Evaluation of prospective living renal donors for laparoscopic nephrectomy with multisection CT: the marriage of minimally invasive imaging with minimally invasive surgery.

Laparoscopic technique for excision of a kidney from a living donor has advantages over conventional open surgery, but operative visibility and surgical exposure are limited. Preoperative multisection computed tomography (CT) can provide necessary anatomic information in a minimally invasive procedure. A three-phase examination is suggested: (a) imaging from the top of the kidneys to the pubic symphysis with a section width of 2.5 mm and no contrast medium, (b) scanning of the kidneys and upper pelvis during the arterial phase of enhancement with a section width of 1.0 mm, and (c) scanning of the kidneys and upper retroperitoneum during the nephrographic phase of enhancement with a section width of 1.0 mm. Emphasis in this article is placed on analysis of the venous anatomy because most radiologists are unfamiliar with the anatomic variations. Conventional radiography of the abdomen and pelvis is performed after CT to evaluate the collecting system and ureters and to provide a lower total radiation dose than if CT were used. Of several postprocessing techniques that may be used, the authors prefer maximum intensity projection for arterial evaluation and multiplanar reformatting for venous evaluation.

Prostate-specific antigen values and their clinical significance in renal transplant recipients.

BACKGROUND: In the diagnosis of prostate cancer, prostate-specific antigen (PSA) is the most clinically useful tumor marker. Its utility in renal transplant patients is unclear. We hypothesized that PSA values might be affected by the renal function, immunosuppression, or proteinuria. METHODS: Three hundred four PSA values were measured in 166 patients >40 years (53.5 +/- 7.2 years, mean +/- SD, range 44.4 to 76.2). Charts were reviewed for 24-hour creatinine clearance, 24-hour urinary protein, cyclosporine use, age at the time of each PSA test, and evaluation done in response to the PSA result. Analyses used the Mann-Whitney U test and simple regression model. RESULTS: Twenty-five values in 13 patients were >4.0 ng/mL. Of these, 6 patients (6 values) had normal repeat PSA values; 3 patients (11 values) had negative evaluations for prostate cancer; and 4 patients (8 values) were diagnosed with prostate cancer. The latter 4 patients were excluded from the denoted normal group leaving 294 PSA values in 162 patients. The mean normal PSA was 1.3 +/- 1.8 ng/mL, range 0.1 to 20.2. The pretreatment mean PSA for recipients with prostate cancer was 302 +/- 800, range 8.0 to 2,281. An elevated PSA value was associated with a 31% incidence of prostate cancer. There was no association of PSA levels with cyclosporine use, 24-hour creatinine clearance, or 24-hour urinary protein, but there was with age. CONCLUSIONS: Prostate-specific antigen values in renal transplant recipients are similar to those in the general population and are not influenced by cyclosporine or by renal function. We recommend routine measurement of PSA in male transplant recipients.

Oral ganciclovir in pediatric transplant recipients: a pharmacokinetic study.

An oral formulation of ganciclovir (GAN) has been shown to be effective as prophylaxis of cytomegalovirus (CMV) after liver transplantation in an adult population. There are no data on the use or dose of oral GAN in pediatric transplant recipients. We evaluated the pharmacokinetics of oral GAN in a group of such patients. Nine patients (4 kidney and 5 liver transplant recipients, age 0.9-13 yr) were treated with the commercial formulation of oral GAN after transplant. All patients were considered at risk for CMV disease based on the use of anti-lymphocyte antibody (n = 5), and/or the use of a CMV positive organ in a CMV negative recipient (n = 5) or based on being a recipient of a liver transplant (n = 4). They received oral GAN for 84 +/- 29 d. All recipients had normal renal function as estimated by the Schwartz formula. While on a stable dose of oral GAN for at least 4 d (mean +/- SD 8.4 +/- 7, range 4-27 d), 1-ml serum samples were obtained before and at various times after dosing for the measurement of GAN levels. GAN levels were determined at a central laboratory by high-performance liquid chromatography. In 7 of the patients, a sufficient number of levels were obtained post-dosing to calculate the area under the curve using the linear trapezoidal rule. Cmin, the morning trough concentration, and Cmax, the peak concentration, were determined by inspection. Doses of oral GAN were increased if Cmin levels were less than 0.5-1.0 microgram/ml. Adequate levels of GAN were achieved in these patients at doses of 21.8-38.5 mg/kg or 568-990 mg/m2 every 8 h. There was a better correlation between the maximum GAN blood concentration and body surface area (R2 = 0.52, p = 0.008) than with body weight (R2 = 0.36, p = 0.04). Oral GAN was well tolerated in the 7 patients without evidence of leukopenia, thrombocytopenia, or nephrotoxicity. No CMV disease occurred, although one patient had probable CMV syndrome with the development CMV IgM antibodies. These data suggest that oral GAN may be safely administered to pediatric transplant recipients. With normal renal function, the dosing should be in the range 20-40 mg/kg or 500-700 mg/m2 q 8 h. Further data in children with impaired renal function is required.

Intraoperative placement of a Wallstent for portal vein stenosis and thrombosis after liver transplantation.

We report a case of orthotopic liver transplantation, in which portal vein thrombosis developed in the immediate postoperative period. Surgical thrombectomy and intraoperative placement of a large caliber Wallstent resulted in long-term patency. The unique feature of this case is the intraoperative placement of the stent via the inferior mesenteric vein under fluoroscopic guidance. The use of a large caliber (16 mm) stent obviated the need for postoperative anticoagulation.

Predictive value of enzyme-linked immunosorbent assay-detected IgG anti-HLA antibodies for pediatric renal allograft rejection.

BACKGROUND: Measurement of panel-reactive antibody (PRA) with an enzyme-linked immunosorbent assay using soluble HLA class I molecules (PRA-STAT) in adult renal transplant recipients predicted graft loss and rejection. We sought to confirm this finding in pediatric recipients, an immunologically distinct group. METHODS: The population consisted of 158 renal transplants in 146 patients (age range, 1-21 years). PRA was determined with PRA-STAT and microlymphocytotoxicity (CDC), using final cross-match sera. An elevated test was defined as > or =5% reactivity. Statistical analysis for rejection used the chi-square test and for graft survival used the log-rank test. RESULTS: Thirty-five patients (22%) had %PRA-STAT > or =5%, compared with 26 (16%) with %PRA-CDC > or =5%. The percentage with elevated %PRA-STAT was found to correlate with subsequent transplantations (first, 15%; second, 67%; third, 75%). Subsequent analyses utilized only the 136 primary recipients, of whom 20 (15%) had %PRA-STAT > or =5% and 16 (12%) had %PRA-CDC > or =5%. Elevated %PRA-STAT correlated with rejection at 3 months (65% vs. 36%), 12 months (84% vs. 50%), and 24 months (84% vs. 54%) (P<0.05). No association was found between elevated %PRA-CDC and rejection. Patients with %PRA-STAT > or =5% vs. %PRA-STAT <5% had graft survival at 1 year of 89% vs. 84%, at 2 years of 88% vs. 77%, and at 3 years of 61% vs. 72% (not significant). CONCLUSIONS: Use of %PRA-STAT > or =5% identifies pediatric recipients who are at increased risk for rejection and may benefit from more potent immunosuppression and/or closer monitoring of graft function.

The arteriovenous fistula for hemodialysis access: gold standard or archaic relic?

A five year retrospective review was undertaken to evaluate the patency rates of arteriovenous fistulae (AVF) in patients with end stage renal disease. From July 1989 through June 1994, 150 fistulae were created in the wrists of 144 patients. Thirty-four percent of the patients had diabetes mellitus. Patient death or irreparable fistulae were considered end points in the study. Patency rates were calculated by the Kaplan-Meier Actuarial Analysis. An analysis to assess the impact of the demographic characteristics, underlying renal disease, and effect of revisions on patency rates was calculated. The results demonstrate a high initial failure rate (less than 1 month) of 13 per cent in the entire cohort undergoing fistulae replacement. The 1 and 5-year patency rates were 56 per cent and 30 per cent, respectively. Diabetics had a significantly lower patency rate at 1 and 5 years (42% and 18%) respectively. Others, who had poor patency rates, include patients 70 years old or greater (40% patency at one year). The results suggest that the AVF should not be the first choice of access in elderly diabetics and that these patients would be better served with other modes of access, such as synthetic conduits or permanent indwelling venous catheters.

Zinc deficiency and its repletion following liver transplantation in humans.

Zinc deficiency is common in patients with end-stage liver disease but its prevalence and resolution in liver transplant recipients has not been reported. We hypothesized that with normalization of liver function after transplant, zinc levels should rapidly return to normal, obviating the need for oral supplementation. Serum zinc levels were obtained as part of routine laboratory studies just prior to liver transplantation in 34 patients. Of these, 22 had at least one additional zinc level obtained post-transplant. The charts of these 34 patients were retrospectively reviewed for pre- and post-transplant zinc, albumin, protein, and cholesterol levels, prothrombin times, use of oral zinc supplementation, and patient demographics including age, gender, cause of liver failure, UNOS status at the time of transplant, and the use of a pre-transplant trans-jugular intrahepatic portosystemic shunt (TIPS). Post-transplant, the patients received standard enteral formula for nutrition. The overall zinc level for the group was 37.4 +/- 9.0 micrograms/dl (mean +/- s.d., normal = 60-150 micrograms/dl). Thirty-two of the 34 patients (94%) had a zinc level in the subnormal range. There were no differences in zinc levels between patients with alcoholic and non-alcoholic liver failure, males versus females, UNOS status (low = status 1 and 2, high = 3 and 4), pre-transplant use of TIPS nor correlation between age and zinc level. All 22 patients who had a post-transplant zinc level demonstrated an increase from 40.1 +/- 9.7 micrograms/dl to 68.5 +/- 14.1 micrograms/dl (p < and = 0.0001, paired t-test). Our findings indicate that zinc deficiency, generally profound, should be assumed to be present in every patient with end-stage liver disease awaiting transplant. During the waiting period oral supplementation with zinc should be provided. The degree of deficiency is not effected by cause of liver failure, UNOS status, or the presence of TIPS. Following transplantation, zinc levels rapidly recover, obviating the need for checking levels and oral supplementation.

Persistence of cyclosporine after withdrawal of the drug in a patient with chronic liver transplant rejection. Role of the monoethylglycinexylidine test.

Patients with chronic rejection of liver allografts may show persistently high cyclosporine levels. This phenomenon may be due to a down-regulation of the P450 cytochrome system. The monoethylglycinexylidine test was useful in confirming this hypothesis.

Metabolic problems in recipients of liver transplants.

We analyzed the metabolic problems in recipients of liver transplants. Immunosuppression consisted of cyclosporine, steroids and azathioprine. With a mean follow up of 3.5 yr, 37% of 71 recipients were rendered permanently diabetic and hyperlipidemic. Recipients who developed posttransplant diabetes had higher cholesterol levels and proteinuria, but decreased creatinine clearance. Transplant recipients who developed posttransplant hyperlipidemia had greater proteinuria, but their sugars and creatinine clearance were comparable to those who did not have hyperlipidemia. The most significant factor responsible for these metabolic complications was the total dosage of prednisone and cyclosporine. There was no effect of risk antigens on the development of diabetes.

Proteinuria in recipients of liver transplants.

We investigated the incidence and significance of proteinuria in recipients of liver transplants. The overall incidence of proteinuria was 59.72%. The peak incidence of proteinuria was at 3 months and at the end of 1 yr posttransplant. Proteinuria was higher in those patients who developed posttransplant diabetes mellitus, and those who developed both posttransplant diabetes and posttransplant hyperlipidemia. Patients who received higher total dosage of steroids and CsA had significantly greater proteinuria. Patients who had a Cr Cl greater than 50 ml/min had greater proteinuria posttransplant for the first 6 months, but the trend was reversed later. We did not find any association of proteinuria with age, weight, rejection episodes, or with the etiology of liver failure. Hypertension was a common occurrence in our patients, and therefore its significance in the causation of proteinuria could not be defined.

Nutrition support following liver transplantation: comparison of jejunal versus parenteral routes.

Liver failure patients are chronically malnourished at the time of transplant. We have used jejunostomy tubes (j-tube) placed at the time of liver transplantation for immediate postoperative enteral nutrition. We compared the effectiveness of this means of nutrition to total parenteral nutrition (TPN). Sixty-three adult patients fed enterally (ENT) with a semi-elemental diet were retrospectively compared to 21 adult controls alimented with TPN, both beginning after liver transplantation. Data collected included: day to initiation of nutrition, day of achieving goal nutrition, day of removal of nasogastric tube, day of initiation of oral nutrition, day of achieving oral nutritional goal, and serum albumin, cholesterol, SGOT, SGPT, GGT, and bilirubin. Intestinal complications of diarrhea, ileus, and perforation were analyzed. Statistical analyses used an unpaired t-test for continuous data, and Chi square for categorical data. Caloric requirements, percentage ideal body weight, age, and initial cholesterol and albumin were equal. Fifty-four of the ENT patients were fed only by j-tube; 9 ENT patients also required TPN. ENT patients started on nutrition sooner (3 +/- 1.7 vs. 1.7 +/- 0.9 days, p = 0.001), reached goal oral nutrition sooner (19.5 +/- 11 days vs. 38.6 +/- 24.6 days, p = 0.0061, Mann-Whitney U test), and had a lower frequency of prolonged postoperative ileus (8.3%, vs. 33%, p = 0.009) than TPN patients. ENT patients had a greater frequency of diarrhea than TPN controls (73% vs. 25%, p < 0.001). This diarrhea was self-limited, lasting 3 to 5 days, and responded to anti-motility drugs.(ABSTRACT TRUNCATED AT 250 WORDS)

Tube jejunostomy in liver transplant recipients.

BACKGROUND: Nutritional support after liver transplantation most often uses intravenous hyperalimentation followed by nasoduodenal tubes until adequate intake is achieved. Because of difficulties with nasoduodenal tubes, we place jejunostomy tubes (j-tube) at the time of the transplantation, allowing immediate postoperative enteral nutrition. This review analyzes the complications of this procedure in transplant recipients. METHODS: J-tubes were placed in 108 of 119 adults who underwent liver transplantation between October 1989 and June 6, 1994. These patients were retrospectively reviewed for the type and frequency of j-tube-related complications. J-tube feeds with a semielemental formula were started within 24 to 48 hours after transplantation. RESULTS: Eighteen complications occurred in 16 patients. Six were mechanical obstructions of the j-tube because of kinking by the fascia. Six exploratory laparotomies were required, two each for infection, small bowel obstruction, or catheter displacement. Four other infections were treated by local incision and drainage or percutaneous drainage. One tube required surgical removal in the operating room. CONCLUSIONS: Tube jejunostomies can be safely placed at the time of liver transplantation with a low risk of serious complications. We recommend the routine use of j-tubes in patients receiving a liver transplant for the immediate posttransplantation institution of enteral nutrition.

Central pontine myelinolysis following orthotopic liver transplant: association with cyclosporine toxicity.

Central pontine myelinolysis can occur after orthotopic liver transplantation leading to high mortality and serious morbidity. In our case, central pontine myelinolysis was associated with wide fluctuations in cyclosporine levels during an episode of hypocholesterolaemia, which may have precipitated central pontine myelinolysis.

Comparison of Minnesota antilymphoblast globulin and Upjohn antithymocyte globulin for induction immunosuppression of human renal allografts.

BACKGROUND: An analysis of heterologous polyclonal antisera in first renal transplants was continued after replacement of Minnesota antilymphoblast globulin (MALG) with antithymocyte globulin (ATGAM), testing the hypothesis that these are functionally equivalent drugs. METHODS: Sequential induction immunosuppression used MALG (20 mg/kg/day, n = 33) or ATGAM (15 mg/kg/day, n = 14), corticosteroids, azathioprine and cyclosporine. White blood cell, platelet, and T-cell subsets were measured. Percent of patients with and time to first rejection were determined. Anti-horse antibody was measured by enzyme-linked immunosorbent assay. Minimum follow-up after transplantation was 1 year. RESULTS: Human leukocyte antigen mismatch, peak and current panel reactive antibodies, age, gender, percent cadaver donors and diabetic recipients were similar. Depletion of CD2, CD3, CD4, and CD8 T-cell subsets and platelet and white blood cells was similar. Early renal function was better with MALG than with ATGAM (p = 0.005, ANOVA), but by 2 weeks the groups were similar. The percent of patients receiving MALG versus patients receiving ATGAM with cytomegalovirus (28 versus 50), anti-horse antibodies (50 versus 62), and rejection (58 versus 50) and the median day of first rejection (48 versus 47) were similar. Three grafts were lost. CONCLUSIONS: MALG and ATGAM are equally effective in eliminating T cells and preventing and delaying the onset of renal allograft rejection.