The conundrum of death, dying and organ donation

Aim: To evaluate the efficacy of oral cyclosporin A in the prevention and treatment of immune graft rejection in heavily vascularised, repeated keratoplasties with high risk for failure. Methods: 21 consecutive patients with 28 repeated corneal transplants and four quadrant vascularised recipient bed were treated with oral cyclosporin A for an average period of 12 months (range 1–41 months) and followed for an average period of 26.6 months (range 6–106 months). The average cyclosporin A blood level was 325 ng/ml (range 180–421 ng/ml). Within this group of 21 patients, another 12 regrafts were not treated with cyclosporin A and served as a control group. Results: Nine of the 28 regrafts (32%) treated with cyclosporin A remained clear. The Kaplan-Meier curve showed a constant decline in survival of the treated grafts, although the survival proportion during the first year of treatment was statistically higher for the treated group compared with the untreated group. Once immune regraft rejection occurred, the regraft failed despite treatment with cyclosporin A and extensive topical and systemic corticosteroids. Nine regrafts (32%) had immune graft rejection and all ultimately failed compared with five in the untreated regrafts (42%, p = NS). Ten other regrafts (36%) in the treatment group failed due to causes other than immune regraft rejection. Conclusions: Systemic cyclosporin A has a limited beneficial effect in preventing immune graft rejection in repeated corneal transplants in a highly vascularised corneal bed. When immune graft rejection occurs in such regrafts, the prognosis is poor despite aggressive medical treatment. Causes other than immune regraft rejection may also result in poor visual outcome in patients with clear regrafts.

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