Marie-Chantal Fortin

Increased Risk of Thrombotic Microangiopathy in Patients Receiving a Cyclosporin–Sirolimus Combination

A single‐center cohort study of kidney and kidney–pancreas recipients was conducted to evaluate the association between new immunosuppressive regimens and risk of thrombotic microangiopathy (TMA). From January 1st,1996 to December 31, 2002, 368 patients received a kidney or kidney–pancreas transplant at our center. Four immunosuppressive regimens were evaluated as potential risk factors of TMA: cyclosporin + mycophenolate mofetil (CsA + MMF), cyclosporin + sirolimus (CsA + SRL), tacrolimus + myophenolate mofetil (FK + MMF), and tacrolimus + sirolimus (FK + SRL). Thirteen patients developed biopsy‐proven TMA in the absence of vascular rejection. The incidence of TMA was significantly different in the four immunosuppressive regimens studied (p < 0.001). The incidence of TMA was highest in the CsA + SRL group (20.7%). The relative risk of TMA was 16.1 [95% confidence interval (CI): 4.3–60.8] for patients in the CsA + SRL group as compared with those in the FK + MMF group. We also investigated in vitro the pathophysiological basis of this association. The CsA–SRL combination was found to be the only regimen that concomitantly displayed pro‐necrotic and anti‐angiogenic activities on arterial endothelial cells. We propose that this combination concurs to development of TMA through dual activities on endothelial cell death and repair.

Policy Statement of Canadian Society of Transplantation and Canadian Society of Nephrology on Organ Trafficking and Transplant Tourism

)wasdevelopedafteradirectivefromtheWorldHealthAssemblyin2004(resolution57.18),whichurgedmemberstates:“totakemeasurestoprotectthepoorestand vulnerable groups from transplant tourism and the saleof tissues and organs, including attention to the wider prob-lemofinternationaltraffickinginhumantissuesandorgans”(

The enigmatic nature of altruism in organ transplantation: a cross-cultural study of transplant physicians' views on altruism

BackgroundAlthough altruism is a key principle in our current organ donation and transplantation system, the meanings and implications of the term have been widely debated. Recently, a new type of living organ donation--anonymous and non-directed, also called living altruistic donation (LAD)--has brought the issue into sharper focus. Transplant physicians views on altruism might influence their attitudes and actions toward living altruistic donors. This study aimed to explore such views among transplant physicians in France and Quebec.FindingsA total of 27 French and 19 Quebec transplant physicians participated in individual, semi-structured interviews between October 2004 and December 2005. The majority of these participants associated altruism with gratuitousness and saw altruistic acts as multiple and varied, ranging from showing consideration to saving a persons life.ConclusionsThe transplant physicians discourses on altruism were quite diverse, leading us to question the relevance of the concept in organ transplantation and the appropriateness of the term living altruistic donation.

Is it ethical to invite compatible pairs to participate in exchange programmes

Living kidney transplantation offers the best results for patients with end-stage renal disease (ESRD). This form of transplantation is no longer restricted to genetically or emotionally related donors, as shown by the acceptance of non-directed living anonymous donors, and the development of exchange programmes (EPs). EPs make it possible to perform living kidney transplantation among incompatible pairs, but while such programmes can help increase living organ donation, they can also create a degree of unfairness. Kidney transplant recipients in the O blood group are at a disadvantage when it comes to EPs because they can only receive organs from O donors, whereas O donors are universal donors. This poses a major challenge in terms of distributive justice and equity. A way to remedy this situation is through altruistic unbalanced paired kidney exchange (AUPKE), in which a compatible pair consisting of an O blood group donor and a non-O recipient is invited to participate in an EP. Although the AUPKE approach appears fairer for O recipients, it still raises ethical questions. How does this type of exchange affect the donor/recipient gift relationship? Should recipients in compatible pairs receive a ‘better organ’ than the one they would otherwise have received from their intended donor? Finally, what is the role of transplant teams in AUPKE? This article will examine the organisational and ethical challenges associated with EPs and AUPKE, and compare different EP policies in countries where such programmes exist.

Differences in psychosocial profiles between men and women living kidney donors

Abstract:u2002 Background:u2002 The expansion of kidney transplantation by living donation has led to a disproportional increase in the women to men ratio among donors and this difference cannot be explained on the basis of medical exclusion. The present study was designed to test whether women donors are more likely to (i) display altruistic and gender‐typed nurturing behaviour and (ii) be subtly influenced by family pressure to donate and less able to resist this pressure.

Complement factor H deficiency in acute allograft glomerulopathy and post-transplant hemolytic uremic syndrome.

Acute allograft glomerulopathy (AAG) is a distinct form of allograft rejection characterized by cytotoxic T‐cell‐mediated injury to the renal glomerular and arteriolar endothelium. Acute allograft glomerulopathy is characterized by mononuclear cell infiltration of glomerular capillary tufts in association with endothelial cell hypertrophy and injury. Intra‐glomerular thrombi have been described in AAG, suggesting that overlapping features of AAG and post‐transplant thrombotic microangiopathy (TMA) may coexist. We present a case suggesting that complement factor H deficiency, a known hereditary risk factor for TMA, may also favor development of AAG. We discuss the potential implications of factor H deficiency in the pathophysiology of renal allograft microvascular injury, leukocyte infiltration and formation of intraglomerular platelet thrombi. We propose that unopposed complement activation is a risk factor for both immune and nonimmune forms of microvascular injuries in renal allografts.

Are ‘anonymous’ and ‘non-directed’ prerequisites for living altruistic donation? The views of transplant physicians from France and Québec

It can be argued that living altruistic donors should remain anonymous and should not express preferences in the selection of organ recipients. This study aimed to describe the views of transplant physicians in France and Québec regarding these issues. A total of 27 French and 19 Québec renal transplant physicians took part in individual, semi-directed interviews. Almost all of the physicians agreed that anonymity is mandatory in living altruistic donation (LAD). Regarding the issue of directed donation, most of the French physicians (78%) were opposed to any form of the practice, compared to only a third of their Québec colleagues (32%). We found that these positions were embedded in their respective cultural, legal and social contexts. These results afford a better understanding of these complex issues in two different cultural contexts, and will be useful in the development of international guidelines for LAD.

Canadian Journal of Kidney Health and Disease: a unique launch of a unique journal

Usually inaugural editorials are written by the Editor-in-Chief to describe the scope and vision for the journal to potential authors and readers. This editorial is written by the Editor-in-Chief, the Deputy Editors and the Associate Editors collaboratively as a clear signal that this is a unique and different journal. We will build this journal on a set of principles which are fundamental to improving the outcomes of patients with kidney disease. To that end, we aim to be supportive, to collaborate, to integrate multiple perspectives and to be open to possibilities.RésuméHabituellement, il revient à l’éditeur en chef de rédiger l’éditorial inaugural décrivant la vision et les champs d’intérêts d’un nouveau journal. Le Journal canadien de la santé et de la maladie rénale a choisi de faire les choses autrement. En effet, cet éditorial est le fruit de la collaboration entre l’éditeur en chef et les éditeurs en chef adjoints. Ce journal s’appuie sur des principes qui seront fondamentaux pour améliorer le sort de patients atteints de maladie rénale. Pour y arriver, nous nous engageons à apporter du support aux auteurs, à collaborer, à intégrer différentes perspectives et être ouverts à des nouvelles possibilités.

Mycobacterium genavense and chronic intermittent diarrhea in a kidney and pancreas transplant recipient.

deficiency. N Engl J Med 1999; 341: 921. 4. Dionisi-Vici C, Rizzo C, Burlina AB, et al. Inborn errors of metabolism in the Italian pediatric population: a national retrospective survey. J Pediatr 2002; 140: 321. 5. Snodgrass PJ. Biochemical aspects of urea cycle disorders. Pediatrics 1981; 68: 273. 6. Thurlow VR, Asafu-Adjaye M, Agalou S, et al. Fatal ammonia toxicity in an adult due to an undiagnosed urea cycle defect: underrecognition of ornithine transcarbamylase deficiency. Ann Clin Biochem 2010; 47: 279. 7. Rohininath T, Costello DJ, Lynch T, et al. Fatal presentation of ornithine transcarbamylase deficiency in a 62-year-old man and family studies. J Inherit Metab Dis 2004; 27: 285. 8. Lien J, Nyhan WL, Barshop BA. Fatal initial adult-onset presentation of urea cycle defect. Arch Neurol 2007; 64: 1777. 9. Gropman AL, Summar M, Leonard JV. Neurological implications of urea cycle disorders. J Inherit Metab Dis 2007; 30: 865.

The use of personalized medicine for patient selection for renal transplantation: Physicians' views on the clinical and ethical implications

BackgroundThe overwhelming scarcity of organs within renal transplantation forces researchers and transplantation teams to seek new ways to increase efficacy. One of the possibilities is the use of personalized medicine, an approach based on quantifiable and scientific factors that determine the global immunological risk of rejection for each patient. Although this approach can improve the efficacy of transplantations, it also poses a number of ethical questions.MethodsThe qualitative research involved 22 semi-structured interviews with nephrologists involved in renal transplantation, with the goal of determining the professionals views about calculating the global immunological risk and the attendant ethical issues.ResultsThe results demonstrate a general acceptance of this approach amongst the participants in the study. Knowledge of each patients immunological risk could improve treatment and the post-graft follow-up. On the other hand, the possibility that patients might be excluded from transplantation poses a significant ethical issue. This approach is not seen as something entirely new, given the fact that medicine is increasingly scientific and evidence-based. Although renal transplantation incorporates scientific data, these physicians believe that there should always be a place for clinical judgment and the physician-patient relationship.ConclusionsThe participants see the benefits of including the calculation of the global immunological risk within transplantation. Such data, being more precise and rigorous, could be of help in their clinical work. However, in spite of the use of such scientific data, a place must be retained for the clinical judgment that allows a physician to make decisions based on medical data, professional expertise and knowledge of the patient. To act in the best interests of the patient is key to whether the calculation of the global immunological risk is employed.