Transplantation or organ transplantation ( Latin transplantatio = 'grafting', 'relocation') describes in medicine the grafting of organic body parts or body tissues for healing purposes. A transplant can consist of cells , tissues , organs or organ systems such as fingers or hands. Transplantation is opposed to implantation, in which artificial implants , such as prostheses , are introduced into the body instead of organic material .
The term “transplant medicine” was introduced by Rudolf Pichlmayr (1932–1997), a leading German transplant doctor.
A transplant is classified according to the origin, location and function of the transplant:
Type of transplant
- Autologous or autogenous transplantation , also called autotransplantation : the donor and recipient are the same person, the transplant is called an autoplasty . Many of the autologous transplants are in the field of plastic surgery . But this also includes, for example, relieving the coronary artery through an endogenous leg or arm artery ( coronary artery bypass ).
- syngeneic or isogenic transplantation: the donor is the identical twin , i.e. i.e., the donor and recipient are genetically identical. This means that immunosuppressive drugs are not required in syngeneic and autologous transplantations described above (the side effects of these drugs are considerable).
- allogeneic transplant : the donor is of the same species . Old name: homogeneous transplant. see also: organ donation .
- Xenogenic transplant : the donor is of a different species (e.g. pig heart valve). Old term: heterogeneous or heterologous transplantation.
- Alloplastic transplantation: here artificial material, i.e. an implant , is introduced into the body. Since this is not organic material, the alloplastic transplantation can no longer be assigned to transplantation in the narrower sense according to the definition presented in the introduction.
- Isotopic transplantation: location and tissue are identical (e.g. islet cell transplantation )
- Orthotopic transplantation: the transplant is transplanted in the natural place (e.g. heart transplant)
- Heterotopic transplant: the transplant is transplanted to a different location (e.g. in the case of a kidney transplant)
- Allovital transplant: the transplant is fully functional and vital
- Allostatic transplantation: the function of the organ is limited in time
- Auxiliary transplant: transplant to support a sick organ
- Substitute transplantation: intended to replace a functionless organ
The removal of the graft is also known as explantation .
- Post-mortem transplantation: the transplant is taken from an anonymous donor after his or her brain death
- Live organ transplant : the transplant is taken from a suitable healthy donor. Often with stem cell, kidney or partial liver transplants. But parts of the pancreas, intestines and lungs have already been transplanted after living donations.
If a patient is not only an organ recipient, but also an organ donor , this is known as a domino transplant . This happens when a healthy organ has to be removed from him - especially due to the operation - which is then implanted in a third person.
Indications for transplants
- Chronic renal failure : kidney transplant
- End stage of coronary heart disease , types of myocardial disease ( cardiomyopathy ): heart transplant
- Eisenmenger reaction : heart-lung transplant
- Liver cirrhosis : liver transplant
- Cystic fibrosis : lung transplant
- Leukemia : bone marrow or stem cell transplant
- Diabetes mellitus : pancreas or islet cell transplantation (allogeneic, orthotopic, auxiliary)
- COPD : lung transplantation (allogeneic, orthotopic, substitutive)
- Bladder cancer : urostoma (autologous, heterotopic, substitutive-auxiliary)
- Breast cancer : breast reconstruction
- Burns and injuries with tissue destruction : flap surgery , motor replacement surgery , hand transplantation , face transplantation , pollution
- Plastic surgery : auricular malformation , hair transplant , skull reconstruction
- Diseases and injuries of the cornea : keratoplasty
- Sex reassignment surgery , testicular prosthesis
- Replacement of joints : endoprosthesis
- Severed limb accidents , e.g. B. Transplantation of arms
- A woman's desire to have children: A transplanted uterus can be removed when the child is born.
In the Federal Republic of Germany , the transplantation of organs from human donors is subject to the Transplantation Act (TPG). Organ trafficking , d. H. Payment or other consideration for the donor or his relatives is prohibited. Transplants are only carried out in certified transplant centers. On November 1, 2012, an important change in the law came into force. In § 2 TPG it says:
“The bodies responsible under state law, the federal authorities within their jurisdiction, in particular the Federal Center for Health Education, and the health insurance funds should inform the population about this on the basis of this law
- the possibilities of organ and tissue donation,
- the prerequisites for organ and tissue removal from dead donors, including the significance of a declaration made during their lifetime on organ and tissue donation, also in relation to an advance directive, and the legal consequences of a failure to make a declaration with regard to the right of the next of kin to decide according to § 4 and
- the importance of organ and tissue transfer in terms of the potential benefits for sick people of medical use of organs and tissues, including drugs made from tissues. "
Every health insurance company has to send the insured person a form with which one decides whether to consent to an organ donation or not. So everyone has to deal with the thought of donating organs.
The Organ Transplantation Act has existed in Austria since 2012 . The essential provision is the so-called "contradiction solution" , according to which the removal is only inadmissible if there is a declaration expressly rejecting an organ donation. This provision was already contained in the KAKuG 1982.
In Switzerland , the Federal Act of October 8, 2004 on the Transplantation of Organs, Tissues and Cells ( Transplantation Act ) regulates this area of law. The focus is on the prohibition of organ trafficking , the free donation, the determination of the death criterion, the requirements for consent to the removal of organs, tissues and cells from deceased persons, as well as criteria and procedures for organ allocation and living organ donation.
The main problem with any transplant is the immune response of the recipient organism to the transplant. The recipient's T cells and antibodies then fight the foreign organ. The reason for rejection is the difference in surface structure of the cells, in particular differences in the histocompatibility - antigens (Abbreviations: MHC antigens and HLA antigens) of the cell membranes of both living beings. This surface structure is genetically determined, so each individual has its own cell surface structure. For this reason, relatives are often particularly suitable organ donors, as there are more genetic matches. The first successful organ transplants were also carried out with - genetically identical - identical twins .
When donor tissue that contains immune cells - especially bone marrow and liver tissue - is transferred, there can also be a "reverse" immune reaction of cells in the transplant against the host body: graft-versus-host reaction .
The rejection reactions are differentiated according to their time course and extent:
The hyper acute / hyperacute rejection occurs within minutes to hours after transplantation and restoration of blood flow. It is caused by allospecific antibodies or by blood group-specific antibodies that are already present at the time of transplantation (cytotoxic antibodies against AB0 or HLA antigens of the transplant). After complement activation, fibrin is deposited in the vessels of the transplant and thus occlusions; the tissue dies.
The acute rejection usually begins within days to weeks. Rejection between the 2nd and 5th day after the operation is also known as accelerated rejection. Most often it is due to cellular interstitial rejection (i.e. infiltration of the organ by cytotoxic T lymphocytes). In kidney transplants in particular, acute vascular rejection occurs, with IgG antibodies synthesized by the recipient being directed against alloantigens in the epithelial cells of the donated transplant.
Acute rejection can usually be treated with glucocorticoids , immunosuppressants, or anti-lymphocyte antibodies such as basiliximab or daclizumab .
The chronic rejection occurs months to years after transplantation. Usually there are hardly any signs of inflammation to be found. This type of rejection reaction can hardly be treated successfully; usually a new transplant has to be carried out. Histologically it is based on a transplant vasculopathy, i. H. irreversible narrowing of blood vessels. CD4-T effector cells of the TH1 type migrate into the vessel walls and stimulate macrophages and endothelial cells there . Further monocytes migrate and differentiate into macrophages that secrete TNF-α and IL-1. A chronic inflammation of the vessel wall develops , which gradually leads to constriction through fibrosis (see fibrosis ) and scarring. Examples are coronary atherosclerosis after heart transplantation, interstitial fibrosis with tubular atrophy after kidney transplantation, bronchiolitis obliterans after lung transplantation.
The aim of immunosuppressive therapy is to preserve the transplant by suppressing the body's defense reaction against the foreign organ. The goal of permanent immune tolerance, i.e. H. The absence of a transplant-specific immune reaction without permanent suppression of the immune system is still not achievable with drugs. Permanent drug rejection prophylaxis is therefore necessary. Certain combinations of medications can be given to avoid rejection reactions. For induction therapy are provided before, during and after transplantation, immunosuppressive agents ( cyclosporin , tacrolimus , azathioprine, or mycophenolate, glucocorticoids , Basiliximab and Antithymozytenglobulinantikörper ) partly in high dosage are available. Fixed long-term medication is prescribed as basic therapy; usually a triple combination of steroids, calcineurin - inhibitors (cyclosporine or tacrolimus) or everolimus or sirolimus and azathioprine (or mycophenolate mofetil ). Induction therapy with monoclonal antibodies against the interleukin-2 receptor (basiliximab) or polyclonal antibodies against T lymphocytes or thymocyte antigens ( antithymocyte globulin ) is widespread in all transplantation indications (kidney, liver, heart, lung, pancreas). Close therapeutic monitoring of immunosuppressants in the first few months after the transplant is of great importance. In the case of long-term transplant recipients, the medication can sometimes be reduced to two modes of action later.
Since these drugs also weaken the defense against infections , the transplant recipients treated with them are particularly susceptible to bacterial, viral (CMV, HSV, HHV 6) and fungal (aspergillus, Candida) diseases. Certain cancers such as Kaposi's sarcoma on the skin and post-transplant lymphoproliferative disease (PTLD) of the lymphatic system are increasing. So are z. B. Children are 200 times more likely to be affected by lymph gland cancer compared to their peers.
- A potentially promising way to reduce or completely exclude an immunologically induced rejection reaction after an organ transplant could be the accompanying transplantation of exogenous stem cells . As studies published in the New England Journal of Medicine (NEJM) show, in addition to the new organ, blood-forming stem cells can also be transferred to the recipient, from which immune cells then arise that prevent this rejection.
- Another option to prevent rejection reactions is to transfer certain white blood cells from the donor to the recipient. This has already been successfully tested on humans. The cells are modified in the laboratory in such a way that they kill immune cells in the recipient, which drive the rejection reaction and promote other populations that have a regulatory effect on the immune system.
- In order to avoid the detrimental rejection of the donated organ, research is being carried out into colonizing the collagen framework of the organ to be transplanted , which has been freed from cells from the donor, with the cells of the recipient prior to implantation. Stem cells alone can tend to grow wild. Another approach is to colonize collagen scaffolds from the 3D printer . Such an organ would, in terms of rejection, be equivalent to a self-donation.
Psychological consequences of transplants
Transplants, especially allogeneic ones, can cause severe psychological stress. As a result, a separate branch of psychiatry emerged - Organ Transplantation Psychiatry ( OTP for short ).
The first literary mention of a transplant (although not necessarily in the modern sense) can be found in the early Christian legend of the saints of the brothers Kosmas and Damian . The world's first allogeneic human transplant was carried out in 1883 by the Bern surgeon Theodor Kocher : He transplanted human thyroid tissue under the skin and into the abdominal cavity of a young man . The modern history of organ transplantation began around 1908 with the experimental research work of Alexis Carrel , who received the Nobel Prize for his research on vascular sutures and on vascular and organ transplants. The French Victor D. Lespinasse (1878–1946) carried out a testicle transplant in humans for the first time in 1913. The first long-term successful kidney transplant was carried out in 1954 by Joseph Edward Murray at the Peter Bent Brigham Hospital . It was still between twin brothers, the first successful kidney transplant in genetically not identical Murray carried out in 1962. The first heart transplant took place in 1967 under the direction of Christiaan Barnard , in the same year the first liver transplant by Thomas E. Starzl . The first successful hand transplant was carried out in 1998 by Jean-Michel Dubernard , the first successful face transplant by Dubernard and Bernard Devauchelle in 2005.
Attitude of religious representatives to transplantation
Judgment in Judaism
In organ transplantation, four questions are asked and answered differently according to Jewish law. How is the date of death of the donor determined? Is the transfer of an organ from the body of a deceased generally permitted? Is a person allowed to put themselves at risk in order to save someone else? Can a child or a person with impaired decision-making skills serve as a donor? In medicine, a person is considered dead when their brain death is determined. In Jewish thought, on the other hand, a person is dead when his heart stops beating. Many Orthodox are therefore against organ removal from the brain dead. But this is also based on the belief that in Judaism a dead person must be buried intact. Otherwise, his resurrection at the end of days would be impossible. For many liberal Jews , saving a human life is more important than ensuring the integrity of the body. The highest rabbinate in Israel officially recognized the concept of brain death in the late 1980s. The removal of tissue donations from living people, namely tissues that regenerate themselves such as blood , skin or bone marrow , is not controversial, as the health of the donor is not endangered. However, tissue donations usually come from the deceased. Like organ donation, tissue donation is not linked to brain death. Tissues can therefore be donated up to three days after the cardiovascular arrest, depending on the tissue. The transfer of a cornea is usually possible because the removal and transfer takes place when the donor's heart has stopped beating. In the opinion of numerous Jewish authorities, the living donation of a kidney is also justifiable if the transplant is vital and the dangers for the donor are classified as low. However, it is not permissible to remove an organ from a potential donor if he is unable to assess the full scope of the organ removal.
Judgment in Islam
The development of transplant medicine led to highly controversial discussions among Islamic legal scholars in the late 1950s. In 1969, the French Ministry of Health banned the removal of organs from deceased Muslims after the director of the Islamic Center in Paris declared in a fatwa that organ transplants were fundamentally contrary to Islamic law. In 1985, however, the Fiqh Academy of the Islamic World League allowed posthumous organ donation on the condition that the donor was of age and consented to the organ removal during his lifetime.
- Transplantation of parts of plants to other plants, see plant grafting
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- ↑ Living donations
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- ↑ https://orf.at/#/stories/3103199/ Uterus transplanted from deceased person: woman became mother, orf.at, December 5, 2018.
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- ↑ JR Thistlethwaite Jr, B. Nashan, M. Hall, L. Chodoff, TH Lin: Reduced acute rejection and superior 1-year renal allograft survival with basiliximab in patients with diabetes mellitus. The Global Simulect Study Group. In: transplant. 70 (5), 2000 Sep 15, pp. 784-790. PMID 11003358
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- ↑ Susanne Donner: Cancer risk increases massively after organ donation In: derbund.ch, September 11, 2018, accessed on September 11, 2018.
- ↑ Press release at ORF science ( page no longer available , search in web archives ) Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice.
- ↑ Press report at medgadget.com ( Memento of the original from August 8, 2008 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.
- ↑ Michael Lange: Bred organs - One heart and one lungs. , Deutschlandfunk - “ Science in Focus ” of March 2, 2014.
- ↑ Anna Bergmann: The dead patient: Modern medicine and death. ISBN 978-3-351-02587-8 .
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- ^ Moshe David Pendler, Organ donation is a mitzvah , Jüdische Allgemeine. Retrieved April 13, 2016.
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- ↑ Martin Kellner: Islamic legal opinions on medical interventions at the limits of life. A contribution to cross-cultural bioethics . Ergon, Würzburg 2010, p. 162.
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