African American Pediatric Liver Transplant Recipients Have an Increased Risk of Death After Transferring to Adult Healthcare.

OBJECTIVE: To analyze the long-term outcomes in pediatric liver transplant recipients after they have transferred to an adult provider and assess for racial disparities in health outcomes. STUDY DESIGN: This is a single-center, retrospective review of pediatric patients who underwent liver transplantation between July 1990 and August 2015 at a tertiary healthcare system with a large transplant center. Patient mortality and retransplantation were assessed after transfer to adult care. RESULTS: There were 120 patients who were transferred, of whom 19 did not meet the inclusion criteria. Of the remaining 101 patients, 64 (63%) transferred care to a nearby affiliated tertiary adult facility, 29 (29%) were followed by other healthcare systems, and 8 (8%) were lost to follow-up. Of the patients followed at our affiliated adult center, 18 of the 64 (28%) died. Of those 18 deaths, 4 (22%) occurred within the first 2 years after transfer, and 10 (55%) within 5 years of transfer. Four patients were retransplanted by an adult provider, of whom 2 eventually received a third transplant. African Americans had higher rates of death after transfer than patients of other races (44% mortality vs 16%, representing 67% of all cases of death; P = .032), with nearly 50% mortality at 20 years from time of transplantation. CONCLUSIONS: Death is common in pediatric liver transplant recipients after transfer to adult care, with African Americans having disproportionately higher mortality. This period of transition of care is a vulnerable time, and measures must be taken to ensure the safe transfer of young adults with chronic health care needs.

[Retrasplante cardiaco electivo. Primer caso en México].

Orthotopic cardiac retransplantation is used to treat transplanted cardiac graft end-stage failure. We present the first case of successful elective cardiac retransplantation in Mexico. It was a 25-year old male with heart transplantation who developed graft-resistant chronic vasculopathy. He underwent elective retransplantation in September 2017; complications during postoperative evolution were treated with favorable response. He was discharged owing to improvement at four weeks postoperatively. It is concluded that in adequately selected cases and comprehensively assessed, cardiac retransplantation is an appropriate option to treat cardiac graft failure.

El retrasplante cardiaco ortotópico se utiliza para tratar la falla cardiaca terminal del injerto cardiaco trasplantado. Presentamos el primer caso exitoso de retrasplante cardiaco electivo en México. Se trató de un varón de 25 años con trasplante de corazón, quien presentó vasculopatía crónica resistente del injerto. Fue retrasplantado electivamente en septiembre de 2017; las complicaciones durante la evolución posoperatoria fueron tratadas con respuesta favorable. Egresó por mejoría a las cuatro semanas del posoperatorio. Se concluye que en los casos apropiadamente seleccionados y valorados integralmente, el retrasplante cardiaco es una opción adecuada para el manejo de la falla cardiaca del injerto.

Nephrectomy Versus Embolization of Non-Functioning Renal Graft: A Systematic Review with a Proportional Meta-Analysis.

There is no standardization on the timing of the best approach to treat a non-functioning renal graft. We reviewed the literature and performed a proportional meta-analysis of case series of transplantectomy and embolization for a non-functioning renal graft. The groups were compared for mortality and morbidity outcomes. A total of 2421 patients were included in this review. Of these, 2232 patients underwent transplantectomy and 189 underwent percutaneous embolization. The mortality rate in the nephrectomy group was 4% [95% confidence interval [CI], 2-7%; I²=87%] as compared with 0.1% [95% CI, 0.1-0.5%; I²=0%] in the embolization group. The rates of common morbidities were 18% [95% CI, 13-26%, I²=79.7%] for nephrectomy compared with 1.2% [95% CI, 0.7-2.1%, I²=26.4%] for embolization. The incidence of post-embolization syndrome was 68%, and 20% of patients needed post-embolization nephrectomy. Percutaneous embolization was associated with lower mortality and morbidity rates but also with a high rate of post-embolization syndrome. However, in most cases this complication had easily manageable symptoms. Embolization is a new and attractive technique that can be considered in treating non-functioning renal grafts.

Heart retransplantation in children without the use of blood product.

This article reports a case of a cardiac retransplantation without the use of blood products, in a 6 year old, with severe dilated cardiomyopathy after chronic graft rejection and refractory to clinical treatment. To avoid a blood transfusion in this surgery a multidisciplinary approach was planned, which involved the use of preoperative erythropoietin, acute normovolemic hemodilution and intraoperative cell savage with autologous blood recovery system, as well as a meticulous hemostasis and reduced postoperative phlebotomy.

Retransplante cardíaco em criança sem o uso de hemoderivados / Heart retransplantation in children without the use of blood product

Este artigo relata um caso de retransplante cardíaco sem o uso de hemoderivados, em uma criança de 6 anos, com miocardiopatia dilatada grave, após rejeição crônica do enxerto e refratária ao tratamento clínico. Para evitar transfusão sanguínea nessa cirurgia, foi realizado planejamento multidisciplinar, que envolveu o uso de eritropoietina no pré-operatório, hemodiluição normovolêmica aguda e recuperação de sangue autólogo no intraoperatório (cell saver), bem como hemostasia meticulosa e redução de flebotomias no pós-operatório.

This article reports a case of a cardiac retransplantation without the use of blood products, in a 6 year old, with severe dilated cardiomyopathy after chronic graft rejection and refractory to clinical treatment. To avoid a blood transfusion in this surgery a multidisciplinary approach was planned, which involved the use of preoperative erythropoietin, acute normovolemic hemodilution and intraoperative cell savage with autologous blood recovery system, as well as a meticulous hemostasis and reduced postoperative phlebotomy.

Duodenum-stomach anastomosis: a new technique for exocrine drainage in pancreas transplantation.

INTRODUCTION: Poor vascular access due to previous surgery can be a major obstacle in pancreas transplantation for which new exocrine and vascular outflow techniques might be useful. A 34-year-old female with early onset type 1 diabetes who underwent living donor kidney transplantation 20 years ago and a failed pancreas transplantation 2 years ago presented for pancreas retransplantation. METHODS: The inferior vena cava was used in the previous deceased donor pancreas transplantation and both iliac arteries had intense perivascular fibrosis, making arterial anastomosis impossible. The only remaining option for the implant was the infrarenal aorta, with venous drainage to the superior mesenteric vein and exocrine drainage to the gastric antrum. RESULTS: The patient had an uneventful recovery and graft function appeared normal. This report shows that when the recipient's abdominal cavity does not provide clear access for the usual surgical techniques regarding exocrine drainage, the stomach drainage procedure is an option. CONCLUSION: Duodenum-stomach anastomosis might be an alternative to portal enteric drainage because there is easy access for graft biopsies and even for procedures involving the papilla major.

[Liver retransplantation. First report in Mexico]. / Retrasplante hepático. Primer reporte en México.

BACKGROUND: The only therapeutic option for patients with hepatic graft failure is retransplant. In Mexico, the number of hepatic transplants is scarce and is even less for retransplants. There are no reports of patients with good results after hepatic retransplant. Here we present the first published case. CLINICAL CASE: We present the case of a 32-year-old male who was transplanted initially for secondary hepatic cirrhosis, sclerosing primary cholangitis and hepatitis C and retransplanted 4 months and 18 days later for severe rejection of the transplant that did not respond to rescue immunosuppressant therapy. After 3 years, 4 months and 4 days the patient shows a good general status. We describe the patient's clinical evolution.

Retrasplante hepático: primer reporte en México / Liver retransplantation: first report in Mexico

Introducción: La única opción terapéutica para pacientes con falla del injerto hepático es el retrasplante. En México todavía es escaso el número de trasplantes hepáticos y menos aún de retrasplantes. Caso clínico: Hombre de 32 años de edad, trasplantado inicialmente por cirrosis hepática secundaria a colangitis esclerosante primaria y virus de la hepatitis C y retrasplantado después a los cuatro meses 18 días por rechazo severo del injerto que no respondió a inmunosupresión de rescate. El paciente estuvo en buen estado y su evolución fue satisfactoria después de tres años cuatro meses. Describimos su evolución clínica.

BACKGROUND: The only therapeutic option for patients with hepatic graft failure is retransplant. In Mexico, the number of hepatic transplants is scarce and is even less for retransplants. There are no reports of patients with good results after hepatic retransplant. Here we present the first published case. CLINICAL CASE: We present the case of a 32-year-old male who was transplanted initially for secondary hepatic cirrhosis, sclerosing primary cholangitis and hepatitis C and retransplanted 4 months and 18 days later for severe rejection of the transplant that did not respond to rescue immunosuppressant therapy. After 3 years, 4 months and 4 days the patient shows a good general status. We describe the patient's clinical evolution.

[Experience with Dohlman-Doane keratoprosthesis: case reports]. / Experiência inicial com a ceratoprótese de Dohlman-Doane: relato de casos.

PURPOSE: To describe 9 eyes in 8 patients who received Dohlman-Doane type 1 keratoprosthesis (KPro) with a mean follow-up of 11.2 months (2 to 25 months). METHODS: A retrospective, non-comparative interventional case series. Previous corneal disease was alcaline burn in 4 eyes, multiple graft failure in 3 eyes, Stevens-Johnson syndrome in 1 eye and thermal injury in 1 eye. Best corrected visual acuity (BCVA) was hand motions or worse in all patients. Glaucoma was present preoperatively in 3 eyes and received Ahmed valve implantation. RESULTS: 88,9% eyes achieved BCVA of better than or equal to 20/100, and 44,4% better than or equal to 20/40. In the postoperative period, 3 eyes developed posterior capsule opacity treated with YAG laser capsulotomy; 3 retroprosthetic membrane treated with tPA injection or steroids; 2 glaucoma in clinical treatment; 1 corneal melting, treated with donor cornea bottom exchange; and 1 fungic endophthalmitis, treated with corneal transplant, anterior vitrectomy, KPro and intraocular lens explantation, and specific intravitreal and endovenous treatment. CONCLUSION: Dohlman-Doane K-Pro seems to be a good option for cases of corneal blindness with poor prognosis for traditional penetrating keratoplasty. Its main advantage is not requesting systemic immunossuppression. Best results were achieved in non-immune diseases.

Experiência inicial com a ceratoprótese de Dohlman-Doane: relato de casos / Experience with Dohlman-Doane keratoprosthesis: case reports

OBJETIVO: Relatar a evolução de 9 olhos (8 pacientes) submetidos ao implante da ceratoprótese de Dohlman-Doane tipo 1, com tempo médio de seguimento de 11,2 meses (2 a 25 meses). MÉTODOS: Trabalho retrospectivo, não comparativo, intervencionista de uma série de casos. Quanto à doença de base, em 4 olhos foram queimadura alcalina, 3 falência de múltiplos transplantes de córnea, 1 síndrome de Stevens-Johnson e 1 queimadura térmica. A acuidade visual pré-operatória era de movimento de mãos ou pior em todos os olhos. Três olhos apresentavam glaucoma pré-operatório, sendo submetidos a implante valvulado de Ahmed. RESULTADOS: A acuidade visual com correção pós-operatória foi melhor ou igual a 20/100 em 88,9 por cento dos olhos e melhor ou igual a 20/40 em 44,4 por cento dos olhos. Como intercorrências pós-operatórias, 3 olhos apresentaram opacidade de cápsula posterior tratada com capsulotomia com YAG laser; 3 olhos membrana retroprotética de fibrina tratada com injeção tPA ou corticoterapia; 2 olhos glaucoma tratado com medicação; 1 olho "melting" corneano tratado com a troca do botão e 1 olho endoftalmite fúngica tratada com transplante a quente, vitrectomia anterior, explante da ceratoprótese e da LIO e tratamento antifúngico. CONCLUSÃO: A ceratoprótese de Dohlman-Doane é uma boa opção para casos graves de cegueira corneana, em que o transplante penetrante de córnea não apresenta bom prognóstico. Sua principal vantagem é não necessitar imunossupressão sistêmica. Casos de queimadura alcalina e de alta chance de rejeição apresentaram os melhores resultados.

PURPOSE: To describe 9 eyes in 8 patients who received Dohlman-Doane type 1 keratoprosthesis (KPro) with a mean follow-up of 11.2 months (2 to 25 months). METHODS: A retrospective, non-comparative interventional case series. Previous corneal disease was alcaline burn in 4 eyes, multiple graft failure in 3 eyes, Stevens-Johnson syndrome in 1 eye and thermal injury in 1 eye. Best corrected visual acuity (BCVA) was hand motions or worse in all patients. Glaucoma was present preoperatively in 3 eyes and received Ahmed valve implantation. RESULTS: 88,9 percent eyes achieved BCVA of better than or equal to 20/100, and 44,4 percent better than or equal to 20/40. In the postoperative period, 3 eyes developed posterior capsule opacity treated with YAG laser capsulotomy; 3 retroprosthetic membrane treated with tPA injection or steroids; 2 glaucoma in clinical treatment; 1 corneal melting, treated with donor cornea bottom exchange; and 1 fungic endophthalmitis, treated with corneal transplant, anterior vitrectomy, KPro and intraocular lens explantation, and specific intravitreal and endovenous treatment. CONCLUSION: Dohlman-Doane K-Pro seems to be a good option for cases of corneal blindness with poor prognosis for traditional penetrating keratoplasty. Its main advantage is not requesting systemic immunossuppression. Best results were achieved in non-immune diseases.

FOXP3-positive regulatory cells inside the allograft and the correlation with rejection.

BACKGROUND: Foxp3 is a transcription factor associated with regulatory T cells. Little is known about the role of Foxp3+ regulatory T cells in relation to graft rejection in humans. METHODS: By using a quantitative polymerase chain reaction assay, we measured the levels of messenger RNA (mRNA) for Foxp3 in 27 samples obtained at allograft nephrectomy for acute nonvascular rejection (ANVR; n = 7), or acute vascular rejection (AVR; n = 15), or loss due to a nonimmune cause (LNIC; n = 5, as control). Granzyme B was also analyzed as a positive control for the host-driven immune response. RESULTS: Median Foxp3 mRNA levels correlated with the severity of rejection: LNIC 1.000, ANVR 1.429, and AVR 3.904 (P = .022 for LNIC and AVR by the Kruskal-Wallis test). The receiver operating characteristic curve for AVR demonstrated an area under the curve of 0.733 (P = .04; 95% CI, 0.528-0.939). The levels of granzyme B mRNA also showed the same profile but did not reach statistical significance. CONCLUSIONS: The presence of mRNA for Foxp3 inside the graft suggested specific homing during severe episodes of acute rejection. Its presence may indicate the development of host immunoregulatory responses during the ongoing cytolytic activity. In addition, assessment of Foxp3 mRNA inside the graft may distinguish vascular from nonvascular rejection.

Sobrevida del paciente y del injerto renal: receptores de trasplante renal en el Hospital de San José de 1996 a 2004 / Patient survival and renal graft: kidney transplant recipients at the Hospital of San José from 1996 to 2004

Es un estudio observacional descriptivo retrospectivo de los pacientes con falla renal terminal sometidos a trasplante renal en el Hospital de San José entre 1996 y 2004. Se analizaron las características clínicas y quirúrgicas y su relación con la sobrevida de los receptores y del injerto a cinco años, usando los métodos univariado, bivariado, de frecuencia y una curva de probabilidad de sobrevida. 110 pacientes recibieron un trasplante renal en el hospital durante este lapso y se obtuvo información de 102 de ellos. El promedio de edad fue 35.53 años con desviación estándar (DE) de 13.25 años, la distribución por género fue 53,9% de hombres y 46.1% mujeres. El tipo de donante fue vivo 13,7% y cadavérico 86,3%. Hubo una tasa de sobrevida de los receptores a cinco años del 86,28% (88 pacientes) y el 92,85% de las muertes ocurrieron en los dos primeros meses. La tasa de sobrevida del injerto a cinco años fue del 70% según los datos analizados en 85 pacientes. Consideramos que el retardo de la función del injerto, el rechazo agudo y la influencia del cambio en los esquemas inmunosupresores debe analizarse puntualmente. Además, se puede desarrollar un sistema de pareamiento de los injertos según la masa metabólica del paciente, la edad y la función previa entre donadores y receptores, para evaluar su influencia en la función del injerto.

[Hepatic retransplant and acute Budd Chiari syndrome. Case report]. / Retrasplante hepático y síndrome de Budd Chiari agudo. Presentación de un caso.

Hepatic retransplant constitutes 10-20% of all orthotopic hepatic transplants. The piggy-back technique was used in hepatectomy with conservation of the retrohepatic vena cava. A side-to-side cavo-cavostomy technique is described in the case of hepatic congestion or acute Budd Chiari syndrome post-transplant. This is an extremely serious condition and can result in death. We present the first case of hepatic retransplant performed in Hospital Hermanos Ameijeiras in a patient who received who received his first transplant due to non-resectable hepatocarcinoma and who required retransplant due to acute rejection and graft dysfunction. During retransplant, the Belghiti side-to-side anastomosis technique was used to resolve the acute Budd Chiari syndrome that presented itself. Post-surgical evolution at 18 months was satisfactory without evidence of complications of the graft. Acute Budd Chiari syndrome post-transplant can satisfactorily be resolved with the Belghiti technique, although it is preferable to take prophylactic measures to avoid it.

Cumulative incidence, indications, morbidity and mortality of transplant nephrectomy and the most appropriate time for graft removal: only nonfunctioning transplants that cause intractable complications should be excised.

PURPOSE: We assessed the cumulative incidence of transplant nephrectomy in our population of patients who underwent transplantation and those in whom the transplant failed due to immunological causes. Transplant nephrectomy indications, morbidity and mortality were analyzed to establish the most appropriate time for graft removal. MATERIALS AND METHODS: We included all patients who underwent transplantation and graft removal at our institution from January 1, 1970 through January 1, 2000. We estimated the noncumulative incidence of transplant nephrectomy, morbidity and mortality. The cumulative incidence of transplant nephrectomy was estimated by Kaplan-Meier curves. RESULTS: Of the 631 renal transplants performed in 598 patients we studied a total of 91 transplant nephrectomies in 85 patients. The cumulative incidence of transplant nephrectomy 15 years after the date of transplantation was 25% (95% CI 14 to 40). The cumulative incidence of transplant nephrectomy at 10 years after the date of return to dialysis was 74% (95% CI 49 to 90). The main indication for transplant nephrectomy was graft related complications associated with chronic rejection in 58.2% of cases. The morbidity rate was 48.3% (95% CI 37.7 to 59). Hemorrhagic events were the chief complication. In 7 patients there was a total of 10 reoperations (10.9%, 95% CI 5.3 to 19.2). The mortality rate was 7% (95% CI 2.6 to 14.7). These patients died of sepsis. Urgent transplant nephrectomies had statistically higher morbidity and mortality (p <0.01 and 0.002, respectively). CONCLUSIONS: Most transplant nephrectomies were performed within 2 years of the transplant date and almost half were done within year 1 after the return to dialysis. The advent of cyclosporine significantly decreased the transplant nephrectomy rate at the expense of fewer graft failures but not at the expense of a lower amount of graft related symptoms after patients returned to dialysis. Bleeding was the leading cause of morbidity and infection was the main cause of mortality. Considering the high morbidity and mortality of transplant nephrectomy, and the potential benefits of leaving nonfunctioning grafts in situ our current policy is to remove the graft only in cases of failed transplants that cause intractable complications.

Laser in situ keratomileusis after penetrating keratoplasty.

PURPOSE: To assess the outcomes of laser in situ keratomileusis (LASIK) after penetrating keratoplasty (PKP). SETTING: Hospital de Clínicas de Porto Alegre, Department of Ophthalmology, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil. METHODS: Fourteen eyes of 13 patients who had LASIK after PKP were retrospectively reviewed. The interval between LASIK and PKP was at least 1 year, and the follow-up after LASIK was also at least 1 year. All patients had a stable refractive error for a minimum of 6 months after all sutures were removed, regular and symmetric topographic astigmatism, and a minimal ultrasonic central corneal pachymetry of 500 microm. The Chiron Automatic Corneal Shaper and the Meditec Aesculap MEL 60 excimer laser were used. RESULTS: At 12 months, mean myopia decreased from -5.33 diopters (D) +/- 4.22 (SD) to 0.19 +/- 1.71 D, mean hyperopia decreased from +5.04 +/- 3.32 D to + 0.42 +/- 0.46 D, and mean astigmatism decreased from 5.37 +/- 2.12 D to 2.82 +/- 2.42 D (47.5% of mean percentage reduction). Retreatment was necessary in 42.9% of eyes because of cylindrical undercorrection. Uncorrected visual acuity improved in 11 eyes (78.6%). Best spectacle-corrected visual acuity improved in 6 eyes (42.8%) and was maintained in 4 eyes (28.6%); 5 eyes (35.7%) lost 1 Snellen line. Intraoperative complications included 1 buttonhole flap. Postoperative complications included interface epithelial ingrowth at the periphery (2 eyes) and pseudophakic retinal detachment 2 years after LASIK (1 eye). CONCLUSION: Laser in situ keratomileusis after PKP safely and predictably corrected the spherical component of the refraction. However, the predictability of LASIK in correcting post-PKP astigmatism was poor.

Trasplante renal: complicaciones vasculares / Renal transplantation: vascular complications

Estudio retrospectivo donde se revisan las complicaciones vasculares y su manejo en pacientes de trasplante renal. A partir de 1975 se han efectuado 293 trasplantes en nuestro servicio, lográndose revisar 238 fichas clínicas correspondientes a 256 trasplantes. El injerto fue de donante vivo en 57 por ciento de los casos y donante cadáver en 43 por ciento. La anastomosis venosa se realizó a vena cava inferior (53.3 por ciento) y a vena ilíaca (46,7 por ciento). La anastomosis arterial termino terminal (TT) a hipogástrica (78,3 por ciento) y término lateral (TL) a ilíaca (21.7 por ciento). Se presentaron 48 complicaciones de las cuales 12 (4.89 por ciento) fueron de tipo vascular 9 estomosis, 2 trombosis y 1 hematoma perirrenal. Para su manejo se realizaron 9 revascularizaciones con diversas técnicas y un reforzamiento de sutura. Un paciente requirió trasplantectomía. Tenemos 5 (40 por ciento) injertos funcionantes y no hubo mortalidad derivadas de las complicaciones o su manejo