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Organ transplantation, once medical exotica, is now almost routine. In the United Kingdom each year are performed cadaveric organ transplants of about 1800 kidneys (in addition to 160 live kidney donors), 700 livers, and 450 heart/lungs (UK Transplant Support Service Authority). The basic surgical techniques were established at the beginning of the century in canine models. Translation of these experiments to humans awaited safe and effective immunosuppression. Until the 1960s, the only forms of immunosuppression were radiation (total body or total lymphoid) and non-selective chemical reagents (benzene and toluene). Then the antiproliferative drug 6-mercaptopurine (6-MP) was introduced, shortly followed by a derivative, azathioprine, with improved oral bioavailability. Combined with corticosteroids, these allowed the first human solid organ transplants to be performed: in 1963 the first lung transplant in Mississippi and liver transplant in Colorado. Then in 1967 Christian Barnard captured the world's imagination with the first heart transplant. His technique has been modified slightly since, but the increasing success of organ transplantation rests mainly on improved immunosuppression with drugs that selectively suppress lymphocytes by inhibiting lymphokine generation (cyclosporin A, tacrolimus), signal transduction (sirolimus, leflunomide), or differentiation (15-deoxyspergualin) pathways. As a result, over the last 10 years in the United Kingdom, the 1 year survival of grafts has improved from 80% to 90% (kidney), 55% to 75% (liver), and 70% to 90% (heart/lung).
Wijdicks estimates that 10% of transplantation patients have a significant neurological complication, the three most common being neurotoxicity of immunosuppressive drugs, seizures, and failure to awaken. Yet this is the first text devoted to the neurological aspects of organ transplantation. It is therefore a timely subject for another title in the excellent Blue Books Of Practical Neurology series. Twenty authors contribute (one Dutch, one Swiss, the rest American) to four chapters on the transplant procedures themselves followed by 10 chapters on neurological complications of transplantation including failure to awaken, and psychiatric, neuromuscular and demyelinating complications. Especially useful to the neurologist without much experience of transplantation are the comprehensive chapters on immunosuppressive drugs and the opportunistic infections associated with them (most commonlyListeria monocytogenes,Aspergillus fumigatus, andCryptococcus neoformans). The peripheral nerve and plexus injuries associated with transplantation are painstakingly described; astonishingly a significant ulnar neuropathy occurs in up to 40% of kidney transplants. The Cincinnati Transplant Tumour Registry has recorded information on 10 813 cancers arisingde novo in organ allograft recipients worldwide and here are presented the data in the 300 of these with CNS involvement. This is one for the shelves of any neurologist involved in organ transplantation.