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1.
Transplant Proc ; 54(8): 2248-2253, 2022 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-36167595

RESUMEN

BACKGROUND: The traditional approach in combined liver-kidney transplantation involves 2 separate and sequential incisions. We describe a modification of the standard Mercedes incision that allows a single-incision operation while providing and maintaining adequate exposure to enable safe dual-allograft transplantation. METHODS: Modification of the standard Mercedes incision includes bilateral, subcostal, muscle splitting incision 4 fingerbreadths below the rib edge with a midline, cephalad incision and inferior ± medial ipsilateral extension on the side of intended iliac fossa laterality for renovascular and ureteroneocystostomy anastomosis. RESULTS: Five consecutive patients (3 women/2 men; mean age, 49 years; median body mass index, 29.8 kg/m2) underwent combined liver-kidney transplantation for end-stage liver disease and progressive hepatorenal syndrome via a modified Mercedes single-incision approach (at a median Model for End-stage Liver Disease of 37) without an additional kidney transplant incision, extraperitoneal exposure, or addition of wound retractors. Two out of the 5 patients experienced postoperative wound complications, including 1 with delayed wound healing and 1 with superficial dehiscence. All patients have normal dual-allograft function at or beyond 6 months posttransplantation. CONCLUSIONS: The modified Mercedes single-incision technique is safe and feasible. Lowering the subcostal incisions with unilateral, inferomedial extension allows adequate visualization of the lower abdominopelvic area without compromising exposure of the upper abdomen for both renal and liver allograft implantation. Further studies are needed to prove the theoretical benefits of this technique.


Asunto(s)
Enfermedad Hepática en Estado Terminal , Trasplante de Riñón , Herida Quirúrgica , Masculino , Humanos , Femenino , Persona de Mediana Edad , Trasplante de Riñón/efectos adversos , Enfermedad Hepática en Estado Terminal/complicaciones , Índice de Severidad de la Enfermedad , Herida Quirúrgica/complicaciones , Complicaciones Posoperatorias/etiología , Abdomen
2.
S D Med ; 75(suppl 8): s21-s22, 2022 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-36745995

RESUMEN

BACKGROUND: The traditional approach in simultaneous liver-kidney transplantation (SLKT) involves two separate and sequential incisions. We describe modification of the classic Mercedes incision which limits the operation to a single incision yet provides and maintains adequate exposure enabling safe dual-allograft transplantation. METHODS: Modification of the standard Mercedes incision includes bilateral, subcostal, muscle splitting incision 4-finger-breadths below the rib-edge with a midline, cephalad incision, and inferior±medial, ipsilateral extension on the side of intended iliac fossa laterality for renovascular and ureteroneocystostomy anastomosis. RESULTS: Five consecutive patients (3 women/2 men; mean age, 49 years; median BMI, 29.8 kg/m2) underwent SLKT for end-stage liver disease and progressive hepatorenal syndrome via modified Mercedes incision approach (at a median MELD of 37) without an additional kidney transplant incision, extraperitoneal exposure, or addition of wound retractors. Two out of the five patients experienced post-op wound complications, including one with delayed wound healing and superficial dehiscence in a diabetic patient. All patients have normal dual-allograft function with four out of five beyond six months and one at two months post-transplantation. CONCLUSION: Modified Mercedes incision technique is safe and feasible. Lowering the subcostal incisions with unilateral, inferomedial extension allows adequate visualization of the lower abdominopelvic area without compromising exposure of the upper abdomen for both renal and liver allograft implantation, respectively. Further studies are needed to prove the theoretical benefits of this technique.


Asunto(s)
Trasplante de Riñón , Trasplante de Hígado , Masculino , Humanos , Femenino , Persona de Mediana Edad , Trasplante de Riñón/métodos , Hígado , Trasplante de Hígado/métodos , Abdomen
3.
4.
Transplant Proc ; 53(6): 1872-1879, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-34246475

RESUMEN

BACKGROUND: Indigenous people experience higher rates of end-stage renal disease as well as negative predictive factors that undermine kidney transplantation (KT) success. Despite these inequalities, data suggest that short-term outcomes are comparable to those of other groups, but few studies have examined this effect in the Northern Great Plains (NGP) region. METHODS: We performed a retrospective database review to determine outcomes of KT in Indigenous people of the NGP. White and Indigenous people receiving a KT between 2000 and 2018 at a single center were examined. RESULTS: A total of 622 KT recipients were included (117 Indigenous and 505 White). Indigenous patients were more likely to smoke, have diabetes, have higher immunologic risk, receive fewer living donor kidneys, and have longer waitlist times. In the 5 years after KT there were no significant differences in renal function, rejection events, cancer, graft failure, or patient survival. At 10 years posttransplant, Indigenous patients had twice the all-cause graft failure (odds ratio = 2.06; 95% confidence interval, 1.25-3.39) and half the survival rate (odds ratio = 0.47; 95% confidence interval, 0.29-0.76); however, this effect was not maintained once the effects of race, sex, smoking status, diabetes, preemptive transplant, high panel reactive antibody status, and transplant type were adjusted for. CONCLUSIONS: KT outcomes in Indigenous patients in the NGP region are similar to those of White patients 5 years posttransplant, with differences emerging at 10 years that could be diminished with greater emphasis on correcting modifiable risk factors.


Asunto(s)
Fallo Renal Crónico , Trasplante de Riñón , Rechazo de Injerto , Supervivencia de Injerto , Humanos , Pueblos Indígenas , Fallo Renal Crónico/cirugía , Trasplante de Riñón/efectos adversos , Donadores Vivos , Estudios Retrospectivos , Resultado del Tratamiento , Estados Unidos
5.
S D Med ; 74(1): 21-27, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33691053

RESUMEN

Advances in the field of solid-organ transplantation (SOT), namely evolution of surgical techniques, developments in immunosuppressive therapies and efforts to maximize utilization of donor allografts (deceased and living), have resulted in growing numbers of SOT performed annually in the United States (U.S.) (36,529 total organs and 21,167 kidneys transplanted in 2018). However, the Native American/American Indian (NA/AI) people of the U.S. experience enormous socioeconomic barriers such as poverty, lack of adequate healthcare, poor health literacy and geographic isolation which limit access to SOT resulting in low rates of organ donation and transplantation, poor quality of life and shorter life expectancy. The NA/AI population is at increased risk for end-stage renal disease secondary to the high prevalence of diabetes mellitus. We review existing challenges to kidney transplantation in NA/AI patients and discuss potential solutions which could improve equitable delivery of specialized healthcare to this underprivileged population.


Asunto(s)
Fallo Renal Crónico , Trasplante de Riñón , Obtención de Tejidos y Órganos , Humanos , Fallo Renal Crónico/epidemiología , Fallo Renal Crónico/cirugía , Calidad de Vida , Estados Unidos , Indio Americano o Nativo de Alaska
6.
Transplant Proc ; 52(9): 2790-2794, 2020 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-32641222

RESUMEN

Cryptococcal infection (CI) is an uncommon fungal disease that poses a particular fatal risk to liver transplant (LT) recipients because of the potential rapid development and dissemination of the disease. Depending on the pathophysiology, CI may manifest with a wide range of clinical presentations that may delay early diagnosis and timely treatment. Additionally, most anticryptococcal therapies may threaten LT recipients owing to the associated hepatotoxicity of these medications. We report a case of a 25-year-old woman who received an LT for cryptogenic cirrhosis and developed rapidly progressive CI with pulmonary, myocardial, and cerebral involvement within a month of transplantation. She presented with severe pulmonary hypertension refractory to medical management and subsequently died despite our efforts. Herein, we review the etiology of cryptococcosis, the natural history of cryptococcal disease, and standard treatments for CI, and we highlight peculiarities of Cryptococcus neoformans infection in solid organ transplant recipients.


Asunto(s)
Criptococosis/etiología , Trasplante de Hígado/efectos adversos , Complicaciones Posoperatorias/microbiología , Adulto , Criptococosis/mortalidad , Cryptococcus neoformans , Resultado Fatal , Femenino , Humanos , Complicaciones Posoperatorias/mortalidad
7.
Transplant Proc ; 52(2): 638-640, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32029315

RESUMEN

Chylous ascites (CA) is an uncommon entity with several etiologies. Only a few cases of CA have been reported as a complication after liver transplantation (LT). Most of these cases occurred within 1 month after surgery and typically resulted from traumatic intraoperative injury leading to disruption of lymphatics. Although peripheral lymphedema has been frequently correlated with use of calcineurin inhibitors, associated spontaneous CA has only been reported in a few cases after renal transplantation. We report a case of delayed spontaneous CA after LT caused by the use of the mammalian target of rapamycin (mTOR) inhibitor everolimus. Everolimus was introduced in our patient early after transplantation because of tacrolimus-induced microangiopathy, and years later the patient presented with spontaneous CA. After excluding other causes of CA, everolimus was discontinued, and immunosuppression was maintained by increasing prednisone and continuing mycophenolate mofetil. Additionally, the patient was treated with percutaneous drain placement and began a low-fat, high-protein diet. One month later the patient had complete resolution of symptoms with no recurrence of ascites. To our knowledge, this is the first case of delayed-onset CA caused by everolimus after LT.


Asunto(s)
Ascitis Quilosa/inducido químicamente , Everolimus/efectos adversos , Inmunosupresores/efectos adversos , Trasplante de Hígado , Humanos , Terapia de Inmunosupresión/métodos , Persona de Mediana Edad
8.
Respir Med ; 146: 81-86, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30665523

RESUMEN

Pulmonary infections are frequent complications in abdominal solid-organ transplantation (aSOT) which may threaten patient and allograft survival. Accurate diagnosis and treatment of pulmonary infections in this population can be challenging. Immunosuppressive therapy not only increases the risk of acquiring opportunistic and non-opportunistic infections, but it also impairs the inflammatory responses associated with microbial invasion which in an otherwise normal host produce clinical and radiologic responses that allow for early identification of the offending pathogen. Serologic testing is not a reliable diagnostic modality. Direct microbiological sampling is often necessary to make a definitive diagnosis early in the clinical course to optimize timely, targeted therapy while reducing the risk of developing antimicrobial resistance, and minimize adverse effects of therapy, if any. Fiber-optic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) or transbronchial lung biopsy (TBB) offers such diagnostic advantage and possesses a potential therapeutic value too. This comprehensive review discusses the potential benefits of FOB alongside its risks and complications, indications and contraindications, and techniques. Additionally, the essay highlights FOB's utility and yield specifically with regard to type and timing of infections in aSOT patients.


Asunto(s)
Broncoscopía/métodos , Inmunosupresores/efectos adversos , Enfermedades Pulmonares/diagnóstico por imagen , Infecciones del Sistema Respiratorio/diagnóstico por imagen , Receptores de Trasplantes/estadística & datos numéricos , Biopsia , Lavado Broncoalveolar , Broncoscopía/efectos adversos , Tecnología de Fibra Óptica , Humanos , Huésped Inmunocomprometido/inmunología , Inmunosupresores/uso terapéutico , Inflamación/patología , Enfermedades Pulmonares/epidemiología , Enfermedades Pulmonares/microbiología , Enfermedades Pulmonares/patología , Infecciones del Sistema Respiratorio/epidemiología , Infecciones del Sistema Respiratorio/etiología
9.
Drugs Ther Perspect ; 35(9): 442-446, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-32288505

RESUMEN

Distributive shock is a serious complication in patients with chronic or end-stage liver disease, and can be exacerbated by vasoplegia in this patient population. Vasoplegic syndrome (VS) is a state of shock refractory to catecholamines and vasopressin that is often multifactorial in liver failure patients, and can occur in any phase of liver transplantation (LT) [i.e., pre-transplantation, intraoperative, and post-transplantation]. Methylene blue (MB) has been a well-established pharmacologic therapy for VS. However, it has been known to cause dose-related toxicity. Hydroxocobalamin (HXC) is not currently FDA approved for the management of VS, but studies have demonstrated its ability to cause an increase in systolic blood pressure by hypothesized mechanisms with only minimal side effects. To date, only three other reports have demonstrated the use of HXC in LT patients, which highlighted its use both intraoperatively and post-transplantation. Our report illustrates the utility of HXC in four LT patients with VS. Two of these cases illustrate the usefulness of HXC in the pre-transplantation period, which has never been previously reported. HXC is a useful pharmaceutical agent in the management of VS, especially if contraindications to MB exist or in cases of MB-resistant vasoplegia. Further studies with large sample sizes are necessary to ascertain the optimal dosage of HXC in LT patients.

10.
J Crit Care Med (Targu Mures) ; 4(3): 83-89, 2018 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-30582000

RESUMEN

The critical care involved in solid-organ transplantation (SOT) is complex. Pre-, intra- and post-transplant care can significantly impact both - patients' ability to undergo SOT and their peri-operative morbidity and mortality. Much of the care necessary for medical optimization of end-stage organ failure (ESOF) patients to qualify and then successfully undergo SOT, and the management of peri-operative and/or long-term complications thereafter occurs in an intensive care unit (ICU) setting. The current literature specific to critical care in abdominal SOT patients was reviewed. This paper provides a contemporary perspective on the potential multifactorial advantages of sub-specialized transplant critical care units in providing efficient, comprehensive, and collaborative multidisciplinary care.

11.
Liver Transpl ; 15(12): 1728-37, 2009 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-19938125

RESUMEN

Liver transplantation may occasionally be indicated in patients with unique clinical scenarios. Little is known regarding the outcomes of patients who have had a pancreatic resection prior to, in combination with, or after liver transplantation. A retrospective review of all patients undergoing liver transplantation from March 1998 to March 2008 identified 17 patients who also underwent pancreatic resection. An additional literature review was performed. Five underwent pancreatic resection prior to liver transplantation (1.7, 3.6, 3.8, 6.8, and 8.1 years), another 9 underwent pancreatic resection together with liver transplantation, and 3 underwent pancreatic resection after liver transplantation (2.2, 2.6, and 3.8 years). Indications for pancreatic resection included cholangiocarcinoma (n = 6), neuroendocrine tumor (n = 5), pancreatic cancer (n = 2), gastrointestinal stromal tumor (n = 1), periampullary adenocarcinoma (n = 1), duodenal adenomas (n = 1), and benign pancreatic mass (n = 1). Indications for liver transplantation were metastatic neuroendocrine tumor disease (n = 5), primary sclerosing cholangitis (n = 5), hepatitis C virus (n = 2), metastatic gastrointestinal stromal tumor (n = 1), Klatskin tumor (n = 1), alcohol cirrhosis (n = 1), alpha-1 antitrypsin deficiency (n = 1), and chemotherapy-induced cirrhosis (n = 1). One patient died intraoperatively, 7 patients died of tumor recurrence, 2 patients died from transplant complications, and 7 patients are still alive. Pancreatic resection-related complications included 4 pancreatic fistulas. A literature review confirmed liver transplantation/pancreatic resection-related complications. In conclusion, liver transplantation and pancreatic resection remain uncommon, and a good outcome can be achieved. Recurrence of malignant disease is the main factor limiting survival, and specific morbidity may be related to pancreatic resection and liver transplantation.


Asunto(s)
Hepatopatías/cirugía , Trasplante de Hígado , Pancreatectomía , Enfermedades Pancreáticas/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Hepatopatías/complicaciones , Hepatopatías/mortalidad , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Pancreatectomía/efectos adversos , Pancreatectomía/mortalidad , Enfermedades Pancreáticas/complicaciones , Enfermedades Pancreáticas/mortalidad , Selección de Paciente , Recurrencia , Medición de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Adulto Joven
12.
Clin Transplant ; 23(2): 168-73, 2009.
Artículo en Inglés | MEDLINE | ID: mdl-19220366

RESUMEN

Organ shortage continues to be a major challenge in transplantation. Recent experience with controlled non-heart-beating or donation after cardiac death (DCD) are encouraging. However, long-term outcomes of DCD liver allografts are limited. In this study, we present outcomes of 19 DCD liver allografts with follow-up >4.5 years. During 1998-2001, 19 (4.1%) liver transplants (LT) with DCD allografts were performed at our center. Conventional heart-beating donors included 234 standard criteria donors (SCD) and 214 extended criteria donors (ECD). We found that DCD allografts had equivalent rates of primary non-function and biliary complications as compared with SCD and ECD. The overall one-, two-, and five-yr DCD graft and patient survival was 73.7%, 68.4%, and 63.2%, and 89.5%, 89.5%, and 89.5%, respectively. DCD graft survival was similar to graft survival of SCD and ECD in non hepatitis C virus (HCV) recipients (p > 0.370). In contrast, DCD graft survival was significantly reduced in HCV recipients (p = 0.007). In conclusion, DCD liver allografts are durable and have acceptable long-term outcomes. Further research is required to assess the impact of HCV on DCD allograft survival.


Asunto(s)
Muerte , Rechazo de Injerto/etiología , Supervivencia de Injerto , Trasplante de Hígado/estadística & datos numéricos , Obtención de Tejidos y Órganos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Estudios de Seguimiento , Hepacivirus/patogenicidad , Hepatitis C/virología , Humanos , Masculino , Persona de Mediana Edad , Preservación de Órganos , Complicaciones Posoperatorias , Pronóstico , Factores de Riesgo , Tasa de Supervivencia , Factores de Tiempo , Donantes de Tejidos , Trasplante Homólogo , Resultado del Tratamiento , Adulto Joven
13.
Liver Transpl ; 14(9): 1294-302, 2008 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-18756457

RESUMEN

Although recurrent hepatitis C virus (HCV) after liver transplantation (LT) is universal, a minority of patients will develop cirrhosis within 5 years of surgery, which places them at risk for allograft failure. This retrospective study investigated whether 2 serum fibrosis markers, serum hyaluronic acid (HA) and YKL-40, could be used to predict rapid fibrosis progression (RFP) post-LT. These markers were compared with conventional laboratory tests, histological assessment, and hepatic stellate cell activity (HSCA), a key step in fibrogenesis, as assessed by immunohistochemical staining for alpha-smooth muscle actin. Serum and protocol liver biopsy samples were obtained from 46 LT recipients at means of 5 +/- 2 (biopsy 1) and 39 +/- 6 (biopsy 2) months post-LT, respectively. RFP was defined as an increase in the fibrosis score >or= 2 from biopsy 1 to biopsy 2 (a mean interval of 33 +/- 6 months). The ability of parameters at biopsy 1 to predict RFP was compared with the areas under receiver operating characteristic curves (AUROCs). Of the 46 subjects, 15 developed RFP. Serum HA and YKL-40 performed significantly better than conventional parameters and HSCA in predicting RFP post-LT for HCV at biopsy 1, with AUROCs of 0.89 and 0.92, respectively. The accuracy of serum HA >or= 90 microg/L and YKL-40 >or= 200 microg/L in predicting RFP at biopsy 1 was 80% and 96%, respectively. In conclusion, we found that elevated levels of serum HA and YKL-40 within the first 6 months after LT accurately predicted RFP. Larger studies evaluating the role of serum HA and YKL-40 in post-LT management are warranted.


Asunto(s)
Fibrosis/sangre , Fibrosis/patología , Hepatitis C/sangre , Hepatitis C/terapia , Trasplante de Hígado/métodos , Adipoquinas , Adulto , Proteína 1 Similar a Quitinasa-3 , Estudios de Cohortes , Progresión de la Enfermedad , Femenino , Glicoproteínas/sangre , Hepacivirus/metabolismo , Humanos , Ácido Hialurónico/sangre , Lectinas , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento
15.
Am Surg ; 74(1): 43-6, 2008 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-18274427

RESUMEN

Alveolar soft-part sarcoma is a highly vascular soft-tissue tumor that is uniformly malignant. It comprises less than 1 per cent of all soft-tissue sarcomas. Patients with alveolar soft-part sarcoma most frequently are aged 15 to 35 years, and the soft tissues of the lower extremities typically are affected. In the pediatric population, it most frequently occurs in the head and neck and particularly affects the tongue and orbit. Alveolar soft-part sarcoma has been described as a primary lesion in the trunk, upper extremities, and retroperitoneum; more novel locations include the mediastinum, female genital tract, stomach, bone, and larynx. Numerous case reports describe alveolar soft-part sarcoma in diverse anatomic locations, but this report is, to our knowledge, the first documentation of primary alveolar soft-part sarcoma of the liver. We describe a 47-year-old woman with such a manifestation. Despite surgical resection and numerous chemotherapeutic regimens, this patient had widespread metastasis and died approximately 2 years after the diagnosis was established.


Asunto(s)
Neoplasias Hepáticas/diagnóstico , Sarcoma de Parte Blanda Alveolar/diagnóstico , Antineoplásicos/uso terapéutico , Resultado Fatal , Femenino , Hepatectomía , Humanos , Neoplasias Hepáticas/tratamiento farmacológico , Neoplasias Hepáticas/cirugía , Persona de Mediana Edad , Sarcoma de Parte Blanda Alveolar/tratamiento farmacológico , Sarcoma de Parte Blanda Alveolar/cirugía
16.
Mayo Clin Proc ; 81(8): 1029-33, 2006 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-16901025

RESUMEN

OBJECTIVE: To assess t he association be tweencytomegalovirus (CMV) serology of donor and recipient and adverse outcomes afterliver transplantation in the era of effective antiviral chemoprophylaxis. PATIENTS AND METHODS: We performed a retrospective cohort study of 193 consecutive patients undergoing their first liver transplantation between February 1998 and July 2000 with targeted and preemptive ganciclovir chemoprophylaxis. Patients were divided into 4 groups by CMV serology of donor and recipient: donor-/recipient-; donor-/recipient+; donor+/recipient+; and donor+/recipient-. Survival to the end points of retransplantation, death, or survival to 1 year after transplantation (whichever occurred first) was assessed. Rates of bacterial, fungal, and CMV Infection and of CMV disease were recorded and compared. RESULTS: No significant differences were observed in the rates of retransplantation, death, or survival to 1 year among the 4 groups of patients. Despite significantly higher rates of CMV infection in the donor+ groups, there were no differences in the rates of bacterial or fungal Infection or of CMV disease. Rejection occurred least frequently in the donor-/recipient- group. CONCLUSION: The adverse effects of CMV on outcomes after liver transplantation have been diminished in the era of effective antiviral chemoprophylaxis.


Asunto(s)
Antivirales/uso terapéutico , Infecciones por Citomegalovirus/prevención & control , Trasplante de Hígado/efectos adversos , Adolescente , Adulto , Anciano , Anticuerpos Antivirales/inmunología , Citomegalovirus/inmunología , Infecciones por Citomegalovirus/epidemiología , Infecciones por Citomegalovirus/virología , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del Tratamiento
17.
Transpl Int ; 19(8): 675-82, 2006 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-16827685

RESUMEN

Fulminant hepatic failure (FHF) is a devastating disease. Liver transplantation is the definitive treatment. However, a third of these patients die due to brain edema before a donor becomes available. Cerebrospinal fluid (CSF) drainage and decompressive craniectomy have been used to treat brain edema in brain trauma and hemispheric stroke. However, their role in brain edema associated with FHF has not been examined. In this study we evaluated the potential effects of CSF drainage and decompressive craniectomy on survival in FHF using an experimental model in rats. In CSF drainage experiments all animals had ventriculostomy placed. Five days later FHF was induced with d-galactosamine. Those FHF rats that progressed into comatose stages either received CSF aspiration or did not. In separate experiments the study rats had either a decompressive craniectomy or a sham procedure. FHF was induced 5 days later. We found that both CSF drainage and decompressive craniectomy significantly increased survival of FHF rats compared with the controls: 53.2 +/- 1.1 vs. 48.7 +/- 1.5 h (P = 0.031), and 69.4 +/- 3.9 vs. 53.7 +/- 3.2 h (P = 0.009), respectively. In conclusion, these findings suggest that CSF drainage and decompressive craniectomy may increase the window of opportunity for liver transplantation.


Asunto(s)
Fallo Hepático Agudo/terapia , Animales , Edema Encefálico/prevención & control , Descompresión Quirúrgica , Modelos Animales de Enfermedad , Humanos , Fallo Hepático Agudo/líquido cefalorraquídeo , Fallo Hepático Agudo/cirugía , Trasplante de Hígado , Masculino , Ratas , Ratas Sprague-Dawley , Succión , Ventriculostomía
18.
Transpl Int ; 19(8): 683-7, 2006 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-16827686

RESUMEN

Bartonella henselae has not only been identified as the causative agent of cat scratch disease, but it is also associated with other significant infectious syndromes in the immunocompromised population. We describe two cases of B. henselae associated diseases in liver transplant recipients who both had contact with cats. The first recipient developed localized skin manifestation of bacillary angiomatosis in association with granulomatous hepatitis. He tested positive for Immunoglobulin G (IgG) antibodies against B. henselae. The second patient developed axillary lymphadenopathy, with biopsy showing necrotizing granulomatous inflammation and polymerase chain reaction studies were positive for B. henselae DNA. Her serology for bartonellosis showed a fourfold rise in antibody titers during her hospitalization. Both patients responded to treatment with Azithromycin in combination with Doxycycline. These were the only cases within a series of 467 consecutive liver transplants performed in 402 patients performed during a 4-year period. Although bartonellosis is a rare infection in liver transplantation recipients, it should always be included in the differential diagnosis of patients presenting with fever, central nervous system (CNS) symptoms, skin lesions, lymphadenopathy, and hepatitis especially if prior contact with cats is reported.


Asunto(s)
Infecciones por Bartonella/etiología , Trasplante de Hígado/efectos adversos , Angiomatosis Bacilar/diagnóstico , Angiomatosis Bacilar/etiología , Animales , Anticuerpos Antibacterianos/sangre , Infecciones por Bartonella/diagnóstico , Infecciones por Bartonella/microbiología , Bartonella henselae/genética , Bartonella henselae/inmunología , Bartonella henselae/aislamiento & purificación , Enfermedad por Rasguño de Gato/diagnóstico , Enfermedad por Rasguño de Gato/etiología , Gatos , Femenino , Hepatitis A/etiología , Humanos , Huésped Inmunocomprometido , Masculino , Persona de Mediana Edad
19.
J Hepatol ; 44(6): 1105-14, 2006 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-16458990

RESUMEN

BACKGROUND/AIMS: Fulminant hepatic failure (FHF) can be dreadful. When coma sets in, brain edema develops taking FHF into a lethal course. Mechanisms of brain extravasation leading to brain edema remain incompletely understood. Matrix metalloproteinase (MMP)-9 is implicated in various brain injuries. We hypothesized that MMP-9 contributes to brain edema in FHF. METHODS: MMP-9 and its proform were assayed using SDS-PAGE and in situ gelatin zymographies. Brain extravasation was assessed with Evans blue. Brain water was determined by specific gravity and astrocytic endfoot swelling by electron microscopy. FHF in mice was induced by azoxymethane. MMP inhibitor GM6001 and MMP-9 monoclonal antibody were used. RESULTS: Active MMP-9 was significantly increased at the onset of coma and brain extravasation in FHF mice. Blocking MMP-9 with either GM6001 or MMP-9 monoclonal antibody significantly attenuated brain extravasation, astrocytic endfoot swelling, and brain edema. Brains of FHF mice did not show MMP-9 activity. In contrast, livers of these animals showed marked up-regulation of MMP-9 activity. CONCLUSIONS: Our findings suggest that MMP-9 contributes to the pathogenesis of brain extravasation and edema in FHF. The necrotic liver is the source of MMP-9 in FHF. Inhibition of MMP-9 may protect against the development of brain edema in FHF.


Asunto(s)
Edema Encefálico/enzimología , Encéfalo/enzimología , Permeabilidad Capilar , Fallo Hepático Agudo/enzimología , Metaloproteinasa 9 de la Matriz/fisiología , Animales , Azul de Evans/metabolismo , Hígado/enzimología , Hígado/patología , Masculino , Metaloproteinasa 9 de la Matriz/genética , Inhibidores de la Metaloproteinasa de la Matriz , Ratones , Ratones Endogámicos C57BL , Regulación hacia Arriba
20.
Mayo Clin Proc ; 80(10): 1303-6, 2005 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-16212143

RESUMEN

OBJECTIVE: To examine the frequency and microbial pattern of pneumonia and its effect on survival in the current era of orthotopic liver transplantation (OLT). PATIENTS AND METHODS: At the Mayo Clinic in Jacksonville, Fla, the medical records of consecutive patients who underwent their first OLT between February 1998 and January 2001 were retrospectively reviewed through the end of the first year posttransplantation. RESULTS: Of 401 study patients, 20 developed pneumonia; estimates of incidence with corresponding 95% confidence interval (CI) at 1 and 12 months were 3% (1%-5%) and 5% (3%-7%), respectively. Pseudomonas aeruginosa was the predominant microorganism identified (in 8 of 14 patients) during the first month after transplantation. Between the second and sixth months, 2 of the 4 cases of pneumonia were due to fungal infections of Aspergillus fumigatus. Cytomegalovirus was associated with Aspergillus in 1 patient. No other viral or Pneumocystis carnil pneumonia was diagnosed. There were only 2 cases of pneumonia between 7 months and 1 year after transplantation, neither of which was fungal. Approximately 40% (95% CI, 14%-58%) of patients with pneumonia died within 1 month after diagnosis. The relative risk of mortality in the first month after onset of pneumonia was estimated to be 24 (95% CI, 10-54), which is strong evidence of increased risk of mortality with pneumonia (P<0.001). CONCLUSIONS: Pneumonia appears to occur less often after OLT than previously reported but still has a substantial negative effect on survival. In the early period after OLT, P. aeruginosa continues to be the predominant organism causing pneumonia.


Asunto(s)
Trasplante de Hígado/mortalidad , Neumonía/mortalidad , Adulto , Aspergilosis/mortalidad , Aspergillus fumigatus , Broncoscopía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neumonía/microbiología , Infecciones por Pseudomonas/mortalidad , Análisis de Supervivencia , Factores de Tiempo
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