Kidney preservation with IGL-1 solution: a preliminary report

The University of Wisconsin (UW) solution is the most commonly used preservation solution. However, a new preservation solution-IGL-1-contains an inversion of K and Na concentrations and substitution of polyethylene glycol for hydroxyethyl starch in the UW solution. The present study is the first clinical experience on the outcome of kidneys preserved in IGL-1 solution. From June 2003 to June 2004, 119 cadaveric kidneys were retrieved and stored in IGL-1 solutions; among the 119 organs, this study includes 37 IGL-1-preserved kidneys that were locally transplanted versus 33 kidneys stored in University of Wisconsin (UW) solution that were also locally transplanted. The groups were comparable with regard to donor and recipient characteristics. Renal function outcome was evaluated by comparing delayed graft function (DGF) rates, the evolution of serum creatinine, daily urine output, and creatinine clearance. Biopsies were performed after reperfusion to evaluate apoptosis. The incidence of DGF was 5.71% among IGL-1 kidneys and 13.79% among UW kidneys. Creatinine values were significantly lower among the IGL-1 group from 2 to 14 days postoperative and at 1 month. Daily urinary output did not show any significant differences between the two groups. IGL-1 kidneys had a superior creatinine clearance during the first 15 postoperative days compared to UW kidneys. Kidneys preserved in IGL-1 solution showed fewer apoptotic cells compared to kidneys preserved in UW solution. This preliminary report suggests a superiority of IGL-1 for the immediate outcome of transplanted kidneys.

[Inequalities to the access of renal transplantation for French patients living in the overseas French territories]

This study explored the access to the French national renal transplantation waiting list and the waiting time before transplantation for the patients with ESRD on dialysis living in the FOT. Overseas health authorities gave data on ESRD incidence and prevalence. Data on patients registered between 1997 and 2000 were extracted from the French national waiting list (390 patients from the FOT and 9378 from continental France). Registered prevalence of ESRD in FOT (726 to 1418 per million population (pmp)) were higher than continental France (580 pmp). The yearly incidence of registration on the national French waiting list was 36 pmp. The same figure was observed in the FAT (French Guyana and Caribbean's islands: 36.8 to 43 pmp), very low in New Caledonia and Tahiti (7.7 and 18.1 pmp), and very high in the Reunion Island, where a renal transplantation unit is available (77.5 pmp). Median waiting times before transplantation varied significantly, FAT: 35.4 months, Reunion Island: 9.9 months, Pacific Territories: 8.8 months and the Metropolitan territory: 12.2 months. After adjustment on risk factors known to be associated with the waiting times before transplantation, we still observed a longer waiting time for patients from FAT (RR = 1,4, p < 0.05) and a lower waiting time for patients from Reunion Island (RR = 0.6, p < 0.001) compared to waiting time observed in patients from continental France. Consequently, transplantation teams in FAT must be developed.

Cornea procurement from very old donors: post organ culture cornea outcome and recipient graft outcome

AIM

To study the suitability of corneas from very old donors for graft after banking and their clinical and endothelial outcomes in recipients.

METHODS

419 corneas stored in organ culture were divided into group 1, donors under 85 years (330 corneas) and group 2, "very old" donors aged 85 years and over (89 corneas). Endothelial cell density (ECD) before and after organ culture, discard rate before and after storage, and clinical and endothelial outcomes of the 196 penetrating keratoplasties (PKP) (158 in group 1 and 38 in group 2) were compared in a prospective longitudinal study.

RESULTS

Initial ECD was lower in group 2 than in group 1 and elimination for low ECD was more frequent in group 2 (respectively 38% v 20.2%, p=0.001). At the end of storage, because very old corneas lost fewer ECs than younger ones (respectively 4.2% v 9.5%, p=0.022), ECD was comparable between the two groups. The corneas of very old donors had a poorer macroscopic appearance at procurement and during surgery. Despite this, in grafted patients, overall graft survival in groups 1 and 2 (respectively 87.4% v 80.6%, p=0.197), visual acuity, and ECD did not differ at completion of the study (mean follow up 25 months).

CONCLUSION

This study suggests that endothelial cell count during banking ensures that functional and cellular results of PKPs are not dramatically influenced by very old donor age. Considering Europe's ageing population, the very elderly should not be deemed off limits for corneal procurement.

Advantages of using a bank of allogenic keratinocytes for the rapid coverage of extensive and deep second-degree burns

In 1975, serial subculture of human keratinocytes was first described. Clinical application of this discovery was made possible after the preparation of these cells into epithelial sheets. In 1981, the earliest application of cultured autologous epithelia was made for the treatment of extensive third-degree burns. Although the most important advantage is the large surface area obtained from a relatively small biopsy of healthy skin from the patient, a disadvantage is the delay, which is too long, especially for the treatment of extensive deep burns. This delay leads to denutrition and infection of the burn wounds, which in turn risks the life of the patient and jeopardizes the engraftment of the cultures. More recently, allogenic cultured epidermis, obtained more quickly from donor skin, has been described in the treatment of leg ulcers, repair of skin donor site harvested for split thickness autograft, dermatological diseases and in second-degree burns, although limited to certain areas. In this last case, grafted cells act by stimulation of epithelialisation from the adnexal appendages. To be able rapidly to treat patients suffering extensive and deep second-degree burns, a bank of allogenic keratinocytes has been created, with due attention to safety and security. The paper demonstrates the advantages of using allogenic keratinocytes in the first phase of treatment of a 97% deep second-degree burn patient awaiting autologous cultured keratinocytes. The time required for complete healing achieved using such a strategy is compared with the results obtained after treatment using autologous sheets of two patients burnt on 80% and 82% of their total body area. The treatment of these two latter patients is relatively long and complicated by potentially lethal problems. In the 97% burnt patient, however, the clinical course is shorter and without complication. Moreover, autologous and allogenic cultured epithelia give good aesthetic results, without the mesh aspect obtained with a split-thickness autograft, and also without the discomfort for the patient of removing a sample of skin. Deep second-degree burns are an application of choice for the cultured epithelia, as the presence of the dermis avoids retractions responsible for functional complications usually observed in third-degree burns where dermis is absent. Because of the safety of the bank of allogenic keratinocytes, the treatment of extensive and deep second-degree burns has become safer and faster, with better functional and aesthetic results.

French legal framework relating to human tissues and cells

Thousands of patients receive human tissue grafts every year. Developments in cell and tissue engineering have also increased considerably the number of available products of human origin. France has very strict regulations, in part stimulated by problems of public health and ethics that have emerged in recent years and also in part as a result of a report by the 'Inspection Générale des Affaires Sociales' on the removal and grafting of human tissues in May 1993. These have resulted in two laws on bio-ethics being passed, in July 1994, that are the basis of current legislation and represent the first steps in differentiating between organs and tissues or cells. Henceforth, the French legal framework covering tissues and cells of human origin has been increased to include a large number of legislative texts and regulations. The fundamental ethical principles that are consent, free donation, anonymity, no publicity and respect for public health have become a major ethical imperative that applies to all products originating from the human body including tissue and cells. In addition, specific provisions have been made covering: removal (conditions for removal and system for authorization); conservation, transformation, distribution, packaging, import and export of tissues and cells; and tissue and cell grafts. Finally, penal and administrative sanctions have been foreseen where there is non-compliance with these regulations.

[Which graft for which patient? and when? III. Organization schema of organ procurement and graft coordination]

Organ and tissue procurement strongly increased during the past decades to become a common activity among accredited hospitals. Structuring efficient regional organ procurement organisations appear as an important goal in order to offer the relevant number and quality of transplants to the patients on the national waiting list maintained by the Etablissement français des Greffes. Two structures acting together coordinate organ and tissue procurement: (i)accredited hospitals allocate some medical and non medical personal interfacing; (ii) the Etablissement français des Greffes through one of its seven regional units or its national unit. These units are in charge with the operational responsibility of multiorgan and tissue retrieval co-ordination in their geographical area, with organ allocation and with an institutional role of local and regional organ procurement development and promotion.

[Can hydroxyethylamidon be used during intensive care of brain-dead organ donors?]

In France, most of the kidney grafts are obtained from brain dead organ donors. Brain death induces numerous changes, especially in haemodynamic status, requiring the infusion of large volumes of fluid. The aim of this study was to evaluate the effect of hydroxyethyl starch (HES) on the organ donors and the kidney graft function in recipients. We compared two groups of brain dead organ donors and the kidney grafts, differing by the infused solutions: either a combination of HES (Elohes, Biosedra) and 4% human albumin solutions (HES group), or albumin alone in the control group (Albumin group). In the two groups, sex-ratio, age, cause of brain death and duration of therapy were similar. Fluid requirements were identical in the two groups: respectively 2,211 +/- 1,512 mL in the Albumin group vs 2,452 +/- 1,094 mL in the HES group (p = 0.17). However, the volume of albumin was significantly decreased in the HES group: 711 +/- 822 mL (p = 0.0001). Therefore the cost was lower in the latter: 638 +/- 633 vs 1766 +/- 788 FF. The coagulation status was not significantly different between the two groups. Amylasemia was higher in the HES group, but the difference was not significant. In the Albumin group, urinary output increased, but not significantly and creatinemia was decreased: 113.9 +/- 62 vs 131.5 +/- 44 mumol.L-1 (p < 0.05). The two groups of recipients were also similar for sex-ratio, age, kind of graft, cause of the chronic renal failure and ischaemia times.(ABSTRACT TRUNCATED AT 250 WORDS)