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Biomedical subjects

J T Mayes

Publications and source records attributed to J T Mayes.

At least 37 records · Page 2Linked to original sources
PubMed1991

Salvage of thrombosed forearm polytetrafluoroethylene vascular access grafts by reversal of flow direction and venous bypass grafting.

A technique is described for salvage of looped forearm polytetrafluoroethylene (PTFE) vascular access grafts that fail because of thrombosis due to cephalic vein outflow obstruction. It entails reversal of blood flow direction through the graft and construction of a new venous outflow in the medial upper arm. This procedure was performed in nine patients and, at the present time, has increased the graft life by an average of 6.2 months (range: 2 to 14 months) in eight. We conclude that this is a useful alternative to abandoning failed looped forearm PTFE grafts that have cephalic vein outflow obstruction.

Anastomosis, Surgical↗
PubMed1991

Independent effects of cyclosporine and prednisone on posttransplant hypercholesterolemia.

To clarify the relative influences of cyclosporine (CsA) therapy, corticosteroid therapy, and other clinical variables on posttransplant hypercholesterolemia, total serum cholesterol levels were measured in 107 renal transplant recipients receiving one of three immunosuppression regimens: CsA and azathioprine (AZA) (group I); CsA, AZA, and prednisone (group II); or AZA and prednisone (group III). Multivariate analysis demonstrated that prednisone therapy, CsA therapy, patient age, and pretransplant cholesterol levels correlated independently with posttransplant cholesterol levels at last follow-up (ranging from 13 to 84 months after transplantation). In 32 patients successfully withdrawn from corticosteroid therapy and maintained on AZA and stable doses of CsA, serum cholesterol decreased from 6.55 +/- 1.1 mmol/L (253.5 +/- 43.1 mg/dL) to 5.27 +/- 1.2 mmol/L (203.9 +/- 45.6 mg/dL). Results of this analysis indicate that prednisone and CsA are independent factors in the pathogenesis of posttransplant hypercholesterolemia. Complete withdrawal of corticosteroids partially corrects hypercholesterolemia in CsA-treated renal transplant recipients.

Adult↗
PubMed1991

Effects of steroid withdrawal on posttransplant diabetes mellitus in cyclosporine-treated renal transplant recipients.

Posttransplant diabetes mellitus (PTDM) traditionally has been attributed to therapy with steroids--however, several lines of evidence suggest that cyclosporine also is diabetogenic. A retrospective review revealed that PTDM developed in 9 of 70 previously nondiabetic kidney transplant recipients (12.9%) maintained on prednisone, azathioprine, and CsA compared with 8 of 83 nondiabetics (9.6%) maintained on azathioprine and prednisone alone in an earlier era (P = NS). Among patients maintained on triple-drug therapy, complete withdrawal of prednisone was attempted in 7 renal transplant recipients with PTDM and in 1 recipient of a combined kidney-pancreas transplant who exhibited evidence of type II diabetes mellitus. Seven of the 8 patients were able to discontinue insulin or oral hypoglycemic agents within 4 months of discontinuing steroids. Mean glycohemoglobin level declined from 10.6 +/- 3.6% prior to steroid withdrawal to 6.0 +/- 1.3% within 1 month of steroid cessation, while mean CsA dose and trough CsA blood levels remained unchanged. In 2 patients, mild rejection episodes prompted a return to steroid therapy. Although CsA may be diabetogenic, evidence from this study suggests that withdrawal of steroid therapy is a safe and effective approach to the management of PTDM in patients subsequently maintained on CsA and azathioprine.

Blood Glucose↗
PubMed1991

Treatment with OKT3 and cyclosporine for acute allograft rejection.

In summary, we believe that our experience with concomitant use of OKT3 and either reduced-dose CyA for treatment of renal allograft rejections or full-dose CyA therapy for treatment of liver allograft rejection is both safe and possibly more effective in reversing allograft rejection than use of the antibody alone. This strategy has also allowed us to use this MAb therapy without incurring the untoward consequence of the development of hightiter anti-OKT3 antibodies that could preclude its subsequent reuse.

Adult↗
PubMed1990

Combined kidney and pancreas transplantation. A safe and effective treatment for diabetic nephropathy.

Seventeen patients with type I diabetes and diabetic nephropathy underwent combined kidney and pancreas transplantation. Mean age was 32 +/- 6 years and average duration of diabetes was 21 +/- 6 years. Transplantation was performed through bilateral iliac fossa incisions, and graft duodenocystostomy was used to achieve exocrine pancreas drainage. The actuarial patient and kidney survival rate was 92% and the pancreas survival rate, 88% (follow-up of 3 to 28 months). One patient with functioning grafts died at 10 months owing to a cardiac arrhythmia and one pancreas was "lost" to early thrombosis. Major morbidity was due to pancreas wound infection (53%) that required reoperation, but all patients have had subsequent healing of their wounds. Rehabilitation with return to meaningful activity has been accomplished by 15 patients. This experience demonstrates that combined kidney and pancreas transplantation can be performed safely and successfully.

Adult↗
PubMed1990

A prospective randomized trial of prednisone versus no prednisone maintenance therapy in cyclosporine-treated and azathioprine-treated renal transplant patients.

The purpose of this study was to evaluate early (6-12 days) prednisone withdrawal in cyclosporine- and azathioprine-treated renal transplant recipients. Patients, including 8 recipients of live-related donor kidneys and 59 recipients of cadaver donor kidneys, were prospectively randomized to receive maintenance prednisone (PRED) therapy or not (NOPRED) in addition to antilymphocyte globulin, cyclosporine, and azathioprine. Rejection episodes were initially treated with methylprednisolone pulses, and OKT3 monoclonal antibody was used to treat steroid resistant rejections that were verified by biopsy. NOPRED patients were declared protocol failures and returned to PRED therapy if they sustained 2 steroid-sensitive rejection episodes in the first 3 months or an OKT3-treated rejection at any time. Patient and graft survival for the LRD patients in both treatment categories were 100% at 12 months. Patient and graft survival for CAD recipients at one year was 94% and 83% (PRED) and 88% and 77% (NOPRED), respectively. Rejection episodes were more frequent (26 of 32 NOPRED patients vs. 19 of 35 PRED patients P = 0.02) and occurred earlier (4.5 weeks in NOPRED vs. 7.7 weeks in PRED patients) in patients not taking maintenance steroids. Rejection severity was also greater in the NOPRED group, as 15 OKT3-treated rejections occurred in that group whereas only 7 OKT3-treated rejections were observed in the PRED group (P = less than 0.01). The incidence of serious infection was similar in each group. Finally, protocol failure occurred in 40% of the LRD patients and 59% of the CAD patients. These data indicate that initiating maintenance therapy without PRED is safe but is attended by a greater risk of developing rejection. Because of this increased incidence and severity of early rejection episodes in NOPRED patients, we do not advise use of this immunosuppressive strategy in renal transplantation.

Azathioprine↗
PubMed1990

Inhibition of anti-OKT3 antibody generation by cyclosporine--results of a prospective randomized trial.

To investigate the influence of therapy with cyclosporine on the generation of antibodies to OKT3, 51 renal transplant recipients previously maintained on CsA, azathioprine, and prednisone were allocated randomly either to receive 50% of their maintenance dose of CsA (group 1, n = 27) or to discontinue CsA (group 2, n = 24) during treatment with OKT3 for acute renal allograft rejection. In the month following therapy with OKT3, anti-OKT3 antibodies were detected in 11% of patients in group 1 and in 42% of patients in group 2 (P less than 0.02). No patient in group 1 developed antibody titers greater than 1:100, whereas 4 patients in group 2 developed titer greater than or equal to 1:1000. Rejection was reversed in 96% of patients in group 1 and in only 75% of patients in group 2 (P less than 0.03), suggesting that continued administration of reduced doses of CsA during therapy with OKT3 improves the short-term response to this monoclonal antibody. Results of this study suggest that concurrent administration of CsA during therapy with OKT3 inhibits the generation of anti-OKT3 antibodies and improves the response to this monoclonal antibody.

Acute Disease↗
PubMed1990

Kidney transplantation in patients aged sixty years and older.

Outcomes of renal transplantation were reviewed for 26 transplants performed in 25 patients 60 years of age or older between 1985 and 1989. Three grafts were from family donors and 23 were from cadaver donors. Twenty-one were first transplants and five were retransplants. Cyclosporine was used as primary immunosuppression and azathioprine and prednisone were administered to most patients. Overall patient and graft actuarial survival rates were 79% and 71%, respectively, at both 1 and 3 years. Patients (n = 14) free of both diabetes and cardiac disease (low risk) had 1- and 3-year patient and graft survival rates of 91% and 84%, respectively. Conversely, high-risk patients (n = 12) had patient and graft survival rates at 1 and 3 years of 67% and 58%, respectively. Early deaths (less than or equal to 6 months) were caused by sepsis (two patients) or cardiac events (three patients), and four of the five were in high-risk patients. Irreversible rejections and serious infectious complications were not as common as steroid-induced diabetes, which occurred in five patients. This experience suggests that kidney transplantation can be done safely and successfully in patients older than 60 years of age and should be the treatment of choice for low-risk patients in this category.

Aged↗
PubMed1990

Choledochocholedochostomy without a T tube or internal stent in transplantation of the liver.

Different techniques have been used for biliary reconstruction in transplantation of the liver. Early techniques of cholecystodoudenostomy and cholecystojejunostomy had high rates of biliary complications often with associated mortality. Today, most centers use a choledochocholedochostomy with a T tube (CC-T) or Roux-en-Y choledochojejunostomy (RYCJ) for biliary reconstruction in hepatic transplantation with a low mortality rate but still significant morbidity. In our early experience at the University of Chicago, we used CC-T as the procedure of choice and RYCJ in the remaining instances. However, it was noted that a large number of biliary complications in the CC-T group were related to the use of T tubes, which prompted us to consider the use of primary anatomosis without tube drainage or stenting (CC). We reviewed 136 transplants with a graft survival rate of greater than two weeks. The over-all complication rates for each group were 38 CC, 18 per cent; 26 CC-T, 35 per cent, and 72 RYCJ, 21 per cent. One patient died as a direct result of a biliary complication. The main difference between CC and CC-T was early biliary complications (5 versus 31 per cent, p less than 0.02 most were T-tube related. We advocate the use of CC (without a T tube) when-possible. We recommend RYCJ whenever reoperation and biliary revision are required. We have found that both CC and RYCJ can be used safely for biliary reconstruction in hepatic transplantation.

Adult↗
PubMed1989

Experience with radical resection in the management of proximal bile duct cancer.

Multiple surgical and nonsurgical approaches have been advocated for the treatment of proximal bile duct cancer. However, survival appears longest when a resection can be performed. Fifteen patients treated at a university center were managed with an aggressive surgical approach. Resection of the tumor was performed in 13 of 15 patients (87%). Of the patients undergoing resection, major hepatic resection was performed in 8 (62%), while excision of vessels with reconstruction was performed in 5 (38%). Eleven of the 13 resected patients (85%) were discharged from the hospital. Clinical symptoms of recurrent disease occurred between 3 and 36 months after surgery in 7 patients, 6 of whom have died. Three other patients are alive at 5, 21, and 36 months without clinical evidence of recurrence. There was no correlation between the completeness of resection 'and the duration of disease-free survival. These results demonstrate that radical resection of high bile duct tumors can be accomplished with an acceptable early mortality rate, thereby extending the benefits of resection to a higher proportion of patients. While resection is clearly effective at controlling local disease and providing palliation of jaundice, surgical cure remains exceptional. Further improvement in the therapy of bile duct cancer must await development of more effective multi-modality approaches.

Adult↗
PubMed1988

Use of a brief steroid trial before initiating OKT3 therapy for renal allograft rejection.

OKT3 (Ortho Pharmaceutical, Raritan, NJ) has been employed in a protocol where all patients received cyclosporine as part of their baseline immunosuppressive regimen and, after the diagnosis of rejection was established, were treated with up to three pulses of methylprednisolone before monoclonal antibody therapy was initiated. Use of this protocol has allowed 46% of rejection episodes encountered to be treated on an outpatient basis without resorting to inpatient use of OKT3, but has avoided delaying OKT3 therapy until after all other methods of rejection treatment were found to be ineffective. Of 83 rejection episodes treated with OKT3 between March 1985 and May 1987, 78 (94%) were reversed. Overall graft survival is 84% and patient survival is 96% in OKT3-treated patients. Of the 17 rejection episodes where OKT3 treatment was a second or third exposure to the drug, rejection was successfully reversed in 15 (88%). In cadaver donor allograft recipients transplanted between March 1985 and May 1986, actual 1-year graft survival is 80% for 30 patients requiring no rejection therapy, 80% for 20 patients with rejection episodes responding quickly to steroids, and 82% for 28 patients with OKT3-treated, steroid-insensitive rejections. Mean serum creatinine at 1 year posttransplant is 1.5 +/- 0.5; 1.9 +/- 0.7; and 2.1 +/- 0.8, respectively, for these groups of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Antibodies, Monoclonal↗
PubMed1988

Complications and monitoring of OKT3 therapy.

Complications of OKT3 therapy were studied in 122 treatment episodes in renal allograft recipients (83 for rejection treatment, 39 for immunosuppression induction). A febrile first-dose reaction to OKT3 was common; no severe pulmonary complications were encountered. Other toxicities of OKT3 therapy were observed later in the treatment course. Most severe were the occurrence of aseptic meningitis in four patients (3%), and seizures in eight (6%). Seizures occurred only when OKT3 was given to patients with nonfunctioning grafts due to acute tubular necrosis. Infections were the only significant late adverse sequelae of OKT3 therapy and occurred more frequently after multiple exposures to the drug (53%) than after a single exposure (22%). IgG antibodies to OKT3 developed after 45% of exposures to the drug in the 74 patients in whom appearance of anti-OKT3 antibodies was monitored. In two patients (3%), anti-OKT3 antibodies were detected before the end of the OKT3 treatment course, neutralizing the immunosuppressive property of the drug. In five patients (7%), strong anti-OKT3 antibody responses were present at the time of subsequent rejection, which precluded reuse of the drug. In 17 other cases, no or only a weak anti-OKT3 response was detectable at the time of rejection following initial OKT3 exposure. Retreatment with OKT3 was successful in reversing rejection in 15 cases (88%). No untoward sequelae were noted after reexposure to OKT3, except the high incidence of subsequent infections.

Adult↗