Solid organ transplantation is now a routine component of management
for organ failure of the kidney, liver, heart, lung, and intestine
in children. Improved patient selection, surgical technique, postoperative
care, organ preservation, and immunosuppression management has led
to tremendous improvements in both graft and patient survival. This
chapter addresses general issues confronted by all solid organ transplantation.
Renal, liver, multivisceral, and heart transplantation are discussed
in subsequent chapters. Hematopoietic stem cell transplantation
(bone marrow transplantation) is discussed in Chapter 133.
Children with progressive organ damage leading to likely end-stage
organ failure should be referred for possible transplantation. The
timing and role of transplant depends on the availability of other
clinical management alternatives, the risk of death from progressive end-stage
organ failure, and the likelihood of receiving a donor organ for
Children referred for transplant must undergo a thorough evaluation
that strives to achieve two objectives: (1) to determine whether
organ transplantation is the appropriate treatment for the child
being evaluated, and (2) to identify and evaluate any additional
medical, surgical, anatomic, or social considerations that may contraindicate
transplantation, or otherwise decrease the likelihood of a successful
outcome following transplantation, in the short and long term. A
complete understanding of the natural history of the underlying
disease, as well as any associated complications or manifestations
of the primary disease, is essential.
The results of all of the diagnostic tests, imaging studies,
and specialty consultations are then reviewed in a multidisciplinary
conference to determine the appropriateness of transplantation,
and to place the child on the national waiting list for transplant.
A specific care plan is developed for any medical, social, nutritional,
or other conditions identified during the evaluation.
Organ allocation policies are guided by the principles of equity
and justice—providing donor organs to those at the greatest
risk of death from their organ failure. The policies ensure that
all candidates waiting for a donor organ have an equitable opportunity
to receive a donor organ and, at the same time, avoiding futile
transplants. These policies assure the best outcomes for donor organs,
recognizing that these organs are a truly scarce resource.
The national transplant program in the United States is administered
by the United Network for Organ Sharing (UNOS). Members of UNOS
include transplant centers and organ procurement organizations that
must comply with existing policy governing organ donation and transplantation.
UNOS maintains a database in which all patients awaiting organ transplantation
at a transplant center and all donors managed by organ procurement
organizations are registered. A match run is performed to allocate
organs from a deceased donor to candidates waiting, in a specific
sequence, according to defined criteria, such as clinical urgency,
ABO blood type, and distance from donor hospital to transplant center, to
name a few.
There are currently more than 100,000 patients awaiting organ
transplantation on the UNOS waiting list; the approximately 2000
children make up a small ...