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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.

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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 transplant.

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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.

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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.

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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.

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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.

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There are currently more than 100,000 patients awaiting organ transplantation on the UNOS waiting list; the approximately 2000 children make up a small ...

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