Volume 67 - 2004 - Fasc.2 - Symposium
History of pediatric liver transplantation in Europe
The european history of pediatric liver transplantation (LT) began ... in 1965, when Jean-Bernard Otte went to Denver (Colorado) to meet the pioneer Thomas Starzl (1) who performed many years ago the first tenta- tives of LT in animal. A long period followed these ini- tial assays, concerning essentially the operative process, the numerous changes it was necessary to modify, even in animal and, later on, in human patients at the ultimate stages of chronic liver disease. The exceptionnal work of Starzl was his certitude to be able to define, finally, the ways necessary to obtain progressively a better selection and preoperative care, before this type of heavy surgery,
Genetic cholestatic liver diseases : The example of progressive familial intra- hepatic cholestasis and related disorders
One of the main features of pediatric hepatology is the importance of genetic disorders. Consequently, the development of new technologies for genomics and pro- teomics research should have an important impact on pediatric hepatology. These technological advances have already allowed the understanding of the role of genetic factors in the pathogenesis of some pediatric cholestatic liver diseases (1, table). It can be expected that it will also facilitate the development of novel treatments (e. g., gene, cell, and pharmacogenetics therapies) and molecu- lar prenatal diagnosis. Characterization of genotype/ phenotype correlations will further increase our ability to understand cellular and molecular disease relation- ships, to develop treatment strategies, and to improve counseling of families. In addition, it is very likely that many of the genetic discoveries that initially focus on pediatric liver disorders will have more widespread application to adult hepatobiliary physiology and dis- eases. One of the major advances in pediatric hepatology over the past 5 years has been the genetic and molecular characterization of the progressive familial intrahepatic cholestasis disorders.
Viral hepatitis B, C and D
Recurrence of the original liver disease is a a major threat to long-term survival in liver transplant reci- pients (1). This is particularly true for viral hepatitis. Recurrence was first best described for hepatitis B, with more than 80% viral recurrence in the era prior to the introduction of immunoprophylaxis (2). Although hepatitis B recurrence has been effectively contained by the use of hepatitis B immunoglobulin with or without lamivudine, recurrent hepatitis C is becoming an increasingly challenging problem to the transplant com- munity (3).
Ethical perspectives about organ allocation for transplantation
The ethical questions suggested by the allocation of organs for transplantation can be assembled around the notion of justice. It is a domain of health care in which there is a chronic lack of resources, but for patients whose life is at stake, sometimes at short term. It has similarities with the triage, imposed in some condi- tions of emergency medicine, at war or during civil catastrophes. The question will be approached from the points of view of the main stakeholders. (Acta gastroenterol. belg., 2004, 67, 168-171).
Introduction
Since the inception of his all brilliant medical carreer, Jean-Bernard Otte has always had a particular interest in liver transplantation. This interest has been concretized early by a research fellowship of the Belgo-American Education Foundation, during his third year surgical residency with Professor Thomas E. Starzl at the University of Colorado in Denver.
After early attempts with professor P.J. Kestens in 1969 and 1971, the liver transplant program at the Cliniques Universitaires Saint-Luc in Brussels was launched in 1983 under the leadership of Jean-Bernard Otte.
Adult liver transplantation at UCL : update 2002
The authors present the results of a single centre study of 587 liver transplants performed in 522 adults during the period 1984-2002.
Results have improved significantly over time due to better pre-, peri- and post-transplant care. One, five, ten and fifteen year actuarial survivals for the whole patient group are 81.2 ; 69.8 ; 58.9 and 51.2%.
The high incidence of de novo tumors (12.3%), of cardiovascu- lar diseases (7.5%) and of end-stage renal function (3.6%) should be further incentives to tailor the immunosuppression to the indi- vidual patient and to direct the attention of the transplant physi- cian to the long-term quality of life of the liver recipient. (Acta gastroenterol. belg., 2004, 67, 188-196).
The paediatric liver transplantation program at the Université catholique de Louvain (1)
The Paediatric Liver Transplant Program at Saint-Luc University Clinics constitutes a substantial single centre experi- ence, including 667 transplantations performed between March 1984 and April 2003, and the history of this program reflects the tremendous progress in this field since twenty years. Liver trans- plantation in children constitutes a considerable undertaking and its results depend on multiple, intermingled risk factors. An analy- sis of the respective impact of several surgical and immunological parameters on patient/graft outcome and allograft rejection after paediatric liver transplantation showed a significant learning curve effect as well as the respective impact of pre-transplant diag- nosis on survival and of primary immunosuppression on the rejec- tion incidence. The introduction of living related liver transplan- tation in 1993 not only permitted to provide access to liver replace- ment in as many as 74% more candidate recipients, but also resulted in better graft survival and reduced retransplantation rate. The results of a recent pilot study suggest that steroid avoid- ance is not harmful, and could even be beneficial for paediatric liver recipients, particularly regarding growth, and that combin- ing tacrolimus with basiliximab (anti-CD25 chimeric monoclonal antibody) for steroid substitution appears to constitute a safe alternative in this context. The long-term issues represent the main future challenges in the field, including the possibility of a full rehabilitation through immunosuppression withdrawal and toler- ance induction, the development of adolescence transplant medi- cine, and the risk of early atherogenesis in the adulthood. (Acta gastroenterol. belg., 2004, 67, 176-178).
The psychological challenge of paediatric organ transplantation: gift and incorporation
The specific feature of organ transplantation is the confronta- tion of the patient with a body part not being his own and coming from somebody else. Thus the psychological challenge of trans- plantation will be the gift and incorporation of the graft.
The given organ confronts the patients with mental manifesta- tions related to emotions of grieving and guilt, most constantly directed to the donor himself. It can also cause a fantastical imag- ination related to the idea of having to some extent inherited the character of the donor. This very special gift relationship has to be questioned, as it can be interpreted in terms of a tyranny of the dept. A dept the recipient will never be able to reimburse.
In this context the contribution of sociological knowledge is determining. It makes it possible to reconsider the problem, and to discover that a gift relationship offers transplant patients much vaster possibilities than a materialistic conception of the gift, based on the dept, would do. (Acta gastroenterol. belg., 2004, 67, 184-187).
Introduction
In 1965, at the University of ColoradO. a young Belgian surgeon named Jean-Bernard Otte established a legendary reputation as one of the most skillful, inex- haustible, and intelligent fellows ever to serve on the transplantation service of that institution. Now, almost 4 decades later, we are celebrating the end of the same man's illustrious academic career.
