Echocardiographic and electrocardiographic presentations of patients with endomyocardial biopsy-proven cardiac amyloidosis.

OBJECTIVE: Cardiac amyloidosis is under diagnosed and its prevalence is unknown. This is a retrospective, nonrandomised, single centre study of patients with endomyocardial biopsy-proven cardiac amyloidosis focusing on their echocardiographic and electrocardiogram (ECG) presentations. This is the first case series in Malaysia on this subject. METHODS: We identified all of our endomyocardial biopsyproven cardiac amyloidosis patients from January 2010 to January 2018 and reviewed their medical records. All patients echocardiographic and ECG findings reviewed and analysed comparing to basic mean population value. RESULTS: In total there are 13 biopsy-proven cardiac amyloidosis patients. All of the biopsies shows light chain (AL) amyloid. Majority of the patients (8, 61.5%) is male, and most of our patients (8, 61.5%) is Chinese. All seven patients on whom we performed deformation imaging have apical sparing pattern on longitudinal strain echocardiogram. Mean ejection fraction is 49.3%, (SD=7.9). All patients have concentric left ventricular hypertrophy and right ventricular hypertrophy. Diastolic dysfunction was present in all of our patients with nine out of 13 patients (69.2%) having restrictive filling patterns (E/A ≥2.0 E/e' ≥15). On electrocardiogram, 12 (92%) patients have prolonged PR interval (median 200ms, IQR 76.50ms) and 9 (69.2%) patients have pseudoinfarct pattern. CONCLUSION: Echocardiography plays an important role in diagnosing cardiac amyloidosis. The findings of concentric left ventricular hypertrophy with preserved ejection fraction without increased in loading condition should alert the clinician towards its possibility. This is further supported by right ventricular hypertrophy and particularly longitudinal strain imaging showing apical sparing pattern.

Postanastomotic transplant renal artery stenosis: association with de novo class II donor-specific antibodies.

In this study, we analyze the outcomes of transplant renal artery stenosis (TRAS), determine the different anatomical positions of TRAS, and establish cardiovascular and immunological risk factors associated with its development. One hundred thirty-seven of 999 (13.7%) patients had TRAS diagnosed by angiography; 119/137 (86.9%) were treated with angioplasty, of which 113/137 (82.5%) were stented. Allograft survival in the TRAS+ intervention, TRAS+ nonintervention and TRAS- groups was 80.4%, 71.3% and 83.1%, respectively. There was no difference in allograft survival between the TRAS+ intervention and TRAS- groups, p = 0.12; there was a difference in allograft survival between the TRAS- and TRAS+ nonintervention groups, p < 0.001, and between the TRAS+ intervention and TRAS+ nonintervention groups, p = 0.037. TRAS developed at the anastomosis, within a bend/kink or distally. Anastomotic TRAS developed in living donor recipients; postanastomotic TRAS (TRAS-P) developed in diabetic and older patients who received grafts from deceased, older donors. Compared with the TRAS- group, patients with TRAS-P were more likely to have had rejection with arteritis, odds ratio (OR): 4.83 (1.47-15.87), p = 0.0095, and capillaritis, OR: 3.03 (1.10-8.36), p = 0.033. Patients with TRAS-P were more likely to have developed de novo class II DSA compared with TRAS- patients hazard ratio: 4.41 (2.0-9.73), p < 0.001. TRAS is a heterogeneous condition with TRAS-P having both alloimmune and traditional cardiovascular risk factors.

Mechanical complications of long-term Tesio catheters.

Vascular access catheters such as Tesio-Caths are preferentially inserted in the internal jugular vein and serve as access for hemodialysis. Complications related to the removal of these types of lines are uncommon. We report four patients in whom the tip of the Tesio-Cath broke and was left stuck in the superior vena cava. Although there is no defined limit to the maximum length of stay of vascular access catheters for dialysis, the possibility of catheter entrapment should be considered. It remains to be determined whether removing Tesio-Caths every 16- 18 months is beneficial in avoiding this complication.

Serum lipoprotein(a) levels in patients with atherosclerotic peripheral vascular disease in Hospital Kuala Lumpur.

OBJECTIVE: The objective of this study was to determine the proportion of patients with atherosclerotic peripheral vascular disease (PVD) who had elevated lipoprotein(a) [Lp(a)] levels, as well as to determine the latter's significance as a risk factor for PVD in the local population. METHODS: This case-controlled study was conducted between June and October 2004 in the Department of Surgery, Kuala Lumpur Hospital. A total of 100 patients were recruited and divided into control and PVD groups. Patients were defined as having PVD if they were symptomatic, with ankle-brachial systolic index < 0.90, or by radiological evidence. Lp(a) concentrations were determined using immunoturbidometry. Absorbance of reaction precipitate was measured by spectrophotometry to give Lp(a) concentration in grams per litre (g/L). The reference value for normal Lp(a) levels was < or = 0.36 g/L. RESULTS: Mean Lp(a) levels for control and PVD groups were 0.29 g/L and 0.56 g/L, and median values were 0.17 g/L and 0.48 g/L, respectively. Elevated Lp(a) levels in the control group was 26% compared to 58% in the PVD group. Analysis with Pearson's chi-squared test achieved a significant p value of 0.001. Multivariate analysis showed that elevated Lp(a) levels contributed significantly to the probability of having PVD with an odds ratio of 7.69. CONCLUSION: Elevated serum Lp(a) has a significant role as a risk factor for atherosclerotic PVD in the local population.

A rare case of Schneiderian papilloma of the middle ear presenting with pulsatile tinnitus.

Schneiderian papillomas (ISP) of the middle ear are uncommon conditions, with only 45 cases published within literature. They are locally aggressive tumours, with a high rate of recurrence and associated malignancy. We present a rare case of a 53-year-old man presenting with unilateral pulsatile tinnitus, otorrhoea, aural fullness, pruritis and hearing loss. Angiography was employed to exclude a glomus tumour and the patient underwent a modified radical mastoidectomy. Tissue samples confirmed a histological diagnosis of ISP of the middle ear. Follow-up magnetic resonanc imaging one year postoperatively showed no evidence of disease recurrence.

Cerebral cortical dysfunction in chronic obstructive pulmonary disease: role of transcranial magnetic stimulation.

SETTING: Chest and Neurology Departments, Assiut and Al-Azhar University Hospitals, Egypt. OBJECTIVES: To study a large population with respect to previous preliminary data, using transcranial magnetic stimulation (TMS) as a prognostic method for evaluation of cerebral cortical functions during acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). DESIGN: In a case-control study, 41 patients with AE-COPD and 30 healthy controls were included. For all, TMS was used to assess corticospinal pathway function and cortical excitability. RESULTS: Patients demonstrated increased motor threshold (resting and active), central motor conduction time and increased cortical silent period. Significant correlation was identified between TMS parameters and pulmonary function tests (forced vital capacity, forced expiratory volume 1%, forced expiratory volume in one second) and arterial blood gases (pH, paO(2) and HCO(3)), serum chloride and potassium. CONCLUSION: These results indicate that the motor cortex is less excitable during AE-COPD. This is attributed to reduction of cortical excitability due to chronic hypoxaemia. Therefore, early detection of cerebral changes might be in accordance with the importance of early O(2) therapy in reducing morbidity and mechanical ventilation dependency in COPD. This opens discussion for future early therapeutic use of GABAergic and glutaminergic modulating drugs with oxygen to protect the brains of COPD patients.

Measurement of hepatic insulin sensitivity early after the bypass of the proximal small bowel in humans.

OBJECTIVE: Unlike gastric banding or sleeve gastrectomy procedures, intestinal bypass procedures, Roux-en-Y gastric bypass in particular, lead to rapid improvements in glycaemia early after surgery. The bypass of the proximal small bowel may have weight loss and even caloric restriction-independent glucose-lowering properties on hepatic insulin sensitivity. In this first human mechanistic study, we examined this hypothesis by investigating the early effects of the duodeno-jejunal bypass liner (DJBL; GI Dynamics, USA) on the hepatic insulin sensitivity by using the gold standard euglycaemic hyperinsulinaemic clamp methodology. METHOD: Seven patients with obesity underwent measurement of hepatic insulin sensitivity at baseline, 1 week after a low-calorie liquid diet and after a further 1 week following insertion of the DJBL whilst on the same diet. RESULTS: Duodeno-jejunal bypass liner did not improve the insulin sensitivity of hepatic glucose production beyond the improvements achieved with caloric restriction. CONCLUSIONS: Caloric restriction may be the predominant driver of early increases in hepatic insulin sensitivity after the endoscopic bypass of the proximal small bowel. The same mechanism may be at play after Roux-en-Y gastric bypass and explain, at least in part, the rapid improvements in glycaemia.

Ureteral stents and their current use.

Stents in urology have been used for a long time in the management of nephro-ureterolithiasis. However, the indications for stent insertion have increased during the last few years and they are now used both diagnostically and therapeutically in a variety of cases. A brief history of the name is presented along with a review of the indications and the complications of stent usage.

Surgical management of multiple donor veins in renal transplantation.

The surgical aspects of renal transplantation have been standardized for decades regarding normal anatomy of donor kidneys. In certain situations, as in multiple donor veins, there are still challenges regarding the technical management. In > 95%, there is only one renal vein, or the additional vein/veins are so small that they can be ligated without hesitation. In < 5%, there are two main draining veins, and they can be similar in diameter. The management of these cases varies. Some surgeons implant both veins separately, leave them on a common caval patch, or implant the smaller vein into the larger vein as an end-to-side anastomosis, allowing for one venous anastomosis in the recipient. We describe two cases of donor kidneys with two similar-sized veins and conclude that ligation of the smaller vein, even if its size is substantial (up to 1 cm), can be the safest option to avoid surgical complications.

Prevalence of chronic airflow limitation in Kashmir, North India: results from the BOLD study.

BACKGROUND: Data on spirometrically defined chronic airflow limitation (CAL) are scarce in developing countries. OBJECTIVE: To estimate the prevalence of spirometrically defined CAL in Kashmir, North India. METHODS: Using Burden of Obstructive Lung Disease survey methods, we administered questionnaires to randomly selected adults aged ⩾40 years. Post-bronchodilator spirometry was performed to estimate the prevalence of CAL and its relation to potential risk factors. RESULTS: Of 1100 participants initially recruited, 953 (86.9%) responded and 757 completed acceptable spirometry and questionnaires. The prevalence of a forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) ratio less than the lower limit of normal was 17.3% (4.5) in males and 14.8% (2.1) in females. Risk factors for CAL included higher age, cooking with wood and lower educational status. The prevalence of current smoking was 61% in males and 22% in females; most smoked hookahs. CAL was found equally in non-smoking males and females, and was independently associated with the use of the hookah, family history of respiratory disease and poor education. A self-reported doctor's diagnosis of chronic obstructive pulmonary disease was reported in 8.4/1000 (0.9% of females and 0.8% of males). CONCLUSION: Spirometrically confirmed CAL is highly prevalent in Indian Kashmir, and seems to be related to the high prevalence of smoking, predominantly in the form of hookah smoking.

Steroid sparing in renal transplantation with tacrolimus and mycophenolate mofetil: three-year results.

Although renal transplantation with a 7-day steroid-sparing regimen, tacrolimus and mycophenolate, is associated with good short-term outcomes, late allograft dysfunction and failure remain concerns. In this study 101 consecutive patients underwent renal transplantation using this immunosuppressive regimen. In addition, anti-CD25 monoclonal antibody was used in 25 high-risk patients (regrafts, two-antigen human leukocyte antigen (HLA)-DR mismatch or sensitized with anti-HLA panel reactivity >30%). After a median follow-up of 39 months (range 29 to 49), overall patient survival is 98%, with two cardiac deaths. Three other graft losses occurred, one each to early venous thrombosis, polyoma viral nephropathy, and late rejection due to noncompliance. Therefore, overall graft survival is 95%. The acute rejection rate at 6 and 12 months was 19% (no rejection occurred between months 6 and 12). Late rejection was uncommon, with only two further episodes beyond 12 months. Mean creatinine at 12 months was 144 micromol/L and mean estimated glomerular filtration rate (GFR) of 55 mL/min. Graft function was stable at 3 years with a mean creatinine of 142 micromol/L and mean estimated GFR 56 mL/min. During the study, five patients developed posttransplant diabetes mellitus (two cases beyond 12 months). Tissue-invasive cytomegalovirus disease and BK viral nephropathy each occurred in three patients, with all episodes in the first 12 months. Mean weight gain is 3.3 kg and mean blood pressure is 135/81 on an average of 1.5 antihypertensive agents. This steroid-avoidance regimen is associated with excellent medium-term patient and graft outcomes and a low incidence of side effects.

Late steroid withdrawal for renal transplant recipients on tacrolimus and MMF is safe.

INTRODUCTION: We conducted a study to assess the safety of staged, late steroid withdrawal in kidney or kidney/pancreas transplant recipients on steroids, tacrolimus, and mycophenolate mofetil (MMF). MATERIALS AND METHODS: We studied 50 patients including 33 recipients of cadaveric kidneys, eight living donor kidneys, and nine kidney-pancreas transplants. The mean time posttransplantation was 5.1 years (range 2.1 to 7.9 years). All patients were induced on prednisolone, tacrolimus, and MMF; steroids were withdrawn over 5 to 6 months. The rate of steroid reduction was altered in the face of typical steroid withdrawal symptoms (limb-girdle arthralgia/myalgia). RESULTS: No rejection episodes occurred during steroid withdrawal. No patient required transplant biopsy for graft dysfunction. Six patients failed steroid withdrawal: five due to arthralgia/myalgia and one due to recurrent pulmonary sarcoidosis. The unexplained rise in serum creatinine following steroid withdrawal described in several other steroid withdrawal studies was not observed in this patient cohort. The mean serum creatinine was 137 micromol/L with deltacreatinine -6.8 micromol/y per year prior to steroid cessation versus 132 micromol/L with deltacreatinine -5.9 micromol/y in the year post-steroid cessation. There were 14 patients with posttransplant diabetes mellitus in this cohort: eight on gliclazide and six on insulin. We observed a reduction in their daily insulin/gliclazide requirements from 52 units to 41 units, and 73 mg to 65 mg, respectively. Two patients became gliclazide-independent at the time of steroid cessation. CONCLUSIONS: Careful steroid withdrawal from a platform of tacrolimus and MMF is safe and not associated with a significant risk of rejection or graft dysfunction.

Tacrolimus monitoring in renal transplantation: a comparison between high-performance liquid chromatography and immunoassay.

It is recommended that specific methods of tacrolimus monitoring rather than immunoassays, which overestimate tacrolimus levels, should be used in transplant recipients. Direct comparison of these techniques, however, has not been conducted in renal transplantation. In this study, 40 renal transplant recipients with tacrolimus monitoring by microparticle enzyme immunoassay (MEIA; target trough level 10 to 15 ng/mL) were compared with 40 patients monitored by high-performance liquid chromatography with tandem mass spectrometry (HPLC-MS; target trough level 8 to 13 ng/mL). All patients received anti CD25 antibody induction and mycophenolate mofetil in a steroid-sparing protocol. No differences were seen between MEIA and HPLC-MS groups in patient demographics. All patients were followed for 6 months. Patient survival was 100% in both groups; graft survival was 100% in the MEIA group and 97.5% in the HPLC-MS group. The groups did not differ in the number of dose changes required in the first 6 months or in the number of patients displaying tacrolimus levels within target range at 3 and 6 months. Delayed graft function occurred in 14 patients in the MEIA group and 12 patients in the HPLC-MS group (P = NS). Biopsy-proven acute rejection occurred in four patients in the MEIA group and one patient in the HPLC-MS group (P < .2). No differences were seen for the following parameters at 3 or 6 months: biopsy-proven tacrolimus nephrotoxicity, serum creatinine or estimated creatinine clearance, systolic or diastolic blood pressure, cholesterol, cytomegalovirus disease, posttransplant diabetes, or tremor. This study suggests that renal transplantation with HPLC-MS monitoring of tacrolimus is safe and effective.

Cytokine polymorphisms do not influence acute rejection in renal transplantation under tacrolimus-based immunosuppression.

INTRODUCTION: Acute rejection remains an important cause of graft loss after renal transplantation. It has been suggested that cytokine genotyping may play a predictive role in identifying individuals who are at higher risk of acute rejection with a view to individualizing their immunosuppression. The aim of this study was to investigate any possible associations between acute rejection and certain cytokine polymorphisms. METHODS: We genotyped 91 cadaveric renal transplant recipients on tacrolimus-based immunosuppression and 84 of their donors. The cytokine polymorphisms studied were the following: tumor necrosis factor (TNF)-alpha-1032 T/C, TNF-alpha-865 C/A, TNF-alpha-859 G/A, interleukin (IL)1-R1-970 C/T, IL-10 haplotype [-1082, -819, -592], and IL-6-174 C/G. RESULTS: We found no association between any polymorphism and the incidence of acute rejection. This was true for both the recipient and donor population. CONCLUSION: Cytokine polymorphisms did not influence acute rejection in our study. We conclude that in the modern era of immunosuppression cytokine genotyping is not a significant predictor of acute rejection in renal transplantation.

Combined transplantation of small and large bowel. FK506 versus cyclosporine A in a porcine model.

Clinically, FK506 is superior to CsA after solitary small bowel transplantation (SBTx). Development of diarrhea after SBTx has been the rationale for adding the colon to small bowel grafts. However, the additional lymphoid and bacterial content transferred with total small plus large bowel transplants (TBTx) might aggravate the alloimmune response-rejection and graft-versus-host disease (GVHD)-and increase the risk of infection. We studied the incidence of rejection, GVHD, and infection after TBTx and the impact of CsA versus FK506. We performed orthotopic TBTx with portal drainage after total enterectomy in outbred Yorkshire Landrace pigs, divided into 3 groups: control pigs (n=6) received no immunosuppression; CsA pigs (n= 14) received CsA (5 mg/kg), antilymphocyte globulin (10 mg/kg for 10 days), prednisone (2 mg/kg), and AZA (2.5 mgtkg); and FK506 pigs (n=9) received FK506 (0.2 mg/kg) and prednisone (2 mg/kg). Trough CsA whole blood levels were >400 ng/ml for the first 7 days and >200 ng/ml thereafter. FK506 levels were > 15 ng/ml. We excluded from further analysis 5 early deaths (<3 days) due to anesthesiologic (n=2) or technical reasons (n=3). Median survival of control pigs was 9.5 days (range, 4-13). Cyclosporine did not extend survival: median, 9 days (range, 5-31) (P=0.6). FK506 prolonged survival: median, 37 days (range, 21-49) (P<0.001 vs. control and CsA pigs). Of FK506 pigs, 60% gained weight (+75 g/day), whereas 100% of controls and 75% of CsA pigs lost weight (-550 g/day and -300 g/day, respectively). All control pigs died of rejection within 2 weeks versus none of the FK506 pigs. However, 36% of CsA pigs died of rejection. Groupwise comparison showed less rejection in FK506 versus control pigs (P<0.001) and in FK506 versus CsA pigs (P<0.03), but no difference between CsA and control pigs. None of the control pigs died of GVHD versus 18% of CsA pigs (by day 31) and 37% of FK506 pigs (by day 49). Groupwise comparison showed increased GVHD in FK506 versus control pigs (P<0.001) and a tendency toward increased GVHD in FK506 versus CsA pigs (P=0.08). None of the control pigs died of infection alone versus 22% of CsA pigs (by day 31) and 67% of FK506 pigs (by day 49). Groupwise comparison showed increased infection in FK506 versus control pigs (P<0.001). We detected significant endotoxemia early and late postoperatively. But we saw no specific correlation between endotoxemia, rejection, GVHD, or infection. Based on this study, we have drawn several conclusions: (1) In untreated pigs, TBTx provokes a severe rejection response, but no lethal GVHD. (2) Cyclosporine and particularly FK506 pigs have a high incidence of infection and lethal GVHD, a complication that we had not seen after solitary SBTx. (3) FK506 is superior to CsA in controlling rejection and in prolonging graft and recipient survival; FK506, however, does not reduce GVHD, but rather tends to augment it. (4) TBTx causes endotoxemia. As with solitary SBTx, FK506 is superior to CsA after TBTx. However, longterm survival is difficult to achieve on FK506 recipients because of the development of GVHD and infection.

Five-year results of kidney transplantation under tacrolimus-based regimes: the persisting significance of vascular rejection.

BACKGROUND: Acute rejection has been the major risk factor for medium-term kidney graft loss because of chronic allograft nephropathy. We investigated whether the use of improved immunosuppression has altered the relationship between acute and chronic rejection by analyzing data from 245 renal transplant patients receiving Tacrolimus-based immunosuppression. RESULTS: Five-year graft survival (censored for death with functioning graft) was 88.8% with no significant difference between living and cadaveric kidney transplants. The only significant predictor of medium-term graft loss was acute vascular rejection. CONCLUSION: Under Tacrolimus-based immunosuppression, the occurrence of acute interstitial rejection, even when occurring late, repeatedly, or with failure of graft function to return to baseline, was not associated with chronic allograft nephropathy or medium-term graft loss. Vascular rejection remains the major immunological obstacle to long-term transplant success. Five-year overall survival rates with a functioning graft of 80% with 90% graft survival censored for death with function seem to be realistic and achievable goals.

Interdigestive gastric motility patterns: the role of vagal and nonvagal extrinsic innervation.

Our study was designed to determine separately the roles of vagal and nonvagal extrinsic innervation in the initiation and coordination of patterns of gastric contractile activity and in the organization of the gastric slow wave. Four dogs first underwent transection of all extrinsic and intrinsic neural continuity to the stomach, except for careful preservation of vagal innervation to the stomach (stage 1). Manometry catheters and serosal electrodes were placed in the antrum, and electrodes were fixed to the small intestine. After recovery, motility was recorded during fasting and after feeding. A cyclic motor pattern occurred in the stomach with a period that was not different from that of the migrating motor complex in the small intestine (113 +/- 11 minutes vs 112 +/- 11 minutes; p greater than 0.05). Gastric and intestinal motility remained coordinated in time. Feeding inhibited this cyclic motor pattern in stomach and intestine. Antral tachygastria (slow wave frequency greater than 8 cycles/min) was infrequent (less than 1% of time). Each animal was restudied after completing extrinsic gastric denervation by a transthoracic vagotomy (stage 2). Vagotomy did not alter the presence, appearance, or period of cyclic gastric activity, nor did it disrupt temporal coordination with the duodenal migrating motor complex or increase the prevalence of tachygastria. In conclusion, neither vagal nor nonvagal extrinsic innervation to the stomach was required for initiation or coordination of the characteristic cyclic gastric motility pattern during fasting; although vagal innervation may modulate gastric myoelectric activity, its precise role is not evident in this study.

Net absorption of water, electrolytes, glucose, and folate from the in vivo, neurally isolated canine jejunum.

This study was designed to determine the effects of neural isolation of the jejunoileum (a model of intestinal transplantation) on jejunal absorptive function and associated changes that might occur over time. Net absorption of a simple, balanced crystalloid solution perfused in an 80 cm enterically isolated jejunal loop was assessed in two groups of conscious dogs with neurally intact jejunal loops or neurally isolated jejunal loops. Experiments were conducted 2, 4, and 8 weeks after surgery during fasting and after feeding to determine temporal changes. Net absorption of water and electrolytes (sodium, potassium, and chloride), glucose, and folate and loop transit times were not different (p greater than 0.05) between groups at any time point despite the presence of ongoing watery diarrhea and weight loss (15% +/- 8% body weight) in the dogs with neurally isolated jejunoileum. The effects of neural isolation (extrinsic denervation and disruption of enteric neural continuity and lymphatic drainage) do not appear to decrease net absorptive capacity for water, electrolytes, simple sugars, or folate when evaluated between 2 and 8 weeks after neural isolation. The watery diarrhea and weight loss do not appear to be related to a jejunal secretory diarrhea. These findings may have important implications in the transplanted small intestine.

Correlation between cystoscopic biopsy results and hypoamylasuria in bladder-drained pancreas transplants.

BACKGROUND: Urinary amylase (UA) remains the most common biochemical parameter to detect rejection in bladder-drained pancreas allografts. With the development of the cystoscopic transduodenal pancreas transplant biopsy technique, tissue samples of the pancreas graft are now frequently obtained. A definitive correlative analysis between UA activity and biopsy results has not been done in the three different pancreas transplant categories (simultaneous pancreas-kidney, pancreas transplant alone, and pancreas after kidney). METHODS: We studied 66 pancreaticoduodenal biopsy specimens obtained for hypoamylasuria. Rejection was defined as a greater than 25% decrease from stable posttransplantation baseline on two consecutive measurements at least 12 hours apart. To perform biopsies we used our newly developed 14- and 16-gauge core-cut needles (50 cm long). Biopsy specimens were considered positive if either pancreatic or duodenal rejection was found. To assess the quality of UA activity we studied 13 biopsy specimens from patients with stable UA levels; these 13 specimens were negative for rejection. RESULTS: Acute rejection was diagnosed in 36 biopsy specimens (55%). The mean decrease in UA levels was 67% +/- 8% (range, 28% to 99%) for the positive biopsy results, and 57% +/- 16% (range, 22% to 92%) for the negative biopsy results (p = 0.147). Within 1 month, UA levels returned to baseline in 19% of our patients with positive biopsy results versus 97% with negative results; postbiopsy 1-year graft survival was 64% versus 97% (p < or = 0.05). In assessing the test quality of our biopsy specimens (including 13 obtained for reasons other than hypoamylasuria), we found a sensitivity of 100% (stable UA levels mean no rejection) and a specificity of 30%. The predictive value of a positive test was 53%; of a negative test it was 100%. By performing biopsies we avoided antirejection treatment in 47% of the patients studied. We found no biopsy-related complications. CONCLUSIONS: Stable UA levels reliably rule out rejection; a decrease is a marker for acute rejection but is unspecific. Performing biopsy is currently the only way to reliably diagnose rejection in solitary pancreas recipients (pancreas transplant alone and pancreas after kidney) and in simultaneous pancreas-kidney recipients with isolated hypoamylasuria. The procedure is safe and should always be attempted to avoid unnecessary rejection treatment.

Duodenal complications in bladder-drained pancreas transplantation.

BACKGROUND: The most common type of pancreas transplantation is whole pancreaticoduodenal (with bladder drainage) from a cadaver donor. Complications can arise not only from the pancreas itself but also from the simultaneously transplanted duodenum. The purpose of this study was to analyze the incidence, diagnosis, and treatment of duodenal complications and their impact on patient and pancreas graft survival rates. METHODS: Our retrospective study is based on 425 pancreaticoduodenal transplantations performed between July 1, 1986, and June 30, 1994. Complications pertaining to the duodenal segment were labeled early if they occurred within the first postoperative month and late otherwise. Mean follow-up was 55 months (range, 13 to 108 months). RESULTS: We noted 85 (20%) duodenal complications: duodenal leaks (n = 42), hematuria (n = 26), recurrent urinary tract infections (n = 9), duodenal ulceration or necrosis (n = 6), and bladder stones (n = 2). Of these complications, 40 (48%) required surgical intervention. In all, duodenal complications resulted in 14 (16%) enteric conversions and eight (9%) pancreas graft losses (six because of duodenal leak and 2 because of hematuria). The mortality rate from duodenal complications was 0%. CONCLUSIONS: Duodenal complications were common, but they were not associated with a high rate of pancreas graft loss (only 9%). With early diagnosis and treatment, morbidity can be reduced and death avoided in pancreas transplant recipients.