Long-Term Outcomes of Intestinal and Multivisceral Transplantation at a Single Center in Argentina.

BACKGROUND: Intestinal failure (IF) patients received parenteral nutrition (PN) as the only available therapy until intestinal transplantation (ITx) evolved as an accepted treatment. The aim of this article is to report the long-term outcomes of a series of ITx performed in pediatric and adult patients at a single center 9 years after its creation. PATIENTS AND METHODS: This is a retrospective analysis of the ITx performed between May 2006 and January 2015. Diagnoses, pre-ITx mean time on PN, indications for ITx, time on the waiting list for types of ITx, mean total ischemia time, and warm ischemia time, time until PN discontinuation, incidence of acute and chronic rejection, and 5-year actuarial patient survival are reported. RESULTS: A total of 42 patients received ITx; 80% had short gut syndrome (SG); the mean time on PN was 1620 days. The main indication for ITx was lack of central venous access followed by intestinal failure-associated liver disease (IFALD) and catheter-related infectious complications. The mean time on the waiting list was 188 days (standard deviation, ±183 days). ITx were performed in 26 children and 14 adults. In all, 32 procedures were isolated ITx (IITX); 10 were multiorgan Tx (MOT; 3 combined, 7 multivisceral Tx (MVTx), 1 modified MVTx and 2 with kidney); 2 (4.7 %) were retransplantations: 1 IITx, 1 MVTx, and 5 including the right colon. Thirteen patients (31%) received abdominal rectus fascia. All procedures were performed by the same surgical team. Total ischemia time was 7:53 ± 2:04 hours, and warm ischemia time was 40.2 ± 10.5 minutes. The mean length of implanted intestine was 325 ± 63 cm. Bishop-Koop ileostomy was performed in 67% of cases. In all, 16 of 42 Tx required early reoperations. The overall mean follow-up time was 41 ± 35.6 months. The mean time to PN discontinuation after Tx was 68 days (P = .001). The total number of acute cellular rejection (ACR) episodes until the last follow-up was 83; the total number of grafts lost due to ACR was 4; and the total graft lost due to chronic rejection was 3. At the time of writing, the overall 5-year patient survival is 55% (65% for IITx vs 22% for MOT; P = .0001); 60% for pediatric recipients vs 47% for adults (P = NS); 64% when the indication for ITx was SG vs 25% for non-SG (P = .002). CONCLUSIONS: At this center, candidates with SG, in the absence of IFALD requiring IITx, showed the best long-term outcomes, independent of recipient age. A multidisciplinary approach is mandatory for the care of intestinal failure patients, to sustain a rehabilitation and transplantation program over time.

Case Report: Multivisceral Transplantation for an Extensive Cystic Lymphangioma of the Mesenteric Root.

BACKGROUND: We report the case of a 7-year-old girl with intestinal failure owing to a cystic lymphangioma compromising the root of the mesentery, not amenable to resection, leading to intestinal failure. Oncologic treatment was attempted to reduce tumor size with no response; therefore, she was listed for multivisceral transplantation. PROCEDURE: Resection of the tumor required resection of all abdominal organs with vascular inflow and outflow. A multivisceral graft (liver, stomach, duodenum-pancreas and spleen complex, small bowel, and right colon) was implanted. For vascular reconstruction, donor's superior vena cava was sutured to the recipient's suprahepatic veins in a common patch. For arterial inflow, an arterial conduit was placed directly to the infrarenal aorta, and sutured to an aortic patch of the graft. Cold ischemia time was 8:45 hours; warm ischemia time was 35 minutes. A double-layer gastrogastric anastomosis and piloroplasty was made; and the distal reconstruction was performed with ileocolic side-to-end anastomosis that allowed to perform of a Bishop-Koop ileostomy for endoscopic monitoring. OUTCOME: The patient recovered well after the procedure and was discharged 36 days after transplantation with intestinal sufficiency. To the best of our knowledge, this is the first report describing cystic lymphangioma as an indication for multivisceral transplantation.

Metabolic inhibition and chloride transport in isolated toad skin.

1. When added to the Na(+)-containing solution bathing the isolated toad skin, dinitrophenol (DNP, an uncoupler of oxidative phosphorilation) caused decreases in the baseline values of short circuit current (SCC) and transepithelial conductance (G). 2. DNP also inhibited the increases in SCC and G caused by theophylline, whether added prior to the xanthine, or after the effect of the latter was fully developed. 3. In skins exposed to theophylline and bathed in Cl(-)-free (sulfate Ringer's) solution, the changes in SCC and G had a similar time course (t1/2 > 15 min). In the presence of Cl- (skins bathed in Ringer's solution), SCC decreased with a similar rate, whereas the rate of the decrease in G was greater (t1/2 < 15 min). 4. DNP also decreased the SCC induced by a Cl- concentration gradient in skins exposed to theophylline (SCCg) with a time course similar to its effect on the theophylline-increased G in the presence of Cl-. DNP was effective irrespective of the presence of ambient Na+. 5. A similar difference was observed in skins bathed in CIR and exposed to forskolin. In contrast to theophylline, however, forskolin partially overcame the inhibition of G brought about by DNP; no such recovery was observed in SCC. 6. In contrast to its influence on the responses to theophylline and forskolin, DNP failed to prevent either the increase in G or the onset of SCCg in skins exposed to dibutyryl cyclic AMP. 7. Rotenone, an inhibitor of the electron-transport chain, significantly decreased SCC and G in the unstimulated skin. It also prevented the SCC response to theophylline, and decreased it if added after the effects of the xanthine were fully developed, but failed to modify the increase in G brought about by theophylline. The time course of SCC inhibition by rotenone was similar to that caused by DNP. 8. Ouabain, an inhibitor of Na+,K(+)-ATPase, decreased SCC in the theophylline-stimulated skin, without affecting G. 9. We conclude that, whereas integrity of oxidative energy metabolism is necessary to sustain SCC in the isolated toad skin, it is not a strict requirement for the increase of Cl(-)-dependent G activated by cAMP. 10. The effect of DNP on Cl(-)-dependent G activated by cAMP is probably exerted at the cAMP generation step, by inhibition of adenyl cyclase and/or a decrease in the availability of ATP.

Inhibitory effect of sodium ursodeoxycholate on basal and stimulated short-circuit current across the isolated toad skin.

The effect of sodium ursodeoxycholate (U) on short-circuit current (SCC), an index of basal and stimulated net ion transport across isolated skins of Bufo arenarum toads, was tested. U inhibited basal SCC when added to the epidermal side of the skins. The inhibitory effect was reversible after rinsing the preparation during 60 min. U also inhibited the natriferic response to oxytocin, db-cAMP and theophylline by 82%, 49% and 47%, respectively. Inhibition of SCC by exposure to U was reversed by the polyene antibiotic nystatin. In turn, SCC induced by nystatin in the amiloride-treated skin was insensitive to U and blocked by ouabain, a Na+, K(+)-ATPase inhibitor. These results strongly suggest that the effect of U is exerted at the apical membrane of sodium transporting cells, and rule out the existence of an additional site of inhibitory action of U.

Kinins contribute to the contractile effects of rat glandular kallikrein on the isolated rat uterus.

Glandular kallikrein is known to promote contractions of the isolated, estrogenized rat uterus, perhaps independently of kinin formation. The recent availability of kinin receptor antagonists led us to study whether they might affect the oxytocic activity of kallikrein. DArg0-Hyp3-Thi5,8-DPhe7-bradykinin (8.5 x 10(-7) M) displaced the dose-response curves to both bradykinin (from 1.0 x 10(-9) to 4.0 x 10(-6) M) and kallikrein (from 4.7 x 10(-11) to 8.0 x 10(-9) M) approximately one order of magnitude to the right. This inhibition could not be due to a nonspecific effect on the uterine muscle, as the contractile response to oxytocin was not altered. In addition, carboxypeptidase B (a potent kininase) and kinin antibodies reduced the contractile response to kallikrein by 70 and 60%, respectively. Removal of the intervening agent restored the normal response. The effect of kallikrein depended on its enzymatic activity, inasmuch as kallikrein inactivated with D-Phe-Arg-Arg-CH2Cl was not oxytocic. Prolonged or multiple exposures to kallikrein completely abolished uterine response, whereas the effect of bradykinin was unaltered. Uterine horns rendered insensitive to kallikrein by prolonged exposure still contracted in response to trypsin. Kininogen was present in the uterine tissue in a concentration of 1.5 +/- 0.3 ng of bradykinin equivalents per mg wet wt. No more than 15.9 +/- 1.2% of this total was due to plasma contamination. Only 21.5 +/- 2.9% of total kininogen could be cleaved by kallikrein. We conclude that part of the oxytocic activity of kallikrein is related to generation of kinins from a kallikrein-sensitive kininogen present in the isolated rat uterus.(ABSTRACT TRUNCATED AT 250 WORDS)

A role for the kallikrein-kinin system in the regulation of osmotic water permeability in the toad bladder.

Captopril (CA), a specific inhibitor of kininase II, did not alter osmotic water permeability (Posm) when present in the mucosal bath of the urinary bladder isolated from the toad Bufo arenarum at a concentration of 2.3 X 10(-3) M. This treatment, however, caused a 65% enhancement in the increase in Posm following serosal exposure to vasopressin, oxytocin or theophylline, agents that increase intracellular cyclic AMP levels. The effect of captopril was prevented by procedures that reduce the kallikrein (KK)-like alkaline esterase activity present in the bladder (such as simultaneous exposure to 2.3 X 10(-5) M aprotinin, or pretreatment of the toads with 0.1 N NaCl for several days before the experiment) or by replacing the mucosal bath with fresh solution of identical composition after exposure to captopril. In contrast, changing the serosal bath did not alter the effect of the drug. These results are consistent with an effect of CA at a step beyond cAMP generation, and suggest it is mediated by release of a soluble factor, probably a kinin, into the mucosal bath. These observations, together with data previously published, suggest that the KK-kinin system may participate in the control of epithelial water and electrolyte permeability in the toad bladder. In particular, under environmental stress, it may become important in the regulation of the animal's extracellular fluid volume, thus exhibiting an adaptive value.