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Solid Organ Transplantation

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Last updated: 5th Sep 2023
Published:9th Mar 2023

Solid organ transplantation (SOT) is now an established and practical definitive treatment option for patients with end-organ dysfunction. SOT has progressed rapidly in recent decades to incorporate a variety of solid organs within the donor pool - kidney, liver, heart, lung, pancreas. Attempts at human heart transplant date back to 1905 with the first success in 1967.

The World Health Organization (WHO) and the Global Observatory on Donation and Transplantation (GODT) estimate that 139,000 transplants take place each year globally, with kidneys and livers the more frequent therapeutic options (65% and 23% respectively). Organ Transplant activities although impressive, barely cover 10% of the global needs. Several factors such a blood typing, tissue typing and cross matching are essential when identifying a suitable donor.

Kidney transplantation is the primary therapy for end-stage renal disease (ESRD; stage 5 chronic kidney disease). The first successful human kidney transplant was performed in 1954. The most common primary causes of ESRD in renal transplant recipients are diabetes, hypertension and glomerulonephritis. Black, Asian and minority ethnic (BAME) communities are five times more likely to develop Chronic Kidney Disease (CKD). Acute kidney injury (AKI) often occurs as a complication of another serious illness. Haemodialysis is the most common treatment choice for dialysis. Mental health is also an important consideration as up to one in three patients with kidney disease will experience depression at some point.

Liver transplantation is the treatment of choice for patients with acute and chronic end-stage liver disease including acute liver failure, decompensated cirrhosis and hepatocellular carcinoma (HCC). Typical presenting clinical features for cirrhosis include jaundice, ascites, hepatic encephalopathy, hepato-renal syndrome, variceal haemorrhage and can be caused by infections, gastrointestinal bleeding, high alcohol intake or drug-induced liver injury. Common diseases that may lead to liver transplantation include primary sclerosing cholangitis, acute hepatic necrosis, cirrhosis, metabolic diseases, portal hypertension, hepatitis (viral, autoimmune and idiopathic), liver tumors and biliary atresia.

Cardiac transplantation is the primary therapy for patients with end-stage heart failure, who remain symptomatic despite optimal medical therapy. For carefully selected patients, heart transplantation offers markedly improved survival and quality of life. The most common indications for adult heart transplantation are cardiomyopathy, coronary heart disease and congenital heart disease.

Lung transplantation is an established treatment for patients with end-stage pulmonary disease from multiple causes. Common primary indications include chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), cystic fibrosis and α1-anti-trypsin deficiency. Lung transplantation is associated with significant mortality and morbidity, and long-term survival is much lower than generally observed for patients receiving kidney, liver or heart transplants.

Pancreas transplantation is the provision or restoration of beta cell function to a diabetic patient. The first successful human pancreatic transplant was performed in 1966 and now single-organ pancreas transplant, or combined pancreas and kidney transplantation, is a common procedure.

While transplantation is limited by the supply of organs, there have been marked improvements in acute rejection rates and graft survival. Graft-versus-host disease (GvHD) is a rare, but often lethal, complication after SOT. The most common type of GvHD is antibody mediated, the second form of SOT-GvHD is cellular. Clinically, immunosuppression takes place in three stages: induction or short-term post-transplant treatment, long-term maintenance, and anti-rejection treatment for acute rejection episodes, with different drugs often called on for each phase.

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