CHU Besançon - Limoges : 7e naissance mondiale après autogreffe de tissu ovarien,1ère en France

"3,7 kg, c'est le poids de la petite fille qui a vu le jour hier au CHU de Besançon. L'enfant et la maman se portent bien. C'est la 7e naissance après autogreffe de tissu ovarien au monde et la première nationale !"

"En 2005, au CHU de Besançon, une patiente atteinte d'une pathologie hématologique a pu bénéficier d'une congélation de tissu ovarien, en prévision d'un traitement curatif mais stérilisant. En 2008, ce tissu ovarien lui a été greffé dans l'espoir de satisfaire à son désir d'enfant. La greffe a été un succès : elle a permis une restauration de sa fertilité suivie d'une grossesse spontanée menée à terme.
Ce succès est le fruit d'une collaboration entre les CHU de Besançon et de Limoges. Une première grossesse avait été obtenue au CHU de Limoges en 2008 mais il s'agissait malheureusement d'une grossesse extra-utérine. Cette patiente est de nouveau enceinte de 20 semaines d'aménorrhée."

Chronologie des événements
"Au CHU de Besançon, une patiente suivie depuis sa petite enfance pour une maladie du sang, une forme grave de drépanocytose, et présentant de nombreuses complications dues à cette maladie s'est vu proposer en 2005 à l'âge de 20 ans (par le professeur Pierre Simon ROHRLICH des services d'hématologie et de pédiatrie), un traitement curatif de sa maladie : une greffe de moelle osseuse provenant d'un donneur compatible. Cette greffe de moelle osseuse nécessitant une destruction des cellules de la moelle osseuse de la patiente par l'administration d'une chimiothérapie intensive, hautement toxique pour sa fonction ovarienne donc stérilisante, il lui a été proposé une autoconservation de son tissu ovarien."

Cryoconservation du tissu ovarien
"Fin 2005, avant l'administration de ce traitement gonadotoxique, un ovaire a été prélevé chez la patiente par le Docteur Germain AGNANI du service de Gynécologie Obstétrique. La zone externe de cet ovaire (la corticale) riche en follicules a été disséquée en petits fragments qui ont été conditionnés, congelés et cryoconservés à -196°C dans l'azote liquide par l'équipe du Pr Christophe ROUX (Unité de biologie de la Reproduction, Cryobiologie - CECOS du service de Génétique Histologie Biologie du Développement et de la Reproduction)."

Autogreffe de tissu ovarien cryoconservé
"En avril 2008, la patiente guérie de sa maladie hématologique mais stérile car ménopausée prématurément suite à la chimiothérapie administrée, désireuse d'avoir un enfant avec son mari, a bénéficié, après accord de l'équipe multidisciplinaire et après avis du comité d'éthique clinique et de la Délégation à la Recherche Clinique et à l'Innovation du CHU, d'une greffe de son tissu ovarien préalablement congelé.
Cette autogreffe a nécessité une décongélation des fragments de corticale ovarienne et une greffe de ces fragments à la patiente. Pour cette greffe proprement dite le Pr Christophe ROUX et le Dr Germain AGNANI se sont adjoints les services du Dr Pascal PIVER du CHU de Limoges, responsable du centre d'assistance médicale à la procréation, Service de Gynécologie Obstétrique du Pr Yves AUBARD, équipe ayant déjà une longue pratique de la greffe d'ovaire chez l'animal puis chez l'homme.

La technique chirurgicale de greffe utilisée pour la patiente fait l'objet d'une communication orale par le Dr Pascal PIVER au 25e congrès de l'ESHRE (European Society of Human Reproduction and Embryology) (Amsterdam 28 juin - 1 juillet 2009)."

Reprise de la fonction gonadique et grossesse
"Un suivi régulier de la patiente au centre d'assistance médicale à la procréation (AMP) du CHU de Besançon a permis de s'assurer de la réussite de la greffe, de la reprise de la fonction ovarienne, et à l'équipe d'AMP d'effectuer un monitorage d'un cycle ovulatoire chez la patiente afin de lui permettre d'obtenir une grossesse spontanée après rapports sexuels programmés avec son conjoint."

Indications de la Cryopréservation de tissu ovarien
"La cryopréservation de tissu ovarien est proposée à des petites filles ou à des femmes jeunes devant subir une chimiothérapie et/ou une radiothérapie lourde(s) pour une maladie qui peut être cancéreuse ou non. Ces traitements administrés sont très souvent responsables d'une stérilité par destruction des cellules ovariennes nécessaires à la reproduction. Le cours délai entre le diagnostic et la mise en route du traitement, le très jeune âge des patientes, l'absence de conjoint sont autant de facteurs qui rendent illusoires d'envisager, avant le traitement, la réalisation d'une tentative d'assistance médicale à la procréation avec congélation d'ovocytes et/ou d'embryons pour tenter de préserver la fertilité de ces patientes. L'autoconservation de tissu ovarien est alors la seule alternative que l'équipe médicale pluridisciplinaire peut proposer à la patiente pour préserver sa fertilité et lui permettre d'avoir, avec ses propres gamètes, un enfant qui, génétiquement, sera le sien.

Cette cryopréservation d'ovaire nécessite le prélèvement de tout ou d'une partie d'un ovaire, acte chirurgical qui se fait généralement par coelioscopie sous anesthésie générale et qui peut être isolé ou réalisé au cours d'une autre intervention nécessaire à la prise en charge de la maladie de la patiente."

Cryopréservation de tissu ovarien au CHU de Besançon
"Depuis 2003, le CHU de Besançon effectue des cryopréservations de tissu ovarien. Les premières tentatives ont fait l'objet d'un protocole de recherche clinique multicentrique coordonné par le CHU de Limoges. Cette pratique d'autoconservation de tissu germinal ovarien est depuis prévue par la loi n°2004-800 du 6 août 2004 (Article L2141-11) et son régime d'autorisation réglementé par le décret n°2006-1660 du 22 décembre 2006 (Article 3). Le CHU de Besançon est actuellement agréé pour ce type d'activité.

Les prélèvements d'ovaire sont effectués, selon l'âge de la patiente, soit en chirurgie infantile, soit en chirurgie gynécologique. La préparation des fragments d'ovaire, leur congélation et leur cryoconservation sont réalisées dans les unités de Biologie de la reproduction et cryobiologie-CECOS du service de Génétique Histologie Biologie du Développement et de la Reproduction du CHU. Au CHU de Besançon, l'âge des patientes au moment de la congélation d'ovaire s'échelonne de 6 à 30 ans."

La greffe de tissu ovarien
"La réutilisation par autogreffe du tissu ovarien cryoconservé est actuellement la seule technique envisageable quand la patiente ayant sa fonction ovarienne irrémédiablement perturbée, désire un enfant. Cette greffe implique que la patiente soit guérie de sa maladie, qu'il n'y ait pas de contre-indication à la grossesse et que la greffe d'ovaire ne présente pas un risque de réintroduction de cellules anormales dans l'organisme. Les techniques de greffe ayant permis des naissances dans le monde ont toutes consisté à replacer les fragments d'ovaire au niveau de l'ovaire restant et/ou dans la région anatomique des ovaires. En cas de succès de la greffe, si une reprise de la fonction ovarienne se manifeste, celle-ci ne semble pas pouvoir excéder quelques années et peut nécessiter la greffe de nouveaux fragments cryoconservés ; à défaut la patiente pourrait se retrouver ménopausée prématurément.
On ne peut écarter la possibilité dans le futur de ne plus avoir recours à la greffe, mais de pouvoir obtenir en laboratoire par culture in vitro, à partir des ovocytes immatures des fragments congelés, des ovocytes utilisables en technique de fécondation in vitro."

Résultats et retombées de la greffe
"Cette naissance fait suite à :

- un prélèvement d'ovaire réalisé en 2005 par le Dr Germain Agnani, du CHU de Besançon ;
- une congélation, une cryoconservation du tissu ovarien et une préparation des greffons (2005 à 2008) par le Pr Christophe Roux, du CHU de Besançon ;
- une autogreffe de tissu ovarien réalisée au CHU de Besançon (2008) par le Dr Pascal Piver, du CHU de Limoges.

C'est une première nationale en terme de naissance et le premier cas mondial dans le cadre d'un traitement pour drépanocytose. Elle offre un espoir de préservation de la fertilité chez des femmes susceptibles de recevoir un traitement stérilisant et pouvant être candidates à la cryoconservation de leur tissu ovarien.

Ces résultats doivent encourager le développement des recherches médicales dans ce domaine.

En effet, si cette greffe a pu être effectuée à Besançon en 2008, les modalités de réutilisation de tissu gonadique cryoconservé sont actuellement du domaine de la recherche suite à la publication de l'arrêté relatif aux règles de bonnes pratiques cliniques et biologiques d'assistance médicale à la procréation, le 23 mai 2008. Une organisation et des moyens devront être mis en place rapidement pour permettre de poursuivre en France les avancées dans ce domaine."

Contacts presse

Pr Christophe ROUX
Service de Génétique Histologie Biologie du Développement et de la Reproduction - CHU de Besançon Tél. 03 81 21 86 98

Dr Pascal PIVER
Service de Gynécologie Obstétrique - CHU de Limoges Tél. 05 55 05 64 72 ou 05 55 05 63 06

Philippe FRUGIER
Responsable communication
Tél. 05 55 05 62 49 - philippe.frugier@chu-limoges.fr

Sophie Muraccioli - CHU de Besançon
Chargée de communication
Tél. 03 81 21 86 26 – smuraccioli@chu-besancon.fr

Secrétariat de la direction générale - CHU de Besançon Tél. 03 81 21 82 15

Source :
La Lettre "Réseau-CHU"
N° 475 - 30 juin 2009

Stranger kidney donations rising

donor kidney: People can live normal, healthy lives with just one kidney

"Twenty-two people have given a kidney to a stranger since the practice became possible in the UK two years ago, the body in charge of such donations says. Ten put themselves forward in the first year and 15 in the second - three of these have not yet undergone surgery."

"'The Human Tissue Authority (HTA), which decides whether people are suitable, said the numbers were 'remarkable'.

There are currently 7,000 people waiting for a kidney in the UK amid a serious shortage of donor organs.

To help tackle this shortage, the HTA changed the rules at the end of 2006 to allow those who were not related - either genetically or through marriage - to become living donors.

'Altruistic act'

'We expected to see a small number of cases when we first started approving this type of transplant, but we did not expect to see the number rise so significantly after just one year,' said Vicki Chapman, director of policy and strategy at the HTA.

'Donating a kidney to someone you do not know really is an altruistic act; the medical tests take time and the procedure is not without risk.

The donors I have come across are genuinely altruistic, they decide that, on balance, donating is unlikely to do them any harm but will transform someone else's life'"

Peter Rowe
Nephrologist
"'I gave away my kidney'"

"'It is the role of the HTA to ensure that those giving so generously fully understand the risks involved.'

The rates of living donations among relatives have also increased, with 1,008 such donations approved in 2008/2009 compared with 961 the previous year.

More than 1,000 other transplants were carried out using organs from deceased donors.

Living donations offer a number of advantages over organs given after death.

The quality of the organ is likely to be higher and surgery can be planned in advance.

Evidence suggests that the long-term success rate for the recipient is higher when he or she has received a living organ.

No pressure

As with all surgery, the operation for the donor is not risk-free and they must undergo a series of rigorous checks in the run-up to the donation.

Assessments are also carried out to ensure that they are not under any pressure to donate, and consent is given freely and voluntarily.

Then, if they are found to be a suitable donor, they will be matched with a recipient.

There are no long-term consequences to living with just one kidney, the organ responsible for removing waste from the body.

When one of the pair is removed, the remaining organ simply increases in size and capacity to compensate.

Plymouth Hospitals NHS Trust has carried out three of the 22 altruistic transplants.

'The donors I have come across are genuinely altruistic, they decide that, on balance, donating is unlikely to do them any harm but will transform someone else's life,' said consultant nephrologist Peter Rowe.

'It would have been difficult for a living person to donate an organ altruistically before the HTA code of practice was published, but now we have a robust regulatory framework to work to.'

A spokesman for Kidney Research UK said: 'We welcome the figures but obviously there's still more that should be done to encourage organ donation, especially when you consider that 7,000 people are currently in need of a kidney.'"

http://news.bbc.co.uk

First Artificial Heart Implanted Successfully

Artificial Heart Implanted

"The first successful artificial heart implant in the nation outside of a clinical trial was undertaken by surgeons at Robert Wood Johnson University Hospital in New Jersey reported Abiomed Inc."

"AbioCor Total Replacement Heart, a self contained devise mostly made of titanium and plastic designed to be fully implantable was implanted in a 76 year old man with congestive, end stage heart failure. He became eligible for the innovative procedure as he did not qualify for a heart transplant or other available therapies and was determined to be in severe end-stage heart failure.

The surgery was led by Dr. Mark Anderson, associate professor of surgery at UMDNJ-Robert Wood Johnson Medical School and chief of the section of cardiac surgery at both the medical school and Robert Wood Johnson University Hospital. He was assisted by Dr. Juan Plate, assistant professor of surgery at UMDNJ-Robert Wood Johnson Medical School and an attending surgeon at Robert Wood Johnson University Hospital.

Anderson is one of the few physicians nationwide trained to perform this procedure and the hospital is one of only three centers nationwide approved to perform the surgery and the only one in the New York and Philadelphia areas. The Centers for Medicare and Medicaid Services agreed to cover the USD 250,000 item.

'Congestive heart failure in this country is really an epidemic,' added Anderson. 'Currently, for patients who are non-transplant candidates, there is really no good option for them. They are faced kind of a slow, or sometimes rapid death, but with really a poor quality of life.'

Approved by the Food and Drug Administration in September 2006, the AbioCor, Total Replacement Heart is the world's first completely self-contained, fully implantable artificial heart and also the first internal artificial organ.

Unlike older artificial hearts that have external power devices that patients must keep with them at all times, the AbioCor Total Replacement Heart has an internal motor that simulates a heartbeat, along with a rechargeable battery.

'Obviously, everyone has been waiting for a really viable, total artificial heart and it's been a long time in the making,' said Anderson. 'This particular device has been in development for about 30 years - just to give you an idea of the effort and the time it took to development something like this.'

Abiomed said the operation took place more than a week ago, and the patient is 'showing signs of a strong and stable recovery.' The hospital and UMDNJ-Robert Wood Johnson Medical School declined to divulge the patient's identity or where he lives and asked that the patient and his family's privacy and confidentiality be respected during his critical recovery period.

Abiomed stock rose 7 cents to USD 8.27 in afternoon trading."
http://topnews.us

"Multi-donor, long-distance kidney swap: a first in Canada"

"Domino kidney transplants mean fewer people are left on waiting lists, says Dr. Edward Cole.Domino kidney transplants mean fewer people are left on waiting lists, says Dr. Edward Cole. (CBC)"

"Four Canadians have new kidneys thanks to the country's first pay-it-forward exchange of organs from Toronto, Edmonton and Vancouver.

Living-donor kidney swaps are based on the idea of group co-operation: a donor whose kidney isn't compatible with a loved one who needs a new kidney agrees to donate to a stranger. In exchange, the partner receives a kidney from someone else.

Simultaneous kidney swaps have been done in Toronto before, but this multi-city swap had to be carefully co-ordinated across three time zones.

'It's been challenging,' said Dr. Edward Cole, chair of the National Living Donor Kidney Exchange Program. 'This is a real success story of people collaborating across the country, and with important input from Canadian Blood Services.'

Timing is key, given ethical fears that once a patient receives a kidney, their partner could rescind an offer to donate. A donor or recipient might also have to back out after falling sick.

To avoid any last-minute problems, all donors were put under general anesthesia and none of the donor operations were started until all surgeons confirmed by telephone that they were ready to begin.

In this case, donors travelled to where the recipients were: two to Toronto General Hospital, one to Edmonton's University of Alberta Hospital, and another to St. Paul's Hospital in Vancouver. Each site had more than 50 medical personnel involved.

It's also possible to fly kidneys between cities, since the organs remain viable for 12 hours after donation.

For some patients with severe kidney failure, a donation from a live donor offers better and faster results than transplants from deceased donors, said Cole, who is also the head of the University Health Network's kidney transplant program in Toronto.

Good Samaritan

In kidney swaps, the living donors are medically acceptable but are incompatible with their loved one based on blood type and other traits. The intricate process was featured on an episode of Grey's Anatomy.

There are 4,380 on Canadians on the kidney transplant waiting list, according to the Canadian Organ Replacement Registry. In many cities, people wait seven or eight years for a kidney from the time they start dialysis, said Dr. Edward Cole, chair of the National Living Donor Kidney Exchange Program.

Previously it has not been possible to use donors in this way because there was no national database to co-ordinate the matches.

Three of the donors had offered to give loved ones a kidney before, but weren't the right match. The fourth donor was a Good Samaritan.

'The best untold story is that one of the donors is an anonymous donor,' said Dr. Sandra Cockfield, medical director of the renal transplant program at the University of Alberta.

'So this is an individual who came forward to donate not to someone they actually know on the waiting list, but had heard about the long waiting lists and the difficulty of living on dialysis,' and came forward to donate to a stranger.

In this surgical marathon, the Good Samaritan or 'non-directed donor' came forward and was matched to a recipient, allowing the chain of paired exchanges or domino surgeries to take place. The Good Samaritan was thus able to facilitate four transplants, including the last to someone on the waiting list.

Since many pairs are needed to improve the odds of a match, a national program works much better than a local one, Cole said.

The transplant surgical marathon required months of planning by Canadian Blood Services, which set up the national registry. Paired exchanges have also been performed in the U.S., but no national registry exists there.

'We're offering a new of getting transplants, and then it puts less pressure for all those who are waiting on the wait list,' said Dr. Peter Nickerson of Canadian Blood Services in Winnipeg.

Donors and recipients are all recovering well in different wards to maintain their anonymity.

The pilot project involving B.C., Alberta and Ontario is going national.

'The fact that it's a possibility for me now opens up so many more doors, and it's a very exciting prospect,' said Didja Nawolsky of Calgary, who is on the waiting list for a kidney. While she waits, Nawolsky gets 10 hours of dialysis daily.

Doctors involved are already scouting their next cross-Canada, multi-kidney swap."

http://www.cbc.ca/health/story/2009/06/25/kidney-swap-toronto-edmonton-vancouver.html

"Don't blame Steve Jobs for scoring a liver transplant"

"If Apple Inc. co-founder Steve Jobs used his billions to obtain a new liver ahead of less-privileged transplant patients, who's to blame ?

Not Jobs, says Arthur Caplan at the University of Pennsylvania's Center for Bioethics. 'He did nothing illegal. And pursuing his own self-interest makes sense,' Caplan said. Instead, the blame goes to transplant doctors, the United Network for Organ Sharing and Congressional leaders. They have failed to cut off an inside track that the rich, famous and gravely ill can follow to snare a spare part ahead of everybody else. 'Ever since Al Gore left Congress, no one has paid any attention to transplant issues,' Caplan said. 'A system that tolerates multiple listing, moving to gain an advantage in wait time and for that matter wealthy foreigners to be listed for transplants, is not an ethical system.'"

Source
"Caplan's take on how the Silicon Valley chieftain wound up in Memphis for a new liver : Did Steve Jobs’ wallet help cut transplant wait ?
Opinion: The Apple co-founder's trip to Tennessee for liver raises questions", by Arthur Caplan, Ph.D."
"Apple CEO Steve Jobs’ recent trip to Tennessee to pick himself up a new liver has raised some sticky questions about what money can buy.

Jobs, 54, was diagnosed with a rare form of pancreatic cancer five years ago and had a piece of his pancreas removed. The prognosis with tumors of the pancreas is not good, the cancer can spread to the liver.

First, let me say I wish Jobs the best. This column is being typed on an Apple computer, while an iPod is playing and an iPhone is displaying missed messages on its screen. You would be hard-pressed to find a stronger Apple devotee and Steve Jobs admirer than I am. But the news that this incredibly wealthy resident of Silicon Valley, Calif., had transplant surgery thousands of miles from his home at the University of Tennessee in Memphis, according to the Wall Street Journal, raises some important questions about access to health care at a time when America is in the midst of a major battle over health reform.

According to data from the United Network for Organ Sharing based in Richmond, Va., the quasi-public agency that distributes donated organs to those on waiting lists around the nation, there were roughly 16,000 people on the national liver waiting list when Jobs got a liver. He was one of 1,581 people who got livers in the United States in the first quarter of this year. Almost none of those people had any form of cancer.

In fact, if Jobs’ tumor has spread from his pancreas into his liver as is likely, some transplant surgeons say that they would not recommend a liver transplant because there is no data that shows a transplant will stop or even slow the spread of the cancer. This raises the question: Is this the best use of a liver?

Not enough is known about Jobs’ condition to say with certainty whether he still has cancer or whether the cancer has spread.

What is known is that Jobs beat very long odds to get a transplant.

Three hurdles to getting an organ
In the United States, three hurdles must be overcome to get an organ. First, you need to have a primary care doctor diagnose that you have a failing organ. Second, you need to gain entry to a transplant center. Third, you have to be selected by both your transplant surgeon and UNOS as the person best suited on the national waiting list of those admitted to various transplant centers as the best recipient.

Jobs did not have problem with the first hurdle. He has plenty of doctors watching him. They found his initial pancreas problem and his subsequent liver problem. Millions of Americans are not so fortunate. They can’t afford a primary care doctor. Some Americans show up at emergency rooms so sick due to failing hearts, livers, lungs and kidneys that they could not possibly survive a transplant. Others simply die without any doctor diagnosing what is going on with their organs. These unlucky patients are rationed out of their chance to get a transplant without even knowing it.

For those who do have a primary care doctor, like Steve Jobs, the next step is to get into a transplant center. This involves getting seen by a specialist, who will perform all sorts of tests both physiological and psychological. Most important, the potential patient must do well on a very precise wallet biopsy performed to ensure they can pay for a surgical procedure that might cost as much as USD 200,000.

The parents of 17-year-old Nataline Sarkisyan sued insurance giant Cigna Healthcare last year for declining to guarantee payment for a liver transplant at UCLA Medical Center. The family could not pay and she was not admitted to the transplant program. So she died.

Besides a lack of money, other factors that might lead a transplant center to reject a potential liver transplant patient include advanced age, mental illness, addiction, lack of a stable family to help after surgery, being a prisoner, or having other complicating diseases.

Jobs did not face these obstacles to gaining entry to a transplant program. But, he does have a complicating illness so he had to find a transplant center willing to ignore that fact. It was probably easier for a wealthy CEO to do that than it would be for you.

The waiting list is long for livers. But different centers have longer and shorter lists. Patients who are smart or who have savvy primary care doctors know that different transplant centers follow different rules in deciding who to admit and not to admit. Some will bargain a lower fee for a liver transplant for a poor family. Some would view a liver transplant for a person with cancer as a 'waste' of an organ. Some might take a chance on a patient with cancer. This likely explains why Jobs went to Tennessee.

According to UNOS, there were 295 newly listed liver patients in Tennessee last year and 1,615 in California.

Shorter wait time in Tennessee
And UNOS data shows the median number of days from getting on the liver waiting list to getting a transplant was 306 nationally, in Tennessee only 48.

By traveling to Memphis, Jobs could drastically increase the odds he would secure a liver and cut the wait time. He also might have tried to gain entry to more transplant centers to increase the odds that he would get a transplant. Jobs or anyone with enough money can 'multiply list' at many centers and, by putting chips on more than one number, boost the odds of winning the transplant lottery. About 3 percent of all those on the national waiting list for livers, hearts and kidneys are listed at more than one program.

Jobs appears to have known exactly how to use his resources to maximize his chances of getting a life-saving transplant. Most Americans do not.

But, regardless of how much money or clout you have, actually getting an organ when one becomes available is the hardest hurdle. Organs are given on the basis of physiological measures of who is most in need, matching of blood type and other biological factors. Getting to the shortest waiting list and finding a transplant center to take him despite his cancer did not guarantee Jobs a liver. There was some amount of luck involved too.

Still, Jobs’ liver transplant shows precisely what is wrong about our nation’s debate over health care. Some say we do not need to reform what American Medical Association officials often refer to as the 'finest health care system in the world.' Really?

The current system is hardly fair. People die every day from a lack of good care or the ability to pay for it. The truth is, those with resources can make the system work in their favor. And celebrity, money and the promise of future gifts can help procure access to scarce, life-saving resources.

The health care system is a broken mess, but not because a Steve Jobs can get a liver. Rather, it is because all too often only the wealthy and privileged can take full advantage of the best our health care system has to offer."

Source:
http://newsblogs.chicagotribune.com
Copyright 2009 msnbc.com

Clergy appeal over organ donors

"Organ for transplant: The NHS has warned the need for organ donors has never been greater. Leaders of the UK's main religions have appealed to their followers to support a campaign to register as organ donors. They are trying to counter uncertainty about what their religions teach about organ donation. The Roman Catholic Archbishop of Westminster, the head of the Muslim Council of Britain and the Chief Rabbi are among those involved."

"Three people die a day in the UK because there is no suitable organ available for transplant for them. BBC News Religious Affairs Correspondent Robert Pigott says senior clergy report that some people are unsure what their religion teaches about the subject."

"Act of generosity
The Church of England says organ donation is a Christian duty.

The leader of the Roman Catholic Church in England and Wales - the Archbishop of Westminster, the Most Reverend Vincent Nichols - described it as a true act of generosity. The head of the UK Hindu Council, Anil Bhanot, said it was natural for Hindus to donate body parts, as well as goods, at the end of their lives. There was a record number of organ transplants in the UK last year but attempts to increase the supply have had limited success. There were 3,504 organ transplants between April 2008 and March 2009, up 8% on the previous 12 months. But the NHS warned the need for donations had 'never been greater', with 10,000 people awaiting a transplant and 7,000 blood donations needed each day."

Source:
http://news.bbc.co.uk

Neuroradiology: "Comatose Patients with Cardiac Arrest: Predicting Clinical Outcome with Diffusion-weighted MR Imaging"

Neuroradiology: Comatose Patients with Cardiac Arrest: Predicting Clinical Outcome with Diffusion-weighted MR Imaging (1). Authors: Ona Wu, PhD, A. Gregory Sorensen, MD, Thomas Benner, PhD, Aneesh B. Singhal, MD, Karen L. Furie, MD, and David M. Greer, MD. (1) From the Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, 149 13th St, CNY 2301, Charlestown, MA 02129 (O.W., A.G.S., T.B.); and Department of Neurology, Massachusetts General Hospital, Boston, Mass (A.B.S., K.L.F., D.M.G.). Received July 21, 2008; revision requested September 18; revision received December 9; accepted December 23; final version accepted January 28, 2009. Supported in part by the Medical Investigation of Neurodevelopmental Disorders, or MIND, Institute. Address correspondence to O.W. (e-mail: ona@nmr.mgh.harvard.edu).

"Purpose: To examine whether the severity and spatial distribution of reductions in apparent diffusion coefficient (ADC) are associated with clinical outcomes in patients who become comatose after cardiac arrest."

"Materials and Methods: This was an institutional review board–approved, HIPAA-compliant retrospective study of 80 comatose patients with cardiac arrest who underwent diffusion-weighted magnetic resonance imaging. The need to obtain informed consent was waived except when follow-up phone calls were required; in those cases, informed consent was obtained from the families. Mean patient age was 57 years ± 16 (standard deviation); 31 (39 per cent) patients were women. ADC maps were semiautomatically segmented into the following regions: subcortical white matter; cerebellum; insula; frontal, occipital, parietal, and temporal lobes; caudate nucleus; putamen; and thalamus. Median ADCs were measured in these regions and in the whole brain and were compared (with a two-tailed Wilcoxon test) as a function of clinical outcome. Outcome was defined by both early eye opening in the 1st week after arrest (either spontaneously or in response to external stimuli) and 6-month modified Rankin scale score.

Results: Whole-brain median ADC was a significant predictor of poor outcome as measured by no eye opening (specificity, 100 per cent [95 per cent confidence interval {CI}: 86 per cent, 100 per cent]; sensitivity, 30 per cent [95 per cent CI: 18 per cent, 45 per cent]) or 6-month modified Rankin scale score greater than 3 (specificity, 100 per cent [95 per cent CI: 73 per cent, 100 per cent]; sensitivity, 41 per cent [95 per cent CI: 29 per cent, 54 per cent]), with patients with poor outcomes having significantly lower ADCs for both outcome measures (P.001). Differences in ADC between patients with good and those with poor outcomes varied according to brain region, involving predominantly the occipital and parietal lobes and the putamen, and were dependent on the timing of imaging.

Conclusion: Spatial and temporal differences in ADCs may provide insight into mechanisms of hypoxic-ischemic brain injury and, hence, recovery."

Source:
http://radiology.rsnajnls.org
Copyright RSNA, 2009

MRI and Prognosis after Cardiac Arrest

"Can diffusion-weighted imaging accurately predict neurological prognosis after cardiac arrest ? Predicting neurological prognosis after cardiac arrest remains an area of uncertainty for many neurologists and intensivists. Although several tools may be helpful — including the clinical exam, neurophysiology, and serum/CSF biomarkers — these have their limitations and usually are helpful only in the rare cases of clear hopelessness or clear rapid improvement."

"To examine the feasibility and predictive potential of MRI for more uncertain cases, researchers prospectively enrolled 51 cardiac arrest survivors who underwent diffusion-weighted MRI within 7 days after cardiac arrest. The authors retrospectively identified apparent diffusion coefficient thresholds associated with three predefined outcome categories:

Group 1: death or vegetative state at 6 months, along with (a) the absence of motor response, pupillary reflexes, or bilateral cortical responses at 72 hours, or (b) vegetative state at 1 month
Group 2a: survival with good neurological outcome at 6 months
Group 2b: survival with poor neurological outcome at 6 months

The authors conclude that, if these findings are confirmed, MRI could be a useful adjunct to other prognostic tools in comatose survivors of cardiac arrest.

Comment: Most studies of neuroimaging for predicting neurological outcome of cardiac arrest have been hindered by small size and poor methodology. Unfortunately, this study also has several flaws. The numerical ordering of the groups is not intuitive, and each group is small (e.g., 13 patients in group 2a and 6 patients in group 2b). Thus, although MRI appears to aid in predicting survival, whether imaging characteristics can be identified that can separate those who just survive from those who survive with meaningful neurological improvement remains to be seen.
The article contains lengthy descriptions of four cases with neuroimaging, an inclusion I find surprising, as it does not provide any statistical weight or importance. Furthermore, the study has several sources of potential bias: Data are sparse regarding the neurological examinations; coma was inadequately defined as 'no eye opening to voice and inability to follow commands,' and, most importantly, a self-fulfilling prophecy of early withdrawal of care likely biased the results, as in other studies. Although treating clinicians were encouraged to follow the 2006 American Academy of Neurology practice parameter when considering when to withdraw care, the manuscript leaves unclear whether this was followed. More important, for patients in whom these strict criteria were not met, it is unclear how long they were allowed to live. The authors rightfully suggest that MRI should not be the only tool used for prognostication in patients with cardiac arrest, and they encourage further study. Fortunately, a more recent study of 80 truly comatose cardiac arrest patients has been conducted." (Radiology 2009; May 6).
— David M. Greer, MD, MA
Dr. Greer is Assistant Professor of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston.
Published in Journal Watch Neurology June 23, 2009
Citation(s):
Wijman CAC et al. Prognostic value of brain diffusion-weighted imaging after cardiac arrest. Ann Neurol 2009 Apr; 65:394.
Medline abstract (Free)
http://neurology.jwatch.org

"Steve Jobs' Reported Liver Transplant Stirs Debate"

"Some Say The Rich May Have Advantage with Multiple Listings on Liver Waiting Lists"

"Reports that Apple CEO Steve Jobs traveled to an unidentified hospital in Tennessee for a liver transplant this March have sparked a debate over whether the wealthy are able to use their resources to game the national organ donation system.

Representatives from Cupertino, Calif.-based Apple declined to answer specific questions from ABCNews.com or confirm the Wall Street Journal report that Jobs, 54, received a liver transplant. However, Apple released this statement: 'Steve continues to look forward to returning to Apple at the end of June and there is nothing further to say.'

But if Jobs did indeed get a transplant at one of the three designated liver transplant centers in Tennessee (Le Bonheur Children's Medical Center in Memphis, Vanderbilt University Medical Center in Nashville and Methodist University Hospital in Memphis) experts agree that he would have cut his waiting time for an organ.

Jobs couldn't pay for an organ. Nor could he pay to cut the queue. But what someone with Jobs' resources could do, according to liver transplant surgeons and ethicists, is to use money and mobility to improve the odds either by going to an area of the country where there are more organ donors, or by signing up at multiple transplant centers.

'It's not for anybody but the rich. It's called multiple-listing, a practice some would say is unethical,' said Arthur Caplan, co-chair of the United Nations Task Force on organ trafficking and chair of the department of medical ethics at University of Pennsylvania.

When a person needs a liver in the United States, the patient must go to a hospital with a transplant center for an extensive medical, mental and financial consultation. Then if he or she is determined a good candidate, the patient will be put on that transplant center's waiting list.

When a liver becomes available, the nearest of the 49 national Organ Procurement Organizations (OPO) will run a database search and algorithm to match the liver to people on all the transplant centers within that OPO's designated local and regional area.

'The local area is not a state, it's that donor service area of that OPO,' explained Anne Paschke, spokesperson for the United Network of Organ Sharing (UNOS). 'For a liver they're going to look in the local and regional areas before they look nationally.'

According to the Organ Procurement and Transplantation Network, 15,771 people are currently waiting for a liver in the United States. Last year, 1,481 people died waiting for a donor liver, almost all of which come from the recently deceased. The national average waiting time for a transplant is about a year, but it can average as little as a few months at some centers, organ experts said.

Paschke said UNOS requires transplant centers to encourage patients to do 'multiple listings' at transplant centers in multiple geographic areas to increase the odds of being matched to a liver. The only catch, Paschke said, is that health insurance policies often cover only one medical evaluation to get on one transplant center list. Most people simply don't have the money to pay for multiple extensive evaluations at far-flung locations.

Money Can Influence Chances on Liver Recipient Lists

'[Multiple listing] is not common. I think you have to have the means to do it and most centers are looking for patients that have a support system within the area,' said Dr. Michael Porayko, medical director of Liver Transplant at Vanderbilt University in Nashville, Tenn.

'So, most people don't travel all around the country to get on a liver transplant list,' he said.

The fact that anyone with Steve Job's level of wealth could use money to get a numerical advantage within the national system irks ethicists like Caplan. According to Caplan 3 to 5 percent of the names on organ waiting lists are 'multiple listing,' including U.S.citizens and wealthy foreigners who moved to the United States for medical treatment.

'Obviously the supply of organs is controlled as a public resource by UNOS,' said Caplan. 'Multiple listing undermines the fairness of the listing, in my opinion.'

While Jobs and Apple have refused to speak about the matter, doctors say what Jobs has publicly revealed about his health makes his case more unusual in the organ donation system.

Changing the Way People Get Liver Donations

Jobs stated in 2004 that he was diagnosed with an uncommon islet cell neuroendocrine tumor in the pancreas. Doctors say under some circumstances the islet cell tumors cancer can metastasize to the liver, thus necessitating the need for a transplant. However, Apple has not commented on whether Jobs' cancer ever metastasized.

'Islet cell tumors are an unusual but an accepted indication for liver transplantation when the primary tumor has been addressed and the metastatic disease is limited to the liver,' said Dr. Michael Millis, chief of transplantation at the University of Chicago Medical Center.

In years past a person needing a liver transplant from islet cell cancer would have to join a local waiting list with patients suffering liver failure from multiple reasons from alcohol abuse to hepatitis C. For years the liver recipient lists were managed by wait time and other factors such as age.

But in 2002 a new metric called MELD, (Model for End Stage Liver Disease) was supposed to level the playing field and make the wait for an organ purely associated with biology.

An Objective Way To Make Liver Recipient Lists ?

'It's an objective score that is generated from patient's blood test to better be able to rank people in the severity of their illness,' said Dr. Ari Cohen, a transplant surgeon with the Ochsner Health System in New Orleans.

'The MELD score makes it purely objective, and it's the same between centers,' he said.

MELD scores range from 0 to a severe near-death score of 40. The sicker one gets, the higher the MELD score goes. At a MELD score of 15 or above, doctors begin to recommend a transplant.

But once the MELD score was implemented a clear geographic difference among waiting lists began to appear, according to Dr. Michael Porayko, medical director of liver transplant at Vanderbilt University in Nashville, Tenn.

'There are differences in wait times for livers,' said Porayko. 'I know for instances at the Mayo Clinic down in Florida, there are so many donors they can transplant somebody at a MELD of 17, 18, 19.'

At Vanderbilt the average MELD score at time of transplant ranks around 24. But on the East and West Coasts, Porayko said the average transplant is done with a person who has a MELD score of 30.

But the original MELD score isn't always used to gauge a patient's needs if the disease that's causing the liver failure won't show symptoms in the MELD blood tests. In the rare case of someone with islet cell cancer, for example, the patient would be reviewed by a regional board that would then assign an 'artificial' equivalent MELD score, said Cohen.

It's unknown whether Jobs fell into this category and what such a score might have been since he is not releasing his medical records.

Despite the cases of the wealthy benefiting from multiple listings, Cohen said he thinks the MELD system has so far proven the best method for fair organ transplants.

'People are constantly looking at ways to improve upon organ availability,' said Cohen. 'None of them are proven yet, so they haven't been applied. This system is the best system we have right now.'"

Copyright 2009 ABC News Internet Ventures
http://abcnews.go.com

Etats-Généraux de la bioéthique : l'avis des Français

"La clôture des Etats-Généraux de la bioéthique a lieu ce matin. Les questions qui sont au coeur du débat sont les suivantes : faut-il sortir du régime dérogatoire actuel et autoriser la recherche sur l'embryon ? L'assistance médicale à la procréation doit-elle devenir un mode alternatif de procréation et être ouvert aux mères célibataires et aux couples homosexuels ? Doit-on autoriser la gestation pour autrui ? Faut-il créer un registre du 'oui' sur lequel puissent s'inscrire les personnes favorables au prélèvement de leurs organes lors de leur décès ?

Si les jurys citoyens n'ont pas eu le droit de divulguer les résultats contenus dans leurs rapports, le Pr. Jean Leonetti, président du comité de pilotage des Etats-Généraux de la bioéthique, se réjouit de ce qu''au final, ils émettent souvent des avis mesurés, dont on ne peut redouter l'extrémisme ou un choix à l'emporte-pièce'. Libération voit d'ailleurs dans l'absence de Nicolas Sarkozy à la clôture des Etats-Généraux le signe qu'il n'y aura pas de bouleversements dans l'architecture actuelle de la loi de bioéthique. Selon Jean Leonetti, les Français seraient plutôt 'pragmatiques et ouverts aux solutions pour augmenter le nombre de donneurs' dans le domaine des greffes d'organes. Quant à la recherche sur l'embryon, les citoyens sont 'convaincus de l'importance de ces recherches, et [qu'] ils trouveraient dommage d'y renoncer. En même temps, ils sont conscients que l'embryon n'est pas une chose.'

Suzanne Rameix, membre du comité d'orientation des Etats-Généraux de la bioéthique voit en cette relative stabilité de la loi à venir le signe d'une grande fiabilité de la loi adoptée en 1994, sur la base de laquelle s'opèrent les révisions successives. Pour elle, la raison d'être de cette législation est de concilier le respect des libertés individuelles et la garantie d'un Etat bienfaisant et protecteur. La liberté de disposer de son corps comporte en effet un risque véritable d'affaiblissement de la personne : 'Dans la bioéthique, nous sommes devant des êtres vulnérables, comme les enfants, les mourants, mais aussi d'une certaine façon, les embryons. Le corps humain doit être protégé. Est-ce que la personne peut faire n'importe quoi de son corps ?' Et d'insister sur idée qui lui paraît essentielle : 'en démocratie, nous n'avons pas à choisir les personnes ni le peuple. Ils sont là, et il faut les prendre tels qu'ils sont. Toutes les technologies médicales ou biologiques qui pourraient conduire à choisir l'autre ou à le sélectionner m'inquiètent.'

Roselyne Bachelot, ministre de la santé, s'interroge pour sa part sur la nécessité de réviser la loi tous les cinq ans : 'Cela ne nous semble plus tout à fait approprié. Il faut aller peut-être vers un système de révision continuelle'."

Le Figaro (Sandrine Cabut) 23/06/09 - Libération (Charlotte Rotman) 23/06/09 - La Croix (Pierre Bienvault) 23/06/09

http://www.genethique.org

"Did Steve Jobs jump the liver transplant queue ?"

"Since the Wall Street Journal announced on Friday that 54-year-old Steve Jobs, co-founder and chief executive of Apple Inc, underwent a liver transplant, questions have been raised about whether he got preferential treatment."

"Livers for transplant surgery aren’t easy to come by. As another WSJ article pointed out over the weekend, 5,771 Americans are currently awaiting a liver. Last year, 1,481 people died before they received one.

The wait for liver transplants, WSJ reporter Laura Meckler wrote, 'is particularly agonizing. Kidney replacements can often be put off for years through dialysis, where a machine does the work of the kidneys. But there is no such treatment for liver disease.'

Why Tennessee?
Where Jobs went for his surgery seems to be the element of this story that has raised the most eyebrows. Although he lives in California, Jobs received his new liver in Tennessee — a state with a much shorter waiting list. In its own Sunday piece on the controversy, the San Francisco Chronicle reported that 1,615 people sought liver transplants in California in 2008 compared with 295 in Tennessee.

(According to United Network for Organ Sharing (UNOS), the organization that runs the national computer registry that matches donor organs to recipients, 506 Minnesotans are currently registered and waiting for a liver donation.)

The WSJ noted that waiting times disparities have 'led to a sometimes nasty fight among hospitals.'

The current system relies heavily on illness and geography, with the chances of getting a donated liver much better for those waiting in the same local area as the donor. In many cases, priority is given to those who sign up locally, even if there are sicker patients waiting in the next city or next region.

But, as the Chronicle article makes clear, anybody can opt to get on another state’s wait list:

'Transplantation is a very public, transparent process,' said UNOS spokesman Joel Newman. 'It certainly wouldn’t be unheard of for people to look at the potential waiting times, look at their center options and make a decision based on that.'

Indeed, it’s not just celebrities who travel to another state in hopes of upping their odds of receiving a new liver. I did a quick Internet search and found a news report of a Massachusetts couple who moved to Florida in 2008 to improve their daughter’s chances of getting the life-saving surgery.

Too soon to judge
It would certainly appear that Jobs went to Tennessee in hopes of having an earlier surgery date. But without knowing the medical details, it’s impossible to speculate whether he jumped the queue once he was put on Tennessee’s list.

It seems unlikely. Newman told the Chronicle that the median wait throughout the country is 20 days for the most acutely ill patients and 100 days for patients at the next highest level of illness. Those are median waits, so half the people in those categories get into the operating room faster than that. News reports had Jobs seeking a liver transplant at least as early as January. His surgery was in April — well past the 100-day mark.

Also, an institution can be severely sanctioned, said Newman, if it doesn’t follow the proper protocol for determining who receives a donor organ. (The Chronicle article didn’t say, however, if any institution had ever received such sanctions.)

A need for change
Due to turf wars, many institutions resist efforts to eliminate the disparities in waiting times. Noted the WSJ:

Over the years, there have been efforts to decrease the importance of geography, and changes have been made in an effort to even out the disparities. But each time there has been resistance from transplant centers.

The controversy over Jobs’ transplant illustrates the ongoing need for more organ donors. If you haven’t already signed up to be a donor with LifeSource, the nonprofit organization that manages organ and tissue donation in the Upper Midwest, you might want to do so now.

Some of you may remember that a similar media storm raged around baseball great Mickey Mantle’s liver transplant in 1995. Charges were made in the press that Mantle had been taken off the transplant list ahead of five other patients because of his celebrity status. UNOS conducted an independent review and determined that Mantle’s organ transplant was done 'properly and according to established policy.' Not everybody was satisfied with that finding, but the publicity surrounding Mantle’s transplant had an immediate positive effect: Requests for organ donor cards skyrocketed."

Source:
http://www.minnpost.com

Troisième forum public des Etats-Généraux : greffes et dons d'organes

"Le dernier des trois forums publics des Etats-Généraux avait lieu hier à Strasbourg. A l'ordre du jour : le don d'organes et la médecine prédictive.

En France, en 2007, on compte près de 5000 greffes, avec 13 000 personnes en attente, et 200 décès faute d'avoir pu bénéficier à temps d'un don d'organes. C'est donc une pratique reconnue, dont le cadre législatif repose sur les principes suivants : l'anonymat, la gratuité, le consentement présumé du donneur."

"Si la pratique du don d'organes et de la greffe, n'est pas remise en cause, la question du consentement présumé fait l'objet de nombreuses interrogations. En France, chacun est en effet supposé pouvoir être prélevé, sauf s'il a manifesté de son vivant son refus. Le consentement présumé est-il conforme au principe de consentement éclairé et à la notion de don indispensables pour sauvegarder l'éthique ? Par ailleurs comment faire lorsque la famille s'oppose au prélèvement ? Dans la pratique, les équipes médicales ne passent jamais outre l'avis familial, mais privent en même temps des patients en attente de greffe. Le panel s'est également vu soucieux de voir clairement défini l'état de mort cérébrale, condition sine qua non de tout prélèvement, ainsi que des conditions de prélèvement respectueuses du corps de la personne décédée prélevée (95 pour cent des prélèvements sont effectués après la mort du donneur)."

"Concernant la gratuité du don, il s'agit de se prémunir contre les risques de marchandisation du corps humain, et notamment d'éviter le trafic d'organes au niveau international : comment éviter par exemple que des habitants de pays démunis ne vendent un de leur rein au profit d'un malade de pays riche ? Le Pr Jacques Belghiti, spécialiste de la greffe du foie, fait pourtant remarquer : 'Nous avons tous la préoccupation légitime de ne pas indemniser le don, mais encore faut-il que le donneur vivant ne soit pas, lui, pénalisé.'

Enfin, concernant les donneurs vivants, qui constituent 5 pour cent des prélèvements en vue des greffes, les débats ont porté sur la possibilité d'un élargissement de leur cercle. Jusqu'à présent, il est possible de donner de son vivant un rein ou un foie à un membre de sa famille ou à une personne avec qui on partage une vie commune depuis au moins deux ans. A l'éventualité d'une extension du don aux personnes liées par des liens d'amitié, le Pr Didier Sicard, président d'honneur du Comité consultatif national d'éthique, a objecté: 'Plus on élargit le cercle familial ou amical des donneurs, plus on élargit ce qu'on pourrait appeler une demande de comptes du donneur qui, quelques années plus tard, pourrait aller voir le receveur en lui disant : Je t'ai donné la vie. Comment comptes-tu me rembourser ?'"

La Croix (Pierre Bienvault) 17/06/09 - Libération (Eric Favereau) 17/06/09
http://www.genethique.org/revues/revues/2009/juin/20090617.1.asp

Mort du double greffé mains-visage

"Le jeune homme qui avait fait l'objet en avril dernier (cf. Synthèse de presse du mardi 7 avril 2009) d'une double greffe mains-visage est décédé lundi dernier d'un arrêt cardiaque durant l'opération qui visait à contenir la progression d'une infection du visage. Celle-ci s'était déclarée quelques semaines après la greffe. Le Pr Lantieri, qui avait co- dirigé cette première médicale à l'hôpital Henri- Mondor à Créteil, explique que "les infections sont une grave menace". Les médicaments destinés à empêcher le rejet du greffon affaiblissent en effet le patient dont le système immunitaire devient moins efficace."
Le Figaro.fr 15/06/09 - Libération.fr 15/06/09
http://www.genethique.org