organ donation and transplantation

ORGAN DONATION AND TRANSPLANTATION

Medical Research in Biblical Times from the Viewpoint of Contemporary Perspective Liubov Ben-Nun

Ben-Gurion University of the Negev Liubov Ben-Nun Professor Emeritus Faculty of Health Sciences, Dept. of Family Medicine Beer-Sheva, Israel

From trephination to modern surgical procedures, transplantation is an exciting technology that has evolved over centuries and is one of the most remarkable and dramatic therapeutic advances in the modern medicine. This study provides an insight into various aspects of organ donation and transplantation, evaluating these issues from a contemporary perspective. The topic is fascinating and like a mirror represents our remote past. The present book widens the horizons of our knowledge and can help us to understand many problems associated with organ donation and transplantation.

NOT FOR SALE

2012

ORGAN DONATION AND TRANSPLANTATION Ben-Gurion University of the Negev Liubov Ben-Nun Professor Emeritus

Faculty of Health Sciences, Dept. of Family Medicine Beer-Sheva, Israel

Published by: B.N. Publications House, Israel First Edition 2009 Second Edition 2010

Third Edition 2012 Fax: +(972) 8 6883376 Mobile 050 5971592 E-Mail: [email protected]

Graphics and Cover: Ilana Ben-Nun © All rights reserved

Distributed Worldwide NOT FOR SALE

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CONTENTS PREFACE TERMINOLOGY FOREWORD INTRODUCTION THE BIBLICAL DESCRIPTION SOME HISTORICAL ASPECTS EPIDEMIOLOGY TYPES OF TRANSPLANTATION HEART LUNG(S) KIDNEY LIVER PANCREAS INTESTINAL OSTEOCHONDRAL RECONSTRUCTION OF MUSCLES HEMATOPOIETIC STEM CELL SKIN HAIR CORNEAL FACE DENTAL ATTITUDES TOWARDS ORGAN DONATION CONSENT FOR ORGAN DONATION STRATEGIES TO INCREASE ORGAN DONATION TISSUE BANKING TRANSPLANT TOURISM SUMMARY

7 8 10 13 16 17 21 31 31 60 78 84 112 124 129 157 164 180 184 189 198 201 208 224 228 238 248 253

ABBREVIATIONS (1) AATB ACL ALD AOFAS ASTP ATRS ATS BCVA BMI CABG CAD CCU CDC CI CHUV CML CMV COPD DVT EEBA ELTR G-CSF GVHD ICU ICRS IKDC ISHLT HbA1c HBV HCC HCV HDV HLA hMADS HR HSCT HUG LVEF LVF MI MM MR MRI MP MV

American Association of Tissue Banks Anterior cruciate ligament Alcoholic liver disease The American Orthopedic Foot and Ankle Society American Society of Transplant Physicians Achilles tendon rupture score American Thoracic Society Best corrected visual acuity Body mass index Coronary artery bypass grafting Coronary heart disease Critical care unit Centers for Disease Control and Prevention Confidence interval Lausanne University Hospital Chronic myelogenous leukemia Cytomegalovirus Chronic obstructive pulmonary disease Deep vein thrombosis European Eye Bank Association European Liver Transplant Registry Granulocyte colony-stimulating factor Graft versus host disease Intensive care unit International Cartilage Repair Society International Knee Documentation Committee International Registry for Thoracic Organ Transplantation Hemoglobin A(1c) Hepatitis B virus Hepatocellular carcinoma Hepatitis C virus Hepatitis delta virus Human lymphocyte antigen Human multipotent adipose–derived stem Hazard ratio Hematopoietic stem cell transplantation University Hospital of Geneva Left ventricular ejection fraction Left ventricular function Myocardial infarction Multiple myeloma Mitral regurgitation Magnetic resonance imaging Metacarpophalangeal Mitral valve

ABBREVIATIONS (2) MVR

Mitral valve regurgitation

NIH NYHA OAT OD OECD

National Institute of Health New York Heart Association Osteochondral autologous transplantation Odds ratio The Organization for Economic Co-operation and Development Organización Nacional de Trasplantes Organ Procurement and Transplantation Network Organ Procurement Organization Per million population Relative risk Type I diabetes mellitus Topography modeling system Uniform Anatomical Gift Act University of California, Los Angeles University of California San Francisco United Network for Organ Sharing World Health Organization

ONT OPNT OPO PMP RR T1DM TMS UAGA UCLA UCSF UNOS WHO

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PREFACE The purpose of this research is to analyze the medical situations and conditions referred to in the Bible, as we are dealing with a contemporary medical record. These are scientific medical studies incorporating verses from the Bible, without no interpretation or historical descriptions of places. Fundamentally, this Research is constructed purely from an examination of passages from the Bible, exactly as written. The research is part of a long series of published studies on the subject of biblical medicine from a modern medical perspective. This is not a laboratory research. The Research is built entirely on a secular foundation. With due to respects to people faith, this Research takes a modern look at medical practices. Each to his own beliefs.

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TERMINOLOGY Allogeneic – the donor is another individual, related or unrelated (1,2). Allograft - the transplant of an organ or tissue from one individual to another of the same species with a different genotype, but not an identical twin. Allograft accounts for many human transplants, including those from cadaveric, living related, and living unrelated donors. Called also a homograft (3). Autograft - tissue transplanted from one part of the body to another in the same individual. Also called an autotransplant (4). Autologous – refers to the self-donor (5). Bone marrow transplantation - intravenous infusion of autologous, syngeneic, or allogeneic bone marrow or stem cells (2). Donate – to give or allow the removal of blood, semen, organs, etc. for the medical treatment of others (6). Graft - a piece of healthy skin or bone, or a healthy organ, which is attached to a damaged part of a body by a medical operation in order to replace it (7). GVHD - a reaction of donor immune cells against host tissues, in which donor T cells attack the recipient resulting in multi-organ attack and morbidity, generally occurring after allogeneic HSCT (8,9). Heterotopic transplantation - transplantation of tissue typical of one area to a different recipient site (2). Homotopic transplantation - orthotopic transplantation of tissue from a donor into its normal anatomical position in the recipient (2). Homotransplant – tissue transplant between individuals of the same sex (6). Orthotopic - transplantation of a donor organ graft into the same site occupied by the original organ that failed (10). Split-liver transplantation - a surgical technique that creates 2 allografts from a single cadaver donor (11). Syngeneic – the donor is an identical twin (1).

9 Transplantation - a surgical operation in which a part of a person's body is replaced because it is diseased. When something is transplanted, it is moved to a different place (6). Xenotransplantation - the use of animals instead of humans as the source of organs and tissues for transplant (12). References 1. Kumar R. Stem cell transplantation: Indian perspective. JIACM. 2002; 3(2):182-8. 2. Dorland's Medical Dictionary for Health Consumers. Saunders, an Imprint of Elsevier, Inc. 2007. 3. Allograft definition. Medical Dictionary definitions. (Accessed 20 January 2012 at www.medterms.com/script/main/art.asp?articlekey=30941). 4. Autograft definition. Medical Dictionary definitions. (Accessed 22 January 2012 at www.medterms.com/script/main/ art.asp?articlekey=40486). 5. Type of Transplants. Medical Dictionary definitions. (Accessed 22 January 2012 at www.fhcrc.org/patient/treatment/choose/ trans_cent.html). 6. The Penguin English Dictionary. Ed. Robert Allen. Penguin Books. 2nd ed. London, New York, Australia. 2003. 7. Collins Cobuild. Essential English Dictionary. Collins, London, Glasgow. 1988. 8. Jacobsohn DA, Vogelsang GB. Acute graft versus host disease. Orphanet Journal of Rare Diseases. OJRD. 2007;2:35. 9. Blazar BR, Murphy WJ. Bone marrow transplantation and approaches to avoid graft-versus-host disease (GVHD). Philos Trans R Soc Lond B Biol Sci. 2005;360(1461):1747–7. 10. McGraw-Hill Concise Dictionary of Modern Medicine. The McGraw-Hill Companies, Inc. 2002. 11. Yersiz H, Renz JF, Farmer DG, et al. One hundred in situ split-liver transplantations: a single-center experience. Ann Surg. 2003;238(4):496-505; discussion 506-7. 12. Platt JL. New directions for organ transplantation. Nature. 1998;392(6679 Suppl):11-7.

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FOREWORD From trephination to modern surgical procedures, transplantation is an exciting technology that has evolved over centuries and is one of the most remarkable and dramatic therapeutic advances in medicine during the past years (1). This field has progressed initially from what can accurately be termed a "clinical experiment" to routine and reliable practice, which has proven to be clinically effective, life saving and cost-effective (2). The remarkable evolution stems from a serial confluence of cultural acceptance; legal and political evolution to facilitate organ donation, procurement and allocation; technical and cognitive advances in organ preservation, surgery, immunology, immunosuppression; and management of infectious diseases (3).

Trephination

Trephinated skull

Modern transplantation of cells, tissues and organs has been practiced within the last century achieving both life saving and enhancing results (1). Organ transplantation is in many cases the preferred treatment for the chronic failure of the organs. There has been considerable success in preventing the rejection of transplanted organs and further improvements in the outcome of transplantation. However, the main limitation on the fullest possible use of organ transplantation is the shortage of donated human organs; one solution to this problem would be xenotransplantation (4). Associated risks have been recognized including infectious disease transmission, malignancy, immune mediated disease and graft failure. This has resulted in establishment of government regulation, professional standard setting and establishment of vigilance and surveillance systems for early detection, prevention and to improve

11 patient safety. The increased transportation of grafts across national boundaries has made traceability difficult and sometimes impossible. Experience during the first Gulf War with miss-identification of blood units, coming from multiple countries without standardized coding and labeling, has led international organizations to develop standardized nomenclature and coding for blood. Following this example, cell therapy and tissue transplant practitioners have also moved to standardization of coding systems. Establishment of an international coding system has progressed rapidly and implementation for blood has demonstrated multiple advantages. WHO has held two global consultations on human cells and tissues for transplantation, which recognized the global circulation of cells and tissues and growing commercialization and the need for means of coding to identify tissues and cells used in transplantation, that are essential for full traceability. There is currently a wide diversity in the identification and coding of tissue and cell products. For tissues, with a few exceptions, product terminology has not been standardized even at the national level. Progress has been made in blood and cell therapies with a slow and steady trend towards implementation of the international code ISBT 128. Across all fields, there are now 3,700 licensed facilities in 66 countries. Efforts are necessary to encourage the introduction of a standardized international coding system for donation identification numbers, such as ISBT 128, for all donated biologic products (2).

Xenotransplantation Major advances in the understanding of the immunologic process responsible for organ or cellular transplant rejection, a dramatic improvement in available immunosuppressive drugs, development of more sophisticated surgical techniques, and important progress in posttransplant intensive care over the last years have led to a remarkable improvement in success following organ transplantation. Whereas excellent short-term survival of most transplanted organs is

12 readily achieved, graft loss because of chronic rejection and the worsening problem of organ donor shortage remain major concerns in the field of transplantation. Recent advances in immunosuppressive drugs, induction of immunologic tolerance, and gene therapy strategies may help to prolong organ allograft survival in the future (5). Organ transplantation is important to replace organs that have failed in their function. This procedure if performed successfully prolongs the life of many people, including children. This study provides an insight into various aspects of organ donation and transplantation evaluating these issues from a contemporary perspective. The topic is fascinating and like a mirror represents our remote past. The present book widens the horizons of our knowledge and can help us to understand many problems associated with organ donation and transplantation. The evaluation of organ transplantation is based on contemporary scientific knowledge. However, it is important also to study ancient descriptions of organ donation and transplantation as an aid providing appropriate care to modern patients. References 1. Bergan A. Ancient myth, modern reality: a brief history of transplantation. J Biocommun. 1997;24(4):2-9. 2. Strong DM, Shinozaki N. Coding and traceability for cells, tissues and organs for transplantation. Cell Tissue Bank. 2010;11(4):305–23. 3. Linden PK. History of solid organ transplantation and organ donation. Crit Care Clin. 2009;25(1):165-84, ix. 4. Platt JL. New directions for organ transplantation. Nature. 1998;392(6679 Suppl):11-7. 5. Weber M, Deng S, Olthoff K, et al. Organ transplantation in the twenty-first century. Urol Clin North Am. 1998;25(1):51-61.

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INTRODUCTION When successful solid organ transplantation was initiated, its current success rate was not anticipated. Nevertheless, continuous efforts were undertaken to overcome the two major obstacles to success: injury caused by interrupting nutrient supply to the organ and rejection of the implanted organ by normal host defense mechanisms. Solutions have resulted from technologic medical advances, and from using organs from different sources. Each potential solution has raised ethical concerns and has variably resulted in societal acclaim, censure, and apathy. Transplant surgery is now well accepted, and the list of transplant candidates has grown far quicker than the availability of organs. More than 30,000 patients were awaiting organs for transplantation at the end of March 1993. While most organs came from donors declared dead by brain criteria, the increasing shortage of donated organs has prompted a reexamination of prior restrictions of donor groups. Subsequently, organ procurement from donors with cardiac death has been reintroduced in the US. This practice has been mostly abandoned by the US and in some, though not all, other countries. Transplantation has been more successful using organs procured from heart-beating, "brain dead" cadavers than organs from non-heart-beating cadavers (1). Organ donation after cessation of circulation and respiration, both controlled and uncontrolled, has been proposed by the Institute of Medicine as a way to increase opportunities for organ procurement. Despite claims to the contrary, both forms of controlled and uncontrolled donation after cardiac death raise significant ethical and legal issues. Identified causes for concern include absence of agreement on criteria for the declaration of death, nonexistence of universal guidelines for duration before stopping resuscitation efforts and techniques, and assumption of presumed intent to donate for initiating temporary organ-preservation interventions when no expressed consent to donate is present. From a legal point of view, not having scientifically valid criteria of cessation of circulation and respiration for declaring death could lead to a conclusion that organ procurement itself is the proximate cause of death (2). The burgeoning scarcity of organs is not a new issue. As early as in 1968, the National Conference of Commissioners on Uniform State Laws drafted the UAGA 1968. This legislation was designed to serve as a guideline for state governments of the principles and procedures for the donation and receipt of transplantable organ (3).

14 Although the revised UAGA of 2006 provides broad immunity to those involved in organ-procurement activities, courts have yet to provide an opinion on whether persons can be held liable for injuries arising from the determination of death itself. Preserving organs in uncontrolled donation after cardiac death requires the administration of life-support systems such as extracorporeal membrane oxygenation. These life-support systems can lead to return of signs of life that, in turn, have to be deliberately suppressed by the administration of pharmacological agents. Finally, allowing temporary organpreservation interventions without expressed consent is inherently a violation of the principle of respect for a person's autonomy. Proponents of organ donation from uncontrolled donation after cardiac death, on the other hand, claim that these nonconsensual interventions enhance respect for autonomy by allowing people, through surrogate decision making, to execute their right to donate organs. However, the lack of transparency and the absence of protection of individual autonomy, for the sake of maximizing procurement opportunities, have placed the current organ-donation system of opting-in in great jeopardy. Current policies enabling and enhancing organ procurement practices, pose challenges to the constitutional rights of individuals in a pluralistic society as these policies are founded on flawed medical standards for declaring death (2). The laws pertaining to organ donation and transplantation are new, innovative, and rapidly evolving. Over the past years, the field has become increasingly legislated and regulated, more formalized, and more organized. Heart transplant centers must be certified in order to receive Medicare funding. OPOs must comply with UNOS policies and procedures in order to receive reimbursement. Cyclosporine is available to many more patients because of government funding. Donated organs must be shared according to specific criteria designed to ration these valuable national resources equitably and efficiently. The field of transplantation faces many challenges in the future. Perhaps one of the most ominous is the threat of increased litigation. Transplantation is no longer considered experimental, and patients are increasingly aware of their rights. The sheer increase in numbers of procedures will afford opportunities for lawsuits. Living related donors have a right to safe, reasonable, and effective treatment, irrespective of their donor status. Recipients have the right to receive viable, functioning organs free of infections and diseases. The law has defined a duty to question and test potential donors to reduce the possibility of transmission of disease and infection. Recipients and live donors have the right to provide informed consent. The physician has the duty to inform the patient of all inherent risks. Recipients also have the right to expect that their transplant will be performed at a

15 level of competency in keeping with the national standard. Despite all the legal, medical, technical, and ethical activity devoted to the field of transplantation, one perplexing problem persists - the shortage of donated organs. Many more patients are availing themselves of the therapeutic effects of transplantation. Unfortunately, organ donation has not experienced a corresponding increase. The UAGA of 1968 failed at its mission to increase substantially the numbers of donated organs. Required request legislation has increased the numbers of donor families who are afforded the opportunity to donate. However, many patients die in hospitals under circumstances permitting organ donation, and their families are never approached. Perhaps the 1987 amendments to the UAGA, once accepted by more states, will afford greater flexibility and a corresponding increase in donorship. If the spirit of cooperation fails, transplant programs and OPOs may be forced to request meaningful sanctions for noncompliance (4).

Thus, organ donation and subsequent transplantation are vital in prolonging life for many individuals. The importance of this research is that it provides information for a better comprehension of the various aspects of organ donation and transplantation. It gives health care providers an excellent opportunity to re-examine and to reevaluate various aspects of this issue. Overall, the research widens the horizons of our knowledge and can help us to understand many health problems associated with these types of procedures. References 1. DeVita MA, Snyder JV, Grenvik A. History of organ donation by patients with cardiac death. Kennedy Inst Ethics J. 1993;3(2):113-29. 2. Verheijde JL, Rady MY, McGregor J. Presumed consent for organ preservation in uncontrolled donation after cardiac death in the United States: a public policy with serious consequences. Philos Ethics Humanit Med. 2009;4:15. 3. Uniform Anatomical Gift Act 1968 1,8A u.l.a.63, 64(1993) (Amended Supp.1994); Note, Regulating the Sale of Human Organs, 71 VA. L. Rev.1015, 1015 (1985) 4. Rodgers SB. Legal framework for organ donation and transplantation. Nurs Clin North Am. 1989;24(4):837-50.

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THE BIBLICAL DESCRIPTION Throughout history, people have always been intrigued by the possibilities of the transplantation of organs and tissues. The history of transplantation is a scientific journey describing the medical community's effort to understand how the human body works. Humans have long realized the possibilities which transplantation of organs and tissue provides (1). Evaluation of biblical verses shows that the performance of organ donation and transplantation is rooted in the Bible. The following verses: "A new heart also I will give you, and a new spirit will I put within you; and I will put away the stony heart out of your flesh [‫]בשר‬, and I will give you a heart of flesh" (Ezekiel 36:26); "And I will give them one heart, and I will put a new spirit within you; and I will take the stone heart out of their flesh, and I will give them a heart of flesh…" (11:19); "…and I will lay sinews [‫ [גידים‬upon you, and will bring up flesh upon you, and cover you with skin, and put breath in you…" (37:6) describe the removal of a stony failed heart and its replacement with a new heart thus giving the individual a new spirit, or a new life. Similarly, sinews, flesh (muscles) and skin are installed. We see that the Bible describes donation and a subsequent transplantation in cases of heart, tendons, skin, and muscles. Are these types of operations performed in modern times? If so, when was the first organ transplantation carried out? Who carried out the first transplantation? What is the epidemiology of this type of procedure? Are there any barriers to performing this surgery? What are the modern attitudes to organ donation and transplantation? What are the pros and cons? Are these procedures acceptable? Is it advisable to follow the biblical description on this matter? This research aims to answer these questions by evaluating biblical verses concerning organ donation and transplantation from a contemporary viewpoint. Reference 1. Karamehic J, Masic I, Skrbo A, et al. Transplantation of organs: one of the greatest achievements in history of medicine. Med Arh. 2008;62(56):307-10.

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SOME HISTORICAL ASPECTS The history of skin grafts has its beginnings in ancient India, where Sans Sushruta is considered the father of plastic surgery and is credited by some as being simply “the father of surgery.” There is some evidence that reconstruction of the nose was considered as early as 1500 BC, perhaps even as early as 2500–3000 years BC (1,2). In the 6th Century BC, Indian surgeons described how to reconstruct facial wounds by transplanting skin from one place to the body of the other. During the middle age, there were many references in historical medical literature of attempted blood transfusions as well as the transplantation of teeth (3).

Surgical tools used in ancient India Removal of the nose was a form of corporal punishment reserved for crimes such as theft and adultery. The Brahmin Koomes Caste undertook the repairs of the subsequent defects (4). Why these operations were in the hands of the bricklayers is unclear. The donors of the skin grafts and of the entire nose were possibly slaves (5). One can assume that slaves were used as the number of other nose donors was limited. It is also assumed that the operations were fair undertakings requiring at least assistants to the surgeon, and to convince the slave to voluntarily participate (1,2). Because of lack of donors, asepsis, modern anesthesia and the ultimate problem of rejection, results were unsatisfactory. Amputation of the nose was practiced until at least 1983 in Afghanistan and Pakistan (2). In his article “Ancient Egyptian Medicine,” Bryan credits the Ebers Papyrus as containing the first written record of the treatment of burns per se (6). The medications were used for burn treatment and their timing is discussed.

18 The early forage in India, involving skin and tissue transplantation, was lost to history for thousands of years and only resurfaced in Western medicine in the 1800s. Credit for publishing the first description of a successful grafting technique, using free skin grafts to treat wounds, is given to Swiss surgeon, Reverdin, although earlier attempts at skin transplantation by other surgeons are mentioned, including Cooper in 1817 and Buenger in 1821 (5). Reverdin, however, received the most credit. During that time, he was an intern or house physician in Paris, France. He published his technique of “Greffe Epidermique” in 1869 (4,6-8). Reverdin‟s published account was a seminal first step in skin grafting. However, Reverdin‟s grafts were miniscule affairs, probably no larger than 1 mm to 2 mm and were taken by lifting the skin to be grafted with the point of a scalpel. Ollier in France, coined the term “dermoepidermic” grafting in 1871 (4) and emphasized the importance of the dermal and epidermal transplantation in 1872 (6,9,10).

Reverdin's needles

Reverdin's small grafts

It is not entirely clear who deserves credit for the first skin graft used in the treatment of burns. Reverdin is credited by some as applying small grafts to an old burn ulcer as early as 1869, but his works did not appear in published form until 1871 (9). Some authors give credit to George David Pollock of London (2,7,11) who published a series of articles dealing with this subject in 1870 (6). A skin transplant and a corneal transplant were reported in medical journals dating as far back as 1880. These early attempts were usually unsuccessful. Early in the twentieth century, transplantation started to offer the promise of restored health and life. One of the exceptional medical advances of the twentieth century, organ transplantation has become a routine treatment for patients with organ failure (3).

19 The concept of transplantation of body parts from one individual to another can be found in paintings from the Middle Ages depicting the transplanting of a leg from an African donor to an Italian noble. Even grafting of animal bone to a human was described as early as 1668. The first clinical autograft was performed in Germany in 1820 and the first human bone allograft in 1880 in Scotland (12). Eduard Zirm performed the first corneal transplant in Vienna, Austria, in 1905, initiating this practice in ophthalmology (13). The pioneers made the basis for transplantation (14). Alexis Carrel is credited with the earliest studies on the storage of tissues and was prophetic in his predictions of the use of cadavers for organ and tissue donation. He was the first to transplant vascular tissues and was the recipient of the Nobel Prize (1912) (15). Dr Joseph Murray performed the first successful kidney transplant, between identical twins, in 1954, which also led to the Nobel Prize and the advent of solid organ transplantation (16). Dr Murray shared the Prize with Dr Donnell Thomas who was instrumental in advancing the field of bone marrow transplantation (17). Others who received the Nobel Prize for their work include Burnet and Medawar (1960), Snell, Dausset and Benacerraf (1980), and Elion and Hitchings (1988). Paralleled with the development of transplantation, other disciplines like immunology have grown up. Today we can transplant kidneys, hearts, livers, and bone marrow as a kind of routine. However, we do treat on the brink of medicine and the suppression of the immune apparatus has a prize, which is a tendency to atherosclerosis, virus infections and malignancies (14). Between 1880 and 1930 there was a rapid surge in experiments with tissue transplantation, initially mainly of endocrine tissues (thyroid, parathyroid, testicles, ovary, adrenals etc.) with the aim of replacing endocrine function. Emerich Ullmann (1861-1937), who was born in Pecs, Hungary, worked his whole life as a surgeon in Vienna and was the first to perform transplantations of solid organs in the modern sense of medicine. Ullmann, who performed tissue transplantations (skin, testicles, and ovaries), made other scientific discoveries and described several novel surgical techniques. Finally, in 1914, he wrote the first monograph on the state of the art of transplantation medicine, a booklet on "Tissue and Organ Transplantation" summarizing the surprisingly extensive experience in transplantation medicine of his time. With the obvious immunologic barriers to transplantation, the first "technical surgical period" of transplantation ended around the times of Ullmann's death and clinical transplantation was not to be revived before effective means of immunosuppression became available in the 1950s (18).

20 Assessment: over the centuries, various techniques of organ donation and transplantation have been used as therapeutic procedures to treat many diseases associated with failed organ function. Many dedicated scientists have received the Nobel Prize for their contribution to the field of organ transplantation and discoveries in this field of medicine, describing novel surgical techniques. In modern times, organ transplantation has become a routine treatment for many patients. References 1. Davis JS. Address of the President: the story of plastic surgery. Ann Surg. 1941;113(5):641-56. 2. Ang GC. History of skin transplantation. Clin Dermatol. 2005;23(4):320–4. 3. Karamehic J, Masic I, Skrbo A, et al. Transplantation of organs: one of the greatest achievements in history of medicine. Med Arh. 2008;62(5-6):307-10. 4. Chick LR. Brief history and biology of skin grafting. Ann Plast Surg. 1988;21(4):358–65. 5. Hauben DJ, Baruchin A, Mahler A. On the history of the free skin graft. Ann Plast Surg. 1982;9(3):242–5. 6. Klassen HJ. History of Burns. Rotterdam. The Netherlands: Erasmus. 2004. 7. Haynes FW. The History of Burn Care. In: Bostwick JA, ed. The Art and Science of Burn Care. Aspen Pub. 1987, pp. 3–9. 8. Reverdin JL. Greffe epidermique. Bull Soc Chir Paris. 1869;23:147. 9. Herman AR. The history of skin grafts. J Drugs Dermatol. 2002;1(3):298– 301. 10. Integra Products. Skin Graft Knives, Padgett Instruments. (Accessed 30 January 2011 at: www.Integra.com). 11. Freshwater MF, Krizek TJ. Skin grafting of burns: a centennial. A tribute to George David Pollock. J Trauma. 1971;11(10):862–5. 12. DeBoer HH. The history of bone grafts. Clin Ortho Relat Res. 1986;226:292– 8. 13. Moffat SC, Cartwright VA, Stumpf PH. Centennial review of corneal transplantation. Clin Exp Ophthalmol. 2005;33(6):642–7. 14. Birkeland SA. The history of transplantation. Dan Medicinhist Arbog. 1999, pp. 163-85. 15. Carel A. The preservation of tissues and its application in surgery. JAMA. 1912;59:523–7. 16. Guild WR, Harrison JH, Merrill JP, Murray J. Successful homotransplantations of the kidney in identical twins. Trans Am Clin Climatol Assoc. 1955–1956;67:167–73. 17. Thomas ED, Lochte HL, Lu WC, et al. Intravenous infusion of bone marrow in patients receiving radiation and chemotherapy. N Engl J Med. 1957;157:491–6. 18. Druml W. The beginning of organ transplantation: Emerich Ullmann (18611937). Wien Klin Wochenschr. 2002;114(4):128-37.

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EPIDEMIOLOGY Continued progress in organ donation will help enable transplantation to alleviate the increasing incidence of end-stage organ disease. It was the first annual report of the Scientific Registry of Transplant Recipients to include national data following initiation of the collaborative in 2003. Prior to that, annual growth in deceased donation was 2-4%; in 2004, while after initiation of the collaborative, deceased donation increased to 11%. Identification and dissemination of best practices for organ donation have emphasized new strategies for improved consent, including revised approaches to minority participation, timing of requests and team design. The number of organs recovered from donation after cardiac death grew from 64 in 1995 to 391 in 2004. While efforts are ongoing to develop methodologies for identifying expanded donors criteria for organs other than kidney, after cardiac death and expanded criteria for donors raised questions regarding cost and recovery. The number of living donor organs increased from 3493 in 1995 to 7002 in 2004; data showed trends toward more living unrelated donors and those providing non-directed donations (1). In the US, despite the Organ Donation Breakthrough Collaborative work to engage the transplant community and the suggested positive impact from these efforts, availability of transplanted organs over the past 5 years has declined. Living kidney, liver and lung donations declined from 2004 to 2008. Living liver donors in 2008 dropped to less than 50% of the peak (524) in 2001. There were more living donors who were older and were unrelated to the recipient. Percentages of living donors from racial minorities remained unchanged over the past 5 years, but percentages of Hispanic/Latino and Asian donors increased, and African American donors decreased. The OPTN/UNOS Living Donor Transplant Committee restructured to enfranchise organ donors and recipients, and to seek their perspectives on living donor transplantation. In 2008, for the first time in OPTN history, deceased donor organs decreased compared to the prior year. Except for lung donors, deceased organ donation fell from 2007 to 2008. Donation after cardiac death has accounted for a nearly 10-fold increase in kidney donors from 1999 to 2008. Use of livers from donation after cardiac death donors declined in 2008 to 2005

levels (2). In Québec, in Canada, the first organ transplantations have been realized in 1958. Several kidney transplant programs started at that time. Cardiac, liver, pancreas and lungs programs followed and

22 reached a full development in the eighties when Cyclosporin became available. Today, there are 4 university transplant programs in Québec (McGill, Montréal, Laval and Sherbrooke) with a total of 7 kidney, 4 liver, 4 heart, 2 pancreas and 2 lungs centers. More than 2,900 transplantations have been realized. Since 1970, organ procurement and distribution are organized by a central agency called QuébecTransplant (previously Métro-transplantation). Organ donation is done on a voluntary basis as everywhere in North America. More than 90% of the organs come from cadaveric donors and more than 90% of the relatives accept organ donation; 50% of the donors have deceased from head trauma and 50% from cerebral hemorrhage. In 1989, multiorgan harvesting has been realized in 64% of the donors. Despite efforts and progress, the number of patients awaiting an organ transplant is steadily growing and exceeds the number of available organs. Maximal utilization of the donors and growing exchanges at a national and international level will help to solve this crucial problem (3). The solid organ transplant rate in Canada grew from 49.5 PMP in 1993 to 56.8 PMP in 2002, with a peak rate of 61.0 in 2000. Most of this increase was seen in living donor kidney, liver, and lung transplants where combined rates rose twofold, from 124.9 per 1000 transplants to 243.5. Despite this, the rate of organ transplantation in the US was 150% than that of Canada in 2002. As of December 31, 2002, there were 3,956 patients waiting for an organ transplant in Canada, an 84% increase in the total number of patients on the waiting list as of December 31, 1993, 10 years ago. Cadaveric organ donation did not change over this period. An international comparison of cadaveric organ donation rates for 2001 places Canada (13.5 PMP) well below Spain (32.5 PMP) and the US (22.6 PMP) but above Australia (9.3 PMP). As a result, the annual gap between transplants performed and the waiting list has grown from 927 in 1992 to 2230 in 2001, representing an annual increase of 8.3% (4). The aim of the present study was to describe the current situation of donation after circulatory death in the Council of Europe, through a dedicated survey. Of 27 participating countries, only 10 confirmed any donation after circulatory death activity, the highest one being described in Belgium, the Netherlands and the United Kingdom (mainly controlled), and France and Spain (mainly uncontrolled). During 2000-2009, as donation after circulatory death increased, donation after brain death decreased about 20% in the three countries with a predominant controlled donation after circulatory death activity, while donation after brain death had increased in the majority of European countries. The number of organs recovered and transplanted per donation after circulatory death increased along time,

23 although it remained substantially lower compared with donation after brain death. During 2000-2008, 5004 organs were transplanted from donation after circulatory death (4261 kidneys, 505 livers, 157 lungs and 81 pancreases). Short-term outcomes of 2343 kidney recipients from controlled vs. 649 from uncontrolled donation after circulatory death were analyzed: primary non-function occurred in 5% vs. 6.4% (p=NS) and delayed graft function in 50.2% vs. 75.7% (p15 years and 5 >20 years (the longest being 26 years). Actuarial survival was 79.4% at 14 years and 53.1% at 20 years. Cardiomyopathy was the reason for transplantation in 71% and congenital heart disease in 29%. At last evaluation, 71% were on a cyclosporine-based regimen and 23% on a tacrolimus-based regimen; 33% were steroid-free. Twenty-seven percent were free from treatable rejection, 44% developed serious infections, 69% were receiving anti-hypertensives, and 8% required renal transplantation. Neoplasms occurred in 23%, cadaver donor graft in 31%, and 15% required re-transplantation. Of the 12 deaths, cadaver donor graft was the most common cause (n=4), followed by non-specific late graft failure (n=3), infection (n=2), rejection (n=1), non-lymphoid cancer (n=1), and lymphoid cancer (n=1). Physical rehabilitation and return to normal lifestyle has been nearly 100%. This study shows that heart transplantation in pediatric patients is compatible with true long-term survival with a growing cohort of children approaching their second and third decades. The gradual constant-phase decrease in survival noted in earlier studies appears to be continuing. Rejection and infection are low but persistent risks after the first years. Cadaver donor graft and nonspecific late graft dysfunction are the leading causes of death after 10 years. Rehabilitation is excellent (4).

43

Pediatric heart transplantation Since 1988, 50 heart transplants were performed in 47 pediatric patients (30 with dilated cardiomyopathy, 17 with congenital heart disease) at the Department of Cardiac Surgery, Ludwig Maximilian University Hospital in Munich-Grosshadern, Germany. Mean age was 9.4 +/- 6.9 years (range, 4 days to 17.9 years). Twenty-three patients had 36 previous operations. Clinical outcome was evaluated retrospectively. Perioperative mortality was 6% due to primary graft failure. Late mortality (12%) was caused by acute rejection (n=2), pneumonia (n=2), intracranial hemorrhage (n=1), and suicide (n=1). Mean follow-up was 5.24 +/- 3.6 years. Actuarial 1, 5, and 10 year survival was 86%, 86%, and 80%, respectively, and improved significantly after 1995 (92% [1 year]; 92% [5 years]). There was insignificant difference between patients with dilated or congenital heart disease (1 year: 86% vs. 82%; 5 years: 83% vs. 74%; 10 years 83% vs. 74%; p=0.62). Three patients, with therapy resistant acute or chronic rejection and assisted circulation, underwent retransplantation and are alive. Freedom from acute rejection after 5 years was 40% with primary cyclosporine immunosuppression regime and 56% with tacrolimus. Since the introduction of mycophenolate mofetil, freedom from acute rejection increased to 62%. All survivors are at home and in good cardiac condition. These data indicate that pediatric heart transplantation is the treatment of choice for end-stage dilated cardiomyopathy as for congenital heart disease with excellent clinical midterm results. It is a valid alternative to reconstructive surgery in borderline patients. However, further follow-up is necessary to evaluate the long-term side effects of immunosuppressants (5). Assessment: heart transplantation, the final option for terminally ill children, has become the treatment of choice for a number of serious acquired or congenital cardiac conditions, which cannot be treated conservatively. Pediatric heart transplantation is the treatment of choice for end-stage dilated cardiomyopathy as for congenital heart disease with excellent clinical midterm results.

44

References 1. Bailey LL. Origins of neonatal heart transplantation: an historical perspective. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2011;14(1):98-100. 2. Milanesi O, Cerutti A, Biffanti R, et al. Heart transplantation in pediatric age. J Cardiovasc Med (Hagerstown). 2007;8(1):67-71 3. Kawauchi M, Gundry SR, Bailey LL. Infant and pediatric heart transplantation: Loma Linda experience. Kyobu Geka. 1991;44(9):748-52. 4. Ross M, Kouretas P, Gamberg P, et al. Ten- and 20-year survivors of pediatric orthotopic heart transplantation. J Heart Lung Transplant. 2006;25(3):261-70. 5. Groetzner J, Reichart B, Roemer U, et al. Cardiac transplantation in pediatric patients: fifteen-year experience of a single center. Ann Thorac Surg. 2005;79(1):53-60; discussion 61.

WHO WAITS FOR CARDIAC TRANSPLANTATION? This study aims to identify characteristics that increase the chance of death of potential cardiac transplant recipients before donor organs become available. Between June 1, 1988, and May 31, 1993, 332 patients were accepted for heart transplantation; 235 underwent surgery. Ninetyseven patients had not received transplants; of these, 71 died, 13 were transferred to other lists, and 13 were awaiting organs at the close of the study. Median waiting time for patients who received organs was 109 days, whereas patients who did not receive organs spent a median of 94 days on the list. Recipients were matched to donor organs according to blood group, size (height), and, recently, preoperative transpulmonary pressure gradient. CMV antibody mismatches (positive donor to negative recipient) have been avoided where possible. These factors, together with age, gender, underlying diagnosis, previous heart surgery, and Toxoplasma antibody status were studied to assess their influence on waiting time and survival. No characteristics were found significantly to influence survival after acceptance, so that the chance of death while the patient was waiting for heart transplantation is mainly affected by the severity of disease and the length of time a patient waits. In multivariate analyses, the following were independently significantly associated with shorter waiting times: small patients (< 1.7 meters tall, p=0.005), patients with blood types B and AB (p=0.003), and patients with cardiomyopathy (p 55 mmHg, systolic arterial pressure < 120 mmHg, cardiac index < 2 l/min/m2, central venous pressure >15 mmHg, right heart function on echocardiography), and functional parameters (peak oxygen uptake 1 year) patient survival rate ranging between 57% and 83%. A long-term patient survival rate in excess of 90% in elective patients, including infants, was commonly obtained in experienced centers. The shortage of size matched liver donors, which was responsible for a high death rate on the cadaveric waiting list, stimulated the development or technical innovations based on the segmental anatomy of the liver: reduced ('cutdown') liver graft, split graft and living liver transplantation. Challenging technical aspects in the recipient have been solved in order to reduce the incidence of surgical complications like outflow obstruction, arterial and portal thrombosis, and biliary problems. The indications of liver transplantation have been refined; regarding biliary atresia, which is the most frequent indication, a consensus has developed to propose a sequential strategy with a single attempt at hepatoportoenterostomy followed, when it fails, by liver transplantation. Some contraindications accepted in the past are not currently valid with better understanding of the pathophysiology and/or increased clinical experience; such is the case of the hepatopulmonary syndrome. A major progress in preoperative management has been achieved through a multidisciplinary approach, particularly regarding nutrition and control of portal hypertension-related bleeding and ascites. Perioperatively, liver transplantation has derived benefit from the expertise of anesthetists managing babies with serious conditions and increased experience of the transplant surgeons regarding the knowledge of all the technical modalities, good strategy, technical skills and meticulous control of bleeding. It is well recognized that children require more immunosuppression than adults do. As in adults, the first breakthrough came with the introduction of cyclosporine, which more than doubled the one-year patient survival rate. FK 506 - Tacrolimus that allows steroid withdrawal with the first year post-transplant in most patients afforded the next advance during the last decade. Besides its efficacy in reducing the incidence of rejection and absence of cosmetic side effects, the steroid-sparing effect of Tacrolimus is of utmost importance to preserve the growth potential of children. The use of OKT-3 both for induction and treatment of rejection has been abandoned nearly universally because its use, cumulating with other immunosuppressants, resulted in a high incidence of lymphoproliferative disorder. By contrast, anti-IL2receptor monoclonal antibodies, will most likely gain an increasing place in induction, with the availability of chimeric or humanized

103 preparations. The side effects of immunosuppression can endanger both the quality of life and the life expectancy; they are a special source of concern in pediatric recipients whose survival can be expected to be more than a few decades. Children would benefit most from the development of a marker able to identify the patients who have developed graft acceptance, allowing complete wearing of immunosuppression. In addition, they would benefit most from research protocols of tolerance induction. Since the vast majority of liver-transplanted children will have a reasonably normal life expectancy, the focus should be switched to their long-term rehabilitation and the assessment of their quality of life when they reach adulthood (1). Successful liver transplantation in a child is often a hard-won victory, requiring all the combined expertise of a dedicated pediatric transplant team. In looking to the future, where should priorities lie to enhance the success already achieved? First, solutions to the donor shortage must be sought aggressively by increasing the use of splitliver transplants, judicious application of living-donor programs, and increasing the donation rate, perhaps by innovative means. The major immunologic barriers to successful xenotransplantation make it unlikely that this option will be tenable in the near future. Second, current immunosuppression is nonspecific, toxic, and unable to be individually adjusted to the patient's immune response. The goal of achieving donor-specific tolerance will require new consideration of induction protocols. Developing a clinically applicable method to measure the recipient's immunoreactivity is of paramount important, for future studies of new immunosuppressive strategies and to address the immediate concern of long-term over-immunosuppression. The inclusion of pediatric patients in new protocols will require the ongoing insistence of pediatric transplant investigators. Third, the current immunosuppressive drugs have a long-term morbidity and mortality of their own. These long-term effects are particularly important in children who may well have decades of exposure to these therapies. There is some understanding of their long-term renal toxicity and the risk of malignancy. New drugs may obviate renal toxicity, whereas the risk of malignancy is inherent in any nonspecific immunosuppressive regimen. Although progress is being made in preventing and recognizing post-transplant lymphoproliferative disorder, this entity remains an important ongoing concern. The global effect of long-term immunosuppression on the child's growth, development, and intellectual potential is unknown. Of particular concern is the potential for neurotoxicity from the calcineurin inhibitors. Fourth, recurrent disease and new diseases, perhaps potentiated by immunosuppressive drugs, must be considered.

104 Already the recurrence of autoimmune disease and cryptogenic cirrhosis has been documented in pediatric patients. A new lesion, a nonspecific hepatitis, sometimes with positive autoimmune markers, that may progress to cirrhosis has been recognized. It is not known whether this entity is an unusual form of rejection, an unrecognized viral infection, or a response to immunosuppressive drugs themselves. Finally, pediatric transplant recipients, like any other children, must be protected and nourished physically and mentally if they are to fulfill their potential. After liver transplantation the child's growth, intellectual functioning, and psychological adaptation may all require special attention from parents, teachers, and physicians alike. There is limited understanding of how the enormous physical intervention of a liver transplantation affects a child's cognitive and psychological function as the child progresses through life. The persons caring for these children have the difficult responsibility of providing services to evaluate these essential measures of children's health over the long term and to intervene if necessary. Part of the transplant physician's duty is to fight for equal access to health care. In most of the developing world, economic pressures make it impossible to consider liver transplantation as a health care priority. In the US and in other countries with the medical infrastructure to support liver transplantation, however, health care professionals must strive to be sure that the policies governing candidacy for transplantation and allocation of organs are applied justly and uniformly to all children whose lives are threatened by liver disease. In the current regulatory climate that increasingly takes medical decisions out of the hands of physicians, pediatricians must be more prepared to protect the unique and often complicated needs of children both before and after transplantation. Only in this way can the challenges of the present and the future be met (2). Pediatric liver transplantation is a challenging and exciting field for all healthcare providers involved with children who have end-stage liver disease. Graft and patient survival continue to improve due to improvements in medical, surgical, and anesthetic management, organ availability, immunosuppression, and identification and treatment of postoperative complications. Although pediatric cases only represent approximately 10% of the total patients on the waiting list, the number of deaths on the waiting list increased from 196 to 1753 between 1988 and 1999. Recently, a new pediatric liver allocation policy was instituted. The utilization of cut down "reduced" livers, split liver grafts, and living-related donors has provided more organs for pediatric patients. Newer immunosuppression regimens, including induction therapy, continue to have a significant impact on graft and patient survival. Excellence in peri-operative management and

105 identification and treatment of complications or infections also has had an impact on graft and patient survival. Pediatric liver transplantation is a challenging and rewarding field with continued improvements in patient and graft survival. A multidisciplinary team approach coupled with improvements in organ availability, immunosuppression, and peri-operative management has had a dramatic impact on survival (3). In previous decades, pediatric liver transplantation has become a state-of-the-art operation with excellent success and limited mortality. Graft and patient survival have continued to improve because of improvements in medical, surgical and anesthetic management, organ availability, immunosuppression, and identification and treatment of postoperative complications. The utilization of split-liver grafts and living-related donors has provided more organs for pediatric patients. Newer immunosuppression regimens, including induction therapy, have had a significant impact on graft and patient survival. Future developments of pediatric liver transplantation will deal with longterm follow-up, prevention of immunosuppression-related complications and promotion of normal growth as possible (4). The main objective of this study was to review the clinical characteristics, outcomes, and risk factors for survival among 57 pediatric patients undergoing orthotopic liver transplantation for fulminant hepatic failure at the University of California, Los Angeles, Center for the Health Sciences. The medical records of 57 consecutive pediatric patients undergoing orthotopic liver transplantation for fulminant hepatic failure from July 1, 1984, to June 25, 1997, were reviewed and survival data were analyzed via univariate and multivariate statistical methods. The type and incidence of posttransplant complications were determined as was the quality of long-term graft function. Median follow-up period was 3.38 years (range, 0-10.02 years). The 1-, 3-, and 5-year actuarial patient survival rates were 77%, 77%, and 77%, respectively, while graft survivals were 73%, 65%, and 65%. Recipient age and ventilator dependency at the time of transplantation were independently and significantly correlated with patient survival, whereas association was not found between survival and grade of encephalopathy, prior abdominal surgery, recipient weight, pretransplantation values for total bilirubin or prothrombin time, ABO match, allograft type, peak posttransplantation aspartate aminotransferase levels, or the presence of posttransplantation hepatic artery thrombosis. Non-ventilatordependent patients demonstrated a 96% 1-, 3-, and 5-year survival as compared with only 56% at these same time points for those children requiring ventilator support at the time of transplantation (p6 months who receive chronic immunosuppression and require transplantation for end-stage renal disease caused by diabetic nephropathy. The second group consists of patients with unsatisfactory glycemic control despite insulin therapy, life-threatening hypoglycemic episodes and a rapid progression of long-term complications. Despite increasingly beneficial outcomes, islet cell transplantation has several limitations. Maintaining normoglycemia without exogenous insulin administration and appropriate selection of immunosuppressive agents to prolong graft survival are the major challenges. The aim of related studies has been to optimize all phases of islet cell transplantation in order to achieve total insulin independence and prolong graft survival (5). Islet cell transplantation has emerged as potential alternative procedure. Its role in the treatment of T1DM remains to be solidified as research (6) especially for preventing unstable metabolic state commonly referred to as brittle diabetes in patients who undergo pancreatic resection given that it is a relatively noninvasive procedure and an attractive alternative to pancreas transplantation for restoring endogenous insulin secretion and holds great promise for treating patients with T1DM. The success of recent clinical trials for allogeneic islet transplantation as well as the increasing centers that perform auto-transplantation is showing that the beta cell replacement therapy for the treatment of patients with diabetes or total pancreatectomy has been firmly established. It needs only to be improved and more widely available to the millions of desperate patients who search for alternatives to a life of insulin injections, hypoglycemia and the risks of end-organ damage. Steady progress has been achieved in recent years in different areas in the pancreatic islet transplantation process, including islet cell processing, preservation, and immune therapies that justify optimism. To implement this therapeutic approach to larger cohorts of patients that would benefit from the restoration of beta cell function requires multiple interventions and the standardization of the different stages of islet transplant process (7). Clinical outcomes of pancreas transplantation were superior to that of islet transplantation until the introduction of the Edmonton protocol. Significant advances in islet isolation and purification technology, novel immunosuppression and tolerance strategies, and effective antiviral prophylaxis have renewed interest in clinical islet transplantation for the treatment of diabetes mellitus. The introduction of a steroid-free antirejection protocol and islets prepared from two

114 donors led to high rates of insulin independence. The Edmonton protocol has been successfully replicated by other centers in an international multicenter trial. A number of key refinements in pancreas transportation, islet preparation, and newer immunological conditioning and induction therapies have led to continued advancement through extensive collaboration between key centers (8). The dramatic breakthrough in 2000 with the "Edmonton protocol" for successful solitary islet transplantation has restored optimism for the application of islet transplantation as a treatment for T1DM. Due to the recent successes, islet transplantation has evolved from a theoretical concept to its current status as a therapeutic option for patients with T1DM. Islet transplantation has shown to normalize metabolic control in a way that has been virtually impossible to achieve with exogenous insulin. The less invasive procedure of islet transplantation as compared to whole pancreas transplantation in patients with T1DM would be expected to be safer and much less costly. However, this procedure also requires lifetime immunosuppression with drugs. The limited availability of donor organs and the necessity of transplantation of several pancreases in order to achieve insulin independence limit this procedure to a small minority of patients. Unlike the North American centers, the European centers concentrated their efforts on islet after kidney and simultaneous islet kidney transplantation. The two Swiss islet transplantation programs have been pioneers in applying the steroidfree "Edmonton protocol" to simultaneous islet-kidney and islet after kidney transplantation. The long-term follow-up showed that islet function decreases over time. In order to maintain insulin independence repeated islet transplants would have to be given to the patients. Therefore, there has been a change in paradigm over time. The major goal of islet transplantation focuses now on achieving a good blood glucose control and avoidance of severe hypoglycaemic episodes rather than only insulin-independence. Thus, due to the limited supply of donor organs, more patients can benefit from islet transplantation. Small insulin doses of exogenous insulin prevent stress on the islet in particular after meals and might help to maintain the transplanted islet mass over time. Due to the severe limitations of immunosuppression, solitary islet transplantation is limited to a very small number of patients with T1DM. The most common indication for islet transplantation in Switzerland is terminal kidney failure in patients with T1DM. A simultaneous islet-kidney or pancreas-kidney transplantation should be offered to these patients. The choice between islet or pancreas transplantation is a matter of age and diabetic complications because the perioperative risk is considerably higher in pancreas transplantation (4).

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Pancreas transplantation Alternative sources of islets have been sought through the generation of beta cells from stem cells, use of porcine islets, and beta cell expansion with growth factors due to the shortage of donor pancreas. However, differentiation and expansion of embryonic and pancreatic stem cells and expansion of differentiated beta cells in vitro is limited. Expansion of primary beta cells by growth factors is also hampered by the senescence of the cells. A human pancreatic beta cell line that is functionally equivalent to primary beta cells can be established and can yield large amounts of cells for transplantation. Using Cre/loxP-based reversible immortalization, a reversibly immortalized pancreatic beta cell clone (NAKT-15) was constructed. The cells may overcome the limitation of primary pancreatic beta cells for transplantation to control T1DM. In order to avoid the use of immunosuppressive agents, an implantable bag-type bioartificial pancreas is developed (9). Cell replacement strategies via islet transplantation offer potential therapeutic options for diabetic patients. However, the discrepancy between the limited number of donor islets and the high number of patients who could benefit from such a treatment reflects the dire need for renewable sources of high-quality beta cells. Human embryonic stem cells are capable of self-renewal and can differentiate into components of all three germ layers, including all pancreatic lineages. The ability to differentiate human embryonic stem cells into beta cells highlights a promising strategy to meet the shortage of beta cells (3). Because diabetes is caused by the loss of a single cell type, it is amenable to treatment by cell replacement therapy. Advances in islet transplantation procedures have demonstrated that people with T1DM can be cured by human islet transplantation, but the severely limited availability of donor islets has restricted the widespread application of this approach, and driven the search for substitute transplant tissues. Recent experimental studies suggest that three separate sources of tissue show therapeutic potential - xenografts from other species, tissue stem cells and embryonic stem cells. Of these, xenografts are

116 closest to clinical application but there are still major obstacles to be overcome. Insulin-expressing cells have been derived from a number of different stem cell populations but embryonic stem cells offer the major advantage of being able, in principle, to provide the vast numbers of cells required for transplantation therapy (10). T1DM has received much attention recently as a potential target for the emerging science of stem cell medicine. In this autoimmune disease, the insulin-secreting beta cells of the pancreas are selectively and irreversibly destroyed by autoimmune assault. Advances in islet transplantation procedures mean that patients with the disease can be cured by transplantation of primary human islets of Langerhans. A major drawback in this therapy is the availability of donor islets, and the search for substitute transplant tissues has intensified in the last few years. Such replacement includes embryonic stem cells and multipotent adult stem/progenitor cells from a range of tissues including the pancreas, intestine, liver, bone marrow and brain. In patients with T1DM, auto-reactive T-cells are programmed to recognize the insulin-producing beta cells. As a result, for therapeutic replacement tissues, it may be more sensible to derive cells that behave like beta cells but are immunologically distinct (11). The ability to achieve single-donor islet transplantation will provide many more islet grafts for treatment of an ever-expanding patient base with T1DM with poor glycemic control. Avoiding exposure of recipients to multiple different donors HLA is critical if risk of donor sensitization is to be avoided. This point is important as further islet or pancreas transplants in the remote future or the potential future need for a solid organ kidney transplant may become prohibitive if the recipient is sensitized. Areas that contribute to the success or failure of single-donor islet engraftment include: donorrelated factors, islet isolation and culture conditions, a series of strategies in the treatment of the recipient to prevent inflammation, apoptosis, islet thrombosis, and metabolic functional outcome. If single-donor islet transplantation can be achieved routinely, therapy will become more widely available, and more accepted by the transplant community (12). The success achieved over the last few decades by the transplantation of whole pancreas and isolated islets suggest that diabetes can be cured by the replenishment of deficient β-cells. These observations are proof-of-principle and have intensified interest in treating diabetes by cell transplantation, and by the use of stem cells. Pancreatic stem/progenitor cells could be one of the sources for the treatment of diabetes. Islet neogenesis and the budding of new islets from pancreatic stem/progenitor cells located in or near pancreatic ducts has long been assumed an active process in the postnatal

117 pancreas. Several in vitro studies have shown that insulin-producing cells can be generated from adult pancreatic ductal tissues. Acinar cells may also be a potential source for differentiation into insulinproducing cells (13). The possibility of generating insulin-secreting cells with adult pancreatic stem or progenitor cells has been investigated extensively. The conversion of differentiated cells such as hepatocytes into beta cells is attempted using molecular insights into the transcriptional make-up of beta cells. Additionally, the enhanced proliferation of beta cells in vivo or in vitro is pursued as a strategy for regenerative medicine for diabetes. Advances have been made in directing the differentiation of embryonic stem cells into beta cells. Although progress is encouraging, major gaps in our understanding of developmental biology of the pancreas and adult beta-cell dynamics remain to be bridged before a therapeutic application is possible (14). There is huge disparity between potential recipients and the availability of donor tissue. Human embryonic stem cells induced to form pancreatic beta cells could provide a replenishable supply of tissue. Early studies on the spontaneous differentiation of mouse embryonic stem cells have laid the foundation for a more directed approach based on recapitulating the events that occur during the development of the pancreas in the mouse. A high yield of definitive endoderm has been achieved, and although beta-like cells can be generated in a step-wise manner, the efficiency is still low and the final product is not fully differentiated. Future challenges include generating fully functional islet cells under Xeno-free and chemically defined conditions and circumventing the need for immunosuppression (15). Progress has been made towards the goal of utilizing stem cells as a source of engineered pancreatic beta cells for therapy of diabetes. Protocols for the in vitro differentiation of embryonic stem cells based on normal developmental cues have generated beta-like cells that produce high levels of insulin, albeit at low efficiency and without full responsiveness to extracellular levels of glucose. Induced pluripotent stem cells also can yield insulin-producing cells following similar approaches. An important recent report shows that when transplanted into mice, human embryonic stem-derived cells with a phenotype corresponding to pancreatic endoderm matured to yield cells capable of maintaining near-normal regulation of blood sugar (16). Major hurdles that must be overcome to enable the broad clinical translation of these advances include teratoma formation by embryonic stem and induced pluripotent stem cells, and the need for immunosuppressive drugs. Classes of stem cells that can be expanded extensively in culture but do not form teratomas, such as amniotic fluid-derived stem

118 cells and hepatic stem cells, offer possible alternatives for the production of beta-like cells, but further evidence is required to document this potential. Generation of autologous induced pluripotent stem cells should prevent transplant rejection, but may prove prohibitively expensive. Banking strategies to identify small numbers of stem cell lines homozygous for major histocompatibility loci have been proposed to enable beneficial genetic matching that would decrease the need for immunosuppression (17). With recent advances in methods of islet isolation and the introduction of more potent and less diabetogenic immunosuppressive therapies, islet transplantation has progressed from research to clinical reality. Presently, several international centers have demonstrated successful clinical outcomes with high rates of insulin independence after islet transplantation. Ongoing refinements in donor pancreas procurement and processing, developments in islet isolation and purification technology, advances in novel immunological conditioning and induction therapies have led to the acceptance of islet transplantation as a safe and effective therapy for patients with T1DM (18).

Islet cell transplantation This was a prospective before-after cohort study carried out in a tertiary referral center. Glycemic control was assessed in 10 patients with diabetes-induced renal dysfunction who were enrolled in a best medical therapy program and then crossed over to islet transplantation. Thirty human pancreas were retrieved from local multiorgan donors and consecutively processed with intraductal collagenase perfusion, continuous digestion, and density gradient purification (group 1, n=9), or similarly processed but impure tissue fractions cultured in vitro and then repurified to retrieve additional islets (group 2, n=21). Islets were implanted by percutaneous portal embolization, providing more than 10,000 islet equivalents per kilogram of body weight (infusions from 1-3 donors per patient) under cover of antithymocyte globulin, sirolimus, or mycophenolate mofetil and tacrolimus. Islet yields, purity, and cell viability (caspase 3,

119 terminal deoxynucleotidyl transferase-mediated biotin-deoxyuridine 5-triphosphate nick-end labeling stain, and insulin secretion in vitro) were compared. In patients, monitored metabolic parameters were Cpeptide secretion, insulin requirements, glycemic excursion, and HbA1c. For group 1 vs. group 2, no differences were observed in pancreas age (43 vs. 44 years), cold storage (5 vs. 4 hours), or weight (73 vs. 82 g). Group 2 yielded 453,690 islet equivalents vs. 214,109 islet equivalents in group 1 (p=0.002). Grafts contained 50% or more endocrine cells in both groups. No difference occurred in cell viability or insulin secretion. Islets from 90% of group 2 pancreas met release criteria for transplantation. C-peptide secretion was detected in all recipients and persisted with a median follow-up to 12 months (range, 6-21 months) after full islet transplantation. Daily insulin dependence was reversed in all patients for at least 3 months. Five patients resumed small insulin doses. Compared with the best care program, all patients had improved metabolic stability. The mean +/- SE HbA1c level at entry into the study was 7.8% +/- 0.5%, and this decreased to 6.9% +/- 0.2% after best care (p=0.38) and further to 6.2% +/- 0.2% at 6 months after transplantation (p=0.002 vs. entry; p=0.15 vs. best care; analysis of variance). This study shows that local pancreas donor retrieval with islet isolation and culture conditioning enabled an offer of islets for transplantation for 90% of consecutively processed pancreas. Isolated islets secreted insulin during prolonged follow-up after implantation into patients, yielding metabolic control comparable with that achieved by best medical therapy (19). Despite substantial advances in islet isolation methods and immunosuppressive protocol, pancreatic islet cell transplantation remains an experimental procedure currently limited to the most severe cases of T1DM. The objectives of this treatment are to prevent severe hypoglycemic episodes in patients with hypoglycemia unawareness and to achieve a physiological metabolic control. Insulin independence and long term-graft function with improvement of quality of life have been obtained in several international islet transplant centers. However, experimental trials of islet transplantation clearly highlighted several obstacles that remain to be overcome before the procedure could be proposed to a much larger patient population (20). The aim of this study was to compare the long-term outcomes in terms of glucose control, renal function and procedure-related complications of simultaneous islet-kidney transplantation with those of simultaneous pancreas-kidney transplantation in patients with T1DM. HbA1c, need for insulin, glomerular filtration rate and complication rate were compared between 13 recipients of simultaneous islet-kidney transplantation and 25 recipients of

120 simultaneous pancreas-kidney transplants at the same institution. The mean follow-up was 41 months. Two primary organ non-functions occurred in the simultaneous islet-kidney transplantation group. HbA1c did not differ at any time point during follow-up in the simultaneous islet-kidney transplantation group compared with the simultaneous pancreas-kidney group (mean during follow-up 6.3 vs. 5.9%). Similarly, kidney function over time was not different between the two groups. A higher rate of insulin independence following simultaneous pancreas-kidney transplantation (after 1 year 96% vs. 31% in the simultaneous islet-kidney transplantation group) was counterbalanced by a higher rate of serious adverse events (40% relaparotomies vs. 0% in the simultaneous islet-kidney transplantation group). These data indicate that the endogenous insulin production achieved by islet transplantation, combined with optimal insulin therapy, was sufficient for maintaining near-normal glucose levels. In terms of glucose control, islet transplantation provides results comparable to those achieved with pancreas transplantation. However, simultaneous pancreas-kidney results in a higher rate of insulin independence, albeit at the cost of more surgical complications. These results have led to a new paradigm in islet transplantation, where the primary goal is not insulin independence, but good glucose control and avoidance of severe hypoglycemia (21).

Simultaneous pancreas and kidney transplantation The main objective of this study was to investigate the influence of primary graft function on graft survival and metabolic control after islet transplantation with the Edmonton protocol. Fourteen consecutive patients with brittle T1DM were enrolled in this phase 2 study and received median 12,479 islet equivalents per kilogram of body weight (interquartile range 11,072-15,755) in two or three sequential infusions within 67 days (44-95). Primary graft function was estimated 1 month after the last infusion by the beta-score, a previously validated index (range 0-8) based on insulin or oral

121 treatment requirements, plasma C-peptide, blood glucose, and A1C. Primary outcome was graft survival, defined as insulin independence with A1C ≤6.5%. All patients gained insulin independence within 12 days (6-23) after the last infusion. Primary graft function was optimal (beta-score ≥7) in nine patients and suboptimal (beta-score ≤6) in five. At last follow-up, 3.3 years (2.8-4.0) after islet transplantation, eight patients (57%) remained insulin independent with A1C ≤6.5%, including seven patients with optimal PGF (78%) and one with suboptimal primary graft function (20%) (p= 0.01, log-rank test). Graft survival was insignificantly influenced by HLA mismatches or by preexisting islet autoantibodies. A1C, mean glucose, glucose variability (assessed with continuous glucose monitoring system), and glucose tolerance (using an oral glucose tolerance test) were markedly improved when compared with baseline values and were significantly lower in patients with optimal primary graft function than in those with suboptimal primary graft function. These data indicate that optimal primary graft function was associated with prolonged graft survival (22). Assessment: the surgical treatment for diabetes mellitus has evolved to become a viable alternative to insulin administration, beginning with pancreatic transplantation. In order to avoid the use of immunosuppressive agents, an implantable bag-type bioartificial pancreas was developed. Whole pancreas transplantation, or alternatively an infusion of isolated islet cells into the hepatic portal venous system are the only clinically acceptable radical treatment for patients with T1DM. Allogeneic transplantation of isolated islet cells is a procedure used only in a highly specific group of recipients, whereas intensive insulin treatment remains the best therapy to achieve glycemia control in most patients with T1DM. With recent advances in methods of islet isolation and the introduction of more potent and less diabetogenic immunosuppressive therapies, islet transplantation has progressed from research to clinical reality. Islet cell transplantation holds great promise for treating patients with T1DM, and for preventing unstable metabolic state commonly referred to as brittle diabetes in patients who undergo pancreatic resection given that it is a relatively noninvasive procedure and an attractive alternative to pancreas transplantation for restoring endogenous insulin secretion. Areas that contribute to the success or failure of single-donor islet engraftment include donor-related factors, islet isolation and culture conditions, a series of strategies in the treatment of the recipient to

122 prevent inflammation, apoptosis, islet thrombosis, and metabolic functional outcome. Three separate sources of tissue show therapeutic potential xenografts from other species, tissue stem cells and embryonic stem cells. Of these, xenografts are closest to clinical application but there are still major obstacles to be overcome. Cell replacement strategies via islet transplantation offer potential therapeutic options for diabetic patients. Pancreatic stem/progenitor cells could be one of the sources for the treatment of diabetes. Islet neogenesis, and the budding of new islets from pancreatic stem/progenitor cells located in or near pancreatic ducts have been assumed as an active process in the postnatal pancreas. Insulin-producing cells can also be generated from adult pancreatic ductal tissues. Acinar cells may also be a potential source for differentiation into insulin-producing cells. Human embryonic stem cells are capable of self-renewal and can differentiate into components of all three germ layers, including all pancreatic lineages. The ability to differentiate human embryonic stem cells into beta cells highlights a promising strategy to meet the shortage of beta cells. The conversion of differentiated cells such as hepatocytes into beta cells is attempted using molecular insights into the transcriptional make-up of beta cells. Additionally, the enhanced proliferation of beta cells in vivo or in vitro is pursued as a strategy for regenerative medicine for diabetes. Advances have also been made in directing the differentiation of embryonic stem cells into beta cells. Induced pluripotent stem cells also can yield insulin-producing cells following similar approaches. When transplanted into mice, human embryonic stem cells-derived cells with a phenotype corresponding to pancreatic endoderm matured to yield cells capable of maintaining near-normal regulation of blood sugar. The most common indication for islet transplantation is terminal kidney failure in patients with T1DM. A simultaneous islet-kidney or pancreas-kidney transplantation should be offered to these patients. References 1. Jahansouz C, Jahansouz C, Kumer SC, Brayman KL. Evolution of βCell Replacement Therapy in Diabetes Mellitus: Islet Cell Transplantation. J Transplant. 2011;2011:247959. 2. Merani S, Shapiro AM. Current status of pancreatic islet transplantation. Clin Sci (Lond). 2006;110(6):611-25. 3. Guo T, Hebrok M. Stem cells to pancreatic beta-cells: new sources for diabetes cell therapy. Endocr Rev. 2009;30(3):214-27. 4. Lehmann R, Pavlicek V, Spinas GA, Weber M. Islet transplantation in type I diabetes mellitus. Ther Umsch. 2005;62(7):481-6.

123 5. Berman A, Pawelec K, Fiedor P. Allogeneic transplantation of isolated islet cells in clinical practice. Pol Arch Med Wewn. 2009;119(5):326-32. 6. Shapiro AM, Lakey JR, Ryan EA, et al. Islet transplantation in seven patients with type 1 diabetes mellitus using a glucocorticoid-free immunosuppressive regimen. N Engl J Med. 2000;343(4):230-8. 7. Sabek OM, Hamilton DJ, Gaber AO. Prospects for future advancements in islet cell transplantation. Minerva Chir. 2009;64(1):59-73. 8. Lakey JR, Mirbolooki M, Shapiro AM. Current status of clinical islet cell transplantation. Methods Mol Biol. 2006;333:47-104. 9. Kobayashi N. Cell therapy for diabetes mellitus. Cell Transplant. 2006;15(10):849-54. 10. Jones PM, Courtney ML, Burns CJ, Persaud SJ. Cell-based treatments for diabetes. Drug Discov Today. 2008;13(19-20):888-93. 11. Burns CJ, Persaud SJ, Jones PM. Diabetes mellitus: a potential target for stem cell therapy. Curr Stem Cell Res Ther. 2006;1(2):255-66. 12. Shapiro AM. Strategies toward single-donor islets of Langerhans transplantation. Curr Opin Organ Transplant. 2011;16(6):627-31. 13. Noguchi H. Pancreatic stem/progenitor cells for the treatment of diabetes. Rev Diabet Stud. 2010;7(2):105-11. 14. Sordi V, Bertuzzi F, Piemonti L. Diabetes mellitus: an opportunity for therapy with stem cells? Regen Med. 2008;3(3):377-97. 15. Docherty K, Bernardo AS, Vallier L. Embryonic stem cell therapy for diabetes mellitus. Semin Cell Dev Biol. 2007;18(6):827-38. 16. Kroon E, Martinson LA, Kadoya K, et al. Pancreatic endoderm derived from human embryonic stem cells generates glucose-responsive insulin-secreting cells in vivo. Nat Biotechnol. 2008;26(4):443-52. 17. Furth ME, Atala A. Stem cell sources to treat diabetes. J Cell Biochem. 2009;106(4):507-11. 18. Nanji SA, Shapiro AM. Advances in pancreatic islet transplantation in humans. Diabetes Obes Metab. 2006;8(1):15-25. 19. Warnock GL, Meloche RM, Thompson D, et al. Improved human pancreatic islet isolation for a prospective cohort study of islet transplantation vs best medical therapy in type 1 diabetes mellitus. Arch Surg. 2005;140(8):735-44. 20. Ichii H, Ricordi C. Current status of islet cell transplantation. J Hepatobiliary Pancreat Surg. 2009;16(2):101-12. 21. Gerber PA, Pavlicek V, Demartines N, et al. Simultaneous isletkidney vs pancreas-kidney transplantation in type 1 diabetes mellitus: a 5 year single centre follow-up. Diabetologia. 2008;51(1):110-9. Comment in: Curr Diab Rep. 2008;8(4):307-9. 22. Vantyghem MC, Kerr-Conte J, Arnalsteen L, et al. Primary graft function, metabolic control, and graft survival after islet transplantation. Diabetes Care. 2009;32(8):1473-8.

124

INTESTINAL Intestinal transplantation is the only definitive therapy for irreversible intestinal failure (1). Emerich Ullmann, the Hungarian, during 1899 to 1900, conducted several experiments with intestinal transplantation and must be regarded as the father of intestinal transplantation (2). Small bowel transplantation for intestinal failure is no longer an experimental procedure, but an accepted treatment for patients when total parenteral nutrition therapy for intestinal failure is unsuccessful. Early referral for screening for small bowel transplantation should be considered in patients with permanent intestinal failure who have occlusion of more than 2 major veins, frequent line-related septic episodes, impairment of liver function, or an unacceptable quality of life. With the increased experience in post-transplant patient care and newer forms of induction (thymoglobulin, IL-2 receptor antagonists) and maintenance (tacrolimus) therapies, the 1-year graft survival has increased to 65% for isolated and to 59% for liver/small bowel transplantation and is further improving. Rejection, bacterial, fungal and viral (CMV, Epstein-Barr-virus) infections, post-transplant lymphoproliferative disease and GVHD are the most common complications after intestinal transplantation. Although most of the long-term survivors are total parenteral nutrition-independent and have a good quality of life, the risk of the procedure and long-term adverse effects of immunosuppressive medication limits small bowel, or liver/small bowel transplantation only to patients with severe complications of total parenteral nutrition therapy (3). Owing to the limited short- and long-term graft survival over the years, intestinal transplantation has been a complementary treatment to home parenteral nutrition. However, the development of intestinal and multivisceral transplantation has been significant over the past 1520 years owing to the progress in immunosuppressive therapy, refinement of surgical techniques, post-transplant care, intestinal immunology, and immunological as well as anti-infectious monitoring. The improvement of patient- and graft survival over the last few years together with data on the cost effectiveness of intestinal transplantation, following 2 years after transplantation, require a redefinition of the indication for intestinal transplantation (1).

125

Plain radiograph of the abdomen. Duodenal atresia. The arrows point to the dilated stomach and that part of the duodenum, which is above the obstruction. Other parts of abdomen do not contain gas. The field of intestinal transplantation has experienced a progressive increase in patient and graft survival over the last few years, leading to a parallel increase in the number of programs performing such type of surgical procedures. Indications for intestinal transplant include irreversible intestinal failure, compounded by potential lifethreatening complications such as loss of intravenous access, liver failure or multiple episodes of infections. The type of graft that is required is highly individualized according to the patient's original diagnosis and status. Presence of short gut syndrome alone is indication for isolated intestinal transplant; liver failure mandates the use of a liver graft (liver-intestine or multivisceral transplant); intestinal dysmotility disorders with intact liver function require the use of a modified multivisceral graft. Most of the current immunosuppression protocols consist of induction of immunosuppression and maintenance doses of tacrolimus. Rejection and infectious complications remain the most common causes of morbidity and mortality; it is therefore essential to closely monitor the intestinal graft to prevent such occurrences. Future developments include the use of non-invasive markers of rejection, a refinement in surgical techniques, development of advanced immunosuppression protocol, expansion of living related transplant and multivisceral transplantation in selected patients (4). Between December 2000 and November 2006, 28 isolated intestinal transplants and nine multivisceral transplants (five with liver) from cadaveric donors have been performed for short gut syndrome (n=15), chronic intestinal pseudo-obstruction (n=10), Gardner's syndrome (n=9), radiation enteritis (n=1), intestinal atresia (n=1), and massive intestinal angiomatosis (n=1) at Multiorgan Transplant Unit, Bologna, Italy. Indications for transplantations were: loss of venous access, recurrent sepsis due to central line infection,

126 and/or major electrolyte and fluid imbalance. Liver dysfunction was present in 19 cases. All patients were adults of median age at transplant of 34.7 years and mean weight 59.6 kg. All recipients were on total parenteral nutrition for a mean time of 38.8 months. Mean donor/recipient body weight ratio was 1.1. The mean follow-up was 892 +/- 699 days. Twenty-five patients were alive (67.5%) with 3-year patient survivals of 70% for isolated intestinal transplantations and 41% for the multivisceral transplantations (p=0.01). The mortality rate was 32.5% with losses due to sepsis (63%) or rejection while 3-year graft survival rates were 70% for isolated intestinal transplantations and 41% for multivisceral transplantations (p=0.02); graftectomy rate was 16%. These were 88% of grafts working properly with patients on regular diet with no need for parenteral nutrition. Induction therapy has reduced the doses of postoperative immunosuppressive agents, especially in the first period, lowering the risk of renal failure and sepsis, while mucosal surveillance protocol for early detection of rejection dramatically reduced the number of severe acute or chronic rejections (5).

Short bowel syndrome

Intestinal transplant

A retrospective study was conducted on 26 children with a mean age of 5 years (range, 0.3 to 14 years) at Necker-Enfants Malades Hospital in Paris. Three groups were isolated. In group A (1987 to 1990), seven patients received nine isolated intestinal transplants for short bowel syndrome. Immunosuppression therapy consisted of cyclosporine, aziathioprine, and corticosteroids. In group B (1994current), nine patients received nine isolated intestinal transplants for short bowel syndrom (n=2), intestinal pseudoobstruction (n=2), neonatal intractable diarrhea (n=3), and Hirschsprung' disease (n=1); hepatic biopsy results showed weak cholestasis or fibrosis. In group C (1994-current), 10 patients received 10 combined liver-small bowel transplants for short bowel syndrome (n=3), neonatal intractable diarrhea (n=4), and Hirschsprung' disease (n=3); hepatic cirrhosis related to total parenteral nutrition was in all cases. Groups B and C received immunosupressive treatment consisting of tacrolimus,

127 aziathioprine, and corticosteroids. Posttransplant follow-up included intestinal biopsies of the small bowel twice a week and more frequently or combined with liver biopsy if rejection was suspected. Overall patient survival and graft survival were 61% (16 of 26) and 50% (13 of 26), respectively. In group A, severe intestinal allograft rejection occurred in six patients leading to graft removal (graft survival, 11%). Five patients died of total parenteral nutrition complications after graft removal (patient survival, 28%). One survivor was off total parenteral nutrition, and one was waiting for a second graft. In group B, six patients survived (patient survival, 66%). Causes of death included hepatic failure (n=1), renal and liver failure (n=1), and systemic infection (n=1). Severe intestinal allograft rejection occurred in five patients, which necessitated aggressive immunosuppression (antilymphocyte serum) leading to an incomplete functional recovery of the graft. Only two patients were off total parenteral nutrition. In group C, eight patients survived (patient survival, 80%) all of which were off total parenteral nutrition. One patient died during the procedure, and one died of severe systemic infection. Intestinal graft rejection occurred in six patients; rejection of the liver allograft occurred in five patients, yet all rejections were weak and successfully treated by corticosteroids (graft survival, 80%(. This study indicates that intestinal transplantation is a valid therapeutic option for children with definitive intestinal failure and not only for short bowel syndrome. Tacrolimus improves graft and patient survival (group A vs. group B). The lower severity of graft rejection in combined liver-small bowel transplantation improves functional results of intestinal transplantation in children without additional mortality or morbidity, group B vs. group C (6).

Congenital short bowel syndrome

Hirschsprung's disease

The aim of this study was to evaluate survival, surgical technique, and patient care in patients treated with intestinal transplantation. Data were reviewed from 95 consecutive intestinal transplants, performed between December 1994 and November 2000, at the University of

128 Miami. Fifty-four of the patients undergoing intestinal transplantation were children and 41 were adults. The series includes 49 male and 46 female patients. The causes of intestinal failure included mesenteric venous thrombosis (n=12), necrotizing enterocolitis (n=11), gastroschisis (n=11), midgut volvulus (n=9), desmoid tumor (n=8), intestinal atresia (n=6), trauma (n=5), Hirschsprung's disease (n=5), Crohn's disease (n=5), intestinal pseudoobstruction (n=4), and others (n=19). The procedures performed included 27 isolated intestine transplants, 28 combined liver and intestine transplants, and 40 multivisceral transplants. Since 1998, daclizumab (Zenepax) for induction of immunosuppression and zoom videoendoscopy for graft surveillance were used. Intense CMV prophylaxis and systemic drainage of the portal vein were used. The 1-year patient survival rates for isolated intestinal, liver and intestinal, and multivisceral transplantations were 75%, 40%, and 48%, respectively. Since 1998, the 1-year patient and graft survival rates for isolated intestinal transplants have been 84% and 72%, respectively. The causes of death were as follows: sepsis after rejection (n=14), respiratory failure (n=8), sepsis (n=6), multiple organ failure (n=4), arterial graft infection (n=3), aspergillosis (n=2), post-transplantation lymphoproliferative disease (n=2), intracranial hemorrhage (n=2), and fungemia, chronic rejection, GVHD, necrotizing enterocolitis, pancreatitis, pulmonary embolism, and viral encephalitis (n=1 case of each). These data indicate that intestinal transplantation can be a lifesaving alternative for patients with intestinal failure. The prognosis after intestinal transplantation is better when it is performed before the onset of liver failure. Rejection monitoring with zoom videoendoscopy and new immunosuppressive therapy with sirolimus, daclizumab, and campath-1H have contributed to the improvement in patient survival (7).

Assessment: small bowel transplantation for intestinal failure is no longer an experimental procedure, it is an accepted treatment for patients when total parenteral nutrition therapy for intestinal failure is

129 unsuccessful. Indications include: short bowel syndrome, chronic intestinal pseudo-obstruction, Gardner syndrome, radiation enteritis, intestinal atresia, neonatal intractable diarrhea, Hirschsprung's disease, mesenteric venous thrombosis, necrotizing enterocolitis, gastroschisis, midgut volvulus, desmoid tumor, intestinal atresia, trauma, Crohn's disease, and massive intestinal angiomatosis. Rejection, bacterial, fungal and viral infections (CMV, EpsteinBarr-virus), post-transplant lymphoproliferative disease and GVHD are the most common complications related to intestinal transplantation. References 1. Pascher A, Kohler S, Neuhaus P, Pratschke. Present status and future perspectives of intestinal transplantation. J. Transpl Int. 2008;21(5):401-14. 2. Druml W. The beginning of organ transplantation: Emerich Ullmann (1861-1937). Wien Klin Wochenschr. 2002;114(4):128-37. 3. Dijkstra G, Rings EH, van Dullemen HM, et al. Small bowel transplantation as a treatment option for intestinal failure in children and adults. Ned Tijdschr Geneeskd. 2005;149(8):391-8. 4. Selvaggi G, Tzakis AG. Intestinal and multivisceral transplantation: future perspectives. Front Biosci. 2007;12:4742-54. 5. Lauro A, Zanfi C, Ercolani G, et al. Italian experience in adult clinical intestinal and multivisceral transplantation: 6 years later. Transplant Proc. 2007;39(6):1987-91. 6. Jan D, Michel JL, Goulet O, et al. Up-to-date evolution of small bowel transplantation in children with intestinal failure. J Pediatr Surg. 1999;34(5):841-3; discussion 843-4. 7. Nishida S, Levi D, Kato T, et al. Ninety-five cases of intestinal transplantation at the University of Miami. J Gastrointest Surg. 2002;6(2):233-9.

OSTEOCHONDRAL Efficacious treatment of chondral and osteochondral defects of the weight bearing surfaces represents a challenge for the orthopedic surgeon. Poor biomechanical characteristics of the reparative fibrocartilage promoted by "traditional resurfacing techniques" provide only moderate clinical outcome in the treatment of such lesions. During the last decade, several new efforts have been expressed to provide a hyaline or hyaline-like gliding surface for a full thickness defected area on the weight-bearing surface. Among several surgical procedures, autologous osteochondral transplantation methods, including osteochondral mosaicplasty, chondrocyte

130 transplantation, periosteal and perichondrial resurfacement and allograft transplantation are the favored "new methods". According to the early and medium term experiences of these methods, a hyaline or hyaline-like resurfacement of the defected area can provide a more durable gliding surface and a better clinical outcome than the so called "traditional resurfacing techniques". Autologous osteochondral mosaicplasty is an easy, one-step procedure, providing a relatively quick rehabilitation, can be an alternative in the treatment of small and medium sized lesions. Excellent clinical outcome, low costs of the treatment and short rehabilitation time represent the main advantages of this method. Autologous chondrocyte transplantation is a promising option in the treatment of larger full thickness defects but requires relatively expensive two-step procedure and longer rehabilitation period. Both of the above-mentioned techniques have femoral, tibial, patellofemoral and talar applications as well. According to the present recommendations, transplantation of osteochondral allografts can be indicated at massive osteochondral lesions. There are less experiences with the clinical use of periosteal and perichondrial resurfacing techniques and biomaterials. Beside the promising early and medium term results of these methods, a successful treatment of the fullthickness cartilage damages of the weight bearing surfaces depends not only the way of the cartilage repair but on the treatment of the underlying cause as well. According to this statement for an effective treatment of full thickness defects on the weight bearing surfaces requires careful patient selection, complex operative plan and well organized treatment course (1). Hyaline articular cartilage is an avascular and insensate tissue with a distinct structural organization, which provides a low-friction and wear-resistant interface for weight-bearing surface articulation in diarthrodial joints. Ideally, articular cartilage is maintained in homeostasis over the lifetime of an individual, with its biomechanical properties inherently suited to transmit a variety of physiologic loads through a functional range of motion. However, in the skeletally mature individual, articular cartilage does not heal effectively when injured. Although several restorative options for biomimetic replacement in acquired articular cartilage defects do exist, fresh osteochondral allografting currently remains the only technique that restores anatomically appropriate, mature hyaline cartilage in large articular defects. The fundamental paradigm of fresh osteochondral allografting is the transplantation of mature orthotopic hyaline cartilage, with viable chondrocytes that survive hypothermic storage and subsequent transplantation while maintaining their metabolic activity and sustaining the surrounding collagen matrix. Fresh osteochondral allografts have application in the treatment of a wide

131 spectrum of articular pathology, particularly conditions that include both an osseous and a chondral component. The surgical procedure for femoral condyle lesions is straightforward but demands precision to achieve reproducible results and to minimize early graft failures related to surgical technique. As with other cartilage-restorative procedures, the indications for use of fresh osteochondral allografts are still being expanded. Many clinical and basic scientific studies support the theoretical foundation and efficacy of small fragment allografting, although more scientific validation of empirical clinical practice is still needed (2).

Osteochondral transplantation of elbow Osteochondral allografts represent an alternative source of satisfactory tissue for reconstruction of skeletal deficits associated with traumatic, degenerative, and neoplastic disorders of the skeleton. Immune responses to graft-associated antigens have been evaluated, but their biological significance remains unknown. The use of massive osteochondral allografts in limb-sparing approaches for the treatment of bone tumors has been particularly rewarding. If the lesion is appropriately resected, the graft is properly implanted and protected, infection is avoided, and good and excellent clinical results can be anticipated in 75-80% of the cases (3). Searches were performed using MEDLINE and cartilage-specific key words to identify all English-language literature. Articles were selected based on their contributions to current understanding of the basic science and clinical treatment of articular cartilage lesions or historical importance. Seventy seven articles were selected, two of which were articles of historical importance. Current cartilage restorative techniques include débridement, microfracture, osteochondral fragment repair, osteochondral allograft, osteochondral autograft, and autologous chondrocyte transplantation. Pending techniques include two-staged cell-based therapies integrated into a variety of scaffolds, single-stage cell-based therapy, and augmentation of marrow stimulation, each with suggested indications including

132 lesion size, location, and activity demands of the patient. The literature demonstrates variable improvements in pain and function contingent upon multiple variables including indications and application (4). Despite significant improvements for the past 20 years in the treatment of full-thickness chondral defects with the use of chondroprotective biological methods (microfracture, autologous chondrocyte transplantation, osteochondral autograft, and periosteal graft), the treatment of large osteochondral defects in young and physically active population is still challenging. Alternatives for the treatment of chondral defects exceeding 3 cm in size are limited, and among them allografts have been used longer than any other treatment methods with the most favorable results. The success rates for osteochondral allograft transplantation have been reported as 95%, 71%, and 66% at 5, 10, and 20 years, respectively. Factors that adversely affect long-term results include advanced age, allograft transplantation to both sides of the joint, inappropriate loading, osteoarthritis, and osteonecrosis due to steroid use. Because of improvements in tissue-organ transplantation, increased availability of fresh tissue from donors, and increased demand from patients and physicians, there has been growing interest in the use of osteochondral allografts in selected patients to delay arthroplasty for chondral defects (5). Fresh osteochondral allografts have a long clinical history and have demonstrated use in a wide spectrum of knee joint pathology. The allografting procedure takes advantage of the unique characteristics of osseous and chondral tissue components. Transplanted bone is readily incorporated by the host while the articular cartilage survives transplantation. Allografts have demonstrated >75% clinical success in the treatment of focal femoral condyle lesions due to trauma, chondral injury, osteochondral trauma, osteochondritis dissecans, avascular necrosis, and post-traumatic reconstruction. Fresh allografts also are finding an increasing role in the salvage of difficult cases that have failed other cartilage procedures, particularly in individuals who are too young and active for joint arthroplasty. Further refinements in the technical aspects of the allografting procedure, as well as further understanding of the biology of osteochondral allografts, should lead to improved clinical outcomes (6).

133

Ostechondritis dissecans The surface of diarthrodial joints is covered by hyaline cartilage, whose regeneration capacity is extremely limited. Conventional surgical techniques enable repair of full-thickness articular cartilage defects only by fibrous cartilage having poor mechanical properties. Recently, new techniques have been developed to provide hyaline or hyaline-like repair tissue in the treatment of full-thickness cartilage defects. Autologous osteochondral transplantation involves press-fit implantation of both bone and cartilage obtained from healthy articular surface. The principal indication for this technique is unifocal full-thickness chondral or osteochondral defects measuring 1 to 4 square centimeters. This surgical procedure can be performed openly or arthroscopically. The graft should be placed vertically and evenly to the joint surface. Although short-term and mid-term results are satisfactory, several problems have been reported including donor site morbidity, damage to cartilage, incongruity and incorporation of the graft. Autologous osteochondral transplantation provides viable osteochondral units at a single stage and eliminates the need for culturing chondrocytes, which is quite expensive. Currently, no surgical technique or medical treatment provide complete healing of articular cartilage defects. Autologous osteochondral transplantation is an important stage worthy of improvement in this respect (7). Summary: among several surgical procedures, autologous osteochondral transplantation methods, including osteochondral mosaicplasty, chondrocyte transplantation, periosteal and perichondrial resurfacement and allograft transplantation are the favored "new methods" Autologous osteochondral transplantation involves press-fit implantation of both bone and cartilage obtained from healthy articular surface. The principal indication for this technique is unifocal

134 full-thickness chondral or osteochondral defects measuring 1 to 4 square centimeters. Osteochondral allografts represent an alternative source of satisfactory tissue for reconstruction of skeletal deficits associated with traumatic, degenerative, and neoplastic disorders of the skeleton. Allografts have demonstrated >75% clinical success in the treatment of focal femoral condyle lesions due to trauma, chondral injury, osteochondritis dissecans, avascular necrosis, and post-traumatic reconstruction. Current cartilage restorative techniques include débridement, microfracture, osteochondral fragment repair, osteochondral allograft, osteochondral autograft, and autologous chondrocyte transplantation. Techniques include two-staged cell-based therapies integrated into a variety of scaffolds, single-stage cell-based therapy, and augmentation of marrow stimulation, each with suggested indications including lesion size, location, and activity demands of the patient. References 1. Hangody L, Sükösd L, Szabó Z. Repair of cartilage defects. Technical aspects. Rev Chir Orthop Reparatrice Appar Mot. 1999;85(8):846-57. 2. Görtz S, Bugbee WD. Allografts in articular cartilage repair. Instr Course Lect. 2007;56:469-80. 3. Friedlaender GE, Mankin HJ. Transplantation of osteochondral allografts. Annu Rev Med. 1984;35:311-24. 4. Farr J, Cole B, Dhawan A, et al. Clinical cartilage restoration: evolution and overview. Clin Orthop Relat Res. 2011;469(10):2696-705. 5. Ozenci AM, Gür S, Aydin AT. Osteochondral allograft transplantation in the knee. Acta Orthop Traumatol Turc. 2007;41 Suppl 2:87-92. 6. Bugbee WD. Fresh osteochondral allografts. J Knee Surg. 2002;15(3):191-5. 7. Taşkiran E, Ozçelik C. Autologous osteochondral transplantation. Acta Orthop Traumatol Turc. 2007;41 Suppl 2:70-8.

OSTEOCHONDRAL REPAIR. Clinical outcomes and basic scientific investigations have supported the theoretic basis for fresh osteochondral allografting for cartilage defects in the knee. At the University of California, San Diego, the experience has encouraged to continue to offer this procedure as a primary treatment for both large and small articular cartilage defects in the young knee. The success rate of fresh osteochondral allografting, particularly in isolated femoral condylar defects, compares favorably with other presently available cartilage repair and resurfacing techniques. In second hundred cases, failure of monopolar allografts has been exceedingly rare in short-term follow-up. Fresh osteochondral allografting is

135 effective in treating larger osteochondral lesions, when there are few other attractive alternatives. Fresh osteochondral allografts can thus be used to treat a wide spectrum of articular pathology. Technical refinements, and improvement in understanding of graft-host interaction, as well as chondrocyte biology, should continue to improve clinical results. Disadvantages of fresh osteochondral allografting include the relative paucity of donor tissue, complexities in procurement and handling, and the possibility of disease transmission through the transplantation of fresh tissue. At present, only institutions that have overcome these obstacles seem capable of routinely performing this type of articular cartilage transplantation (1). Fresh osteochondral allografts have a long clinical history and have demonstrated use in a wide spectrum of knee joint pathology. The allografting procedure takes advantage of the unique characteristics of osseous and chondral tissue components. Transplanted bone is readily incorporated by the host while the articular cartilage survives transplantation. Allografts have demonstrated >75% clinical success in the treatment of focal femoral condyle lesions due to trauma, chondral injury, osteochondral trauma, osteochondritis dissecans, avascular necrosis, and post-traumatic reconstruction. Fresh allografts also are finding an increasing role in the salvage of difficult cases that have failed other cartilage procedures, and particularly in individuals who are too young and active for joint arthroplasty. Further refinements in the technical aspects of the allografting procedure, as well as further understanding of the biology of osteochondral allografts, should lead to improved clinical outcomes (2). Iliac bone grafting and matrix-guided autologous chondrocyte implantation can be combined to treat large osteochondral defects of the knee. In this prospective study, clinical and MRI findings were evaluated after one and two years of this treatment method. This study included 12 patients who completed a follow-up period of two years. Preoperative arthroscopic and MRI studies revealed grade 3 or 4 osteochondritis dissecans in all cases. In the first operation, a deep debridement of the sclerotic subchondral bone was performed, followed by press-fit filling of the defect with cancellous bone. In the second operation, a double-layer matrix-guided autologous chondrocyte implantation was fixed within the defect with fibrin glue. The clinical outcomes were evaluated using clinical scores. The clinical outcomes before and 24 months after surgery were as follows: the mean Meyers score increased from 10.2 to 18, Lysholm-Gillquist score increased from 56.6 to 100, and Tegner-Lysholm score increased from 1.8 to 4. These scores did not show notable changes after 12 months. On MRI images, subchondral edema within the bone graft disappeared until the sixth month. Within a year, MRI signal

136 intensity of the cartilage repair tissue approximated to the healthy surrounding cartilage. The thickness of the cartilage repair tissue increased from 1 mm to 1.8 mm within 6 to 12 months (3).

Posttraumatic osteoarthritis Fresh osteochondral allograft transplantation has been an effective treatment option with promising long-term clinical outcomes for focal posttraumatic defects in the knee for young, active individuals. Histological features of 35 fresh osteochondral allograft specimens were retrieved at the time of subsequent graft revision, osteotomy, or total knee arthroplasty. Graft survival time ranged from 1 to 25 years based on their time to reoperation. Histological features of early graft failures were lack of chondrocyte viability and loss of matrix cationic staining. Histological features of late graft failures were fracture through the graft, active and incomplete remodeling of the graft bone by the host bone, and resorption of the graft tissue by synovial inflammatory activity at graft edges. Histological features associated with long-term allograft survival included viable chondrocytes, functional preservation of matrix, and complete replacement of the graft bone with the host bone. Thus, given chondrocyte viability, longterm allograft survival depends on graft stability by rigid fixation of host bone to graft bone. With the stable osseous graft base, the hyaline cartilage portion of the allograft can survive and function for 25 years or more (4). Osteochondral defects of the femoral head are exceedingly rare, with limited treatment options. This report presents a young patient who had a symptomatic osteochondral defect of the femoral head developed secondary to trauma and underwent subsequent treatment using a fresh-stored osteochondral allograft via a trochanteric osteotomy. At the 1-year follow up, the patient was symptom free with near-complete incorporation of the graft radiographically. This observation suggests that osteoarticular implantation is an appropriate alternative treating osteochondral defects of the femoral head (5).

137

Chondrocytes from the allograft donor remain alive Sixty-four patients (66 knees) underwent fresh osteochondral allografting for the treatment of osteochondritis dissecans. Each patient was evaluated both preoperatively and postoperatively using an 18-point modified D'Aubigné and Postel scale. Subjective assessment was performed using a patient questionnaire. Radiographs were evaluated preoperatively and postoperatively. Mean follow-up was 7.7 years (range, 2-22 years). There were 45 men and 19 women with a mean age of 28.6 years (range, 15-54 years). All patients had undergone previous surgery. Forty-one lesions involved the medial femoral condyle, and 25 involved the lateral femoral condyle. All were osteochondritis dissecans type 3 or 4. The mean allograft size was 7.5 cm(2). One knee was lost to follow-up. Of the remaining 65 knees, 47 (72%) were rated good/excellent, 7 (11%) were rated fair, and 1 (2%) was rated poor. Ten patients (15%) underwent reoperation. The mean clinical score improved from 13.0 preoperatively to 16.4 postoperatively (p4 cm wide (mean 4.5 cm), and 4 were >5 cm wide. The mean follow-up period was 26 months (range 16-52 months). Patients were operated with a mini-open technique, and reconstructed after primary repair with 18 total and 28 partial free transfer of the coracoacromial ligament. Patients were evaluated by Constant-Murley score, and the degree of active flexion and abduction. Tendon thickness was measured with ultrasonography during follow-up. Mean preoperative shoulder flexion was 27.5° (range 5-40°), and mean abduction was 22.5° (range 10-30°). Shoulder flexion was significantly greater postoperatively (mean 102.6°, range 70-150°), as

150 was shoulder abduction (mean 96.5°, range 60-150°). Mean preoperative and postoperative Constant-Murley score was 45 and 80, respectively. Surgical complications, particularly recurrence, did not occur in any patient during the follow-up period. The integrity and tendon thickness of the repairs were similar to those of normal tendons at the end of follow-up. Augmentation with a free transfer of the coracoacromial ligament provides excellent and promising functional results in the operative treatment of massive rotator cuff tears with a mini-open technique (16).

Coracoclavicular reconstruction using semitendinosus graft Patellofemoral dislocations are common. In cases with recurrence or residual instability, surgical intervention is usually considered. Numerous treatment protocols have been used in the past to treat patellofemoral instability secondary to patella dislocation. Reconstruction of the medial patellofemoral ligament is one of the possible options, since it was acknowledged to have a major medial stabilizing role on the patella. A technique for reconstruction of the medial patellofemoral ligament using an autologous gracilis tendon graft is described by Goorens (17). The main aim of this study was to analyze whether MRI is useful in the follow-up of reconstruction of the ulnar collateral ligament of the MP joint of the thumb, to describe normal postoperative findings, and to evaluate different magnetic resonance sequences. This study material consists of 10 patients who, because of a chronic rupture of the ulnar collateral ligament of the thumb, had been operatively treated using a free tendon graft. The patients were, in addition to the clinical examination and radiographs, imaged using MRI both preand postoperatively. The postoperative MRI controls, undertaken at 2, 12 and 24 months were analyzed without knowledge of the clinical or radiographic findings. The reconstructed ulnar collateral ligament was visualized on MRI. One graft rupture was diagnosed on MRI and was later operatively confirmed. No increase in osteoarthritis of the MP joint of the thumb was seen during the follow-up. The single most

151 informative magnetic resonance sequence was T2TSE in the coronal plane. MRI provides a clinically valuable means of assessing graft integrity in patients with suspected postoperative graft failure after ulnar collateral ligament reconstruction, although is MRI unnecessary in the routine follow-up of patients with an uneventful recovery (18). The main objective of this study was to report emergency reconstruction of the complex dorsal digital defect using the composite flap with extensor tendon graft from the second toe. From February 2001 to March 2010, 6 fingers in 6 patients with complex dorsal digital defects were repaired using the composite flap. The defect of the extensor tendon was also repaired with the extensor tendon graft harvested from the second toe. All the flaps survived completely with primary healing. The patients were followed up for 5 to 10 years. The flaps had a good match in skin color and texture. Both the esthetic and functional results were satisfactory either in recipient or in donor sites. The emergency reconstruction of the complex dorsal digital defect using the composite flap with extensor tendon graft is an effective way to repair the skin defect and extensor tendon defect simultaneously with good long-term results (19). The clinical outcome of tendon reconstruction, using tendon graft or tendon transfer and the parameters related to clinical outcome in 51 wrists of 46 patients with rheumatoid arthritis with finger extensor tendon ruptures, was evaluated. At a mean follow-up of 5.6 years, the mean MP joint extension lag was 8 degrees (range, 0-45) and the mean visual analogue satisfaction scale was 74 (range, 10-100). Clinical outcome did not differ significantly between tendon grafting and tendon transfer. The MP joint extension lag correlated with the patient's satisfaction score, but the pulp-to-palm distance did not correlate with patient satisfaction. These data indicate that both tendon grafting and tendon transfer are reliable reconstruction methods for ruptured finger extensor tendons in rheumatoid hands (20). The palmaris longus and plantaris tendon are generally considered best for tendon grafting. The purpose of this study was to evaluate these tendons in regard to adequacy as tendon grafts. To evaluate adequacy for grafting, the palmaris longus and plantaris tendons were harvested from 92 arms and legs of 46 cadavers. Macroscopic evaluation and measurements concerning presence, length, and diameter of the tendons were obtained. Criteria for adequacy were a minimum length of 15 cm with diameter of 3 mm or, alternatively, 30 cm with a diameter of 1.5 mm. The palmaris longus tendon was present bilaterally in 36 cases and was absent bilaterally in 4 cases. The plantaris tendon was present bilaterally in 38 cases and absent bilaterally in 4 cases. In 29 cadavers, the palmaris longus tendon did not meet the criteria to be used as a tendon graft. Only in 8 cases the

152 tendons were satisfactory for bilateral grafting. The plantaris tendon met criteria for grafting in 20 cases bilaterally. In 17 cases, the tendons were considered inadequate bilaterally. Despite their presence, the palmaris longus and plantaris tendons were adequate for grafting less often than previously thought. In less than 50%, the tendons, although present, would serve as useful grafts. These findings underscore the importance of choosing a second donor site before surgery in case the primarily selected tendon is not found to be suitable (21). While conservative treatment is successful in most cases, partial rupture at the calcaneal insertion point is a significant concern with insertional Achilles tendinopathy. The outcomes of a surgical technique for Achilles tendon augmentation using a bone-tendon graft, harvested from the knee extensor system, are reported. A retrospective case series includes 25 surgical procedures performed in 24 patients, 19 males and 5 females, with a mean age of 47 (range, 30 to 59) years, 18 of whom were athletes. The mean follow up period was 52 (range, 12 to 156) months. All patients underwent MRI examination prior to surgery, which showed partial Achilles tendon rupture. The Achilles tendon was debrided through a posterolateral approach. The bonequadriceps tendon graft was harvested, and then the bone plug of the graft was inserted into a blind tunnel drilled into the calcaneous and fixed with an interference screw. The fibers of the quadriceps tendon were sutured to the residual part of the Achilles tendon with the foot at an angle of 90 degrees. Patients were able to resume their sporting activity after an average of 6.7 months. At last follow up examination, physical activity was scored 5.2 on the 10-point Tegner Scale; the mean AOFAS score was 98.4. MRI examination showed good graft integration 1 year postoperatively. These results show that the bonequadriceps tendon grafting technique is a good alternative for the insertional Achilles lesions with partial detachment which required augmentation (22). Assessment: tendon reconstructions, evaluated in this research, include: free semitendinosus tendon graft transfer due to Achilles tendon ruptures with large gaps (>6 cm); the bone-quadriceps tendon grafting for the insertional Achilles lesions with partial detachment; anatomic reconstruction of the lateral ankle ligaments using the long extensor tendon of the fourth toe; an autogenic, allogenic or synthetic graft for large ACL rupture; emergency reconstruction of the complex dorsal digital defect using the composite flap with extensor tendon graft from the second toe; reconstruction of the elbow motion in tetraplegic patients using the posterior portion of the deltoid muscle; dislocated sternoclavicular joint treated by open reduction and

153 reconstructive surgery by gracilis tendon graft technique; repair of massive rotator cuff tears; reconstruction of the medial patellofemoral ligament in patellofemoral dislocations; reconstruction of the ulnar collateral ligament of the MP joint of the thumb; and graft to protect and augment the repair of massive rotator cuff tears. Many graft options are available for ACL reconstruction, including different autograft and allograft tissues. Autografts include bonepatellar tendon-bone composites, combined semitendinosus and gracilis hamstring tendons, and quadriceps tendon. Allograft options include the same types of tendons harvested from donors, in addition to Achilles and tibialis tendons. Tissue-engineered anterior cruciate grafts are unavailable yet for clinical use, but may become a feasible alternative in the future. References 1. Cooper JL, Beck CL. History of Soft-Tissue Allografts in Orthopedics. Sports Medicine & Arthroscopy Review: 1993;1:1-16. 2. Reinhardt KR, Hetsroni I, Marx RG. Graft selection for anterior cruciate ligament reconstruction: a level I systematic review comparing failure rates and functional outcomes. Orthop Clin North Am. 2010;41(2):249-62. 3. Ahn JH, Choy WS, Kim HY. Reconstruction of the lateral ankle ligament with a long extensor tendon graft of the fourth toe. Am J Sports Med. 2011;39(3):637-44. 4. Inacio MC, Paxton EW, Maletis GB, et al. Patient and Surgeon Characteristics Associated With Primary Anterior Cruciate Ligament Reconstruction Graft Selection. Am J Sports Med. 2012;40(2):339-45. 5. Struewer J, Frangen TM, Ishaque B, et al. Knee function and prevalence of osteoarthritis after isolated anterior cruciate ligament reconstruction using bone-patellar tendon-bone graft: long-term follow-up. Int Orthop. 2012;36(1):171-7. 6. Romanini E, D'Angelo F, De Masi S, et al. Graft selection in arthroscopic anterior cruciate ligament reconstruction. J Orthop Traumatol. 2010;11(4):211-9. 7. Barrett AM, Craft JA, Replogle WH, et al. Anterior cruciate ligament graft failure: a comparison of graft type based on age and tegner activity level. Am J Sports Med. 2011;39(10):2194-8. 8. Noyes FR, Barber-Westin SD. Anterior cruciate ligament graft placement recommendations and bone-patellar tendon-bone graft indications to restore knee stability. Instr Course Lect. 2011;60:499-521. 9. Bencardino JT, Beltran J, Feldman MI, Rose DJ. MR imaging of complications of anterior cruciate ligament graft reconstruction. Radiographics. 2009;29(7):2115-26. 10. Mehta VM, Mandala C, Foster D, Petsche TS. Comparison of revision rates in bone-patella tendon-bone autograft and allograft anterior cruciate ligament reconstruction. Orthopedics. 2010;33(1):12.

154 11. Chen CH. Strategies to enhance tendon graft - bone healing in anterior cruciate ligament reconstruction. Chang Gung Med J. 2009;32(5):483-93. 12. Mascarenhas R, Tranovich M, Karpie JC, et al. Patellar tendon anterior cruciate ligament reconstruction in the high-demand patient: evaluation of autograft versus allograft reconstruction. Arthroscopy. 2010;26(9 Suppl):S58-66. 13. Sarzaeem MM, Lemraski MM, Safdari F. Chronic Achilles tendon rupture reconstruction using a free semitendinosus tendon graft transfer. Knee Surg Sports Traumatol Arthrosc. 2011 Oct 29. [Epub ahead of print] 14. Estrada Malacón CA, Torres Roldán F, Valdés Martínez L. Treatment of chronic lateral ankle instability with a minimally invasive technique with autologous peroneus brevis tendon graft. Acta Ortop Mex. 2009;23(1):3-8. 15. Cizmar I, Florian Z, Navrat T, Palousek D. A biomechanical study of a suture between the deltoid muscle and a free tendon graft for reconstruction of the elbow extension. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2011;155(1):79-83. 16. Bektaşer B, Oçgüder A, Solak S, et al. Free coracoacromial ligament graft for augmentation of massive rotator cuff tears treated with mini-open repair. Acta Orthop Traumatol Turc. 2010;44(6):426-30. 17. Goorens CK, Robijn H, Hendrickx B, et al. Reconstruction of the medial patellofemoral ligament for patellar instability using an autologous gracilis tendon graft. Acta Orthop Belg. 2010;76(3):398-402. 18. Lohman M, Vasenius J, Nieminen O, Kivisaari L. MRI follow-up after free tendon graft reconstruction of the thumb ulnar collateral ligament. Skeletal Radiol. 2010;39(11):1081-6. 19. Lin J, Yu YL, Wu C, et al. Emergency reconstruction of the complex dorsal digital defect using the composite flap with extensor tendon graft from the second toe]. Zhonghua Zheng Xing Wai Ke Za Zhi. 2011;27(2):101-3. 20. Chung US, Kim JH, Seo WS, Lee KH. Tendon transfer or tendon graft for ruptured finger extensor tendons in rheumatoid hands. J Hand Surg Eur Vol. 2010;35(4):279-82. 21. Jakubietz MG, Jakubietz DF, Gruenert JG, et al. Adequacy of palmaris longus and plantaris tendons for tendon grafting. J Hand Surg Am. 2011;36(4):695-8. 22. Philippot R, Wegrzyn J, Grosclaude S, Besse JL. Repair of insertional achilles tendinosis with a bone-quadriceps tendon graft. Foot Ankle Int. 2010;31(9):802-6.

BONE TISSUE ENGINEERING. The loss of cartilage and bone because of congenital defects, trauma and after tumor resection is a major clinical problem in head and neck surgery. The most prevalent methods of tissue repair are through autologous grafting or using implants. Tissue engineering applies the principles of engineering and life sciences in order to create bioartificial cartilage and bone. Most strategies for cartilage tissue engineering are based on

155 resorbable biomaterials as temporary scaffolds for chondrocytes or precursor cells. Clinical application of tissue-engineered cartilage for reconstructive head and neck surgery as opposed to orthopedic applications has not been well established (1).

Tissue engineering While in orthopedic and trauma surgery engineered constructs or autologous chondrocytes are placed in the immunoprivileged region of joints, the subcutaneous transplant site in the head and neck can lead to strong inflammatory reactions and resorption of the bioartificial cartilage. Encapsulation of the engineered cartilage and modulation of the local immune response are potential strategies to overcome these limitations. In bone tissue engineering, the combination of osteoconductive matrices, osteoinductive proteins such as bone morphogenetic proteins and osteogenic progenitor cells from the bone marrow or osteoblasts from bone biopsies offer a variety of tools for bone reconstruction in the craniofacial area. The utility of each technique is site dependent. Osteoconductive approaches are limited in that they merely create a favorable environment for bone formation, but do not play an active role in the recruitment of cells to the defect. Delivery of inductive signals from a scaffold can incite cells to migrate into a defect and control the progression of bone formation. Rapid osteoid matrix production in the defect site is best accomplished by using osteoblasts or progenitor cells (1). Biologic scaffolds have become an integral part of surgical soft tissue reconstruction in recent years. The increased use of these materials can be partially attributed to poor long-term outcomes with synthetic products as well as the cost and morbidity associated with allografts and autografts. Bioscaffolds can augment natural healing processes of tendons and ligaments while providing additional structural support. Although these implants lack the mechanical strength of synthetics and other transplants, proper preparation can optimize their load-sharing capacity. Available studies in foot and ankle applications have shown minimal complications in a variety of techniques (2).

156

Bioscaffolds Successful ACL reconstruction with a tendon graft necessitates solid healing of the tendon graft in the bone tunnel. Improvement of graft healing to bone is crucial for facilitating an early and aggressive rehabilitation and ensuring rapid return to pre-injury levels activity. Tendon graft healing in a bone tunnel requires bone ingrowth into the tendon. Indirect Sharpey fiber formation and direct fibrocartilage fixation confer different anchorage strength and interface properties at the tendon-bone interface. For enhancing tendon graft-to-bone healing, a strategy includes the use of periosteum, hydrogel supplemented with periosteal progenitor cells and bone morphogenetic protein-2, and a periosteal progenitor cell sheet. Future studies include the use of cytokines, gene therapy, stem cells, plateletrich plasma, and mechanical stress for tendon-to-bone healing. These strategies are currently under investigation, and will be applied in the clinical setting in the near future (3). Assessment: in bone tissue engineering the combination of osteoconductive matrices, osteoinductive proteins such as bone morphogenetic proteins and osteogenic progenitor cells from the bone marrow or osteoblasts from bone biopsies offer a variety of tools for bone reconstruction in the craniofacial area. Biologic scaffolds have become an integral part of surgical soft tissue reconstruction in recent years. Bioscaffolds can augment natural healing processes of tendons and ligaments while providing additional structural support. For enhancing tendon graft-to-bone healing, a strategy includes the use of periosteum, hydrogel supplemented with periosteal progenitor cells and bone morphogenetic protein-2, and a periosteal progenitor cell sheet. Future studies include the use of cytokines, gene therapy, stem cells, platelet-rich plasma, and mechanical stress for tendon-to-bone healing.

157 References 1. Rotter N, Haisch A, Bücheler M. Cartilage and bone tissue engineering for reconstructive head and neck surgery. Eur Arch Otorhinolaryngol. 2005;262(7):539-45. 2. Cook JJ, Cook EA. Bioscaffolds and the reconstruction of ligaments and tendons in the foot and ankle. Clin Podiatr Med Surg. 2009;26(4):535-43. 3. Chen CH. Graft healing in anterior cruciate ligament reconstruction. Sports Med Arthrosc Rehabil Ther Technol. 2009 23;1(1):21.

RECONSTRUCTION OF MUSCLES SKELETAL MUSCLES. Skeletal muscle tissue engineering is a promising interdisciplinary specialty which aims at the reconstruction of skeletal muscle loss caused by traumatic injury, congenital defects or tumor ablations. Due to the difficulty in procuring donor tissue, the possibilities for alternative treatment like autologous grafting (e.g. muscle flaps) are limited. This process also presents consistent problems with donor-site morbidity. Skeletal muscle tissue engineering tries to overcome this problem by generating new, functional muscle tissue from autologous precursor cells (stem cells). Multiple stem cells from different sources can be utilized for restoration of differentiated skeletal muscle tissue using tissue engineering principles. After 15 years of intensive research in this emerging field, for the first time, solutions using different strategies (e.g. embryonic stem cells, arterio-venous loop models, etc.) are presented to resolve problems like vascularisation of tissue engineered constructs (1). The engineering of functional skeletal muscle tissue substitutes holds promise for the treatment of various muscular diseases and injuries. However, no tissue fabrication technology currently exists for the generation of a relatively large and thick bioartificial muscle made of densely packed, uniformly aligned, and differentiated myofibers. In this study, a versatile cell/hydrogel micromolding approach where polydimethylsiloxane molds, containing an array of elongated posts, were used to fabricate relatively large neonatal rat skeletal muscle tissue networks with reproducible and controllable architecture. By combining cell-mediated fibrin gel compaction and precise microfabrication of mold dimensions including the length and height of the polydimethylsiloxane posts, simultaneously support high cell viability, guide cell alignment along the microfabricated tissue pores, and reproducibly control the overall tissue porosity, size, and thickness. The interconnected muscle bundles within the porous tissue

158 networks were composed of densely packed, aligned, and highly differentiated myofibers. The formed myofibers expressed myogenin, developed abundant cross-striations, and generated spontaneous tissue contractions at the macroscopic spatial scale. The proliferation of nonmuscle cells was significantly reduced compared to monolayer cultures. The more complex muscle tissue architectures were fabricated by controlling the spatial distribution and direction of the polydimethylsiloxane posts (2). The reconstruction of the lost skeletal muscle tissue function caused by congenital defects, tumor ablation, prolonged denervation, traumatic injury, or different myopathies (3) is hampered by the lack of functional tissue substitutes. Current surgical treatments, including autologous muscle transplantation and transposition, only yield a limited degree of success (4). An alternative approach is the transplantation of exogenous myogenic cells (satellite cells and myoblasts) in the site of injury. Previous clinical trials with intramuscular injection of skeletal myoblasts yielded poor outcomes due to inadequate distribution and low retention and survival of the injected cells (3). The implantation of an engineered skeletal muscle tissue, although surgically more complex, holds potential to improve retention and survival of the transplanted cells (5). In addition, the shape and architecture of the engineered muscle could be pre-designed for the precise structural repair at the site of damage (e.g., during craniofacial reconstruction). The engineered muscle could also be preconditioned for specific mechanically or metabolically demanding host environments (e.g., sarcopenic muscle in the elderly or at the site of traumatic injury). Upon implantation, the tissue graft is expected to incorporate into the host neuromuscular system and directly augment the compromised muscle function while potentially being designed to exert additional regenerative effects via localized delivery of angiogenic and anti-apoptotic paracrine factors (2). The reconstruction of skeletal muscle tissue lost either by traumatic injury or tumor ablation or functional damage due to myopathies is hampered by the lack of availability of functional substitution of this native tissue. Loss of muscle mass and their function can be surgically managed in part using a variety of muscle transplantation or transposition techniques. These techniques represent a limited degree of success in attempts to restore the normal functioning, however they are not perfect solutions. A new alternative approach to addressing difficult tissue reconstruction is to engineer new tissues. Although those tissue engineering techniques attempting regeneration of human tissues and organs have recently entered into clinical practice, the engineering of skeletal muscle tissue is still a scientific challenge (4).

159 MYOPATHIES. Transplantation of cells with the ability to differentiate into skeletal muscle is an approach under study for the treatment of some myopathies, mainly those of recessive genetic origin. Cells potentially useful for this purpose need to have one of the following properties (ideally the three): (i) ability to fuse with preexisting myofibers, (ii) ability to form new myofibers, and (iii) ability to produce myogenically committed stem cells. The first property allows integrating exogenous nuclei in the myofibers of the recipient. Exogenous nuclei can thus express therapeutic genes in myofibers that previously suffered a genetic disorder. The second property would be important to treat skeletal muscles in which there were severe loss of myofibers. The third property ensures a permanent source of normal myogenically committed stem cells in the recipient (6). Myoblasts were the first myogenic cells to be proposed for this therapeutic approach (7). In postnatal life, myoblasts derive from satellite cells, the committed stem cells of skeletal muscles. Satellite cells can be isolated from muscle biopsies by standard cell-culture techniques and can be easily expanded in vitro to produce large amounts of myoblasts, maintaining their capacity to fuse and to differentiate into myofibers (8). Myoblasts were the first myogenic cells transplanted in mice (9), dogs (10), monkeys (11), rabbits (12), and pigs (13). Duchenne muscular dystrophy is characterized by the absence of dystrophin in muscles. A therapeutic approach to restore dystrophin expression in Duchenne muscular dystrophy patient‟s muscles is the transplantation of muscle precursor cells. However, this transplantation is limited by the low muscle precursor cells capacity to migrate beyond the injection trajectory. Matrix metalloproteases are key regulatory molecules in the remodeling of extracellular matrix components. Muscle precursor cells over-expressing matrix metalloproteases-9 were tested by zymography, migration and invasion assays in vitro and by transplantation in mouse muscle. In vitro, muscle precursor cells over-expressing matrix metalloproteases have a better invasion capacity than control muscle precursor cells. When these cells are transplanted in mouse muscles, the transplantation success is increased by more than 50% and their dispersion is higher than normal cells. Matrix metalloproteases overexpression could thus be an approach to improve cell transplantation in Duchenne muscular dystrophy patients by increasing the dispersion capacity of transplanted cells (14).

160

Healthy muscles

Muscular dystrophy

Satellite cells after they have been grown in laboratory Myogenic cell transplantation is an experimental approach for the treatment of myopathies. In this approach, transplanted cells need to fuse with pre-existing myofibers, form new myofibers, and generate new muscle precursor cells. The last property was fully reported following myoblast transplantation in mice but remains poorly studied with human myoblasts. In this study, the intramuscular transplantation of postnatal human myoblasts in immunodeficient mice generates donor-derived muscle precursor cells and specifically donor-derived satellite cells. In a first experiment, cells isolated from mouse muscles 1 month after the transplantation of human myoblasts proliferated in vitro as human myoblasts. These cells were retransplanted in mice and formed myofibers expressing human dystrophin. In a second experiment, inducing muscle regeneration 2 months following transplantation of human myoblasts led to myofiber regeneration by human-derived muscle precursor cells. In a third experiment, abundant human-derived satellite cells in mouse muscles 1 month after transplantation of postnatal human myoblasts were detected by immunohistochemistry. These human-derived satellite cells may correspond totally or partially to the human-derived muscle precursor cells evidenced in the first two experiments. The data indicate that donor-derived satellite cells may be produced in patients who receive myoblast transplantation (6).

161 The goal of this work was to improve the myogenic potential of hMADS cells and assess the impact on muscle repair. Forced expression of MyoD in vitro strongly induced myogenic differentiation while the adipogenic differentiation was inhibited. Moreover, MyoD-expressing hMADS cells had the capacity to fuse with DMD myoblasts and to restore dystrophin expression. Importantly, transplantation of these modified hMADS cells into injured muscles of immunodepressed Rag2−/−γC−/− mice resulted in a substantial increase in the number of hMADS cell–derived fibers. This approach combined the easy access of MSCs from adipose tissue, the highly efficient lentiviral transduction of these cells, and the specific improvement of myogenic differentiation through the forced expression of MyoD. Altogether, these results highlight the capacity of modified hMADS cells to contribute to muscle repair and their potential to deliver a repairing gene to dystrophic muscles (15). Myoblast transfer therapy was proposed in the 70's as a potential treatment for muscular dystrophies, based upon the early results obtained in mdx mice: dystrophin expression was restored in this model by intramuscular injections of normal myoblasts. These results were quickly followed by clinical trials for patients suffering from Duchenne Muscular Dystrophy in the early 90's, based mainly upon intramuscular injections of allogenic myoblasts. The clinical benefits obtained from these trials were minimal, if any, and research programs concentrated then on the various pitfalls that hampered these clinical trials, leading to numerous failures. Several causes for these failures were identified in mouse models, including a massive cell death of myoblasts following their injection, adverse events involving the immune system and requiring immunosuppression and the adverse events linked to it, as well as a poor dispersion of the injected cells following their injection. These studies were conducted in mouse models, not taking into account the fundamental differences between mice and men. One of these differences concerns the regulation of proliferation, which is strictly limited by proliferative senescence in humans. Although this list is certainly not exhaustive, new therapeutic venues were then explored, such as the use of stem cells with myogenic potential, which have been described in various populations, including bone marrow, circulating blood or muscle itself. These stem cells presented the main advantage to be available and not exhausted by the numerous cycles of degeneration/regeneration, which characterize muscle dystrophies. However, the different stem candidates have shown their limits in terms of efficiency to participate to the regeneration of the host. Another issue was raised by clinical trials involving the injection of autologous myoblasts in infarcted hearts, which showed that limited

162 targets could be aimed with autologous myoblasts, as long as enough spared muscle was available. This resulted in a clinical trial for the pharyngeal muscles of patients suffering from Oculo-Pharyngeal Muscular Dystrophy. The results of this trial will not be available before 2 years, and a similar procedure is being studied for FascioScapulo-Humeral muscular Dystrophy. Concerning muscular dystrophies, which leave very few muscles spared, such as Duchenne Muscular Dystrophy, other solutions must be found, which could include exon-skipping for the eligible patients, or even cell therapy using stem cells if some cell candidates with enough efficiency can be found. Recent results concerning mesoangioblasts or circulating AC133+ cells raise some reasonable hope, but still need further confirmations, since we have learned from the past to be cautious concerning a transfer of results from mice to humans (3). Assessment: reconstruction of the lost skeletal muscle tissue function caused by congenital defects, tumor ablation, prolonged denervation, traumatic injury, or different myopathies is hampered by the lack of functional tissue substitutes. Current surgical treatments, including autologous muscle transplantation and transposition, yield a limited degree of success. An alternative approach is the transplantation of exogenous myogenic cells (satellite cells and myoblasts) in the site of injury. The intramuscular transplantation of postnatal human myoblasts in immunodeficient mice generates donorderived muscle precursor cells and specifically donor-derived satellite cells. A therapeutic approach to restore dystrophin expression in Duchenne muscular dystrophy patient‟s muscles is the transplantation of muscle precursor cells, and mesenchymal stem cells. Myoblast transfer therapy was proposed in the 70's as a potential treatment for muscular dystrophies, based upon the results obtained in mdx mice: dystrophin expression was restored in this model by intramuscular injections of normal myoblasts. These results were followed by clinical trials for patients suffering from Duchenne Muscular Dystrophy in the early 90's, based mainly upon intramuscular injections of allogenic myoblasts. Recently, the injection of autologous myoblasts in infarcted hearts is studied. This resulted in a clinical trial for the pharyngeal muscles of patients suffering from Oculo-Pharyngeal Muscular Dystrophy. A similar procedure is studied for Fascio-Scapulo-Humeral Muscular Dystrophy. A new alternative approach to addressing difficult tissue reconstruction is to engineer new tissues. Although tissue-engineering techniques, attempting regeneration of human tissues and organs, have

163 recently entered into clinical practice, the engineering of skeletal muscle tissue is still a scientific challenge. References 1. Stern-Straeter J, Riedel F, Bran G, et al.. Advances in skeletal muscle tissue engineering. In Vivo. 2007;21(3):435-44. 2. Bian W, Bursac N. Engineered skeletal muscle tissue networks with controllable architecture. Biomaterials. 2009;30(7):1401–12. 3. Mouly V, Aamiri A, Perie S, et al. Myoblast transfer therapy: is there any light at the end of the tunnel? Acta Myol. 2005;24(2):128–33. 4. Bach AD, Beier JP, Stern-Staeter J, Horch RE. Skeletal muscle tissue engineering. J Cell Mol Med. 2004;8(4):413–22. 5. Kondoh H, Sawa Y, Miyagawa S, et al. Longer preservation of cardiac performance by sheet-shaped myoblast implantation in dilated cardiomyopathic hamsters. Cardiovasc Res. 2006;69(2):466–75. 6. Skuk D, Paradis M, Goulet M, et al. Intramuscular transplantation of human postnatal myoblasts generates functional donor-derived satellite cells. Mol Ther. 2010;18(9):1689–97. 7. Partridge TA, Grounds M, Sloper JC. Evidence of fusion between host and donor myoblasts in skeletal muscle grafts. Nature. 1978;273:306–8. 8. Konigsberg IR. The differentiation of cross-striated myofibrils in short term cell culture. Exp Cell Res. 1960;21:414–20. 9. Watt DJ, Morgan JE, Partridge TA. Use of mononuclear precursor cells to insert allogeneic genes into growing mouse muscles. Muscle Nerve. 1984;7:741–750. 10. Bartlett RJ, Sharp NJ, Hung WY, et al. Molecular markers for myoblast transplantation in GRMD. Adv Exp Med Biol. 1990;280:273–8. 11. Kinoshita I, Vilquin JT, Gravel C, et al. Myoblast allotransplantation in primates. Muscle Nerve. 1995;18:1217–8. 12. Boubaker el Andalousi R, Daussin PA, Micallef JP, et al. Changes in mass and performance in rabbit muscles after muscle damage with or without transplantation of primary satellite cells. Cell Transplant. 2002;11:169–80. 13. Holzer N, Hogendoorn S, Zürcher L, et al. Autologous transplantation of porcine myogenic precursor cells in skeletal muscle. Neuromuscul Disord. 2005;15:237–44. 14. Pichavant C, Gargioli C, Tremblay JP. Muscular dystrophy. Intramuscular transplantation of muscle precursor cells over-expressing MMP-9 improves transplantation success. PLoS Curr. 2011 October 26;3: RRN1275. 15. Goudenege S, Pisani DF, Wdziekonski B, et al. Enhancement of myogenic and muscle repair capacities of human adipose–derived stem cells with forced expression of MyoD. Mol Ther. 2009;17(6):1064–72.

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HEMATOPOIETIC STEM Bone marrow transplantation, or perhaps more accurately, HSCT offers great promise for the treatment of a variety of diseases ranging from cancer, autoimmunity, aplastic anemia and other diseases of hematopoietic origin. Bone marrow transplantation originated as a means to repopulate the hematopoietic stem cell compartment after myeloablative exposure to radiation as a means of „rescue‟. It has evolved into a means to induce anti-tumor responses when used in cancer. HSCT can be either autologous (the transferred hematopoietic stem cells are obtained from the patient) or allogeneic (hematopoietic stem cells are from a donor that is, optimally, totally matched at the major histocompatibility complex loci and is related to the patient). Classically, HSCT involves some means of cytoreductive conditioning the recipient either by irradiation and/or by chemotherapy. Initially hematopoietic stem cells were provided exclusively by bone marrow cells. Subsequently, other sources that contain hematopoietic stem cells have shown efficacy for hematopoietic reconstitution including mobilized peripheral blood, and more recently, cord blood. The advent of non-myeloablative or reduced intensity conditioning has allowed HSCT to be performed in patients with advanced age due to lesser toxicities from the use of lower cytoreductive conditioning. Allogeneic HSCT engraftment requires immunosuppression and the anti-tumor effects are dependent upon the immune effector cells that are contained within or generated from the donor graft. The latter is supported by earlier observations that the relapse rates for allogeneic bone marrow transplantation were markedly lower than autologous bone marrow transplantation due to the occurrence of graft-versustumor effects after the transplant. However, allogeneic HSCT is hampered by significant toxicities, which currently limit its efficacy. These problems include: (i) GVHD, (ii) a profound period of immune deficiency following bone marrow transplantation leaving the patient susceptible to opportunistic infections, and (iii) donor graft rejection. Unfortunately, common means to prevent or treat GVHD with systemic immunosuppression (i.e. by corticosteroids and use of cyclosporin A) can lead to impaired immune recovery, increased opportunistic infections, and higher relapse rates (1). HSCT derived from bone marrow or peripheral blood has been used as a therapeutic procedure since the mid-seventies. In recent years, the number of transplants reported annually to the European Group for Blood and Marrow Transplantation Registry is approximately 23,500 including 38% of allogeneic and 62% of autologous procedures. In most developed countries, the incidence of

165 HSCT reaches 400/10 million inhabitants per year and 220/10 million per year in Poland. To recommend transplantation, it is necessary to compare the risk associated with the disease itself vs. that of the transplantation procedure which depends on the stage of the disease, patient's age, time interval from diagnosis to transplantation, donor type (siblings or unrelated subjects), sex of the donor and individual features. According to the European Group for Blood and Marrow Transplantation recommendations, the following categories of indications have been used: "standard procedure" category - S, "clinical option"- CO, indication of "developmental" character - D and "generally not recommended" - NR. The tabular presentation of indications is an approximation since approach to each patient should be individualized (2). INDICATIONS. The indications for HSCT (3) include: (a) Malignant diseases – leukemias, lymphomas, MM, and solid tumors, like breast cancer, and testicular cancer. In these indications, the cure or palliation is by the high doses of chemotherapy or radiation therapy, while the transplant serves to rescue the patient from the myelotoxic effect of the anticancer therapy. In allogeneic type of transplants, there is an additional immunological advantage of graft versus cancer effect, which contributes to the disease relief. (b) Nonmalignant diseases – thalassaemia, aplastic anemia, Gaucher's disease, bone marrow aplasia, severe immunodeficiencies, paroxysmal nocturnal hemoglobinuria, etc. In these conditions, the abnormal marrow is deliberately destroyed and replaced by donor marrow (3,4). Transplantation of hematopoietic stem cells from blood or bone marrow has become accepted therapy for many diseases. Numbers of transplants have increased significantly and stem cell source, donor type and indications have changed during this decade. Information on these changes is essential for interpretation of current data, patient counseling and health care planning. Since 1990, members of the European Group for Blood and Marrow Transplantation and teams known to perform blood or marrow transplants have been invited annually to report their transplant numbers by indication, donor type and stem cell source. Data from these surveys have been used to present data for 1998, to assess current status and to give numbers of transplants per participating country, coefficients of variation between countries for individual indications and changes in indication, stem cell source and donor type over the past decade. In 1998, 20,892 transplants were performed by 528 teams in 31 European countries. Of these transplants, 18,400 were first transplants, 5308 (29%) were allogenic, and 13 092 (71%) were autologous. Of the autologous transplants, 809 (6%) were bone marrow derived, and 12 283 (94%)

166 were from peripheral blood stems cells. Of the allogeneic transplants, 3372 (64%) were bone marrow derived, and 1936 (36%) were peripheral blood stem cell transplants. In 1990, the respective figures were 2137 allogeneic (50%) and 2097 (50%) autologous transplants, all exclusively bone marrow derived. Main indications in 1998 were leukemias with 6015 transplants (33%), 68% thereof allogeneic transplants; lymphomas with 7492 transplants (41%), 94% thereof autologous transplants; solid tumors with 4025 transplants (22%), 99% thereof autologous transplants; non-malignant disorders with 868 transplants (5%), 80% thereof allogeneic transplants. Absolute numbers of transplants per year did increase from 4234 in 1990 to 20,892 in 1998. Increase was higher for autologous, than for allogeneic transplants. There were differences in absolute or relative increase over time for individual indications. Transplant rates per number of inhabitants varied between countries, ranging from 0 to >500 total transplants per 10 million inhabitants with a clear correlation between number of teams and transplants per 10 million inhabitants (r=0.61, p10(9)/L. The primary end points were engraftment and incidence of acute GVHD. The secondary end points were the incidence of chronic GVHD, relapse, and overall disease-free survival. The study and control groups were comparable for age, sex, donor selections, conditioning regimens, and disease status. The median times to both neutrophil and platelet engraftment (absolute neutrophil counts > 0.5 x

169 10(9)/L; platelets > 20 x 10(9)/L) were significantly faster in the study group than in the control group, at 15 vs. 21 days (p