Imaging in Transplantation

258 Pages·2008·2.69 MB·English

by  Christiane Kulinna-Cosentini MD, Alexander A. Bankier MD (auth.), Alexander A. Bankier MD (eds.)

Contents I
MEDICAL RADIOLOGY
Diagnostic Imaging
Editors:
A. L. Baert, Leuven
M. Knauth, Göttingen
K. Sartor, Heidelberg
Contents III
Alexander A. Bankier (Ed.)
Imaging
in
Transplantation
With Contributions by
H. Antretter · A. A. Bankier · T. Franquet · M. Freund · N. Grenier · N. Heaton
P. Jaksch · D. Kienzl · J. B. Kruskal · J. E. Kuhlman · C. Kulinna-Cosentini · G. Laufer
S. Mehrain · P. Merville · G. Pasticier · I. Pedrosa · V. Raptopoulos · J. Sierra
O. Tucker · K. M. Unsinn · G. A. Zamboni
Foreword by
A. L. Baert
With 213 Figures in 424 Separate Illustrations, 99 in Color and 15 Tables
123
IV Contents
Alexander A. Bankier, MD
Director of Functional Respiratory Imaging
Beth Israel Deaconess Medical Center
Harvard Medical School
330 Brookline Avenue
Boston, MA 02215
USA
Medical Radiology · Diagnostic Imaging and Radiation Oncology
Series Editors:
A. L. Baert · L. W. Brady · H.-P. Heilmann · M. Knauth · M. Molls · C. Nieder · K. Sartor
Continuation of Handbuch der medizinischen Radiologie
Encyclopedia of Medical Radiology
Library of Congress Control Number: 2006930914
ISBN 978-3-540-40229-9 Springer Berlin Heidelberg New York
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Contents V
Foreword
Organ transplantation is considered one of the major advances in modern medicine
and surgery of recent decades.
Thousands of patients all over the world owe their lives to the revolutionary surgical
techniques and new methods in immunosuppression applied in human transplanta-
tion, which is also a supreme example of human interindividual solidarity.
As in most other domains of modern medicine, radiological imaging plays a major
role in the correct selection of donors and donor organs, as well as in the optimal thera-
peutic management and care of the transplanted patients.
I am very much indebted to A. Bankier for accepting the challenging task of editing
a much needed volume dedicated to all radiological aspects of organ transplantation in
humans. This book is the result of a very successful collaboration between a group of
international experts in the fi eld and offers a comprehensive overview of all radiologi-
cal issues relevant to all those involved in the care of transplanted patients.
I congratulate the editor and contributing authors for this outstanding, well
researched, and superbly illustrated book.
I am convinced that this volume on a hot clinical topic will be of great interest to both
radiologists in training and certifi ed radiologists, as well as to transplant s urgeons and
medical specialists with an interest in transplantation.
I sincerely hope that it will meet with the same success as the many other volumes
previously published in the series, Medical Radiology – Diagnostic Imaging.
Leuven Albert L. Baert
Contents VII
Preface
By the time I started my medical internship – which, despite many grey hairs on my
head, is not too long ago – the “art” of transplantation was a somewhat esoteric subdis-
cipline of medicine reserved for a handful of experts based in highly specialized aca-
demic institutions. Although this core of transplantation medicine still exists today,
substantial progress in the fi eld of surgical transplantation techniques and post-trans-
plantation care has brought transplant recipients beyond the boundaries of specialized
centers into a much wider medical environment. As a consequence, organ recipients,
notably after bone marrow, kidney, liver, and heart transplantation, are now seen in the
daily practice of many general practitioners and, thereby, of many general radiologists.
The primary aim of this book, therefore, was to provide the non-specialized radiologist
with an easily accessible and comprehensive manual covering essential and routine-
relevant diagnostic topics in the imaging of transplantation.
The second aim of this book was fostered by personal experience. Throughout my
radiological practice in the fi eld of transplantation, I have witnessed the simple impos-
sibility of providing meaningful diagnostic and clinical care in the absence of a sincere
devotion to strong interdisciplinary collaboration. This conviction is mirrored in the
structure of this book. The radiological chapters are all preceded by clinical chapters
aimed at embedding radiological information in the indispensable background of clin-
ical knowledge. The second aim of this book, thus, was to enforce a multidisciplinary
approach to diagnostic imaging in the fi eld of transplantation medicine.
The book’s third aim was to increase awareness of the open issues in transplantation
medicine. Despite the tremendous advances that transplantation has made over the last
decade, substantial problems remain. Many of these problems have moved from the
early post-transplantation period into the mid- and long-term follow-up of transplant
recipients, and thereby into the fi elds of chronic allograft rejection, chronic infection,
sequels of chronic high-dosed medication, and transplant-unrelated co-morbidity.
Without any doubt, radiological techniques have a key role to play in all of these areas;
hence, suffi cient attention from the radiologist to these still emerging and ever expand-
ing issues is required, as are adequate related training efforts in this fi eld. Hopefully,
this volume will contribute a modest part to this effort.
I will not end this preface without expressing my gratitude to the individuals who
have – voluntarily or not – substantially contributed to making this book happen. I
would fi rst like to thank all the authors involved in this work. I strongly believe that
the quality of their contributions has made this a comprehensive, informative, and up-
to-date contribution to the fi eld of transplantation medicine. I would then like to thank
VIII Preface
my fellows and residents. They have missed their teacher quite a bit during
the “hot” periods of this project, and they paid me back, not by complain-
ing, but by asking pertinent questions and by providing me with interesting
cases. I would like to thank Peter Jaksch and Walter Klepetko from the Lung
Transplantation Unit of my home University of Vienna, Austria. Their clinical
and surgical competence, combined with their reliability, have made our daily
collaboration a productive and enjoyable partnership. I owe my deep gratitude
to Pierre Alain Gevenois, Department of Radiology, and Marc Estenne, Lung
Transplantation Unit, both at the Hôpital Erasme, University of Brussels, Bel-
gium. Their support, expertise, and friendship have aided our fruitful research
collaboration in the fi eld of lung transplantation over the past decade. Without
their ongoing input, many things would simply not have happened. I would
also like to thank Christiane Knoop, Alain Van Muylem, and Denis Tack, all
from the same institution, for satisfying my often intrusive (and most likely
annoying) avidity for their help and knowledge.
It is to Ursula N. Davis at Springer-Verlag that I sincerely apologize for my
sometimes more than undulating working rhythm, a rhythm she tolerated with
admirable patience and humor. Without her moral support and her enduring
determination, I would not have made it through this project.
I am also grateful to Prof. Albert L. Baert, AZ Gasthuisberg, University of
Leuven, Belgium, who put his paternal trust in me to get this volume accom-
plished.
My fi nal thanks go to my children. Particularly during the fi nal phases of
this book project, their father had – as worded by a reasonably impatient
daughter – his “head in the clouds,” while he should have been caring for the
really important things in life such as homework and ball games…
Boston Alexander A. Bankier
Contents IX
Contents
1 Solid Organ Transplantation: Past, Present, and Future Challenges
Christiane Kulinna-Cosentini and Alexander A. Bankier. . . . . . . . . . . . 1
2 Heart Transplantation
Herwig Antretter, Guenther Laufer and Janet E. Kuhlman . . . . . . . . . . 11
2.1 Epidemiological, Clinical and Surgical Considerations
Herwig Antretter and Guenther Laufer . . . . . . . . . . . . . . . . . . . . 11
2.2 Imaging in Heart Transplantation
Janet E. Kuhlman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3 Renal Transplantation: Epidemiological, Clinical, Radiological and
Surgical Considerations
Nicolas Grenier, Pierre Merville and Gilles Pasticier . . . . . . . . . . . . . 51
4 Liver Transplantation
Olga Tucker, Nigel Heaton, Giulia A. Zamboni, Ivan Pedrosa,
Jonathan B. Kruskal and Vassilios Raptopoulos . . . . . . . . . . . . . . . . . . 99
4.1 Epidemiological, Clinical and Surgical Considerations
Olga Tucker and Nigel Heaton . . . . . . . . . . . . . . . . . . . . . . . . . . 99
4.2 Imaging of Liver Transplantation
Giulia A. Zamboni, Ivan Pedrosa, Jonathan B. Kruskal
and Vassilios Raptopoulos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
5 Lung Transplantation
Peter Jaksch, Sheida Mehrain, Daniela Kienzl and Alexander A. Bankier . . 139
5.1 Epidemiological, Clinical and Surgical Considerations
Peter Jaksch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
5.2 Imaging in Lung Transplantation
Sheida Mehrain, Daniela Kienzl and Alexander A. Bankier. . . . . . . . 153
6 Bone Marrow Transplantation
Jorge Sierra and Tomas Franquet . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
6.1 Hematopoietic Transplantation
Jorge Sierra. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
6.2 Imaging in Bone Marrow Transplantation
Tomas Franquet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
7 Imaging in Pancreas and Intestinal Transplantion
Martin C. Freund and Karin M. Unsinn . . . . . . . . . . . . . . . . . . . . . . . . 211
Subject Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Solid Organ Transplantation: Past, Present, and Future Challenges 1
Solid Organ Transplantation: 1
Past, Present, and Future Challenges
Christiane Kulinna-Cosentini and Alexander A. Bankier
C O N T E N T S The earliest evidence of an orthotopic autograft
(organ is placed in its normal anatomic position) has
1.1 Historical Overview 1 been preserved from the Bronze Age. A circular disk
1.2 Organ Procurement for Transplantation 2 of bone was removed from the calvarium to relieve
intracranial pressure and later replaced as an auto-
1.3 Patient Selection for Transplantation 3 graft (Sharma and Unruh 2004). Written accounts
1.3.1 Donor Selection Criteria 3
1.3.2 Recipient Selection Criteria 3 from Egypt, China and India dating back many cen-
turies describe manifold experimentations in graft-
1.4 Immune Responses to
Allografts/Xenotransplantation 4 ing (Sharma and Unruh 2004). Potters of the Koo-
1.4.1 Xenotransplantation 5 mas caste in India reported that around 800 bc, the
surgeon Susrata grafted a new nose from skin fl aps
1.5 Role of Imaging in Transplantation 5
1.5.1 Evaluation of Living Donors 5 (Transweb 2000). In the sixteenth century, reports
1.5.2 Evaluation of Cadaveric Donors 5 of tissue autograft transplantation (transplants us-
1.5.3 Recipient Evaluation 6 ing the patient’s own tissue) were more congruent to
1.5.4 Diagnosis of Graft Function 6 our current scientifi c standards. Tagliocozzi from
1.5.5 Diagnosis and Treatment of Complications 6
Italy successfully transplanted skin fl aps from the
1.6 Ethical and Economical Issues in patient’s own arms to re-create their nose (rhino-
Organ Transplantation 7 plasty) (Calne 1963; Transweb 2000). It was not
1.6.1 What are some Ethical Issues in
Transplantation Today? 7 until a couple of centuries later that successful al-
1.6.2 Defi ning the Components of Costs 7 lografts (transplants from one human individual
to another) or xenografts (from animal to human
References 8
individual) were carried out: in 1668 van Meeneren
(Transweb 2000) documented the fi rst success-
ful bone graft, whereby bone from a dog’s skull
was used to repair a defect in human cranium. The
1.1 modern age of organ transplantation began in the
Historical Overview twentieth century with Alexis Carrel, based on his
pioneering work devoted to vascular replacement.
The dream of curing illness and injury by transplant- He described the method of joining blood vessels
ing tissues or entire organs is probably as old as the by replacing the artery with a segment of a vein in
history of healing itself. Transplantation began in- the early 1900s (Sharma and Unruh 2004). An or-
deed many centuries ago as a primitive practice and gan perfusion system created by Carrel and Charles
has since evolved into a modern medicine reality. Lindbergh led to the development of cardiopulmo-
nary bypasses, thus making open heart surgery a
C. Kulinna-Cosentini, MD reality (Sharma and Unruh 2004). The kidney was
Department of Radiology, Medical University of Vienna, the fi rst vital organ to be successfully transplanted.
Waehringer Guertel 18–20, 1090 Vienna, Austria In 1933, the Russian surgeon Veronoff performed
A. A. Bankier, MD
Director of Functional Respiratory Imaging, Beth Israel the fi rst human allograft (kidney from mother to
D eaconess Medical Center, Harvard Medical School, 330 son) without the benefi t of tissue typing. The pro-
Brookline Avenue, Boston, MA 02215, USA cedure failed, the kidney never functioned, and the
2 C. Kulinna-Cosentini and A. A. Bankier
16-year-old boy died from rejection 22 days later Although these measures have decreased inappro-
(Sharma and Unruh 2004). In 1954, Joseph Mur- priate organ allocation, the problem of donor organ
ray achieved the fi rst successful kidney transplan- shortage is far from being solved. Most early trans-
tation from one identical twin to another without plant programs were operated locally, and waiting
using anti-rejection drugs (Houston Chronicle lists were short. Therefore, suitable recipients could
2004; Transweb 2000). In 1962 the fi rst cadav- often not be found for the available organs (Cohen
eric kidney transplant was performed (Transweb and Wight 1999). This issue promoted centralized
2000). The organ functioned for 21 months. This organizations aimed to coordinate organ procure-
was made possible thanks to 6-mercaptopurine, the ment and allocation in larger geographic perspec-
fi rst useful immunosuppressive drug. Soon after tives. The OEOs were generated for this requirement,
the fi rst successful kidney transplantations, other ensuring the best possible match between donor and
organ transplantations followed: in 1963 James recipient, and prioritizing the most urgent cases.
Hardy transplanted the fi rst lung (Gift of Life Most OEOs operate on a national basis such as
Donor Program 2004). In 1966 there was the fi rst in Italy or Spain (Cohen and Wight 1999). Other
simultaneous pancreas/kidney transplantation and European countries, for example Austria, Belgium,
1 year later the fi rst successful liver transplantation Germany, Luxembourg and the Netherlands, oper-
followed (Barber 2003; Gift of Life Donor Pro- ate together and are organized by the Eurotransplant
gram 2004). Foundation (Cohen and Wight 1999). The United
There was a period of 62 years from the fi rst ex- Kingdom Transplant Support Service Authority
perimental cardiac transplantation in animals at (UKTSSA) serves the UK and Ireland; and Scandia
the University of Chicago in 1905 until the fi rst suc- Transplant serves Denmark, Finland, Iceland, Nor-
cessful human heart transplantation on 3 Decem- way and Sweden. In the USA, the national organi-
ber 1967 by Christian Barnard (Gift of Life Donor zation is the result of an alliance between regional
Program 2004; Sharma and Unruh 2004). The agencies, known as the Organ Procurement and
transplant recipient was a 54-year-old man with end- Transplantation Network (OPTN). Eurotransplant
stage ischemic heart disease; the donor was a young is the largest OEO in Europe and serves an area of
2
man with severe brain injury. The recipient initially 500,000 km and a population of 116 million. In con-
recovered but subsequently died of pseudomonas trast Scandia Transplant serves an area of 1,100,000
2
pneumonia 18 days later. After multiple attempts of km and a population of 24 million, whereas the
2
cardiac transplantation with poor outcomes, the 1- OEO of Spain covers an area of 500,000 km and
year survival during the 1970s improved from 22% serves 40 million (Cohen and Wight 1999).
in 1968 to 65% in 1978 (Sharma and Unruh 2004). Cadaveric organ donation remains the most im-
This success occurred because of improved manage- portant graft source for organ transplantation. The
ment of infectious complications, the aggressive di- concept of brain stem death is essential to the process
agnosis and treatment of rejection, and better donor of cadaveric heart-beating organ donation (Depart-
and recipient selection. ment of Health 1983). Potential donors include any
patient deeply unconscious on a ventilator as a result
of severe irreversible brain injury of known etiology or
patients who have suffered spontaneous intracerebral
hemorrhage, acute neurological trauma and cerebral
1.2 anoxia from different causes. The fi rst step following
Organ Procurement for Transplantation identifi cation of a potential organ donator is the as-
sessment of clinical signs of brain death (Kaufmann
A worldwide shortage of donor organs has led to the and Lynne 1986). Brain stem death must be recog-
development of national and international systems nized by two independent physicians not involved in
for organ procurement and allocation. Such systems the organ procurement team. These two physicians
promote organ donation and ensure fair distribution should perform two sets of brain stem function tests,
of available donor organs through a combination of before brain stem death is confi rmed (Kaufmann
legislation, organ exchange organizations (OEOs), and Lynne 1986). In a deeply comatose patient, main-
transplant coordinators, publicity campaigns, do- tained on a ventilator, the criteria to be satisfi ed that
nor cards, and professional training programs (de brain stem death has occurred are (Royal College
Meester 1997). of Physicians Working Party 1995):