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Diego Bogetti,
Howard N Sankary,
Tomasz M Jarzembowski,
Antonio Manzelli,
Peter S Knight,
James Thielke,
Gregorio Chejfec,
Scott Cotler,
Jose Oberholzer,
Giuliano Testa,
Enrico Benedetti
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ABSTRACT: Interventions that minimize hepatic ischemia/reperfusion injury (IRI) can expand the donor organ pool. Thymoglobulin (TG) induction therapy has been shown to ameliorate delayed graft function and possibly decrease IRI in cadaver renal transplants recipients. This controlled randomized trial was designated to assess the ability of TG to protect against IRI in liver transplant recipients.
Twenty-two cadaveric liver transplant recipients were randomized to receive either TG (1.5 mg/kg/dose) during the anhepatic period and QOD x2 doses or no TG. No differences in recipients' demographics were present and donor characteristics were similar in terms of age, cause of death, and cold ischemia time. Maintenance immunosupression consisted of Tacrolimus (or Cyclosporine) and steroids for both groups. Donor biopsies were obtained during organ procurement, cold storage and 1 h after re-vascularization. Post-operative liver function tests were monitored. Early graft function, length of stay, patient and graft survival rates, incidence of primary non-function and rate of rejection were assessed.
Patient and graft survival at 3 months was 100%. There was no incidence of primary graft non-function and no need for re-transplantation. The incidence of acute rejection was similar between the two groups. Patients in the TG group had significant decreases in alanine aminotransferase test at day 1 compared to the control group (p = 0.02). There were also near significant decreases of total bilirubin at day 5 and shorter length of hospitalization. Liver biopsy (at procurement, when cold, and post-reperfusion) of TG group demonstrated a trend for increased central ballooning.
The TG allowed for more compromised liver grafts to be transplanted with less clinical evidence of IRI and improved function. Further studies on the degree of apoptosis in the liver biopsy post-reperfusion are underway.
Clinical Transplantation 09/2005; 19(4):507-11. · 1.67 Impact Factor
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ABSTRACT: There is only limited experience in patients with systemic lupus erythematosus (SLE) with drugs that have developed for immunosuppression after organ transplantation, namely calcineurin inhibitors (CI). The aim of this study is to determine the effect of these drugs on disease activity after kidney transplant in patients affected by SLE.
Between January 1990 to March 2003, 13 patients with end- stage renal disease secondary to SLE received 14 kidney transplants. The outcome variables assessed include graft and patient survival as well as clinical and serological lupus activity.
All received CI-based immunosuppression (cyclosporine or tacrolimus). Actuarial patient and graft survivals at 5 yr were 100 and 93%, respectively. Recurrence of clinical or serological disease was never detected.
To date, only anecdotal experience with CI in the treatment of SLE has been reported. The favorable response observed in our patients suggests that CI at low-doses are effective in preventing SLE-reactivation. Further studies focused on calcineurin inhibitor treatment in SLE patients who fail to respond to standard medical management should be conducted.
Clinical Transplantation 03/2005; 19(1):56-60. · 1.67 Impact Factor
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ABSTRACT: Renal transplantation is the therapy of choice for children with end-stage renal disease. Despite excellent patient survival, long-term graft survival is poor, especially in the African-American (AA) population. This article addresses non-compliance as a major cause of late-term graft loss in the pediatric population. Between July 1995 and September 2002, a total of 50 pediatric kidney transplants were performed at our institution. We have analyzed data for 44 of these kidney transplants. Twelve recipients were AA, 14 Caucasian (C) and 18 Hispanic (H). The remaining six patients of different racial origin were not included in this analysis. The mean age of the recipients was 10.9 yr (range 1.7-17.8). Thirty-one were cadaveric and 13 were living donor transplants. We analyzed creatinine level and graft and patient survival at 1, 3 and 5 yr post-transplant. Compliance was evaluated based on trends in cyclosporine levels, attendance to clinic visits, individual interviews and unexplained late graft dysfunction. One- and 3-yr patient survival rates were 100% for all racial groups, except the 3-yr patient survival rate for C, which was 86%. One and 3-yr graft survival rates for AA, C and H were 92 and 67%, 86 and 79% and 100 and 100%, respectively. However, at 5 yr, we found that AA recipients had a significantly higher rate of graft loss when compared to both H and C recipients (42 vs. 95 vs. 71%, respectively). Non-compliance was the main factor, accounting for 71% of cases of late graft loss. In conclusion, non-compliance is a problem of great importance in the pediatric transplant population, particularly in AA recipients, where it plays a major role in late-term graft loss.
Pediatric Transplantation 09/2004; 8(4):367-71. · 1.48 Impact Factor
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ABSTRACT: : Total parenteral nutrition (TPN) is a life-saving therapy for patients with short bowel syndrome. However, TPN is associated with a high incidence of serious complications, poor quality of life, and elevated cost. An attempt was made to avoid TPN-related complications associated with trauma-induced short bowel syndrome by using early living related donor bowel transplantation.
: Three men 27 to 30 years of age with trauma-induced short bowel syndrome received early living related donor bowel transplantation using segmental ileal grafts.
: All the donors had an uncomplicated postoperative course. After a mean follow-up period of 40 months, all three recipients were alive and well, and did not require any TPN support. The ileal graft adapted perfectly to support fully the nutritional needs of young, active individuals.
: Early living related donor bowel transplantation is a successful treatment for trauma-induced short bowel syndrome. It is associated with a lower incidence of complications, better quality of life, and lower cost than long-term TPN.
The Journal of trauma 08/2004; 57(1):164-70. · 2.48 Impact Factor
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ABSTRACT: The malignant degeneration of a chronically rejected kidney allograft has been rarely reported. Almost invariably such malignancies originated in the transitional epithelium. We herein present the first occurrence of squamous cell carcinoma (SCC), originating from occult donor cells, in a chronically rejected renal allograft. Nearly 20 years after chronic rejection and loss of function of a cadaver renal graft, our patient developed increasing abdominal discomfort, decrease in appetite and weight loss. A CT-scan of the abdomen showed an abnormally enlarged and irregularly contoured mass at the level of the rejected allograft. Given the clinical and radiologic picture suggestive of either an infectious or intraparenchymal hemorrhagic process, a transplant nephrectomy was performed. At surgery, it was immediately evident that a malignant degenerative process had affected the graft. The histological features of the specimen were diagnostic for a well-differentiated SCC. The donor origin of the tumor was established through a DNA microchimerism assay performed on the operative specimens. The patient did well after resection of the malignancy, although he died 5 months later owing to a myocardial infarction. In summary, even several years following the transplant, the possibility of a malignancy of donor origin developing within a failed allograft should always be considered as part of the differential diagnosis in unusual post-transplant settings.
American Journal of Transplantation 08/2004; 4(7):1208-11. · 6.39 Impact Factor
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ABSTRACT: We review our experience with enteric conversion of previously bladder-drained pancreas transplants (PTx) using a short perioperative course of octreotide (OCT). Between July 1994 and December 2001, 45 consecutive primary bladder-drained PTx were performed. Immunosuppression consisted of a combination of tacrolimus, mycophenolate mofetil and steroids after induction with monoclonal or polyclonal antibodies. A total of 16 patients underwent enteric conversion at an average of 3 months after the initial transplant. Each patient received OCT perioperatively. We report no technical complications with the exception of one superficial wound infection and good early and late PTx survival rates. Perioperative treatment with octreotide is well tolerated and may reduce technical complications while performing enteric conversion of previously bladder-drained PTx.
Clinical Transplantation 05/2004; 18(2):137-41. · 1.67 Impact Factor
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ABSTRACT: Graft congestion is one of the causes of poor graft function in segmental liver transplantation. Three factors are implicated in segmental graft congestion: graft size, hepatic venous outflow and portal inflow. The graft size must be matched to the body weight, which is conventionally done by using graft to body weight ratio. Hepatic blood outflow must be optimized by hepatic vein reconstruction, which can be complicated. High portal blood flow has been shown to be detrimental to small-for-size grafts. These factors are strictly connected to each other. They can all contribute to graft congestion and poor function, while one factor can compensate for the others and decrease congestion. Ideally, all the accessory veins should be reconstructed, if possible, to maximize the outflow. In the absence of portal hypertension and with an adequate sized graft, complex venous reconstruction may not be necessary. We present a case report of an adult living donor liver transplant with the favorable conditions of normal portal pressure and a large sized graft, but complicated by the presence of several accessory hepatic veins. A simple hepatic vein anastomosis was sufficient for adequate outflow and prompt graft function.
Clinical Transplantation 05/2004; 18(2):222-6. · 1.67 Impact Factor
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ABSTRACT: The evaluation of the small bowel vascular anatomy of living small bowel donors (LSBD) is usually performed with conventional angiography (CA). Recently, angio computed tomography (CT) has become a valid study of the vascular anatomy for kidney and liver living donors. We studied the applicability of angio CT with 3-D reconstruction (3-D-ACT) in the evaluation of LSBD. Potential LSBDs for pediatric transplant underwent both CA and 3-D-ACT to evaluate the anatomy of the distal branches of the superior mesenteric artery and vein. Angio-CT was performed with General Electric Lightspeed Scanner. The 3-D reconstruction was performed on the TeraRecon workstation. Adverse reactions, contrast dosage, test duration, invasiveness, hospital-stay, patient discomforts and accuracy were evaluated. Four potential donors (four female; mean age: 30.5 yr; mean BMI: 28.4) underwent both tests. Adverse reactions correlated to contrast agent used (90 mL CA, 150 mL 3-D-ACT) were not reported. CA required a hospitalization of 6 h as opposed to immediate discharge after the 3-D-ACT. The CA required the placement of transfemoral catheter and therefore greater patient discomfort than with 3-D-ACT. The 3-D-ACT arterial images were rated as equivalent to CA, however, 3-D-ACT venous images were rated better than the CA in all cases. CT-angiography with 3-D reconstruction is an acceptable method for vascular evaluation. When compared with routine angiography, it is less invasive, better tolerated and faster, but does require a significantly greater volume of venous contrast. 3-D-ACT also offers a better evaluation of the venous phase, and thus may become the test of choice to evaluate the vascular anatomies of LSBD candidates.
Pediatric Transplantation 03/2004; 8(1):65-70. · 1.48 Impact Factor
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ABSTRACT: A positive pretransplant flow cytometry cross-match (FC-XM) allows precise identification of high-risk recipients vulnerable to hyperacute or accelerated rejection after transplantation. Living donor kidney transplant recipient candidates with positive cross-match have been successfully treated with a combination of plasmapheresis (therapeutic plasma exchange, TPEX) and intravenous immunoglobulin (IVIG), achieving conversion to negative cross-match and successful transplant. We report the first successful case of simultaneous pancreas kidney transplant (SPKT) from a living donor (LD) performed against an initially positive FC-XM, converted to negative using a protocol based on TPEX and IVIG in combination with antiCD20 monoclonal antibody. This strategy of overcoming the cross-match barriers in living donation may offer a chance of successful transplantation to highly sensitized candidates for SPKT, for whom cadaveric transplant is difficult to achieve.
American Journal of Transplantation 02/2004; 4(1):140-3. · 6.39 Impact Factor
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ABSTRACT: In the case of coexisting abdominal aortic aneurysm (AAA) and liver/renal failure, the controversial issue is the timing of the AAA repair and the transplantation of the affected organs. The question is whether to repair the AAA first and perform the double transplantation at a later time, or to perform all three procedures in the same operative session. This patient was affected by hepatic/renal failure and had also developed AAA. We describe the operative strategies utilized to perform the cadaver donor and recipient operations in this setting. In our patient, a combined liver/kidney transplantation with simultaneous aneurysm repair using arterial allografts was successfully performed. In a patient affected by end-stage liver, kidney, and aneurysmatic disease, a simultaneous liver/kidney transplant and AAA repair may represent the safest and most efficient treatment solution.
American Journal of Transplantation 09/2003; 3(8):1036-9. · 6.39 Impact Factor
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ABSTRACT: Simultaneous pancreas and kidney transplantation (SPK) from cadaveric donors has become a widely accepted therapeutic option for insulin-dependent uremic patients. In 1996 the first SPK from a live donor was performed. This procedure offers the advantage of a better immunologic match, reduced cold ischemia injury, and decreased waiting time. As such, it is an attractive alternative treatment for diabetic patients with end-stage nephropathy with an available living donor.
We performed six SPKs from living-related donors. There were four men and two women among the recipients; median age was 34 (range, 29-39) years. All donors were recipients' siblings with excellent HLA matching. Donors underwent standardized metabolic workup, anti-insulin and anti-islet antibody assays, and computed tomography of the abdomen. Both donors and recipients were treated with octreotide for 5 days perioperatively. After transplantation, the patients were maintained on tacrolimus-based immunosuppression, with the exception of one recipient of SPK from an identical twin, who received cyclosporine monotherapy.
All the donors are doing well and have normal renal function and blood glucose levels. One-year patient, renal, and pancreatic graft survival rates were 100%, 100%, and 83%, respectively. Acute kidney rejection was documented in two patients, and both recovered completely after OKT3 therapy. No rejection of pancreatic graft has been documented. Except for one patient who lost the graft because of hemorrhagic pancreatitis, all recipients maintained serum glucose levels at less than 130 mg/dL without insulin therapy. No major surgical complications such as graft thrombosis, intra-abdominal infection, or abscess were reported.
Living donor SPK can represent a successful alternative to cadaveric donor SPK. The procedure can be performed safely in the donor and with low morbidity in the recipient.
Transplantation 09/2003; 76(3):547-52. · 4.00 Impact Factor
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ABSTRACT: Chronic pancreatitis (CP) is an inflammatory disease that causes progressive and irreversible structural changes to the pancreas, resulting in permanent impairment of both endocrine and exocrine functions. In advanced cases of CP, pain can be relieved only with pancreatic resection. However, even partial resection of the pancreas in this setting may cause diabetes. Furthermore, postsurgical diabetes (PSD) always occurs after total or near-total pancreatectomy, which is commonly performed for CP. Auto transplantation of pancreatic islets into the portal vein after pancreatic resection can prevent PSD. The results of this strategy, which are already encouraging, are likely to improve in the near future because of significant progress in the isolation and preservation of pancreatic islets. This review discusses the current status and future prospects for auto-islet transplantation after pancreatic resection for CP.
Expert Opinion on Biological Therapy 05/2003; 3(2):207-14. · 3.51 Impact Factor
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ABSTRACT: Spur cell anemia is an acquired form of hemolytic anemia caused by a structural abnormality of red cell membranes that results in spiculated erythrocytes. These peculiarly shaped red blood cells, called acanthocytes, have a shortened survival and undergo splenic sequestration and destruction. Spur cell anemia has been known to occur in several conditions, including chronic liver disease, and more specifically in alcoholic cirrhosis. Treatment of this disorder has been disappointing and usually indicates end-stage liver disease. Liver transplantation has been reported as the most effective treatment. We herein present a case of severe spur cell hemolytic anemia that successfully reverted after orthotopic liver transplantation and recurred secondary to resumption of alcohol intake and consequent liver graft failure. This case conclusively demonstrates the association among alcoholic cirrhosis, end-stage liver disease, and spur cell hemolytic anemia.
International surgery 87(4):201-4. · 0.36 Impact Factor
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ABSTRACT: Hepatic artery pseudoaneurysm (HAP) is an uncommon but life-threatening complication of liver transplantation (LTx). It is often associated with a local infection. Prompt diagnosis and intervention are necessary. We report the first occurrence of such complication in the setting of adult living donor liver transplant. A 48-year-old female with primary sclerosing cholangitis underwent living donor right lobe LTx. Her postoperative course was uneventful. A month later, she developed massive gastrointestinal bleeding, with negative endoscopy and angiography. She rebled 2 weeks later, and an HAP was shown on angiography. On exploration, she was found to have an HAP caused by bile leakage from an accessory bile duct and a dissection of the native artery, likely a result of the angiography. The liver was revascularized using a cadaveric iliac artery conduit between the donor hepatic artery and the aorta, and the hepaticojejunostomy was reconstructed. Biliary complications are the most frequent complications in living donor LTx. A clinically silent bile leak can cause an HAP, resulting in massive gastrointestinal bleeding. Surgical repair and biliary reconstruction can yield an excellent clinical result.
International surgery 93(5):300-3. · 0.36 Impact Factor
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ABSTRACT: We describe a two-step procedure in the transplantation of a right lobe liver graft obtained from a living donor, in which the biliary anastomosis is delayed until the day after the actual implantation of the graft. The purpose of the two-step procedure is to minimize the factors that might contribute to biliary complications in living donor liver transplantation (LDLT). Three patients who received a graft with two hepatic ducts underwent Roux-en-Y hepatico-jejunostomies during a separate procedure the day after the implantation of the graft. Length of intubation, recovery of enteral alimentation, and hospital stay were similar to the patients who underwent one-step transplant. No biliary or infectious complications occurred. Delaying the hepatico-jejunostomy when two ducts are present and a bilio-digestive anastomosis is planned has no negative impact on the postoperative course of the patients but can ameliorate the conditions under which the anastomoses must be performed.
International surgery 94(3):217-20. · 0.36 Impact Factor
