The evaluation of hemodynamic changes during the reperfusion phase in adult living donor liver transplantations: the role of cardiovascular problems.

OBJECTIVE: This study sought to evaluate the hemodynamic changes of and to analyze the effects of coronary artery disease (CAD) as well as its risk factors on hemodynamic parameters during the reperfusion phase (RP) in adult living donor liver transplantation (ALDLT). PATIENTS AND METHODS: This single-center retrospective study evaluated 154 adult patients being assessed from January 2001 to December 2013 for orthotopic liver transplantation (OLT). The patients were divided into separate groups according to the presence or absence of CAD and its risk factors, including diabetes, hypertension, dyslipidemia, smoking, sex, and age. The hemodynamic parameters were noted during the RP with respect to the patient files. The comparison of the groups and the effects of cardiovascular problems on hemodynamic parameters were statistically analyzed. RESULTS: A decrease of more than 20% in systolic arterial pressure was seen in 16 (16.7%), 7 (43.8%), and 17 (40.5%) patients without CAD, with CAD, and with its high risk factors (>2), respectively (P < .05). Moreover, diastolic hypotension was seen in 59 (38.3%) patients during RP; of those, 10 (62.5%) had CAD and 19 (45.2%) had CAD high-risk factors. The decline in both systolic and diastolic arterial pressure was significantly correlated with the increased number of risk factors (P < .05). CONCLUSIONS: RP in ALDLT remains an issue not only for the surgeons but also for the anesthesiologists. Clinicians should be aware of CAD and its risk factors before OLT and successful management of such problems are mandatory for hemodynamic stability during this formidable process.

Management of early hepatic arterial thrombosis after pediatric living-donor liver transplantation.

PURPOSE: Early hepatic arterial thrombosis after living-donor liver transplantation is a cause of graft loss and patient mortality. We analyzed early hepatic arterial thrombosis after pediatric living-donor liver transplantation. MATERIALS AND METHODS: Since September 2001, we performed 122 living-donor liver transplants on 119 children. Ten hepatic arterial thromboses developed in the early postoperative period. The 7 male and 4 female patients of overall mean age of 6.3±6.1 years underwent 5 left lateral segment, 3 right lobe, and 2 left lobe transplantations. RESULTS: Among 10 children with hepatic arterial thrombosis, 8 diagnoses were made before any elevation of liver function tests. One child displayed fever at the time of the hepatic arterial thrombosis. The median time for diagnosis was 5 days. Hepatic arterial thrombosis was treated with interventional radiologic techniques in 9 children, with 1 undergoing surgical exploration owing to failed radiologic approaches, and a reanastomosis using a polytetrafluoroethylene graft. Successful revascularization was achieved in all children, except 1. Four children died, the remaining 6 are alive with good graft function. During the mean follow-up of 52.7±18.8 months, multiple intrahepatic biliary stenoses were identified in 1 child. CONCLUSION: Routine Doppler ultrasonography is effective for the early diagnosis of hepatic arterial thrombosis. Interventional radiologic approaches such as arterial thrombolysis and intraluminal stent placement should be the first therapeutic choices for patients with early hepatic arterial thrombosis; if radiologic methods fail, one must consider surgical exploration or retransplantation.

Rifle criteria for acute kidney dysfunction following liver transplantation: incidence and risk factors.

RIFLE criteria have been used to determine the incidence of acute kidney dysfunction (AKD) after orthotopic liver transplantation (OLT). However, no studies have focused on the incidence of AKD after OLT in patients with normal pre-OLT kidney functions. Using the RIFLE criteria, we determined the incidence and risk factors for AKD after OLT in patients with normal pre-OLT kidney function. We retrospectively analyzed the records of 112 patients who underwent OLT from January 2000 to February 2009 with normal prior kidney function. We investigated three levels of renal dysfunction outlined in the RIFLE criteria: risk (R); injury (I); and failure (F). Preoperative, intraoperative, and postoperative variables were collected. AKD occurred in 64 (57%) OLTs with risk, injury, and failure frequencies of 19%, 11%, and 28%, respectively. Compared with those who did not develop AKD postoperatively, those who did had significantly higher MELD scores (19 ± 7 vs 16 ± 8; P = .018), more frequently use of inotropic agents intraoperatively (54% vs 35%; P = .070), more colloid treatment (300 ± 433 mL vs 105 ± 203 mL; P = .007), longer anhepatic phase (88.0 ± 42.0 minutes vs 73.0 ± 20.0 minutes; P = .037), and a greater incidence of intraoperative acidosis (64% vs 44%; P = .047). Logistic regression analysis revealed that MELD score (odds ratio 1.107, 95% CI 1.022-1.200, P = .013), duration of anhepatic phase (odds ratio 1.020 95% CI 1.000-1.040, P = .053), and intraoperative acidosis (odds ratio 0.277 95% CI 0.093-0.825 P = .021) were independent risk factors for AKD. In conclusion, our results suggested that, based on RIFLE criteria, AKD occurs in more than half of OLTs postoperatively. A higher MELD score, longer anhepatic phase, and occurrence of intraoperative acidosis were associated with AKD.

Preemptive living donor renal transplantation: a single-center experience.

Renal transplantation is considered preemptive if it occurs before initiation of dialysis. In our experience and in the literature, preemptive transplantation has been shown not only to reduce the costs of renal replacement therapy but also to avoid the long-term adverse effects of dialysis. Preemptive renal transplantation therefore is associated with better survival of both the allograft and the recipient. Our aim was to evaluate the outcomes of preemptive renal transplantation experience at our center. Since 1985, 1385 renal transplantations have been performed at our center. We retrospectively analyzed the 16/1385 recipients (11 male, 5 female) of overall mean age of 28.5 +/- 15 years who underwent preemptive procedures. The causes of end-stage renal failure were focal segmental glomerulosclerosis (n = 5), vesicular ureteral reflux (n = 4), Berger disease (n = 2), polycystic renal disease (n = 2), and others (n = 3). Ten patients were adults, the remaining six, children. The mean creatinine clearance and plasma creatinine levels of the recipients before renal transplantation were 13.5 +/- 8.5 mL/min and 6.7 +/- 2.4 mg/dL, respectively. All renal transplantations were performed from living related donors. The mean preoperative serum creatinine levels, mean glomerular filtration rate, and creatinine clearance rates of the donors were 0.8 +/- 0.1 mg/dL, 61.6 +/- 6.5 mL/min, and 112.5 12 mL/min, respectively. Two episodes of acute cellular rejection and one of humoral rejection occurred during a mean follow-up of 48.7 +/- 14 months (range = 25-76 months). The two patients who experienced graft losses due to humoral rejection or chronic rejection were retransplanted 2 and 48 months thereafter, respectively. At this time all patients are alive with good renal function. In conclusion, our single-center results are promising for preemptive renal transplantation as the optimal, least-expensive mode of treatment for end-stage renal disease.

Living related liver transplantation in Crigler-Najjar syndrome type 1.

Four children underwent living related liver transplantation because of Crigler-Najjar syndrome type 1. Three were infants aged 2, 8(1/2), and 15 months, and weighed 5, 8, and 10 kg, respectively. Pretransplantation unconjugated bilirubin concentration was 22 to 30 mg/dL despite 12 to 14 hours of phototherapy daily. Patient 1, the 2-month-old infant, with unconjugated bilirubin concentration of 30 mg/dL, had a high-pitched cry, suggestive of bilirubin encephalopathy; results of neurologic examination were normal. Plasmapheresis and urgent liver transplantation were performed. Patient 4, a 13-year-old girl, had learning difficulties at school and attended a special class. Three patients received left lateral liver segments, and 1 patient received a left lobe. Biliary reconstruction was completed with duct-to-duct anastomosis. Bile leakage developed at the anastomosis in 2 patients, which was treated successfully with cholangioplasty. In all patients, the unconjugated bilirubin concentration normalized by day 1 posttransplantation, and no phototherapy was necessary. After transplantation, the 2-month-old infant with suspected encephalopathy exhibited hypotonia, spasticity of the lower extremities, and lack of head control. He died after vomitus aspiration during sleep at 10 months posttransplantation. The other 3 patients are alive with normal neurodevelopmental milestones. Irreversible brain damage may occur early in the course of Crigler-Najjar syndrome type 1. Urgent treatment including plasmapheresis, exchange transfusion, phototherapy, and liver transplantation may not reverse brain damage. Young infants must be evaluated carefully for subtle signs and symptoms of bilirubin encephalopathy. Liver transplantation is curative if performed before development of neurologic dysfunction.

Liver transplantation in management of alveolar echinococcosis: two case reports.

Hepatic alveolar echinococcosis is an infectious disease caused by the larval stage of Echinococcus multilocularis, which grows primarily in the liver of an infected person and develops as a tumorlike lesion. In advanced cases, the organisms infiltrate every organ neighboring the liver and spread hematogenously to distant organs such as lungs and brain. Surgical resection and liver transplantation are accepted treatment options for early and advanced disease, respectively. Herein, we present case reports of 2 patients with advanced alveolar echinococcal disease that invaded both lobes of the liver and neighboring vital structures including the inferior vena cava. Despite the technical difficulty of the surgery, both patients were successfully treated with living donor liver transplantation. Liver transplantation should be accepted as a life-saving treatment of choice in patients with alveolar echinococcosis for whom there is no other medical or surgical treatment options.

A comparison of right and left lobectomies for living donor liver transplantation: an anesthesiologist's point of view.

Because of the shortage of cadaveric donor organs, living donor liver transplantation (LDLT) has become an established therapy modality for end-stage liver disease. Based on recipient size, both right and left liver lobe grafts have been used successfully in LDLT. The aim of this study was to compare the risk of intraoperative complications and transfusion requirements between right and left lobe donors. We reviewed the charts of 54 right lobe (Group RL), 29 left lobe (Group LL), and 31 left lateral segment (Group LLS) donors who underwent lobectomy from January 2003 through January 2007. We recorded patient demographics, perioperative laboratory values, intraoperative fluid and transfusion requirements, intraoperative hemodynamic parameters, and complications. Demographic features and preoperative laboratory values were similar for the 3 groups, except for age (Group RL, 37.3 +/- 8.7; Group LL, 36.0 +/- 9.3; Group LLS, 31.7 +/- 9.4; P = .02). There were no significant differences in mean liver volumes among the groups (P > .05). Respective graft volumes were 803.1 +/- 139.2 mL, 438.0 +/- 122.7 mL, and 308.2 +/- 76.6 mL for Groups RL, LL, and LLS, respectively (P < .001). More patients in Group LLS required heterologous blood transfusion than did those in the other groups (P = .01). The incidence of intraoperative hypotension was similar for all groups (P > .05). Group RL had a significantly higher rate of intraoperative hypothermia than the other groups (P = .01). There were no intraoperative respiratory complications or cardiac events. These results indicated that both right and left donor lobectomies for LDLT were safe procedures with acceptable rates of minor intraoperative complications.

Corner-saving renal artery anastomosis for renal transplantation.

Renal transplantation is the preferred treatment for most patients with end-stage renal disease. Postoperative vascular complications that significantly affect graft loss include stenosis and renal artery thrombosis. Our transplant team has performed 1635 procedures since 1975. Since December 2003, we have performed a corner-saving technique for the renal artery anastomoses in 183 recipients. In this study, we retrospectively analyzed the outcome data from these procedures in 43 women and 140 men of overall mean age of 31.6 years (range, 7-66 years). Graft tissue was obtained from deceased donors in 47 and from living donors in 136 recipients. The mean age of the donors was 39.8 years (range, 6-67 years). The graft renal arteries were spatulated from the posterior walls of the renal artery to provide wide anastomoses. Using this technique, a renal artery stenosis occurred at 5 months after renal transplantation in 1 recipient (0.54%). It was treated successfully with balloon angioplasty and placement of an intraluminal stent. We did not encounter any instances of renal artery thrombosis during a mean follow-up of 20.6 +/- 11.6 months (range, 1-40 months). During follow-up, 5 recipients died, and 9 returned to hemodialysis. At the time of this writing, the remaining 169 recipients (92.3%) are alive with good graft function. In conclusion, owing to its low complication rate, we believe our new corner-saving technique to be the safest way to perform a renal artery anastomosis.

Effect of restrictive fluid management and acute normovolemic intraoperative hemodilution on transfusion requirements during living donor hepatectomy.

The aim of this study was to evaluate the safety and effectiveness of a restrictive fluid management strategy and acute normovolemic intraoperative hemodilution (ANIH) to decrease transfusion requirements among living-donors for liver transplantation (LDLT). We retrospectively reviewed the data of 114 consecutive LDLT donors. The patients were divided into 2 groups based on whether (Group I; n = 73) or not (Group II; n = 41) a restrictive fluid management strategy with ANIH was used during the procedure. For each group we recorded demographic features, intraoperative and postoperative transfusions, amount of administered intraoperative crystalloid and colloids, intraoperative hemodynamics, preoperative and postoperative laboratory values (renal and liver functions), intraoperative and postoperative urine output, and length of hospital stay. Demographic features and preoperative laboratory values were similar for the 2 groups, except for age (Group I, 36 +/- 9 vs Group II, 33 +/- 8; P = .04). Intraoperatively, 7 patients (10%) in Group 1 and 9 (22%) in Group II required blood transfusions (P = .06). The respective amount of heterologous blood transfusion for Groups I and II was 96 +/- 321 mL vs 295 +/- 678 mL (P = .06). Postoperative renal and liver functions were not different between the 2 groups (P > .05). Patients in Group I had a shorter hospital stay than those in Group II (8.2 +/- 4.6 days vs 10.1 +/- 4.9 days; P = .03). In conclusion, a restrictive fluid management strategy with ANIH was a safe blood-salvage technique for LDLT. This approach was also associated with decreased length of hospital stay and a trend toward decreased transfusion requirements.

Liver transplantation for Wilson's disease.

Wilson's disease is an inherited disorder of copper metabolism characterized by reduced biliary copper excretion, which results in copper accumulation in the tissues with liver injury and failure. Orthotopic liver transplantation (OLT) can be lifesaving for patients with Wilson's disease who present with fulminant liver failure and for patients' unresponsive to medical therapy. The aim of this study was to review our experience with OLT for patients with Wilson's disease. Between September 2001 and April 2007, 25 OLTs were performed in 24 patients (7 females and 17 males) with Wilson's disease of mean age 15.6 +/- 9.9 years (range, 5-51 years). Six patients underwent transplantation owing to coexistent fulminant hepatic failure and 18 with chronic advanced liver disease with (n = 8) or without (n = 10) associated neurologic manifestations. We performed 3 full-size, deceased-donor OLTs and 22 living-related donor OLTs. Eight patients had a family history of Wilson's disease. We detected a Kayser-Fleischer ring in 18 patients. All patients had a low serum ceruloplasmin level (mean, 27.8 mg/dL) and a high urinary copper excretion level (mean, 4119 mug/d) before OLT. Following successful OLT, there was a significant reduction in urinary copper excretion (median, 37.1 mug/d) in all patients. Mean follow-up was 21.7 +/- 19.8 months (range, 2-60 months). Retransplantation was required in 1 patient at 12 days after the first OLT owing to primary graft nonfunction. Five of the 24 patients died within 4 months of the surgery. The remaining 19 survivors (79%) have remained well, with normal liver function and no disease recurrence. In conclusion, OLT was a curative procedure for Wilson's disease among patients presenting with fulminant hepatic failure and others with end-stage hepatic insufficiency. After OLT, the serum ceruloplasmin level increased to the normal range, urinary copper excretion decreased, and neurologic manifestations improved.

Liver transplantation for biliary atresia.

Biliary atresia is the most common indication for liver transplantation (OLT) in children. We present our experience with OLT as a treatment for end-stage liver disease in children with biliary atresia. We performed a retrospective review of 20 biliary atresia patients (11 male, 9 female patients; mean age, 21.4 months; range, 6 to 84 months) who had undergone OLT. Mean preoperative weight and height were 10.1 +/- 5.8 kg and 72.5 cm, respectively. Thirteen recipients were younger than 1 year of age, and 15 weighed less than 10 kg at the time of OLT. Fourteen recipients had undergone a Kasai operation prior to the OLT. The mean serum total bilirubin level was 22.56 mg/dL before OLT. Eighteen left lateral segment grafts and two whole grafts were transplanted. The mean recipient operative time was 9.25 hours. The mean recipient intraoperative blood loss was 1.81 U. Two hepatic arterial thromboses and one biliary leak occurred soon after surgery. Portal vein stenoses developed in two recipients at 10 and 12 months after OLT; both were treated with balloon dilatation. Two biliary stenoses, which occurred at 10 months and 3.5 years after surgery, were treated with balloon dilatation. Two recipients died at 2 and 12 days after OLT because of respiratory distress syndrome and sepsis, respectively. The remaining 18 (90%) recipients are alive with good graft function. The overall rejection rate was 31.25%. OLT is an effective treatment for children with biliary atresia and a failed Kasai procedure. Living related liver grafts represented an excellent organ supply for these patients.

Bile duct reconstruction without a stent in liver transplantation: early results of a single center.

Biliary complications may present significant problems in orthotopic liver transplantation (OLT). Herein we have presented our outcomes of a biliary reconstruction technique without stenting in deceased- and living-donor OLT. Between September 2001 and May 2007, we performed 174 OLTs in 172 recipients. Before December 2006, we used various drainage techniques for biliary reconstruction. We retrospectively reviewed the biliary reconstructions performed without a drainage catheter in 33 OLTs (19 males, 14 females; median age, 25.2 +/- 20.7 years; range, 0.5-60 years) since December 2006. Thirteen of the 33 recipients were children: 7 were younger than 1 year at the time of OLT. Biliary reconstruction was performed with a duct-to-duct anastomosis in 25 recipients and with a Roux-en-Y hepaticojejunostomy in 8. Nine of the 33 grafts had 2 bile ducts, 2 had 3 bile ducts, and the remaining 22 had 1 bile duct. Biliary leak from the anastomotic site was seen in 1 recipient. The biliary stenoses observed in 2 recipients after OLT were treated with interventional radiologic techniques. Mean follow-up was 4.1 +/- 1.6 months (range, 20 days to 7 months). Biliary reconstruction without using a stent is safe for deceased- and living-donor OLT in all ages.

Etiologic agents of diarrhea in solid organ recipients.

After transplantation, diarrhea may be caused by infectious agents, drug-specific effects, metabolic conditions, or mechanical complications of surgery. Determining the cause helps to determine whether to initiate antimicrobial therapy and the duration of treatment. In this study we aimed to determine the causes of diarrhea in kidney or liver recipients. Fifty-two diarrhea episodes among 43 solid organ recipients were evaluated. The cause of diarrhea was detected in 43 patients (82.6%). Infectious etiologies accounted for 33 out of the 43 episodes (76.7%) in which a specific cause was determined: Giardia lamblia in 9, Cryptosporidium parvum in 7, cytomegalovirus (CMV) in 6, Clostridium difficile in 3, Campylobacter jejuni in 2, Shigella sonnei in 2, Salmonella enteritidis in 1, rotavirus in 1, Entamoeba histolytica in 1, and Blastocystis hominis in 1. Non-infectious etiologies were found for 10 episodes (23.3%): mycophenolate mofetil-associated diarrhea in 5, antibiotic-associated diarrhea in 2, colchicine-associated diarrhea in 2, and laxative drug-associated in 1. Non-infectious etiologies seem to be relatively common causes of diarrhea among transplant recipients. Therapy was adjusted in 5 patients because of mycophenolate mofetil-associated diarrhea. CMV and C. parvum, which are seldom seen in the normal population, were frequent causes of diarrhea in this group. Evaluating the transplant recipients for non-infectious causes of diarrhea is important in prompt diagnosis and treatment.

Right hepatic lobe donation: impact on donor quality of life.

The aim of this study was to assess the impact of living-donor liver transplantation on the donor's quality of life. Among the 48 performed at our hospital from October 2003 to June 2006, 46 (27 men, 19 women; mean age, 37.4 years) were followed for more than 4 months (mean, 16.5+/-8 months). In April 2006, these donors participated in a survey that included medical and psychosocial outcomes. Seven complications occurred in four of 46 donors (8.6%): two biliary leaks, two wound infections, one incisional hernia, one portal vein thrombosis, and one deep venous thrombosis. For the donor with portal vein thrombosis, the vein was recanalized, and she recovered without treatment; a bile leak from the cut liver surface and an incisional hernia also developed in the same donor. The biliary leak was treated with percutaneous drainage, and the incisional hernia was repaired surgically. Fifteen donors were housewives, 31 worked outside the home, and 94% returned to their work. A change in body image was reported in 4.3% of the donors. None reported impaired sexual function. Complete recovery occurred in 86% of donors, 94% of the donors said that they would donate again if necessary, and 97% believe that they had benefited from the donation experience. In conclusion, almost all donors were able to return to their prior jobs within a few months of surgery, and most donors were satisfied with the donation procedure.

Right lobe adult living-donor liver transplantation.

Living-donor liver transplantation is another treatment option to cadaveric liver transplantation in adult recipients. We report the outcomes of 49 right lobe adult living-donor liver transplantations performed at our institution between April 2003 and June 2006. The mean age of the recipients was 41.7 +/- 12.5 years. The median graft-to-recipient weight ratio was 1.2% +/- 0.4%. In recipients, the mean operative time was 10.6 +/- 2.7 hours. The mean number of blood transfusions administered was 4.1 +/- 5.1 units. The mean time spent in the intensive care unit was 2.3 +/- 1.5 days. In recipients, five vascular and five biliary complications occurred during the early postoperative period, and four vascular and two biliary complications developed in the late postoperative period. Thirteen of the 49 recipients died within 4 months of surgery. The mean age of the donors was 36.6 +/- 9 years. In the donors, the mean operative time was 6.4 +/- 1.6 hours, mean residual liver volume was 43.3% +/- 6.1%, and the mean hospital stay was 9.5 +/- 4.5 days. Two donors required an intraoperative blood transfusion. None of our donors died, but six complications occurred in four donors. The mean postoperative follow-up was 13.4 +/- 9.6 months. In conclusion, in Turkey, as in other countries, organ demand exceeds organ availability. Graft size presents a problem for adult recipients, but right lobe living donor transplant may be a life-saving option for these recipients when performed by experienced surgical teams.

Intraoperative transhepatic biliary catheter insertion technique for biliary reconstruction: early results.

Biliary complications are critical problems in liver transplantation. Herein, we retrospectively analyzed the early results of an intraoperative transhepatic biliary catheter insertion technique for biliary reconstruction. Since November 2004, we have used this technique in 66 patients (32 children and 34 adults). In the new technique, a 5- F Kumpe catheter is inserted into the biliary system in 2 steps. One step is completed at the back table; the second step is completed during the recipient operation. Fourteen patients received whole-liver grafts, 25 received a right lobe, and 27 received a left-lateral or a left lobe. The mean graft weight-to-body weight ratio in the living-donor liver transplantations was 1.6% +/- 1.0% (range, 0.8%-4.1%). Intraoperative transhepatic biliary catheter insertion was performed with a duct-to-duct anastomosis in 60 patients and with a Roux-en-Y hepaticojejunostomy in 6 patients. Five biliary complications occurred in 4 patients. Two of these 4 patients had bile leakage from the anastomotic site during the early postoperative period. Biliary stenoses developed at the anastomotic site in 2 patients and from a nonanastomotic site in 1 patient in the late postoperative period. In conclusion, this new technique of biliary reconstruction with intraoperative biliary catheter insertion has significantly reduced our complication rate. Transhepatic biliary stenting seems to prevent biliary complications and makes it simple to maintain percutaneous access in the event that problems arise. Intraoperative transhepatic biliary catheter insertion at the back table is a safe means of providing good biliary drainage after liver transplantation.

Predictors of immediate tracheal extubation in the operating room after liver transplantation.

Immediate postoperative extubation may reduce the incidence of postoperative respiratory complications after orthotopic liver transplantation (OLT). We evaluated the predictors of immediate tracheal extubation in the operating room (OR) in our patients by retrospectively reviewing data from all patients who underwent OLT between January 2004 and June 2006. The patients were divided into two groups according to whether they had undergone extubation in the OR (group 1 n=52) or in the intensive care unit (ICU; group 2 n=48). When compared with the patients in group 2, those in group 1 had lower mean preoperative serum creatinine levels (0.9 +/- 1 vs 0.6 +/- 0.3 mg/dL, P=.04) and intraoperative transfusion requirements (packed red blood cells, 35.5 +/- 29.8 vs 25.6 +/- 19.0 mL/kg; P=.05, and fresh frozen plasma, 33.1 +/- 15.6 vs 25.7 +/- 14.3 mL/kg; P=.01). The incidence of intraoperative hypotension and emergent OLT was significantly greater in group 2 than group 1 (33.3% vs 13.5%, P=.01 and 45.8% vs 21.2%, respectively, P=.009). On logistic regression analysis, only emergent OLT (P=.009, odds ratio = 3.5) and intraoperative hypotension (P=.018, odds ratio = 3.7) were significantly associated with a lower probability of immediate postoperative extubation in the OR. Our results suggested that hemodynamic stability and elective OLT were predictors of successful immediate tracheal extubation in the OR.

Respiratory problems in renal transplant recipients admitted to intensive care during long-term follow-up.

Cardiovascular disease, malignancies, and infectious complications are major causes of morbidity and mortality of renal transplant recipients. Mortality rates vary between 16% and 40% in an intensive care unit (ICU). The aims of this study were to identify the types incidences of respiratory problems that affected renal transplant recipients admitted to the ICU during long-term follow-up thereby determining the impact of respiratory problems on mortality. We reviewed the data for 34 recipients who had 39 ICU admissions from January 2000 through December 2003. Twenty-four admissions (61.5%) had at least one respiratory problem at admission or developed at least one during the ICU stay. The most frequent problem was pneumonia (n=18, 46.2% of the 39 readmissions), followed by acute respiratory failure (n=10, 25.6%), atelectasis (n=9, 23.1%), pleural effusion (n=8, 20.5%), and pulmonary edema (n=2, 5.1%). The patients who had respiratory problems showed a significantly higher mortality rate than those who did not have respiratory problems (66.6% versus 26.6%, respectively; P<.05). The overall mortality rate was 58.8% (20 patients). Thus, infectious and respiratory problems are the most frequent indications for admission and the most common problems during an ICU stay. The prognosis for patients who either have a respiratory problem upon admission to the ICU or develop one during the ICU stay is poor.

A corner-saving ureteral reimplantation technique without stenting.

In this study we present our new technique, which will simplify reconstruction of even a small-caliber ureter. Our transplantation team has performed 1523 renal transplantation since 1975. From 1975 to 1983, we performed 300 ureteroneocystostomies using the modified Politano-Leadbetter technique. Since 1983, the extravesical Lich-Gregoir technique was used in combination with temporary ureteral stenting in 1141 patients. After September 2003, we began a corner-saving technique. Eighty-two (62 living related, 20 cadaver) renal transplantations have been performed since September 2003. The mean recipient age was 32.2 +/- 10.9 years (range, 7 to 63). Mean donor age was 38.9 +/- 13.1 years. For ureteral reimplantation, a running suture is started from 3 mm ahead from the middle of the posterior wall and finished 3 mm afterward. After the last stitch, both ends of the suture material are pulled and the posterior wall of the ureter and bladder are approximated tightly. The anterior wall is sewn either with the same suture or another running suture. Since using this technique, we have not employed a double J or any other stent to prevent ureteral complications at the anastomosis side. We have seen only two (2.4%) ureteral complications. In conclusion, due to the low complication rate, we believe that our new technique is the safest way to perform a ureteroneocyctostomy.

Successful treatment of a child with fulminant liver failure and coma due to Amanita phalloides poisoning using urgent liver transplantation.

Intoxication due to eating wild mushrooms presents with a variety of signs, ranging from mild diarrhea to severe organ failure. We present the case of an 11-year-old boy with fulminant liver failure and hepatic coma due to Amanita phalloides poisoning treated with an urgent pediatric orthotopic liver transplantation. Successful treatment of patients with fulminant liver failure and hepatic coma caused by Amanita phalloides poisoning is possible using urgent orthotopic liver transplantation when conservative medical treatment modalities are ineffective.