RESUMO
Both bacteremia and biliary cast syndrome are serious post-transplant complications in liver transplant recipients. In the setting of increasing drug resistance in the current era, management of infections caused by multidrug-resistant (MDR) bacteria has proven challenging. We present a case of a liver transplant recipient who developed biliary cast syndrome and intractable MDR Pseudomonas bacteremia that failed to resolve with conventional antimicrobial therapy and which was finally controlled by a novel combination regimen of colistimethate, doripenem, and tobramycin. Future studies validating the clinical efficacy of this combination strategy are warranted.
Assuntos
Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Farmacorresistência Bacteriana Múltipla , Transplante de Fígado/efeitos adversos , Infecções por Pseudomonas/tratamento farmacológico , Pseudomonas aeruginosa/efeitos dos fármacos , Antibacterianos/farmacologia , Bacteriemia/microbiologia , Doenças dos Ductos Biliares/tratamento farmacológico , Doenças dos Ductos Biliares/microbiologia , Carbapenêmicos/uso terapêutico , Colistina/análogos & derivados , Colistina/uso terapêutico , Doripenem , Quimioterapia Combinada , Humanos , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Infecções por Pseudomonas/microbiologia , Tobramicina/uso terapêutico , Resultado do TratamentoRESUMO
We sought to determine the approach to antifungal prophylaxis, and diagnostic and therapeutic practices for the management of invasive aspergillosis in liver transplant recipients. Data were collected by an electronic survey questionnaire sent to all active liver transplant programs in North America; 63% (67/106) of the sites completed the survey. Overall, 91% of the sites employed antifungal prophylaxis; 28% used universal prophylaxis and 72% targeted it toward high-risk patients. Fluconazole was the most commonly used agent for universal and targeted prophylaxis. The leading choice for mold-active agents for antifungal prophylaxis was the echinocandins. Combination therapy was used as primary therapy for invasive aspergillosis in 47%, and as salvage in 80%. Thus, a vast majority of the surveyed programs employ antifungal prophylaxis and most use targeted prophylaxis. Consideration of these practices could guide clinical trial design to optimize antifungal prophylaxis in these patients. Our findings also merit investigations to better define the role of diagnostic assays and combination therapeutic strategies for invasive aspergillosis in liver transplant recipients.
Assuntos
Antifúngicos/uso terapêutico , Transplante de Fígado/efeitos adversos , Micoses/prevenção & controle , Complicações Pós-Operatórias/microbiologia , Aspergilose/tratamento farmacológico , Aspergilose/epidemiologia , Seguimentos , Inquéritos Epidemiológicos , Humanos , Micoses/classificação , América do Norte , Complicações Pós-Operatórias/prevenção & controle , Inquéritos e Questionários , Fatores de Tempo , Obtenção de Tecidos e Órgãos/métodos , Obtenção de Tecidos e Órgãos/estatística & dados numéricosRESUMO
Liver allografts declined by local transplant centers are then offered regionally or nationally as imported grafts. Most of these grafts are declined because of poor donor quality. We retrospectively reviewed the medical records of patients who underwent liver transplantation between January 2004 and December 2005. There were 102 liver transplants in 98 recipients. They were divided into two groups: imported graft recipients (n = 37) and locally procured grafts recipients (n = 61). Eighty-six percent (32 of 37) of imported grafts were obtained from extended criteria donors defined as subjects treated with high doses of ionotropes with elevated liver enzymes, donor age over 70 years, macrosteatosis above 25%, positive hepatitis C or hepatitis B core antibody serology, systemic disease, history of cancer, hypernatremia, or with infection. The remaining grafts were declined due to unavailability of suitable recipients or social history. Recipient age and etiology of liver disease were similar for both groups. The mean MELD score was 22.1 +/- .9 among the imported graft recipients and 26.1 +/- 1 for the locally procured graft recipients (P < .01). There was no difference in blood loss or postoperative complications. Postoperative mean peak total bilirubin was similar in both groups. However, imported graft recipients had significantly higher mean peak AST (2436 +/- 282 vs 1380 +/- 165 U/L, P < .001) and ALT (1098 +/- 114 vs 803 +/- 87 U/L, P < .05). Primary graft nonfunction as well as 30 day and 1-year patient and graft survivals were similar for both groups. In conclusion, imported grafts can be transplanted in selected patients with outcomes comparable to locally procured grafts.
Assuntos
Transplante de Fígado/fisiologia , Doadores de Tecidos/provisão & distribuição , Hepatite C/epidemiologia , Humanos , Seleção de Pacientes , Reoperação , Estudos Retrospectivos , Transplante Homólogo , Resultado do TratamentoRESUMO
RATIONALE AND DESIGN: The accuracy of a prospective histopathologic diagnosis of rejection and recurrent hepatitis C (HCV) was determined in 48 HCV RNA-positive liver allograft recipients enrolled in an "immunosuppression minimization protocol" between July 29, 2001 and January 24, 2003. Prospective entry of all pertinent treatment, laboratory, and histopathology results into an electronic database enabled a retrospective analysis of the accuracy of histopathologic diagnoses and the pathophysiologic relationship between recurrent HCV and rejection. RESULTS: Time to first onset of acute rejection (AR) (mean, 107 days; median, 83 days; range, 7-329 days) overlapped with the time to first onset of recurrent HCV (mean, 115 days; median, 123 days; range, 22-315 days), making distinction between the two difficult. AR and chronic rejection (CR) with and without co-existent HCV showed overlapping but significantly different liver injury test profiles. One major and two minor errors occurred (positive predictive values for AR = 91%; recurrent HCV = 100%); all involved an overdiagnosis of AR in the context of recurrent HCV. Retrospective analysis of the mistakes showed that major errors can be avoided altogether and the impact of unavoidable minor errors can be minimized by strict adherence to specific histopathologic criteria, close clinicopathologic correlation including examination of HCV RNA levels, and a conservative approach to the use of additional immunosuppression. In addition, histopathologic diagnoses of moderate and severe AR and CR were associated with relatively low HCV RNA levels, whereas relatively high HCV RNA levels were associated with a histopathologic diagnosis of hepatitis alone, particularly the cholestatic variant of HCV. CONCLUSIONS: Liver allograft biopsy interpretation can rapidly and accurately distinguish between recurrent HCV and AR/CR. In addition, the histopathologic observations suggest that the immune mechanism responsible for HCV clearance overlap with those leading to significant rejection.
Assuntos
Rejeição de Enxerto/diagnóstico , Hepacivirus/isolamento & purificação , Hepatite C/diagnóstico , Transplante de Fígado , Doença Aguda , Adulto , Idoso , Biópsia , Doença Crônica , Feminino , Rejeição de Enxerto/prevenção & controle , Hepacivirus/genética , Hepatite C/etiologia , Humanos , Hospedeiro Imunocomprometido , Imunossupressores/uso terapêutico , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , RNA Viral/análise , Recidiva , Reprodutibilidade dos Testes , Estudos RetrospectivosRESUMO
The present study examined 144 pediatric liver transplants to determine the impact of ABO matching on liver allograft outcome. Pediatric transplants were divided into 3 groups: ABO identical (ABO-Id; n = 108), ABO-compatible nonidentical (ABO-Comp; n = 22), and ABO incompatible (ABO-Inc; n = 14). A higher proportion of United Network for Organ Sharing status 4 recipients in the ABO-Comp group (50% vs. 22% and 36% for ABO-Id and ABO-Inc, P < 0.05) and less time spent on the waiting list for ABO-Inc recipients (46 +/- 12 vs. 87 +/- 11 and 61 +/- 20 days for ABO-Id and ABO-Comp, P < 0.01) were noted. OKT3 induction therapy was greater in ABO-Inc grafts (57% vs. 19% and 14% for ABO-Id and ABO-Comp, P < 0.05), as was incidence of acute cellular rejection (79% vs. 59% and 41% for ABO-Id and ABO-Comp, P = 0.08). One- and 3-year patient survival rates were 87% and 83% in the ABO-Id group, 95% and 88% in the ABO-Comp group, and 79% and 79% in the ABO-Inc group (P = NS). One- and 3-year graft survival rates were 83% and 78% in the ABO-Id group, 87% and 80% in the ABO-Comp group, and 71% and 71% in the ABO-Inc group (P = NS). ABO-Inc transplantations can be performed successfully in pediatric recipients and warrant a reassessment of the utilization of ABO-Inc livers.
Assuntos
Sistema ABO de Grupos Sanguíneos , Incompatibilidade de Grupos Sanguíneos/diagnóstico , Transplante de Fígado/imunologia , Pré-Escolar , Seguimentos , Sobrevivência de Enxerto/imunologia , Humanos , Terapia de Imunossupressão/métodos , Lactente , Estudos Retrospectivos , Resultado do TratamentoRESUMO
The technical and medical management of small infants requiring orthotopic liver transplantation remains a challenge. The present study examined 117 orthotopic liver transplantations performed in 101 infants from <1 to 23 months of age between March 1988 and February 1995 to determine factors that influence patient and graft outcome. Factors analyzed included etiology of liver disease, recipient and donor age and weight, United Network for Organ Sharing (UNOS) status, retransplantation, ABO-compatibility, full-size (FS) versus reduced-size grafts, vascular thrombosis (VT), including hepatic artery and portal vein (PVT), and the presence of lymphoproliferative disease (LPD). UNOS status 1, fulminant hepatic failure, and the development of Epstein-Barr virus-associated LPD were each associated with 10-20% lower patient and graft survival rates. Of 101 infants, 11 (11%) developed LPD with an associated 36% mortality. VT occurred in 10 (9 hepatic artery and 1 portal vein) of 117 orthotopic liver transplantations (9%), all less than 1 year of age, and was associated with significantly poorer 1-year (50% vs. 85% no VT, P<0.01) and 5-year patient survival rates (50% vs. 83% no VT, P<0.01). One-year graft survival rates for FS grafts in recipients <12 months versus 12-23 months were 67% vs. 94% (P<0.01); the patient survival rate was also significantly lower in FS graft recipients <12 months (76% vs. 100%, P<0.05). Recipients <5 months of age had the worst survival rates: 1-year and 5-year patient survival rates were 65% and 46% for recipients 0-4 months (n=17) versus 82% and 82% for recipients 5-11 months (n=56), and 93% and 93% for recipients age 12-23 months (n=28; P<0.05). In summary, factors associated with reduced survival rates include recipient age <5 months, recipient age <12 months who received FS grafts, development of VT and donor weight <6 kg. There was a trend for UNOS status 1, fulminant hepatic failure, and presence of LPD to be associated with reduced survival rates.
Assuntos
Transplante de Fígado/mortalidade , Envelhecimento/fisiologia , Soro Antilinfocitário/uso terapêutico , Causas de Morte , Ciclosporina/uso terapêutico , Rejeição de Enxerto/etiologia , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto/fisiologia , Humanos , Lactente , Transplante de Fígado/efeitos adversos , Transplante de Fígado/imunologia , Transtornos Linfoproliferativos/etiologia , Transtornos Linfoproliferativos/mortalidade , Veia Porta , Estudos Retrospectivos , Taxa de Sobrevida , Trombose/etiologiaRESUMO
BACKGROUND: Posttransplant lymphoproliferative disease (PTLD) after pediatric liver transplantation has been associated with high mortality rates. METHODS: The present study examined 282 consecutive pediatric liver transplant recipients from October 1989 to June 1996 who received primary tacrolimus immunosuppression. The aim was to determine the incidence of PTLD, management strategies, and patient outcome. RESULTS: The incidence of PTLD was 13% (361282) with a mean age of 5.5+/-0.7 years (range 0.6 to 15) at diagnosis. The average time from transplantation to PTLD was 10.1+/-2.1 months. Initial treatment of PTLD consisted of reduction (3 patients) or discontinuation (33 patients) of tacrolimus and initiation of antiviral therapy (intravenous ganciclovir, 14 patients; intravenous acyclovir, 22 patients; or both, 5 patients). Alpha-interferon was used in four patients (two successfully). One patient also received gamma-interferon, chemotherapy, and radiation for a central nervous system lesion. Chemotherapy was also used in one patient with Burkitt's, whereas one patient with a pulmonary lesion received additional radiation therapy. Three patients received supportive surgery for gastrointestinal involvement, and one patient had a splenectomy for hemolysis. Overall mortality was 22% (8/36) with 5 (14%) PTLD-related deaths (disseminated disease, 4 patients; bowel perforation, 1 patient). Of 31 survivors, 23 had acute rejection at a median time of 24 days after PTLD, with 2 patients developing chronic rejection. One patient required retransplantation. Present immunosuppression consists of tacrolimus monotherapy in 14 patients, tacrolimus/prednisone in 8 patients, and none in 6 patients. CONCLUSION: In summary, PTLD can be successfully treated with reduction of immunosuppression and administration of antiviral agents in most patients. The management of rejection after PTLD requires reassessment of disease status and judicious reintroduction of immunosuppression therapy.
Assuntos
Imunossupressores/uso terapêutico , Transplante de Fígado , Transtornos Linfoproliferativos/terapia , Complicações Pós-Operatórias/terapia , Tacrolimo/uso terapêutico , Adolescente , Antivirais/uso terapêutico , Criança , Pré-Escolar , Estudos de Coortes , Infecções por Vírus Epstein-Barr/complicações , Infecções por Vírus Epstein-Barr/tratamento farmacológico , Rejeição de Enxerto/epidemiologia , Humanos , Incidência , Lactente , Intestinos/cirurgia , Transtornos Linfoproliferativos/epidemiologia , Transtornos Linfoproliferativos/mortalidade , Transtornos Linfoproliferativos/virologia , Prednisona/uso terapêutico , Reoperação , Esplenectomia , Análise de Sobrevida , Resultado do TratamentoRESUMO
We have adopted the use of an oral tacrolimus induction protocol in pediatric liver transplantation since the commercial release of tacrolimus in 1994. In this study we analyzed the efficacy of oral tacrolimus induction therapy in 17 consecutive transplants (15 patients) performed between 6/94 and 2/95 and 4 additional patients who were retransplanted between 11/93-5/94 and received compassionate oral tacrolimus induction. Sixteen transplants were treated with oral tacrolimus induction only; 5 transplants, oral tacrolimus + ATGAM/OKT3 induction. The protocol consisted of 0.2 mg/kg of tacrolimus orally on the first postoperative day with a corticosteroid taper. Oral tacrolimus was started at day 1-8 in the 5 patients receiving ATGAM/OKT3 induction. Dosages were adjusted over time to maintain a whole-blood trough level of 12-15 ng/ml at 0-1 month, 10-12 ng/ml at 1-3 months, and 5-10 ng/ml after 3 months. The incidence of acute rejection was 50% (8/16) in children on oral tacrolimus induction alone and 80% (4/5) in the tacrolimus + ATGAM/OKT3 group. Epstein-Barr virus infection occurred in 6 of 19 children (32%), with no child developing lymphoproliferative disorder. No adverse effect on renal function was noted. Serum fasting glucose was stable over time while a trend was noted in decreasing serum cholesterol levels at 6 months. Antihypertensive medication was required in 4 of 19 children (21%) posttransplantation. Corticosteroids were withdrawn in 11% (2/19) of patients. Actuarial 1-year patient and graft survivals were 95% and 86%, respectively. The use of oral tacrolimus induction therapy was associated with excellent survival and a low incidence of complications.
Assuntos
Rejeição de Enxerto/prevenção & controle , Imunossupressores/administração & dosagem , Transplante de Fígado , Tacrolimo/administração & dosagem , Administração Oral , Adolescente , Criança , Pré-Escolar , Seguimentos , Sobrevivência de Enxerto , Humanos , LactenteRESUMO
BACKGROUND: The shortage of donor organs occasionally mandates the use of hepatic allografts from anti-HBc+ donors in recipients who are susceptible to de novo hepatitis B virus (HBV) infection. The efficacy of hepatitis B immune globulin and lamivudine to prevent de novo HBV infection in anti-HBs negative recipients of allografts from anti-HBc+ donors has not been investigated. METHODS: After liver transplantation with an allograft from a donor positive for anti-HBc, recipients who were anti-HBs-, HbsAg- received hepatitis B immune globulin (HBIG) 10,000 IU i.v. daily for 7 days and monthly for 6 months. After 6 months, 1000 IU of HBIG was given IM. every 2 weeks for 18 months. Patients transplanted after 4/1/97 were given lamivudine 150 mg daily starting postoperative day 1. RESULTS: Between 8/14/96 and 6/10/98, 264 orthotopic liver transplants were performed and 16 anti-HBs-, HbsAg- patients received an hepatic allograft from a donor positive for anti-HBc. HBIG mono-therapy was administered to one patient. HBIG and lamivudine combination therapy was administered to 15 patients. Of the 16 patients, 8 were positive only for anti-HBc before transplant, and 8 were naive (anti-HBs-, anti-HBc-). The single patient who received HBIG monotherapy became HbsAg+ at 6 months. All patients receiving combination therapy with HBIG and lamivudine have remained HbsAg-. The average follow-up is 459 days (range 170-754). Two patients died from unrelated causes. CONCLUSIONS: Combination therapy with HBIG and lamivudine may prevent de novo HBV infection in anti-HBs-, HbsAg- recipients of hepatic allografts from anti-HBc+ donors.
Assuntos
Anticorpos Anti-Hepatite B/sangue , Antígenos do Núcleo do Vírus da Hepatite B/imunologia , Vírus da Hepatite B/imunologia , Hepatite B/prevenção & controle , Transplante de Fígado/efeitos adversos , Hepatite B/sangue , Humanos , Imunização Passiva , Imunoglobulinas , Lamivudina/uso terapêutico , Estudos Prospectivos , Inibidores da Transcriptase Reversa/uso terapêutico , Doadores de Tecidos , Transplante HomólogoRESUMO
BACKGROUND: The present study analyzes pretransplantation variables associated with long-term liver allograft survival in 278 children who underwent transplantation under primary tacrolimus (FK506) therapy at a single center between October 1989 and October 1996. METHODS: The influence of 17 pretransplantation variables on long-term liver allograft outcome was analyzed. Donor variables included age, weight, gender, and cold ischemia time. Recipient variables included age, weight, gender, original liver disease, pretransplantation waiting time, previous abdominal surgery, United Network of Organ Sharing (UNOS) status, ABO blood group, bilirubin level, prothrombin time, ammonia level, creatinine level, and reduced-size/split liver grafts. RESULTS: Overall actuarial graft survival was 79.9% at 1 year, 79.1% at 2 years, and 78.3% at 3, 4, and 5 years. Retransplantation rate was 10.8%. Pretransplantation variables with a significant adverse effect on graft survival by univariate analysis were donor age < or = 1 year (P<0.004), donor weight < or = 10 kg (P<0.003), UNOS status I and II (P<0.007), ABO type O, B, and AB (P<0.03), and reduced-size/split liver grafts (P<0.02). Pretransplantation variables significant by multivariate analysis and therefore independent predictors of inferior graft outcome were donor weight '10 kg (relative risk [RR] 2.91, confidence interval [CI] 1.53-5.51); reduced-size/split liver grafts (RR 2.53, CI 1.30-5.64); and UNOS status I (RR 2.22, CI 1.11-4.43). CONCLUSIONS: Pediatric liver transplant recipients receiving primary tacrolimus therapy have long-term graft survival rates approaching 80%. UNOS status, donor weight, and the use of reduced-size/split liver grafts are the most important factors affecting survival.
Assuntos
Imunossupressores/uso terapêutico , Transplante de Fígado , Tacrolimo/uso terapêutico , Adolescente , Peso Corporal , Criança , Pré-Escolar , Feminino , Rejeição de Enxerto/etiologia , Humanos , Lactente , Transplante de Fígado/métodos , Estudos Longitudinais , Masculino , Análise Multivariada , Prognóstico , Fatores de Risco , Análise de Sobrevida , Doadores de Tecidos , Transplante Homólogo , Resultado do TratamentoRESUMO
BACKGROUND: Few data are available describing the natural history of the Epstein-Barr virus (EBV) viral load after the diagnosis of EBV-associated posttransplant lymphoproliferative disease (PTLD). Accordingly, we prospectively followed the EBV viral load after the diagnosis of EBV/PTLD in seven pediatric orthotopic liver transplant recipients. METHODS: EBV viral loads were serially measured by quantitative competitive polymerase chain reaction of the peripheral blood from pediatric patients with PTLD and correlated with the clinical course of these children. Viral loads >200 genome copies/10(5) peripheral blood lymphocytes were considered consistent with an increased risk of PTLD. Viral loads <200 obtained during treatment for PTLD were considered evidence of "clearance" of EBV; subsequent loads >200 were considered evidence of virologic "rebound." RESULTS: The mean EBV viral load at the time of diagnosis of PTLD was 1029. All patients "cleared" their EBV viral load during the treatment of PTLD; patient and graft survival in this series was 100%. The mean time to clearance of EBV from the peripheral blood (18.8 days) was similar to the mean time to onset of first rejection (13.8 days). EBV viral load at the time of diagnosis of rejection after PTLD was always <100. A rebound in the EBV viral load to >200 was noted in five of seven patients a median of 3.5 months (range 2.3-13 months) after the diagnosis of EBV/PTLD. However, none of these children has had any evidence of PTLD recurrence. CONCLUSIONS: Clearance of the EBV viral load from the peripheral blood seems to correlate with restoration of the host's immune response as noted both by the regression of the PTLD and the onset of rejection. Late rebound of the EBV viral load is common and does not seem to predict disease recurrence.
Assuntos
Herpesvirus Humano 4/isolamento & purificação , Transplante de Fígado/efeitos adversos , Transtornos Linfoproliferativos/virologia , Viremia/virologia , Criança , Pré-Escolar , Humanos , Lactente , Transtornos Linfoproliferativos/terapiaRESUMO
BACKGROUND: The Banff schema is the internationally accepted standard for grading acute liver-allograft rejection, but it has not been prospectively tested. METHODS: Complete Banff grading was prospectively applied to 2,038 liver-allograft biopsies from 901 adult tacrolimus-treated primary hepatic allograft recipients between August 1995 and September 2001. Histopathologic data was melded with demographic, clinical, and laboratory data into a database on an ongoing basis using locally developed software. RESULTS: Acute rejection developed in 575 of 901 (64%) patients and the worst grade was mild in 422 of 575 (73%). At least one episode of moderate or severe acute rejection developed in 153 of 901 (17%) patients and most episodes, irrespective of severity, occurred within the first year after transplantation. Patients with moderate or severe acute rejection showed higher alanine aminotransferase (P =0.007) and aspartate aminotransferase ( P=0.07) levels and were more likely to develop perivenular fibrosis on follow-up biopsies (P =0.001) and graft failure from acute or chronic rejection ( P=0.004) than those with mild rejection. Regardless of severity, 80% of patients with acute rejection did not develop significant fibrosis in follow-up biopsies, and graft failure from acute or chronic rejection occurred in only 11 of 901 (1%) allografts. CONCLUSIONS: Most acute-rejection episodes are mild and do not lead to clinically significant architectural sequelae. When tested prospectively under real-life and -time conditions, the Banff schema can be used to identify those few patients who are potentially at risk for more significant problems. Creation, capture, and integration of non-free text, or "digital," pathology data can be used to prospectively conduct outcomes-based research in transplantation.
Assuntos
Sistemas Computacionais , Rejeição de Enxerto/patologia , Transplante de Fígado/efeitos adversos , Patologia/métodos , Doença Aguda , Adulto , Biópsia , Doença Crônica , Rejeição de Enxerto/complicações , Rejeição de Enxerto/epidemiologia , Rejeição de Enxerto/fisiopatologia , Humanos , Fígado/patologia , Falência Hepática/etiologia , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Transplante HomólogoRESUMO
BACKGROUND: This study examines factors associated with the performance of orthotopic liver transplantation (OLT) without red blood cell (RBC) transfusion. METHODS: Between January 1992 and December 1994, 306 primary OLTs were performed with recipients divided into two groups: group 1 patients (61 recipients, 20% of total) underwent transplantation without packed RBCs, and group 2 patients (245 recipients, 80% of cases) received a transfusion of at least 1 unit of RBCs during operation. RESULTS: Recipients in group 1 compared with group 2 had less advanced liver disease (20% hospitalized and 48% Child's class C versus 58% hospitalized and 73% Child's class C, p < 0.01) and lower frequency of right upper quadrant surgery (13% versus 25%, p < 0.05). Group 1 recipients also had significantly higher preoperative hematocrits (38% versus 33%, p < 0.01), lower prothrombin times (15.4 versus 16.7 seconds, p < 0.001) and partial thromboplastin times (36.9 versus 42.2 seconds, p < 0.01), a greater proportion of patients transplanted by piggyback technique (87% versus 59%, p < 0.001), and shorter operative times (7.9 hours versus 9.2 hours, p < 0.001). Moreover, a greater percentage of patients underwent OLT without RBC transfusion in each successive year: 9% in 1992, 21% in 1993, and 31% in 1994 (p < 0.001). Logistic regression analysis showed the following factors to be independent predictors of OLT without RBC transfusion. Preoperative Hct, United Network of Organ Sharing status, piggyback technique, operative time, and year of transplantation. CONCLUSIONS: OLT can be performed without transfusion of RBCs in recipients with less advanced liver disease, and surgical technique, along with increased experience by the transplant team, are important factors.
Assuntos
Transfusão de Eritrócitos , Transplante de Fígado , Adolescente , Adulto , Fatores Etários , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Transfusão de Plaquetas , Análise de Regressão , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: To evaluate the effect of intraoperative transfusion of red blood cells (RBCs) on patient and graft survival. DESIGN: A retrospective study. SETTING: A tertiary care referral center. PATIENTS: Between January 1, 1992, and December 31, 1994, medical records from 225 adult patients who underwent primary liver transplantations were analyzed. RESULTS: Overall patient survival was 90% at 1 year and 86% at 3 years, while graft survival was 89% at 1 year and 85% at 3 years. The following factors were associated with patient and graft survival: age, sex, medical condition at the time of transplantation, and intraoperative transfusion of RBCs. When these factors were subjected to a multivariate analysis, all were independently associated with survival. Fifty-four recipients (24%) underwent transplantation without intraoperative transfusion of RBCs, while 171 recipients (76%) received at least 1 U of RBCs intraoperatively. Recipients who did not receive transfusion of RBCs had higher patient and graft survival rates than patients who did receive RBCs. By multivariate analysis, transplantation without intraoperative transfusion of RBCs no longer remained statistically significant, and only sex and the patient's medical condition were independently associated with patient and graft survival. Patient and graft survival decreased if 5 or more U were transfused, but transfusion of 5 or more U was not independently associated with survival by multivariate analysis. CONCLUSIONS: Increased transfusion requirement for RBCs was independently associated with patient and graft survival. While transplantation without transfusion of intraoperative RBCs was associated with superior patient and graft survival, these effects were overridden by patient sex and medical condition at the time of transplantation.
Assuntos
Transfusão de Eritrócitos , Cuidados Intraoperatórios , Transplante de Fígado , Feminino , Sobrevivência de Enxerto , Humanos , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do TratamentoRESUMO
We present an unusual case of a young woman with a several-month history of bronchopulmonary infection, symptomatic on the left side, who underwent complete studies showing bilateral pulmonary sequestration with suspected bridging tunnel. A bilateral resection was performed as a single procedure through a left thoracotomy.
Assuntos
Sequestro Broncopulmonar/complicações , Pulmão/anormalidades , Adulto , Sequestro Broncopulmonar/diagnóstico por imagem , Sequestro Broncopulmonar/cirurgia , Feminino , Humanos , Radiografia , Recidiva , Infecções Respiratórias/etiologiaRESUMO
The influence of delayed renal graft function on long-term allograft outcome remains uncertain. All 495 cyclosporine treated cadaver donor renal transplants within a single center were analyzed with respect to dialysis dependence in the early posttransplant period. When compared with immediate allograft function, dialysis dependence for more than one week posttransplant was associated with prolonged cold ischemia time (27 +/- 11 vs 32 +/- 12 hours), cytotoxic antibodies > 30% (14% vs 25%), black race (29% vs 41%), increased incidence of acute rejection in the first year posttransplant (31% vs 67%) and inferior 1-year (85% vs 52%) and 5-year (68% vs 33%) graft survival among primary transplants. No adverse effect however was noted on renal function in long-term survivors.
Assuntos
Ciclosporina/uso terapêutico , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto/fisiologia , Transplante de Rim/fisiologia , Adulto , Negro ou Afro-Americano , Cadáver , Feminino , Humanos , Terapia de Imunossupressão , Incidência , Transplante de Rim/estatística & dados numéricos , Masculino , Prednisona/uso terapêutico , Diálise Renal , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
The influence of timing of FK 506 (Tacrolimus) administration on renal function and recovery from renal warm ischemia was studied in Sprague-Dawley rats. Animals were administered FK 506 and subjected to 60 min of renal warm ischemia by temporary occlusion of the renal artery and vein. No significant differences in serum creatinine levels among rats subjected to renal ischemia, FK 506, or FK 506 vehicle (methanol and 5% dextrose in water) were demonstrated. In contrast, FK 506 administration (4 mg/kg intraperitoneally) in combination with renal warm ischemia resulted in significant deterioration of renal function with peaking of serum creatinine on day 2. The timing of FK 506 administration relative to renal ischemia did not significantly affect serum creatinine levels. Rats that received FK 506 either 24 hr pre-ischemia, 4 hr pre-ischemia, 4 hr post-ischemia, or 24 hr post-ischemia all showed similar serum creatinine levels on day 2 (3.85 +/- 0.9, 4.7 +/- 0.5, 3.8 +/- 0.9, and 5.1 +/- 0.6 mg/dl, respectively, p = NS). In all animals, serum creatinine returned to baseline values by day 10. Histopathologic examination of kidneys revealed tubular atrophy and dilatation with tubular calcifications at the corticomedullary junction in FK 506 treated animals with or without ischemia. Our data suggest the timing of FK 506 administration in rats subjected to renal warm ischemia does not influence the extent of renal injury with an equally deleterious effect seen when administered within a 24 hr period of an ischemic event. Changes in kidney morphology, however, were seen in all FK 506 treated rats, with or without a period of warm ischemia.