Nuclear imaging of the liver: is there a diagnostic role of HIDA in posttransplantation?

BACKGROUND AND AIMS: Biliary complications are common after liver transplantation. This study sought to assess the value of hepatic iminodiacetic acid (HIDA) scans (hepatobiliary iminodiacetic acid scan) to detect early posttransplantation biliary complications. METHODS: From April 2003 to June 2006, 34 liver transplantations (recipients of mean +/- SD age of 43.0 +/- 15.7 years) were performed in 25 (73.5%) males from 20 (58.8%) cadaveric donors and 14 (41.2%) living-related donors. The subjects underwent HIDA scans using a single head gamma camera Meridian (Philips) after intravenous (IV) administration of 185 MBq Tc-99m Disofenin. The mean time +/- SD posttransplantation to HIDA scan was 14.6 +/- 18.2 days (range, 0-74). The results were compared with endoscopic retrograde cholangio pancreatography, magnetic resonant cholangiopancreatography, percutaneous cholangiograhy, and/or liver biopsy. RESULTS: Twenty-four abnormalities were detected by HIDA scan in 16 patients (47.1%): 10 (29.4%) biliary leaks; 4 (11.4%) biliary obstruction or cholestasis; 1 (2.9%) delayed uptake; 5 (14.7%) delayed blood pool clearance; and 8 (23.5%) delayed transit to the bowel. The complications were more common among living-donor compared with deceased-donor graft recipients, albeit a not statistically significant difference (P = .066). Total and direct bilirubin levels were significantly higher in patients with abnormal than normal HIDA scans (P = .011 and P = .040, respectively). The sensitivity and specificity of HIDA scans to detect overall postoperative complications were 100% and 66.7%, respectively. Biliary leak results were false positives in 7/10 patients, and true in 3. Detection of obstruction was 75% sensitive by HIDA. CONCLUSION: HIDA scans are a noninvasive, reliable modality for early exclusion of posttransplantation biliary complications. However, correlation with clinical status and imaging modalities is essential to confirm detected abnormalities.

The efficiency of utilization of potential donors for organ transplantation in Saudi Arabia: a pilot study.

Organ shortage has been the main obstacle in the progress of organ transplantation in Saudi Arabia. The aim of this pilot study was to determine the percentage of potential donors among all deaths in Riyadh hospital intensive care units (ICUs). Mortality data were collected by a medical professional in each ICU and analyzed on weekly basis for 1 year (June 2001 through May 2002): The final analysis at the end of the year showed the number of brain death cases in all hospitals to be 114 out of 542 deaths. Fifty-four percent occurred in one hospital. Thirty-eight cases were reported to the Saudi Center for Organ Transplantation (33%). Documentation was completed in only 23 cases (60%). Only four cases became actual donors. In conclusion, there is underreporting of brain death cases. Dealing with the reported cases is inefficient since only four cases became actual donors out of 38. Improving the efficiency of ICUs in dealing with brain death cases (reporting, documentation, maintenance and consent) will require solving several problems at the medical, administrative, religious, and mass media levels.

Knowledge and attitude of intensivists toward organ donation in Riyadh, Saudi Arabia.

Organ transplantation has been widely accepted as a solution for end-stage organ failure. The limitation has been organ shortage. The intensivist plays a major role in the different stages of the donation process. This study investigated the knowledge and attitude toward organ donation and transplantation amongst intensivists in the major hospitals of Riyadh. The study was conducted in June 2002. Twenty-two intensivists in the intensive care units (ICUs)of 4 hospitals in Riyadh participated in the study. A questionnaire was distributed concerning knowledge and attitude on donation and transplantation. The information was tabulated and analyzed. Only 50% appreciated the high success rate of modern organ transplantation. One fourth did not know of the role of the Saudi Center for Organ Transplantation (SCOT). Most of the intensivists knew the Islamic view on transplantation. Many would be willing to allow donation from a deceased relative. However, only 13% carry donation cards. Most participants believed that the organ shortage was mainly due to family refusal to donate. Intensivists need to have better insight into the obstacles to donation that can be solved at the level of the hospital and the ICUs. Moreover, the communication gap between ICUs and SCOT needs to be bridged to optimize the use of all potential donors.

Hepatic artery thrombosis after orthotopic liver transplantation.

OBJECTIVE: Hepatic artery thrombosis after liver transplantation is uncommon, but represents an important cause of morbidity and mortality. The aim of this study is to identify the possible risk factors for the development of hepatic artery thrombosis, and the impact of hepatic artery thrombosis on the patients and graft survival. METHODS: Between January 1994 and June 1998, we reviewed retrospectively a series of 86 liver transplant procedures performed on 81 adult patients. Arterial anomalies of the donor graft, rejection episodes, cold ischemia time, ABO matching, the use of blood/fresh frozen plasma during and after surgery, and the use of heparin as prophylactic anticoagulation therapy were examined as a possible contributing risk factors for the development of hepatic artery thrombosis. RESULTS: Hepatic artery thrombosis occurred in 7 procedures out of 86 (9%). Early cases of Hepatic artery thrombosis within 15 days after transplant occurred in 4 patients. Late thrombosis occurred in 3 patients. Analysis of potential risk factors for the development of hepatic artery thrombosis was carried out. Five out of 40 patients who did not received prophylactic heparin had hepatic artery thrombosis (12.5%), while only 2 out of 46 patients who received prophylactic heparin had hepatic artery thrombosis 4%. On the other hand, 6 out of the 7 patients developed hepatic artery thrombosis received more than 5 units of blood transfusion during the transplant procedure (11%) while only one patient developed hepatic artery thrombosis who received less than 5 units intra-operatively (3%). Management of hepatic artery thrombosis cases were carried out in the form of: thrombectomy (n = 1), thrombectomy followed by retransplantation (n = 2), and non-surgical or conservative treatment (n = 4). The overall survival rate was (43%) (3 out of 7). Out of four deaths, 3 were directly related to hepatic artery thrombosis while the cause of death iin the remaining patients was attributed to pulmonary sepsis. CONCLUSION: Early hepatic artery thrombosis leads to death unless quick retransplantation follows. Conservative treatment for the late onset hepatic artery thrombosis on occasion has been useful. The use of postoperative prophylactic anticoagulation therapy might be of benefit in the prevention of hepatic artery thrombosis after liver transplantation. Increased transfusion requirement for red blood cells during transplant procedure was independently associated with increase incidence of hepatic artery thrombosis.

Knowledge and Attitude towards Organ Donation among Males in Riyadh, Saudi Arabia.

Organ transplant programs are increasing in Saudi Arabia with the major barrier to transplantation being a shortage of organs. The majority of Saudi Nationals are reluctant and unwilling to donate or consent for donation. This study was undertaken to determine the knowledge and attitude towards organ donation among males in Riyadh, Saudi Arabia. A questionnaire was distributed to 223 men attending the out-patient department of the National Guard Hospital, Riyadh. A total of 205 (92%) individuals answered the questionnaire. Of them, 187 (91%) were Saudis and 18 (9%) were non-Saudis. A total of 187 (88%) had heard about organ donation of whom 80 (43%) each, had acquired this knowledge through television or radio, 16 (8%) through newspaper and magazines, seven (4%) through friends and relatives, and four (2%) through health-care workers. Of the 205 study subjects, 88 (43%) claimed they understood the concept of brain-death, 96 (47%) did not, and 19 (10%) did not respond to this question. One hundred and thirty-eight (67%) were willing to donate, and 156 (76%) were willing to receive an organ. One hundred and fifteen (56%) believed that Islam permits people to donate organs, five (2%) thought Islam does not permit organ donation, 64 (31%) gave a "don't know" answer and 21 (11%) did not attempt to answer the question. In addition, 41 (20%) thought organ donation disfigures the body. In conclusion although 67% of the respondents in this survey were willing to donate, there was a significant lack of knowledge and misconception with regard to Islamic support to, and the mutilating effects of, organ donation. Public educational programs and other measures addressing these issues may help in increasing the rate of organ donation among Saudis.

Hepatitis C associated glomerulonephritis.

To determine the prevalence and type of glomerulonephritis (GN) associated with hepatitis C virus (HCV) cirrhosis, we prospectively evaluated 28 consecutive Saudi patients with HCV cirrhosis for liver transplantation. Six patients (21%) underwent kidney biopsies for proteinuria, unexplained elevated serum creatinine or both. All 6 had GN, 4 had membranoproliferative, one focal segmental and one membranous GN. Immunologic and electron microscopic studies demonstrated immune complex deposition in the glomeruli. Two patients with significant proteinuria were treated with interferon alpha for 3 months with improvement in kidney and liver function. To our knowledge, this is the first report of focal segmental GN associated with HCV. This high prevalence of HCV associated GN is alarming and warrants further studies in cirrhotic and noncirrhotic patients, particularly as an indication for therapeutic intervention.

Assessment of severity in acute pancreatitis: Use of prognostic factors.

This prospective study evaluates the value of Ranson's prognostic factors in predicting severity of acute pancreatitis. One hundred-fourteen patients with 124 attacks of acute pancreatitis were studied duringa 4-year period at Riyadh Central Hospital. The majority of patients were Saudi males, their mean age being 46.5 years. Cholelithiasis was the leading cause of pancreatitis. Ranson's 11 prognostic factors were estimated within 48 hours of admission. Sixty-six percent of the cases were graded as mild pancreatitis with less than 3 Ranson's factors present, whereas 34% were classified as severe pancreatitis with 3 or more of Ransosn's factors present. Prognostic factors correctly predicted severity in 6% of patients, but only 36% from the severe group developed severe disease (complications and/or death). Overall mortality was 5.3%. Ranson's prognostic factors help in identifying severe pancreatitis but their accuracy may be improved by the use of modern imaging techniques.

Traumatic diaphragmatic hernia: review of 15 cases.

From January 1985 to December 1987, 292 laparotomies were performed for injury in Riyadh Central Hospital. Of these, 15 cases were associated with diaphragmatic injuries (5.1 per cent). The diagnosis was missed in 5 cases (30 per cent) and was incidental (at laparotomy) in 3 cases (20 per cent). Therefore in about 50 per cent of the cases, the diagnosis was not made at the initial presentation. In this paper we stress the importance of maintaining a high degree of clinical suspicion in order not to miss traumatic diaphragmatic hernia in multiply injured patients.