Gabriel M. Danovitch - Handbook of Kidney Transplantation

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Sixth Edition

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Library of Congress Cataloging-in-Publication Data

Names: Danovitch, Gabriel M., editor.

Title: Handbook of kidney transplantation / edited by Gabriel M. Danovitch.

Description: Sixth edition. | Philadelphia, PA : Wolters Kluwer, [2017] | Includes bibliographical references.

Identifiers: LCCN 2017003544 | eISBN 9781496388841

Subjects: | MESH: Kidney Transplantation

Classification: LCC RD575 | NLM WJ 368 | DDC 617.4/610592dc23 LC record available at shttps://lccn.loc.gov/2017003544

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Dedicated to the UCLA Kidney Transplant Program that has been my clinical and academic home for over three decades, and to my many friends and colleagues at UCLA that it is my enduring pleasure and privilege to work alongside.

And to Nava, my beloved companion on this journey, who made it all possible.

The modern era of transplantation can be said to have begun with two momentous events in the early 1950s. In 1953, Peter Medawar and his colleagues at University College London described actively acquired immunologic tolerance in rats, thus heralding the science of transplant immunology and an ongoing search for a similar, reproducible phenomenon in humans. The modern era of clinical transplantation began on December 23, 1954, when Joseph Murray and his colleagues at Harvard performed the first kidney transplantation between identical twin brothers. Both of these pioneers were rewarded with the Nobel Prize for their contributions. In many ways, the promise of these discoveries has been fulfilled in the over 60 years that have followed. The mere fact that organ transplantation is the subject of a handbook series such as this reflects the extent to which it has become normative medical practice. Hundreds of thousands of lives have been saved, and quality years have replaced years of suffering. Our understanding of the complex immunobiology of the immune response has advanced and has brought widespread benefits well beyond the field of organ transplantation. A broad armamentarium of immunosuppressive medications is now available, and innovative surgical techniques serve to expand the donor pool and minimize morbidity. National and international organ-sharing organizations are an accepted part of the medical landscape of the developed world.

Modern organ transplantation can be visualized as a complex edifice that rests on a triangular base: in one corner is the basic research that is the lifeblood of improvement and innovation; in another corner is clinical transplant medicine, a relatively new medical subspecialty that requires compulsive, detail-oriented clinical care and both organ-specific and broad medical expertise; in the third corner are the ethical and cultural underpinnings of the whole transplantation endeavor, an endeavor that is utterly dependent on a well-developed sense of shared humanity and community and on absolute trust among medical staff, patients, and families. Trust is the bedrock of societal acceptance of organ donation, from both the living and the dead. The generosity and altruism of organ donors and their families can provide an enlightening antidote to our sometimes cruel and fragmented world.

Yet the success of clinical transplantationwith low mortality, high graft survival, and a low incidence of rejection episodeshas, paradoxically, made it more difficult to prove the benefit of new approaches. Because the demand for organs greatly outstretches supply, patients with advanced kidney disease who do not have a living donor may be faced with an interminable, and often morbid, wait for an organ from a deceased donor. The need for living donors has, on the one hand, provided a stimulus to develop ingenious new approaches to facilitate donation, and on the other hand, spawned an illegal, exploitive, global market in purchased organs. The Declaration of Istanbul on Organ Trafficking and Transplant Tourism (see Chapter 23) serves to codify the protection of the health and welfare of living donors while promoting the effective and healthy practice of deceased donation all over the globe. The chronic shortage of transplantable organs is unlikely to be solved without dramatic progress in the prevention of end-stage organ failure. Clinical xenotransplantation, a procedure that promised to provide the ultimate answer to the organ donor shortage, remains remote. Regenerative techniques and organ printing may yet provide an inexhaustible supply of organs, but not for a while!

This sixth edition of the Handbook of Kidney Transplantation has been thoroughly updated and revised to reflect the most current knowledge and practice in the field. Like its predecessors, its mission is to make the clinical practice of kidney transplantation fully accessible to all those who are entrusted with the care of our long-suffering patients.