Biomedical subjects

J D Pirsch

Publications and source records attributed to J D Pirsch.

At least 91 records · Page 5Linked to original sources

PubMed1993

Risk factors for primary dysfunction after liver transplantation--a multivariate analysis.

In a retrospective analysis on 323 orthotopic liver transplant procedures performed between July 1984 and October 1991 the incidence of two forms of primary dysfunction (PDF) of the liver: primary nonfunction (PNF), and initial poor function (IPF) were studied. The incidence of PDF was 22% (73/323) with 6% PNF (20/323) and 16% IPF (53/323), while 78% (250/323) had immediate function (IF). Occurrence of both IPF and PNF resulted in a higher graft failure rate (P < 0.001), retransplantation rate (P < 0.001), and patient mortality (P < 0.003) within the first three months after OLTx. Univariate analyses of donor and recipient factors and their influence on PDF demonstrated that longer donor hospitalization (> 3 days), older donor age (> 49 years), extended preservation times (> 18 hr), and fatty changes in the donor liver biopsy, as well as reduced-size livers, younger recipient age, and renal insufficiency prior to OLTx, significantly affected the incidence of IPF and PNF. Multivariate analysis of potential risk factors showed that reduced-size liver (P = 0.0001), fatty changes on donor liver biopsy (P = 0.001), older donor age (P = 0.009), retransplantation (P = 0.01), renal insufficiency (P = 0.02), and prolonged cold ischemia times (P = 0.02) were independently associated with a higher incidence of IPF and PNF. No statistical correlation was found between PDF and etiology of ESLD, nutritional status of the recipient, UNOS status, and Child-Pugh classification in this study. We conclude that PNF and IPF are both separate clinical entities that have a significant effect on outcome after OLTx. Routine donor liver biopsies are recommended to decrease the rate of IPF and PNF. The combination of risk factors shown to be significant for PDF should be avoided--and, if that is not possible, the only variable that can be controlled, the preservation time, should be kept as short as possible.

Adolescent↗

PubMed1993

Retransplantation of the liver--a seven-year experience.

Three hundred and four patients underwent 362 liver transplants between July 1984 and April 1992. Fifty-eight retransplants were performed in 44 patients (14.5%). Thirty-four patients underwent two (77.3%), seven patients three (15.9%), two patients four (4.5%), and one patient five (2.3%) transplants. Poor function accounted for 23 retransplants (6.4%), technical problems for 19 retransplants (5.2%), and rejection for 15 retransplants (4.1%). One-month patient survivals after retransplantation for poor function, technical problems, or rejection were similar (79.0%, 73.4%, and 80.0%, respectively). No difference in retransplantation rates were seen between adults and children receiving whole liver transplants (WLT) (11.6% versus 19.1%). However, retransplantation for poor function was more common in pediatric recipients receiving reduced-size liver transplants (RLT) (20.0% versus 0.0%, P < 0.01), while retransplantation for hepatic artery thrombosis (HAT) was more common in pediatric recipients receiving WLT (16.7% versus 2.8%, P < 0.05). The presence of multiorgan system failure of greater than four was associated with a high mortality (90%), whereas patients undergoing emergent retransplantation who had less than four systems fail had a survival of 73.9% and patients who underwent elective retransplantation had a survival rate of 81.8%. Length of stay and cost of liver transplantation was higher in patients undergoing retransplantation when compared with primary transplants (29.7 +/- 14.9 days versus 58.4 +/- 38.9 days and $122,358 +/- 59,782 versus $289,302 +/- 126,907, P < 0.01). The overall actuarial one-year patient survival in primary transplants was 86.6% and in retransplants 74.8%, and at five years these were 71.4% versus 62.5%, respectively (P < 0.05). Our results support continued retransplantation of the liver unless the patient's medical condition dictates otherwise.

Adolescent↗

PubMed1993

Immunosuppressive therapy as a determinant of transplantation outcomes.

Although surgical proficiency is essential to the immediate outcome of transplantation, long-term success depends upon how adequately the transplantation recipient is managed. Immunosuppression, the most critical aspect of after care, is subject to wide variation. In January 1990, a survey was sent to the directors of all transplant programs in the United States performing one or more kidney, heart, liver, heart-lung, or pancreas transplant in 1988. Detailed data were obtained on both the drugs and methods used for induction and maintenance immunosuppression, as well as the treatment of rejection. Each program director was asked to rank each immunosuppressive approach according to its perceived impact on patient outcomes. Over 85% of all eligible program directors completed the survey. There is no evidence of survey respondent bias. The use of polyclonal and monoclonal agents for induction immunosuppression was favored most by pancreas program directors (72-76%). These agents were least preferred by liver transplant programs (35-37%). About half of kidney, heart, and heart-lung program directors preferred these agents. Triple-drug therapy consisting of CsA, PRED, and AZA was considered the most preferable maintenance protocol for all transplants (i.e., kidney, 89%; heart, 94%; liver, 88%; heart-lung, 86%; pancreas, 96%). Either i.v. steroids or OKT3 were regarded as the preferred approaches for the treatment of acute or resistant rejection. Finally, the acceptability of outpatient treatment of rejection varied by transplant type (i.e., kidney, 9%; heart, 58%; liver, 5%; heart-lung, 29%; pancreas, 8%). Although there are similarities in the ratings of various aspects of immunosuppressive therapy, there are important differences. This information is critical to anticipate the implications of new immunosuppressive agents and to evaluate changes in the use of existing drugs and therapeutic approaches.

Data Collection↗

PubMed1993

Renal transplantation at the University of Wisconsin in the cyclosporine era.

1. Immunological graft loss in the cyclosporine (CsA) era has been decreasing over the past decade with current 94% immunological graft survival at one year. 2. The rates of both immunological graft loss and graft loss from all causes gradually decrease after the first year for primary transplants. This implies that rejection gradually becomes less likely between one and 10 years follow-up. 3. On CsA immunosuppression, better DR matching results in significantly less immunological graft loss and a slower rate of late graft loss. 4. Roughly equal proportions of cadaveric renal transplants are lost due to acute rejection, chronic rejection, and death with a functioning graft (25-30% each). 5. Improving immunological graft outcome correlates with a lower incidence of a first rejection episode. Although OKT3 increases the success of rejection treatment, having a rejection episode nevertheless increases one's risk of immunological graft loss. 6. Cardiovascular deaths are by far the leading cause of mortality (42%) in this series. Improved strategies of prevention and treatment of cardiovascular disease are needed in this patient group. 7. Long-term CsA immunosuppression usually is not associated with graft loss due to CsA toxicity. Late graft loss from acute and chronic rejection is far more common, implying the need for continued immunosuppression even in patients with long-surviving grafts. 8. There is no measurable benefit of 3 or more random blood transfusions prior to cadaveric renal transplantation in the CsA era.

Academic Medical Centers↗

PubMed1993

Histocompatibility and liver transplantation.

BACKGROUND: The role of histocompatibility between donor and recipient in liver transplant rejection is unclear because of a paucity of data. The influence of human leukocyte antigen (HLA) type on immunologic graft loss was examined for primary liver transplantations performed at this center. METHODS: Immunologic graft loss included patient death or retransplantation as a result of rejection or impending graft loss caused by either late hepatic artery thrombosis or severe, unremitting rejection requiring FK 506 rescue therapy. HLA A, B, and DR matching was available on 205 donor-recipient combinations, and an additional 31 patients had A and B matching only. RESULTS: A mismatch of class I antigens (HLA A and B) was predictive of immunologic graft loss (p = 0.018). DR mismatch did not correlate with graft loss. When the A and B loci were analyzed separately, an A mismatch correlated significantly with immunologic graft loss (p = 0.02), in contrast to a B mismatch (p = 0.17). Better matching significantly improved patient survival (p = 0.02) and overall graft survival (p = 0.009). CONCLUSIONS: The beneficial effect of HLA class I antigen compatibility on liver transplantation outcome is in contrast to pancreatic and kidney transplantation in which class II antigen matching but not class I matching is beneficial. Immunologic mechanisms of hepatic allograft rejection may differ from those involved in kidney transplant rejection.

Forecasting↗

PubMed1993

Long-term results of liver transplantation for biliary atresia.

BACKGROUND: Biliary atresia can be treated by portoenterostomy, which is primarily palliative, or by liver transplantation, which is primarily curative. The purpose of this study was to determine the long-term outcome of liver transplantation for the treatment of biliary atresia. METHODS: During an 8-year period, 45 patients who underwent liver transplantation for biliary atresia and 10 patients who were referred to our center for portoenterostomy were retrospectively analyzed. RESULTS: No patient with biliary atresia died awaiting liver transplantation. The waiting time for all patients was 36.7 +/- 42.8 days. Thirty-four patients (75.6%) required one transplant, whereas 11 patients (24.4%) required 17 retransplants. Twenty-two patients (48.9%) required 39 reoperations (1.8 per patient). There were 4.9 infectious episodes, 2.2 rejection episodes, and 4.4 readmissions per patient. However, 91% of reoperations, 80% of infections, and 78% of rejections occurred within 6 months of transplantation. The overall 7-year actuarial patient and graft survival for patients with biliary atresia was 86.2% and 62.7%, respectively. CONCLUSIONS: Our results indicate that long-term patient survival after liver transplantation for biliary atresia is excellent. However, portoenterostomy continues to have an initial complementary but limited long-term role in the treatment of infants with biliary atresia.

Biliary Atresia↗

PubMed1993

Two hundred consecutive simultaneous pancreas-kidney transplants with bladder drainage.

BACKGROUND: Since 1982, 288 pancreas transplantations have been performed at the University of Wisconsin. This report reviews our experience with 200 consecutive simultaneous pancreas-kidney (SPK) transplantations during a 7-year period. METHODS: Two hundred consecutive SPK transplantations were performed between December 1985 to October 1992. Immediate posttransplant function and surgical and infectious complications were evaluated. Frequency of rejection episodes were analyzed, as was 5-year patient and graft survival. RESULTS: All but four pancreas transplants functioned immediately after transplantation. Three pancreas transplants failed because of thrombosis and one from primary nonfunction. Five-year patient survival was 90.2%, kidney survival 80.3%, and pancreas survival 78.6%. There were 54 surgical complications. Fifteen patients have died since 1985. The most frequent cause of death was infection (three patients). A total of 678 infectious episodes were recorded. Urinary tract infection (n = 344) was the most frequent type of infection. Enteric conversion was necessary in 35 patients, with the most frequent indication being a leak of the duodenal segment. CONCLUSIONS: We concluded from this series that SPK transplantation is associated with higher cost and morbidity as compared with kidney transplantation alone. However, excellent long-term survival in combination with the clearly demonstrated benefits for secondary diabetic complications indicate that SPK transplantation is the procedure of choice for carefully selected patients with diabetes.

Adolescent↗

PubMed1993