RESUMO
BACKGROUND: The aim of this study is to determine the relationship between immunosuppression, disease state, and osteoporosis in an outpatient liver transplant clinic. METHODS: All liver transplant recipients visiting an outpatient transplant clinic received bone density scanning with a dual-energy X-ray absorptiometry (DEXA) device of the calcaneal bone after completing a questionnaire assessing risk and medications currently being used. RESULTS: Of the 137 liver transplant (OLT) recipients completing questionnaires and receiving DEXA screening, patients with low bone density (n = 50) were older (56.6 +/- 12.7 years vs 50.2 +/- 10.1 years; P = .02) compared with normal density patients (n = 87) and were predominately female (64.0% vs 35.6%; P = .01). Based on disease state, patients with cholestatic liver failure had lower bone calcaneal area (17.3 +/- 1.3 cm2 vs 18.9 +/- 1.57 cm2; P < .01). Patients taking tacrolimus (n = 112), as compared with cyclosporine (n = 25), had a tendency toward fewer findings of low bone density (37.5% [42 of 112] vs 56.0% [14 of 25]; P = .08) but had more risk factors (3.1 +/- 1.2 vs 2.1 +/- 0.8; P = .001) and a higher prednisone dose (4.4 +/- 5.9 mg/d vs 2.1 +/- 3.8 mg/d; P = .026). For patients weaned from prednisone, the tacrolimus patients were less likely to have low bone density (36.2% vs 68.8%; P = .02). Mycophenolate mofetil did not influence bone density or area measured. CONCLUSIONS: After liver transplantation, patients taking cyclosporine were more likely to have low bone density compared with those taking tacrolimus.
Assuntos
Terapia de Imunossupressão/efeitos adversos , Transplante de Fígado/imunologia , Osteoporose/epidemiologia , Absorciometria de Fóton , Fatores Etários , Densidade Óssea , Doenças Ósseas Metabólicas/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Valores de Referência , Fatores de Risco , Caracteres Sexuais , Inquéritos e QuestionáriosRESUMO
Transmission of donor infections to immunosuppressed recipients may produce serious complications. Here, we report two cases of ruptured renal artery pseudoaneurysm within a few months after renal transplantation from a donor with Gorham's syndrome, a rare disease characterized by proliferation of vascular and lymphatic channels associated with extensive bony destruction. The donor had died of respiratory failure, sepsis, and anoxic brain death due to difficult airway control secondary to a maxillofacial deformity.
Assuntos
Transplante de Rim/métodos , Osteólise Essencial , Artéria Renal/cirurgia , Doadores de Tecidos , Adulto , Anastomose Cirúrgica , Falso Aneurisma , Humanos , Masculino , Resultado do TratamentoAssuntos
Hepatite C/cirurgia , Imunossupressores/uso terapêutico , Transplante de Fígado/imunologia , Ácido Micofenólico/uso terapêutico , Progressão da Doença , Seguimentos , Hepatite C/prevenção & controle , Humanos , Ácido Micofenólico/análogos & derivados , Complicações Pós-Operatórias/prevenção & controle , Recidiva , Fatores de TempoAssuntos
Hepatite C/epidemiologia , Hepatite C/cirurgia , Imunossupressores/uso terapêutico , Transplante de Fígado/imunologia , Ácido Micofenólico/uso terapêutico , Progressão da Doença , Seguimentos , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Humanos , Ácido Micofenólico/análogos & derivados , Prognóstico , RNA Viral/sangue , RNA Viral/isolamento & purificação , Recidiva , Estudos Retrospectivos , Fatores de Tempo , Carga ViralRESUMO
Retrograde embolization of atherosclerotic arterial plaque remains a threat at the time of organ perfusion in elderly donors. In order to circumvent this potential procurement complication, we describe a technique with two variations. This technique allows for perfusion with UW solution without having to cannulate through severely atherosclerotic distal aortic walls.
Assuntos
Doenças da Aorta/patologia , Cateterismo/métodos , Doadores de Tecidos , Obtenção de Tecidos e Órgãos , Adenosina , Idoso , Alopurinol , Aorta Abdominal , Glutationa , Humanos , Insulina , Pessoa de Meia-Idade , Soluções para Preservação de Órgãos , Perfusão , RafinoseRESUMO
Injuries sustained by major vessels during procurement pose a major threat to organ viability. Aortic and inferior vena cava lacerations produce rapid hemorrhage associated with hypoperfusion and ischemic damage. We describe a technique that will prevent such damage in the event of vascular mishaps.
Assuntos
Aorta Abdominal/lesões , Cateterismo Periférico , Complicações Intraoperatórias , Lacerações/terapia , Transplante de Órgãos/efeitos adversos , Veias Cavas/lesões , Humanos , PerfusãoAssuntos
Anti-Hipertensivos/uso terapêutico , Epoprostenol/uso terapêutico , Hipertensão Pulmonar/tratamento farmacológico , Falência Hepática/cirurgia , Transplante de Fígado/efeitos adversos , Óxido Nítrico/uso terapêutico , Vasodilatadores/uso terapêutico , Adulto , Estudos de Viabilidade , Humanos , Hipertensão Pulmonar/etiologia , Falência Hepática/complicações , Pessoa de Meia-IdadeAssuntos
Transplante de Fígado , Transtornos Linfoproliferativos , Complicações Pós-Operatórias , Adolescente , Criança , Pré-Escolar , Ciclosporina/uso terapêutico , Feminino , Humanos , Imunossupressores/uso terapêutico , Incidência , Lactente , Transtornos Linfoproliferativos/diagnóstico , Transtornos Linfoproliferativos/epidemiologia , Transtornos Linfoproliferativos/terapia , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Tacrolimo/uso terapêutico , Resultado do TratamentoRESUMO
OBJECTIVE: To determine whether liver transplantation is judicious in recipients older than 60 years of age. SUMMARY BACKGROUND DATA: The prevailing opinion among the transplant community remains that elderly recipients of liver allografts fare as well as their younger counterparts, but our results have in some cases been disappointing. This study was undertaken to review the results of liver transplants in the elderly in a large single-center setting. A secondary goal was to define, if possible, factors that could help the clinician in the prudent allocation of the donor liver. METHODS: A retrospective review of a prospectively maintained single-institution database of 1,446 consecutive liver transplant recipients was conducted. The 241 elderly patients (older than 60 years) were compared with their younger counterparts by preoperative laboratory values, illness severity, nutritional status, and donor age. Survival data were stratified and logistic regression analyses were conducted. RESULTS: Elderly patients with better-preserved hepatic synthetic function or with lower pretransplant serum bilirubin levels fared as well as younger patients. Elderly patients who had poor hepatic synthetic function or high bilirubin levels or who were admitted to the hospital had much lower survival rates than the sicker younger patients or the less-ill older patients. Recipient age 60 years or older, pretransplant hospital admission, and high bilirubin level were independent risk factors for poorer outcome. CONCLUSIONS: Low-risk elderly patients fare as well as younger patients after liver transplantation. However, unless results can be improved, high-risk patients older than 60 years should probably not undergo liver transplantation.
Assuntos
Transplante de Fígado/mortalidade , Fatores Etários , Idoso , Feminino , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Análise de Regressão , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Resultado do TratamentoRESUMO
Post-transplant lymphoproliferative disease remains a complication with a high morbidity and mortality. The present study examined 291 pediatric liver transplants performed in 263 children from October 1984 to December 1999. Post-transplant lymphoproliferative disease has an overall incidence of 12%. Tacrolimus and cyclosporine had a similar incidence of post-transplant lymphoproliferative disease. Fifty-six per cent of patients who developed post-transplant lymphoproliferative disease were Epstein-Barr virus negative at the time of transplantation. Mean time of conversion to Epstein-Barr virus positivity was 1.1 years after liver transplantation. Ten per cent of those who developed post-transplant lymphoproliferative disease never had Epstein-Barr virus detected. Mean time from Epstein-Barr virus positivity to detection of post-transplant lymphoproliferative disease was 2.68 years, and 3.13 years from liver transplantation (OLTx) to post-transplant lymphoproliferative disease. There was a 35% incidence of mortality. Deaths occurred a mean of 0.76 years after diagnosis of post-transplant lymphoproliferative disease. Most cases of post-transplant lymphoproliferative disease had extranodal location. There was one recurrence in 10% of patients, and two in 3%. All recurrent cases were seen in recipients who became Epstein-Barr virus positive after transplantation. There has been a decrease in the incidence of post-transplant lymphoproliferative disease from 15% to 9% to 4%. Post-transplant lymphoproliferative disease should be diagnosed promptly and treated aggressively. The best treatment, however, seems to be prevention, starting in the immediate postoperative period. Survivors should be monitored for both recurrence of post-transplant lymphoproliferative disease and acute cellular rejection.
Assuntos
Transplante de Fígado/imunologia , Transtornos Linfoproliferativos/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Adolescente , Criança , Pré-Escolar , Infecções por Vírus Epstein-Barr/epidemiologia , Feminino , Seguimentos , Herpesvirus Humano 4/isolamento & purificação , Humanos , Incidência , Lactente , Transplante de Fígado/mortalidade , Transtornos Linfoproliferativos/mortalidade , Transtornos Linfoproliferativos/virologia , Masculino , Recidiva , Estudos Retrospectivos , Fatores de TempoAssuntos
Soro Antilinfocitário/uso terapêutico , Rejeição de Enxerto/prevenção & controle , Imunossupressores/uso terapêutico , Transplante de Fígado/imunologia , Corticosteroides/uso terapêutico , Adulto , Azatioprina/uso terapêutico , Doenças Transmissíveis/epidemiologia , Ciclosporina/uso terapêutico , Esquema de Medicação , Quimioterapia Combinada , Feminino , Rejeição de Enxerto/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Muromonab-CD3/uso terapêutico , Complicações Pós-Operatórias/epidemiologia , Fatores de TempoRESUMO
Candidates for hepatic transplant require a careful identification of risk factors present in the preoperative period. Child C patients have a higher incidence of renal function derangement, septic complications and mortality than Child A or B patients. Alterations in cardiovascular, renal, respiratory and neurologic systems, that sometimes constitute clearly defined syndromes, have important prognostic implications. These alterations shed doubts on the moment and indications for transplantation and on the correct preoperative management of these patients.
Assuntos
Transplante de Fígado , Seleção de Pacientes , Cuidados Pré-Operatórios , Humanos , Medição de RiscoRESUMO
Rejection remains a major obstacle to successful small bowel transplantation in humans, irrespective of the immunosuppressants. Previous large animal studies have not used quadruple immunosuppression (with high-dose intravenous cyclosporine A [CSA]) for induction, followed by triple immunosuppression for maintenance therapy. Nor have immunosuppressive doses been comparable to clinical solid organ transplants. We studied, in 78 nonrelated outbred pigs, the effect of quadruple immunosuppression (including horse anti-pig thymocyte globulin [ATG] and high-dose intravenous CSA) on the incidence and severity of rejection in the early, critical posttransplant period. Group A (n = 19) pigs were nonimmunosuppressed. Group B (n = 20) received quadruple immunosuppression: pig ATG (10 mg/kg/day x 10 days), intravenous CSA (3.0 mg/kg/day), prednisolone (2 mg/kg/day), and azathioprine (2.5 mg/kg/day); prednisolone and azathioprine were each reduced by 50% on posttransplant Days 8 and 15. Trough CSA levels were > or = 400 ng/ml for the first 7 days posttransplant, > 200 ng/ml thereafter. Recipient pigs underwent resection of large and small bowel; orthotopic transplants (proximal duodenojejunostomy, distal ileostomy) were done with systemic vein drainage. We developed a scoring system (no, mild, moderate, severe rejection) to grade the extent of both interstitial and vascular rejection: biopsies were obtained daily from the ileostomy. Rejection-free graft survival at posttransplant Days 7, 10, and 14 was 32, 26, and 16% in the nonimmunosuppressed group versus 95, 90, and 85% in the immunosuppressed group (P < 0.0001). Rejection grades were significantly better over the whole observation period in immunosuppressed pigs: interstitial rejection was not present in up to 67% of all daily biopsy specimens. Rejection was present in all specimens of nonimmunosuppressed pigs. Vascular rejection was uncommon (incidence < 10%) in both groups. Isolated vascular rejection without interstitial rejection was not found. Graft-versus-host reaction was noted in both groups in the skin only; liver and native bowel were not involved. We conclude that quadruple immunosuppression with pig ATG and high-dose intravenous CSA for induction effectively prevents moderate and severe rejection in this model. Since clinical transplant complications (rejection, lymphomas) have persisted under FK 506 treatment, our immunosuppressive regimen should be considered an alternative for bowel transplantation in humans to prevent early rejection.
Assuntos
Terapia de Imunossupressão , Intestino Delgado/transplante , Animais , Soro Antilinfocitário/uso terapêutico , Azatioprina/farmacologia , Ciclosporina/farmacologia , Relação Dose-Resposta a Droga , Rejeição de Enxerto/patologia , Rejeição de Enxerto/prevenção & controle , Doença Enxerto-Hospedeiro/patologia , Cavalos , Injeções Intravenosas , Contagem de Leucócitos , Prednisolona/farmacologia , Análise de Sobrevida , SuínosRESUMO
OBJECTIVE: To study whether bacterial translocation is more prevalent after small-bowel transplantation with systemic venous drainage (SVD) vs portal venous drainage (PVD) and whether it is influenced by immunosuppression. DESIGN: We performed 15 small-bowel transplantations in pigs. Group 1 (n = 5) had SVD and no immunosuppression; group 2 (n = 6), PVD and no immunosuppression; and group 3 (n = 4), PVD and immunosuppression with tacrolimus and methylprednisolone sodium succinate. Portal and systemic blood, portal and mesenteric lymph nodes, and liver were cultured in donors and recipients on postoperative day 0 (POD 0) and in recipients on postoperative day 3 (POD 3). Jejunal and ileal contents were also sampled at these times. SUBJECTS: Outbred male Yorkshire-Landrace pigs. MAIN OUTCOME MEASURES: (1) Blood and tissue bacterial cultures, (2) blood endotoxin levels, and (3) histopathologic examination. RESULTS: Cultures were positive for bacteria in 32% (16/50) of samples on POD 0 and 88% (22/25) on POD 3 in group 1, in 18% (11/60) of samples on POD 0 and 97% (29/30) on POD 3 in group 2, and in 8% (3/40) of samples on POD 0 and 95% (19/20) on POD 3 in group 3. Systemic blood cultures were positive for bacteria on POD 3 in 60% (3/5) of pigs in group 1, 83% (5/6) in group 2, and 100% (4/4) in group 3. Significantly more bacteria were present in the ileum than in the jejunum on POD 0 in group 2; this difference approached significance in groups 1 and 3. Bacterial numbers were identical in the ileum and jejunum by POD 3 in all groups. Circulating endotoxin levels were significantly elevated on POD 3 vs POD 0 only in group 1. Endotoxin levels were not significantly different between the SVD group (group 1) and either PVD group (groups 2 and 3). CONCLUSIONS: Bacterial translocation is prevalent after small-bowel transplantation in pigs whether PVD or SVD is used. Immunosuppression with tacrolimus does not prevent bacterial translocation but may reduce systemic endotoxemia.
Assuntos
Translocação Bacteriana , Intestino Delgado/microbiologia , Intestino Delgado/transplante , Animais , Translocação Bacteriana/efeitos dos fármacos , Drenagem , Imunossupressores/farmacologia , Intestino Delgado/patologia , Masculino , Suínos , Tacrolimo/farmacologiaAssuntos
Soro Antilinfocitário/uso terapêutico , Terapia de Imunossupressão/métodos , Transplante de Rim , Transplante de Pâncreas , Linfócitos T/imunologia , Adulto , Feminino , Rejeição de Enxerto/prevenção & controle , Humanos , Transplante de Rim/mortalidade , Masculino , Pessoa de Meia-Idade , Transplante de Pâncreas/mortalidade , Taxa de SobrevidaRESUMO
BACKGROUND: Symptomatic lymphoceles are not uncommon after kidney transplantations. Surgical marsupialization with internal drainage is the treatment of choice. However, laparoscopic drainage is reportedly as effective, with only minimal trauma. METHODS: We attempted 14 laparoscopic lymphocele drainages during a 3-year period and studied the indications and limitations, using intraoperative ultrasonography in all cases. RESULTS: Laparoscopic drainage was successful in only 9 (64%) of 14 patients. A conversion to open laparotomy was necessary in five patients; their lymphoceles were lateral and either posterior or inferior to the kidney. Two patients with initially successful laparoscopic drainage required conversion to open laparotomy 21 and 83 days later; their lymphoceles were inferior to the kidney. Laparoscopic drainage shortened the median hospital stay by 4 days versus open surgical drainage and by 7 days versus conversion. Hospital costs for laparoscopic drainage averaged $7400 less versus open drainage and $10,300 less versus conversion. CONCLUSIONS: In patients with symptomatic lymphoceles medial and either superior or anterior to the kidney, laparoscopic drainage under intraoperative ultrasonographic guidance is easy, safe, and effective. It decreases hospitalization, convalescence, and costs. In patients with symptomatic lymphoceles lateral and either posterior or inferior to the kidney, laparoscopic drainage may fail because of anatomic inaccessibility and technical impracticability.