transplantation
- James Baker
- C. Spencer Yost
- Claus U. Niemann
The improvement in the success of solid organ transplantation
over the past decades is remarkable and well documented. It is now a well-accepted
treatment modality for patients with end-stage organ disease. Refinement of perioperative
care and improved post-transplant patient management over recent years have resulted
in a dramatic improvement in both 1- and 5-year graft survival. These changes have
led to a significant increase in the number of medical centers performing solid organ
transplantation and, hence, increased public awareness. In addition, the indications
for solid organ transplantation have been broadened. Some perceived contraindications
such as concomitant human immunodeficiency virus (HIV) infection and excessive age
are being abandoned in selected cases.[1]
[2]
Similarly, patients receiving methadone maintenance therapy are considered for transplantation.
[3]
[4]
In the
United
States, the number of patients wait-listed for solid organ transplantation increased
by 8.7% between 2000 and 2001, yet the number of organs transplanted in the same
period increased by only 4.7%.[5]
[6]
The organs most frequently transplanted are the kidney and liver, which accounted
for 59% and 21% of all transplanted organs, respectively, in 2001. On the other
hand, only 54% of all donated cadaveric organs were actually recovered in 2001.
This fact, in conjunction with public perception about organ donation and brain death
and limited awareness of health care professionals, has contributed to a severe shortage
of cadaveric donor organs. Different strategies have been adopted to increase the
donor pool, including extension of donor criteria and the use of living donors, particularly
for kidney and liver transplantation.[7]
[8]
However, it is unlikely that these attempts alone will ameliorate the shortage in
the long run.
The success of organ transplantation is based on a highly specialized
team approach, including the cooperation of procurement organizations, transplant
coordinators, nurses, and physicians from many specialties. With the
exception of kidney transplantation, most solid organ transplantations are performed
at tertiary medical centers, which can provide all the needed medical, logistic,
and technical expertise necessary to support a successful transplant program. Increasingly,
medical subspecialties are providing physicians dedicated to the field of transplantation.
In addition to transplant surgeons, most major centers rely on dedicated transplant
hepatologists, nephrologists, pulmonologists, and cardiologists. With regard to
anesthesia providers, transplant specialization is not generally the rule. Anesthesia
for kidney and pancreas transplantation is performed by most anesthesiologists.
A cardiac anesthesia team generally performs heart and lung transplantation. Most
major centers have a dedicated liver transplant anesthesia team. However, smaller
centers may not have enough transplant volume or personnel to staff a separate liver
transplant anesthesia team. As a result, anesthesiologists who have experience in
major hepatic surgery or cardiothoracic surgery are frequently called on to provide
anesthesia for these complex and challenging cases.
In this chapter we will review anesthetic considerations for kidney,
liver, pancreas, heart, lung, and intestinal transplantation in adult recipients.
Solid organ transplantation in the pediatric population is not addressed in this
chapter, and it is recommended that Chapter
60
in this edition be consulted for an introduction to pediatric anesthesia.
Furthermore, pediatric solid organ transplantation is discussed in detail in the
textbook Pediatric Anesthesia.[9]
