J.-M. Dubernard - Böcker

In all varieties of organ transplants, early results have dramatically improved over the past two decades and failures due to acute rejection are becoming rarer. Efficient immunosuppressive regimens have been developed with the objective of very good results at 1, 3 and 5 years. Successful transplants, however, are significantly less frequent at 10 and 20 years, and many patients require retransplantation. Many factors are involved in late graft loss and it is now well recognized that, in addition to chronic rejection, a number of non-immunologic factors play a prominent role. In the caseof renal transplantation, a reduced mass loss (transplantation of a single kidney, sometimes from an aged donor, ischemic injury and alteration of some nephrons in the case of early acute rejection) will result in slowly progressing chronic renal failure, even in the absence of any supplementary attack of an immunological nature. The new treatments must be analyzed in the light of their capacity to reduce these late failures. Several preventive measures can also limit both immunologic and non-immunologic factors of late transplant deterioration.

With a long practice of organ transplantation, retransplantation has become a major goal in patients with long-term failure of their first transplant (chronic rejection, exhaustion of the transplant, recurrence of the initial disease, etc. ). In addition, retransplantation can be necessary in the initial period, due to severe acute rejection, a non-functioning organ, or surgical complication. Immunological and non-immunological factors affecting the success of a second transplant are described in this volume, together with alternatives to retransplantation. It is hoped that in the future retransplants will be less frequent, as a result of improved prevention of transplant failure. J. L. Torrroine et a/. (ens. ), Retra~isplantation, xvii. Q 1997 Kluwer Academic Pirblislters. P~. iilted in Great Britain. List of contributors R. ARNOLD Y. W. CHO University of Pittsburgh UCLA School of Medicine Center for Medical Ethics Tissue Typing Laboratory Division of General Internal Medicine 950 Veteran Avenue 200 Lothrop Street - MUH, Suite W-919 Los Angeles, CA 90095-1652 Pittsburgh, PA 15213-2582 USA USA P. COCHAT M. A.BELGER Hopital Edouard Herriot UKTSSA Pavillon S Fox Den Road 5, Place d'Arsonva1 Stoke Gifford F-69437 Lyon Cedex 3 Bristol BS12 5RR France UK B. CUZIN F. BERTHOUX Hopital Edouard Herriot Service de Nephrologie et Pavillon V Transplantation Renale 5, Place d3Arsonval Hopital Nord F-69437 Lyon Cedex 3 F-42055 Saint Etienne Cedex 2 France France J. H. DAUBER C.

Organ Shortage: The Solutions is the latest subject in the Continuing Education series, organized by Fondation Marcel Mérieux and Université Claude Bernard in Lyon. The annual subject is chosen to reflect the status of the topical issues of the year, as taught by leading international experts. The contribution of transplantation and clinical immunology to advanced medicine is considerable and promising. The annual volumes in this series keep the reader abreast of these developments.

Rejection and Tolerance is the latest subject in the Continuing Education series, organized by Fondation Marcel Mérieux and Université Claude Bernard in Lyon. The annual subject is chosen to reflect the status of the topical issues of the year, as taught by leading international experts. The contribution of transplantation and clinical immunology to advanced medicine is considerable and promising. The annual volumes in this series keep the reader abreast of these developments.

Over the last few years, transplantation knowledge and techniques, as well as insights into pharmacology, have improved, thus enabling greater access to transplantation for patients. The pool of organs for transplantation is stable, and therefore insufficient to cope with the growing demand. To adjust demand and resources in the most equitable way, organ procurement and allocation have been organized nationally and often across borders. The national and international organ exchange programs were studied and discussed during the Congress on Organ Allocation, from which this book is derived. This book describes the state of the art in the management of waiting lists and the allocation of organs in transplantation. It includes chapters on the possibilities of expanding the pool of available cadaver organs. It also analyzes the results of transplantation of cadaver organs from older donors and marginal, non-heart beating donors. Transplantation policies based on the offering of organs by living donors are also described, as is the impact of delayed graft function on organ allocation.

At the brink of the third millennium organ transplanta­ mati on how, in the case of shortage, a fair allocation of tion will become routine and the results will be so ex­ the scarce organs can be achieved. This is a very cellent that every patient in need of a transplant timely subject that continues to be discussed between deserves to be transplanted. How to provide every doctors and between laymen. patient with his or her organ and how to guarantee This book serves the needs of several groups of that the organ is in a superb condition? That is the specialists working with transplant patients. Firstly, the challenge for all of us privileged to work in this doctors who are directly involved in the care of the magnificent field of medicine. multi-organ donor, and who have to collaborate to do In this book, an international team of experts has the best for their recipients. Heart surgeons might like laid down their intellectual knowledge on the process to learn from liver surgeons and vice versa. Secondly, that precedes successful transplantation: Procurement, the paramedical specialist who is involved in the treat­ Preservation and Allocation. In four sections important ment of transplant patients and their families will find aspects of this preamble of the actual transplantation in this book many answers to questions. Students can are dealt with. also use it as a source for general information.

In all varieties of organ transplants, early results have dramatically improved over the past two decades and failures due to acute rejection are becoming rarer. Efficient immunosuppressive regimens have been developed with the objective of very good results at 1, 3 and 5 years. Successful transplants, however, are significantly less frequent at 10 and 20 years, and many patients require retransplantation. Many factors are involved in late graft loss and it is now well recognized that, in addition to chronic rejection, a number of non-immunologic factors play a prominent role. In the case of renal transplantation, a reduced mass loss (transplantation of a single kidney, sometimes from an aged donor, ischemic injury and alteration of some nephrons in the case of early acute rejection) will result in slowly progressing chronic renal failure, even in the absence of any supplementary attack of an immunological nature. The new treatments must be analyzed in the light of their capacity to reduce these late failures. Several preventive measures can also limit both immunologic and non-immunologic factors of late transplant deterioration.

Malignancies are frequent complications in organ transplantation, mainly as the result of infection with certain viruses and of long-term immunosuppression. The epidemiology confirms that the increased incidence concerns certain cancers, especially HIV-related skin cancers and EBV-related lymphoproliferative malignancies. This book covers all currently available information on this important topic of the relationships between transplantation and malignancies: preexisting cancers, posttransplant cancers, their etiology and pathophysiology, their prevention and treatment. A significant part of the volume is devoted to prophylaxis, early detection and modern forms of therapy in posttransplant lymphomas. As a conclusion of all these new data, the theory of immunosurveillance deserves to be significantly modified.