Biomedical subjects
B W Shaw
Publications and source records attributed to B W Shaw.
Long-term follow-up of auxiliary orthotopic liver transplantation for the treatment of fulminant hepatic failure.
BACKGROUND: Auxiliary orthotopic liver transplantation (AOLT) was investigated as a bridge to native liver recovery in patients with fulminant hepatic failure (FHF). METHODS: In the last 5 years seven patients with FHF were treated with AOLT at our institution. Five patients underwent resection of the native left lobe and orthotopic replacement with a donor left lobe (n = 3) or left lateral segment (n = 2). Two patients underwent left trisegmentectomy and whole liver auxiliary grafting. Conventional immunosuppression was used in all patients. RESULTS: One patient had poor initial graft function and required retransplantation. Native liver function returned to normal in the six other patients. Immunosuppression was gradually tapered and completely discontinued in three patients, allowing for atrophy of the allograft. The allograft was removed in the other four patients. Despite evidence of native liver regeneration, two patients with aplastic anemia died after allograft removal. Four patients are alive at a mean follow-up of 3.5 years. CONCLUSIONS: AOLT is technically feasible, rapidly restores liver function, and should be considered an important alternative to standard orthotopic liver transplantation (OLT) in the treatment of FHF. AOLT has the advantage that patients transplanted for FHF are not committed to lifelong immunosuppression with its attendant risks.
Impact of liver transplantation on quality of life: a longitudinal perspective.
The impact of transplantation on quality of life in liver transplant recipients was studied in a longitudinal sample of 41 subjects. Quality of life was measured during the pretransplantation and posttransplantation phases of the transplant process. Quality of life improved significantly over time, except in the family domain. This study suggests that quality of life improves after a liver transplant despite the number and length of rehospitalizations. Satisfaction and importance of family remained high throughout the transplant phases. Of the demographic variables, only age and income correlated significantly with quality of life.
The role of liver transplantation in the management of portal hypertension.
Liver transplantation is the treatment of choice for end stage liver disease and not a treatment specifically for portal hypertension. A patient with complications of portal hypertension must be evaluated for the presence, etiology, and severity of liver disease to determine the most appropriate therapy. In a Child's Class A patient, who would not be a liver transplant candidate for two to three years, surgical shunts may be indicated. Shunt surgery, however, does not address the underlying liver disease. Liver transplantation is reserved for the patient with complications of cirrhosis (such as ascites, encephalopathy, malnutrition, intractable pruritus, and variceal hemorrhage) for whom no other form of therapy exists.
Shunt surgery during the era of liver transplantation.
OBJECTIVE: The indications for and the results of portosystemic shunts done in the authors' institution since initiation of a liver transplant program 10 years ago were reviewed. SUMMARY BACKGROUND DATA: With the widespread availability of liver transplantation as definitive treatment of chronic liver disease, the role of shunts in the overall management of variceal bleeding needs to be redefined. METHODS: Seventy-one variceal bleeders with cirrhosis who received a shunt (82% distal splenorenal shunts) because of sclerotherapy failure or because endoscopic treatment was not indicated were reviewed retrospectively. In 44 patients with well-preserved hepatic reserve, the shunt was used as a long-term bridge to transplantation (shunt group 1). The remaining 27 patients with shunts were not transplant candidates mainly because of uncontrolled alcoholism or advanced age (shunt group 2). Survival of both shunt groups was compared to that of 180 adult patients with a history of variceal bleeding who underwent transplantation soon after referral. RESULTS: Because of their more advanced liver disease, the liver transplant group had a higher operative mortality rate (19%) than did either of the shunt groups (5% and 7%, respectively) (p < 0.02). Kaplan-Meier survival analysis showed better survival in shunt group 1 (seven patients thus far transplanted) than in either the liver transplant group or shunt group 2 during the early years and superior survival of shunt group 1 and the liver transplant group as compared to shunt group 2 during the later years of the analysis. Only two patients from shunt group 1 have died of late postoperative hepatic failure without benefit of liver transplantation. CONCLUSIONS: A shunt may serve as an excellent long-term bridge to liver transplantation in patients with well-preserved hepatic reserve. Shunt surgery still plays an important role in treatment of selected patients with variceal bleeding who are not present or future transplant candidates.
Combined liver/small bowel transplantation using a blood group compatible but nonidentical donor.
A successful liver/small intestinal transplantation with a blood group O donor to a blood type A recipient is described. Mild graft versus host disease developed, manifested by hemolysis, but did not result in graft loss or patient mortality. This suggests that minor ABO incompatibility may be tolerated with intestinal transplantation, despite the transplantation of large amounts of lymphoid tissue.
Morbidity in patients with posttransplant diabetes mellitus following orthotopic liver transplantation.
It is not well understood whether posttransplant diabetes mellitus (PTDM) following orthotopic liver transplantation (OLTx) alters postoperative morbidity. This study was designed to evaluate this question. All adult patients who received an OLTx between July 1985 and March 1993 (n = 497) were evaluated by retrospective chart review for evidence of PTDM after OLTx. The patients identified with PTDM (n = 26) were case matched with nondiabetic OLTx recipients based on primary liver disease diagnosis, age, gender, date of first OLTx, and survival. Liver synthetic function, number and severity of rejection episodes, graft survival, total number of hospital days within the first year post-OLTx, renal function, and number and type of infection episodes were analyzed to assess differences in morbidity between the PTDM and control patients after OLTx. Of the 497 adult patients who underwent OLTx, 26 (5.2%) were identified as having PTDM within 1 month of discharge. Factors which identified individuals at higher risk for DM after OLTx included higher pre-OLTx fasting blood glucose (P = .04); lower body mass index after OLTx (P = .02); and cyclosporine rather than OKT3 induction (P = .009). Graft survival, synthetic function, and the total number of rejection episodes during the first year were not different between the two groups. The morbidity variables of total number of days in the hospital during the first 12 months, renal function, and type and number of infections were also similar between the two groups. In summary, 5.2% of adult patients developed DM within 1 month of OLTx. Pre-existing insulin resistance, postoperative stress, and immunosuppression medications all likely contribute to the development of overt hyperglycemia after OLTx. Although PTDM can be a consequence of OLTx, it does not have a significant impact on patient outcome in the first year after OLTx.
Influenza vaccination following liver transplantation in children.
Our objective was to determine the immunologic response to two influenza vaccine doses in 39 children who had undergone liver transplantation. Patients received two doses of trivalent inactivated influenza vaccine 4 weeks apart. Sera were collected 4 weeks after each dose and analyzed by a hemagglutination inhibition assay (HAI) for evidence of antibody response to the antigens A/Taiwan/1/86 (H1N1), A/Beijing/32/92 (H3N2), and B/Panama/45/95. Patients with HAI titers of 1:40 or greater were considered to have protective titers. Twenty-six (67%) patients showed a 1:40 or greater titer response to A/Beijing/32/92 1 month after the first vaccination. Only two additional patients were found to have similar titers after the second dose. A higher proportion of patients with protective titers were on smaller amounts of prednisone for body weight or alternate day low dose (< 10 mg/day) prednisone compared to patients on daily low dose or daily high dose prednisone. Patients with protective titers were significantly older (9.0 +/- 2.8 years) than those without protective titers (4.2 +/- 3.4 years, p = .002) following the first inoculation of the A/Beijing/32/92 vaccine component. Similar results were found for the second vaccination and with the H1N1 antigen. Cyclosporine level, gender, and body mass index were not associated with any outcome measures. We conclude that most liver transplant recipients had a protective antibody titer after a single influenza inoculation, but little further advantage was gained after an additional dose. Vaccination of household contacts of younger patients and those patients on daily prednisone or patient chemoprophylaxis may offer greater benefit in prevention of influenza in liver transplant recipients than multiple vaccine doses with current vaccine preparations.
The American experience with transplantation for acute liver failure.
Liver transplantation has become the major therapy for acute liver failure (ALF) in the United States. Survival rates range from 46% to 89%. Appropriate patient selection, timely referral, and management of common complications have improved survival. Donor organ shortage may prompt further use of extracorporeal support systems and auxillary transplantation in the future. This article reviews the American experience of liver transplantation in patients with ALF.
Preliminary experience with intestinal transplantation in infants and children.
OBJECTIVE: This report discusses the preliminary experience with intestinal transplantation in children at the University of Nebraska Medical Center. PATIENTS: During the past 4 years, 16 intestinal transplants have been performed in infants and children. Thirteen have been combined liver and bowel transplants, and the reminder were isolated intestinal transplants. Nearly half of the patients were younger than 1 year of age at the time of surgery, and the vast majority were younger than 5 years of age. All but one had short bowel syndrome. RESULTS: The 1-year actuarial patient and graft survival rates for recipients of liver and small bowel transplants were 76% and 61%, respectively. Eight of 13 patients who received liver and small bowel transplants remain alive at the time of this writing, with a mean length of follow-up of 263 (range, 7 to 1223) days. Six patients are currently free of total parenteral nutrition. All three patients receiving isolated intestinal transplants are alive and free of parenteral nutrition. The mean length of follow-up is 384 (range, 330 to 450) days. Major complications have included severe infections and rejection. Lymphoproliferative disease, graft-versus-host disease, and chylous ascites have not been major problems. CONCLUSIONS: Although intestinal transplantation is in its infancy, these preliminary results suggest combined liver and bowel transplants and isolated intestinal transplantation may be viable options for some patients with intestinal failure caused by short bowel syndrome or other gastrointestinal disease in whom long-term total parenteral nutrition is not an attractive option.
Preoperative estimation in living related donor transplantation: clinical correlation and donor/recipient ratio.
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Intestinal transplantation in children.
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The candidate in the intensive care unit: assessing risk.
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The impact of immunosuppressive regimens on the cost of liver transplantation--results from the U.S. FK506 multicenter trial.
In an effort to determine the total one-year cost of liver transplantation, the underlying drivers of that cost, and any cost differences between alternative immunosuppressive regimens, an analysis was performed comparing the average one-year posttransplant charges of 322 patients participating in the "U.S. Multi-center Prospective Randomized Trial Comparing FK-506 to Cyclosporine in Liver Transplantation." Total one-year inpatient charges including all readmissions were examined. Professional fees and outpatient charges were excluded. Costs for tacrolimus drug and blood assays were assumed to be equal to those in the CsA group. For patients completing the study, the tacrolimus group had an average length of stay and average one-year cost seven days (P = .06) and $19,290 (P = .05) lower than the CsA group. The difference in rejection profiles between the two arms seems to largely account for the lower costs. The tacrolimus arm consistently had fewer patients in the more severe rejection groups. Increased incidence and severity of rejection were directly related to higher average lengths of stay and costs of transplantation (P < .001). Tacrolimus immunosuppression during the first year after liver transplantation is more cost-effective than CsA in achieving similar patient and graft survival rates. Differing incidence and severity of rejection can dramatically affect the first-year cost of liver transplantation.
Procurement and preparation of human isolated small intestinal grafts for transplantation.
We have developed a donor operation that incorporates en bloc removal of the liver and intestine with a limited surgical resection in vivo. Over the past 18 months, we have used the following technique for the retrieval and preparation of seven isolated small intestinal allografts. The donor operation and bench preparation can be divided into three phases. During the first phase, the small intestine is removed with the liver, pancreas, and an aortic segment. In the second phase performed ex vivo, the donor liver can be separated from the specimen. The third phase involves additional bench dissection to yield an isolated intestinal allograft. The principle advantage of this technique is that it reduces potential liver injury by minimizing the surgical dissection required in vivo. Also, dividing the liver from the intestine ex vivo allows the organs to be separated in a bloodless field under controlled conditions that may be especially important when two different surgical teams are involved.
Immunosuppressive drugs and hypertrophic cardiomyopathy.
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Auxiliary liver transplantation for acute liver failure.
In summary, the following principles are worth reiterating: 1. In the treatment of acute liver failure, protection of the native liver in anticipation that it will recover, but positioning of the allograft in a manner that optimizes its function for both the short and long term (in the event that the native liver does not recover) are important goals. Therefore, orthotopic positioning offers advantages over the heterotopic position in most cases. Development of better techniques for predicting native liver recovery might remove any of these advantages of the orthotopic position. 2. Other than the presence of fibrosis, the performance of a native liver biopsy does not appear to predict native liver recovery. The decision of whether to attempt auxiliary grafting must be based on an understanding of the natural history of the disease causing the acute liver failure. 3. The heterotopic position has the advantage of not requiring partial native hepatectomy in order to accommodate the allograft. However, except for the recent experience of Terpstra et al, this technique has carried a higher risk of venous outflow obstruction. It also requires additional space within the abdomen, usually mandating the use of prosthetic abdominal wall closures and the construction of venous conduits for portal venous inflow to the liver. There is the additional theoretical concern about competition for portal venous flow leading to eventual atrophy of the allograft liver. 4. Common events that follow liver transplantation result in changes in portal venous resistance within the liver, events that therefore alter the relative distribution of portal venous inflow between native and auxiliary livers. These events include reperfusion injury, allograft rejection, allograft viral infection (e.g., cytomegalovirus, Epstein-Barr virus, recurrent viral hepatitis), and native liver regeneration. Attempts to control portal venous flow to favor one liver over the other must account for the effect of these factors. 5. In general terms, auxiliary transplantation is not indicated for diseases in which the residual native liver either represents an ongoing threat to the recipient or is incapable of supporting life alone. This may be the case in both metabolic disorders and in cirrhosis. Most of the alleged difficulties of native hepatectomy are no longer relevant. Therefore, auxiliary transplantation is rarely if ever indicated for chronic liver disease and may not be of any additional benefit over total transplantation in the treatment of many metabolic disorders. 6. In the treatment of acute liver failure, the value of an auxiliary transplant over total transplant is obtained when the native liver recovers and the patient is withdrawn from immunosuppression. If further experience shows the effectiveness of this option, total liver transplantation with the requirement for life-long immunosuppression will no longer be appropriate for the treatment of patients with acute liver disease.
Surf's up.
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