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Biomedical subjects

J Rakela

Publications and source records attributed to J Rakela.

At least 163 records · Page 9Linked to original sources
PubMed1989

Failure of interferon to prevent recurrent hepatitis B infection in hepatic allograft.

Chronic liver disease associated with hepatitis B virus infection is both common and serious; no satisfactory treatment currently exists. Orthotopic liver transplantation is an option for patients with end-stage liver disease associated with hepatitis B virus infection despite the risk of allograft reinfection. Passive immunoprophylaxis has been attempted perioperatively to prevent graft infection but has not been beneficial. Some patients with chronic type B hepatitis have benefited clinically from antiviral therapy and, in particular, interferon, but its use has not previously been reported as an approach to prevent allograft infection. We administered recombinant leukocyte A interferon perioperatively to a patient who underwent liver transplantation for type B chronic active hepatitis and cirrhosis. Circulating hepatitis B virus DNA was found postoperatively while the patient was receiving interferon, and stainable viral antigen subsequently reappeared in the transplanted liver. Thus, the drug failed to prevent viral replication and allograft infection. Thus far, no evidence of progression of the chronic hepatitis has been noted.

Female↗
PubMed1989

Delayed hemolysis resulting from anti-A1 after liver transplantation.

The authors report a case of a delayed hemolytic transfusion reaction in a type A2 recipient of a type O liver allograft. An anti-A1 antibody reactive at 37 degrees C in the indirect antiglobulin test was identified both in the patient's serum and in an eluate. Hemolysis secondary to the production of anti-A1 has been reported to be extremely rare. The English-language literature has six cases before 1979. During the 1980s, an additional seven cases were reported; six involved transplantation of a solid organ, and in each such case the donor was type O and the recipient was type A1 or A2. Recommendations regarding transfusion practice in such cases are made. An association among the transplantation of a type O organ to a type A recipient, the use of cyclosporine, and an apparent increase in the occurrence of clinically significant anti-A1 is suggested.

Autoantibodies↗
PubMed1989

Cytomegalovirus hepatitis in liver transplantation: prospective analysis of 93 consecutive orthotopic liver transplantations.

Ninety-three consecutive orthotopic liver transplantations in 78 patients were followed prospectively to study the incidence of cytomegalovirus (CMV) hepatitis. CMV hepatitis occurred in 13 (17%). The diagnosis was established by both histology and culture in 5, only by histology in 6, and only by culture in 2. All 13 patients had CMV viruria and 9 had viremia at diagnosis. CMV hepatitis developed in 64% of CMV-seronegative (pretransplantation) patients who received a liver from a CMV-seropositive donor, compared with 3% or 6% of CMV-seropositive patients who received a liver from a CMV-seronegative or CMV-seropositive donor, respectively (P less than .001). CMV hepatitis was not a cause of fulminant or irreversible liver dysfunction in any of the 13 cases. Ganciclovir was administered to 6 of the 13 patients and was associated with clinical and virologic cure in 5. CMV hepatitis was self-limited in patients not treated with ganciclovir (illness less severe). The presence of inclusions within the liver tissue correlated with active disease.

Age Factors↗
PubMed1989

Soluble interleukin-2 receptor level as an indicator of liver allograft rejection.

We studied the serum levels of soluble interleukin-2 receptors (SIL-2R) in liver allograft recipients: a control group without rejection or CMV disease, a group with only rejection episodes, and a group with only cytomegalovirus disease. Rejection was diagnosed by the presence of compatible laboratory and histologic abnormalities and absence of other causes of graft dysfunction. CMV disease was diagnosed by isolation of CMV in blood or liver specimen cultures or identification of cytomegalic inclusions in the liver biopsy specimen. Of 82 consecutive recipients treated with cyclosporine and prednisone, 12 were in the control group, 20 in the rejection group, and 5 in the CMV disease group. The remaining 45 had other or multiple complications. In the control group the SIL-2R levels (determined by an ELISA) decreased by a mean of 4% per day after transplantation; in the rejection group the levels increased by a mean of 17% per day in the 10 days prior to the diagnosis of rejection; in the CMV disease group the levels tended to increase prior to the diagnosis of CMV disease. The rejection group had significantly higher SIL-2R levels than the control group at comparable times. Thus, SIL-2R levels were significantly increased at the time of allograft rejection compared with levels in a control group, and recipients with CMV disease had increased levels of SIL-2R but they were not as high as in recipients with rejection episodes.

Cytomegalovirus Infections↗
PubMed1988

Features reflective of early prognosis in corticosteroid-treated severe autoimmune chronic active hepatitis.

To identify features reflective of early prognosis in corticosteroid-treated severe autoimmune chronic active hepatitis, we compared the initial findings and immediate biochemical response of 5 patients who died soon after institution of corticosteroid therapy (mean survival, 2.5 +/- 0.7 mo) with those of 108 patients who survived for at least 6 mo after comparable therapy (mean survival, 94 +/- 6 mo). Early mortality could not be predicted before therapy by individual clinical, laboratory, or histologic findings. Patients who resolved at least one pretreatment laboratory abnormality, improved a pretreatment hyperbilirubinemia, or did not experience biochemical deterioration after 2 wk of corticosteroid treatment survived for at least 6 mo in 98% of instances. Patients who died early had multilobular necrosis at presentation and manifested at least one deficiency in their immediate biochemical response. Death invariably occurred in patients with multilobular necrosis and an unimproved hyperbilirubinemia after 2 wk of therapy. Only 3 of the 5 patients who died, however, could be identified in this fashion. We conclude that no individual abnormality at presentation predicts early mortality. Only patients with multilobular necrosis are at risk for an early demise and death can be predicted in those with an unimproving hyperbilirubinemia. Laboratory improvement after 2 wk of corticosteroid therapy virtually assures immediate survival.

Adult↗
PubMed1988

Postdilution hemofiltration in the management of acute hepatic failure: a pilot study.

We conducted a pilot study to assess the feasibility and efficacy of postdilution hemofiltration (PDHF) in the management of acute hepatic failure. From January 1984 through May 1986, we encountered seven patients with acute hepatic failure and entered these consecutive patients in the study; three had non-A, non-B hepatitis and one each had type B hepatitis, fulminant Wilson's disease (hepatolenticular degeneration), acute allograft (liver) failure, and acute fatty liver of pregnancy. Two of these seven patients were unable to undergo PDHF because of a precarious hemodynamic status. Of the five patients treated with PDHF, four had amelioration of hepatic encephalopathy; in two of these patients, a close temporal relationship was noted between the improvement and the procedure. Four patients had appreciable thrombocytopenia related to PDHF and bleeding complications. Our preliminary results support a possible role for PDHF as a temporary artificial liver support system for patients with acute hepatic failure.

Acute Kidney Injury↗
PubMed1988

Selective bowel decontamination to decrease gram-negative aerobic bacterial and Candida colonization and prevent infection after orthotopic liver transplantation.

Gram-negative bacterial and fungal infections are a major cause of morbidity and mortality following liver transplantation. We therefore used selective bowel decontamination (SBD) to eliminate the endogenous source of gram-negative aerobic bacteria and Candida pathogens in an attempt to reduce the high incidence of infection related to these organisms. Thirty consecutive patients undergoing liver transplantation were treated with SBD starting 3 days prior to donor search and continuing for 21 days postliver transplantation. Selective bowel decontamination consisted of administering nonabsorbable antibiotics (Polymixin E, gentamicin, Nystatin) and a low bacterial diet. Surveillance cultures of the throat and rectum were obtained to monitor efficacy of selective bowel decontamination. In addition, in the posttransplant period, tracheal, wound, blood, and bile cultures were obtained to screen for gram-negative bacterial and Candida colonization and infection. Our baseline surveillance culture revealed that 29/30 (97%) of recipients were colonized with gram-negative aerobic bacteria and 16/30 (53%) with Candida. Three days after selective bowel decontamination was started, 26/30 (87%) were free of gram-negative bacteria, and 100% were free of Candida colonization of the gastrointestinal tract. There was a similar reduction in the oropharyngeal gram-negative aerobic bacteria and Candida colonization. In the first 30 days following liver transplantation, gram-negative infections were not diagnosed in any of our patients. Following discontinuation of SBD, recolonization of the gastrointestinal tract with gram-negative aerobic bacteria and Candida occurred within 5 days in 26/28 (90%) and 11/28 (35%), respectively. Our study suggests that prophylactive administration of nonabsorbable antibiotics will markedly reduce gram-negative aerobic bacterial and Candida colonization and appears to reduce the high incidence of infection related to these organisms in the early posttransplant period.

Adolescent↗
PubMed1988

Efficacy of ganciclovir in liver and kidney transplant recipients with severe cytomegalovirus infection.

Twelve liver and 5 kidney transplant recipients with severe cytomegalovirus infection were treated with Ganciclovir (7.5 mg/kg/day, intravenously). Ten were evaluable (compatible clinical picture, organ involvement shown histopathologically or by culture, viremia, and absence of concomitant infection). All 17 patients were studied for adverse drug side effects. A total of 9 evaluable patients survived the infection; 1 died during treatment due to infection or drug toxicity. A death 19 days after completion of treatment was due to unrelated causes. Patients became afebrile after 2-9 days (mean, 5.3 days) of treatment. Liver function improved, pulmonary infiltrates cleared, and hypoxemia reversed during therapy. Viremia ceased during therapy in 9 patients; asymptomatic viruria persisted or recurred in 6 of 7 patients studied. No relapses occurred during follow-up (7-17 months; mean, 13 months). Transient neutropenia and thrombocytopenia occurred in 3 and 1 patients, respectively. Ganciclovir appears promising for treatment of severe CMV infection in patients with kidney or liver transplants.

Acyclovir↗
PubMed1987

Central nervous system toxicity after liver transplantation. The role of cyclosporine and cholesterol.

We describe severe central nervous system (CNS) toxicity, manifested by confusion, cortical blindness, quadriplegia, seizures, and coma, associated with cyclosporine treatment in three patients undergoing liver transplantation. CT and magnetic resonance studies disclosed a severe, diffuse disorder of the white matter. All side effects and radiographic findings were reversed with discontinuation or a reduction in the dose of cyclosporine. We also observed an inverse association between CNS side effects and total serum cholesterol levels after transplantation. A retrospective analysis of 54 liver transplantations performed in 48 patients revealed that 13 patients had symptoms of CNS toxicity associated with the use of cyclosporine. These patients' total serum cholesterol levels in the first week after transplantation were reduced as compared with those in patients without symptoms (mean +/- SE, 94 +/- 4 mg per deciliter vs. 132 +/- 6, or 2.44 +/- 0.10 mmol per liter vs. 3.43 +/- 0.16). We conclude that cyclosporine therapy for immunosuppression in liver transplantation may cause a syndrome of encephalopathy, seizures, and white-matter changes and that this is most likely to occur in patients with low total serum cholesterol levels after transplantation.

Blindness↗
PubMed1987

Diagnostic laparoscopy in gastroenterology. A 14-year experience.

Between 1970 and 1983, we performed 1121 diagnostic laparoscopies in 1119 patients. More than 50% of the examinations were performed for malignant disease. An adequate examination was accomplished in 917 (82%) procedures. The most frequent reason for inadequate evaluation was the presence of dense intraabdominal adhesions from previous surgery. We observed 105 (9.4%) minor complications and 20 (1.8%) major complications including one death following hemorrhage from liver biopsy. Major complications included abdominal wall hematoma, perforated abdominal viscus, hemoperitoneum, bleeding from liver biopsy, and respiratory depression. We observed a trend to decreased use of laparoscopy. Ascites of unknown origin and certain specific situations in patients with chronic liver disease remain as major indications for this diagnostic technique.

Biopsy↗
PubMed1987

Late manifestation of chronic liver disease in adults with alpha-1-antitrypsin deficiency.

A review of 19 adult patients with alpha-1-antitrypsin deficiency (A1AT deficiency) and chronic liver disease revealed a late onset of symptomatic hepatic abnormalities in this condition. Thirteen patients (68%) were 60 years or older when the liver disease was discovered. The mean age of the patients with the ZZ, SZ, and MZ phenotypes was 58, 66, and 72.5 years, respectively; this suggested a later onset of the liver disease in the heterozygotes. At the time of diagnosis, the hepatic condition usually was advanced; in eight patients (42%) the survival was less than two years. The most important associated condition was chronic obstructive lung disease which was found in 10 patients (53%). We conclude that advanced age and the high incidence of obstructive lung disease make it unlikely that liver transplantation will become a common therapeutic option for adult patients with A1AT deficiency and associated liver disease. Periodic screening of liver function may be indicated in patients with A1AT deficiency so that chronic liver disease can be diagnosed early, particularly if current attempts to develop effective medical therapy for this condition are successful.

Adult↗
PubMed1987

Noncirrhotic portal hypertension due to lymphoma. Reversal following splenectomy.

We report a case of bleeding esophageal varices associated with lymphoma. Splenectomy alone reversed the patient's portal hypertension as assessed hemodynamically and clinically. Mechanisms leading to portal hypertension in the setting of splenomegaly from hematologic disorders are discussed. An approach to operative management of these patients, based on preoperative hemodynamic measurements, is suggested for future consideration.

Aged↗
PubMed1987

Hepatitis B virus deoxyribonucleic acid in serum during hepatitis B e antigen clearance in corticosteroid-treated severe chronic active hepatitis B.

The relationship between hepatitis B virus deoxyribonucleic acid in serum and histologic activity was determined in 11 patients with corticosteroid-treated severe chronic active hepatitis B who underwent clearance of hepatitis B e antigen. All patients cleared hepatitis B virus deoxyribonucleic acid from the serum, and clearance preceded the loss of hepatitis B e antigen by 9-49 mo (mean 24 +/- 4 mo). Seropositivity for hepatitis B virus deoxyribonucleic acid was always associated with histologic features of chronic active hepatitis. Resolution of histologic activity followed the loss of hepatitis B virus deoxyribonucleic acid from the serum and it preceded clearance of hepatitis B e antigen in all patients. A transient elevation of serum aspartate aminotransferase activity occurred in 5 patients at the time that absence of hepatitis B virus deoxyribonucleic acid in serum was first demonstrated, and it was followed by resolution of histologic activity. The serum level of hepatitis B virus deoxyribonucleic acid slowly decreased or remained unchanged in all but 1 patient during long-term corticosteroid therapy. We conclude that hepatitis B virus deoxyribonucleic acid in serum is associated with histologic activity in corticosteroid-treated patients with severe chronic active hepatitis B. Disappearance of hepatitis B virus deoxyribonucleic acid from the serum precedes the loss of histologic activity and clearance of hepatitis B e antigen. Serum hepatitis B virus deoxyribonucleic acid levels usually do not increase during long-term corticosteroid therapy.

Adrenal Cortex Hormones↗
PubMed1987

Auranofin-associated colitis and eosinophilia.

Gold compounds, often used in the treatment of rheumatoid arthritis, have been associated with gastrointestinal disturbances in some patients. Use of auranofin, an oral gold preparation, in a 50-year-old woman with rheumatoid arthritis resulted in diarrhea, abdominal tenderness, nausea, and vomiting, which persisted despite discontinuation of auranofin therapy. The presumptive diagnosis was gold-induced colitis and eosinophilia. Administration of cromolyn sodium provided relief. Although this complication may be rare, evolving bowel symptoms in patients receiving auranofin demand prompt attention.

Arthritis, Rheumatoid↗