BACKGROUND AND AIMS: Liver regeneration and functional interaction between native liver and graft after auxiliary partial orthotopic liver transplantation (APOLT) are not entirely understood and, therefore, require an experimental model simulating the clinical features of acute liver failure (ALF) and the surgical technique of APOLT. MATERIALS AND METHODS: ALF was induced by subtotal hepatectomy in 50 Lewis rats (200-250 g). Sham operation (I), ALF without treatment (II), ALF with portocaval shunt for decreasing blood flow of the remnant liver (III), and ALF treated by APOLT (IV) were performed. The auxiliary graft represented a left donor liver lobe which was orthotopically implanted using a microsurgical technique including reconstruction of the graft artery and internal biliary drainage. Operative outcomes, serum chemistry and histopathological findings were examined up to the 14th day. RESULTS: ALF without treatment (groups II and III) led to a small droplet fatty degeneration in the hepatocytes and a significant increase of liver parameters until the death of the animals within the first two postoperative days ( P<0.05). After APOLT (group IV), 80% of the animals survived up to the 14th day, revealing significantly decreased liver parameters ( P<0.05), a well-perfused graft and an up to five times increased native liver size with normal architecture. CONCLUSION: This new rat model simulates the clinical features of an ALF treated by APOLT and is especially interesting for further basic research on the interaction between native liver and auxiliary graft after APOLT.

Animals↗

PubMed2001

[Fulminant liver failure after administration of the herbal antidepressant Kava-Kava].

HISTORY AND CLINICAL FINDINGS: A 60 year-old woman was admitted to hospital because of jaundice, fatigue, weight loss over several months and icteric skin. Because of progressive liver failure, concomitant renal failure and progressive encephalopathy she was transferred to an intensive care unit. INVESTIGATIONS: Biochemical tests revealed acute liver failure with high levels of total and conjugated bilirubin (30 mg/dl) as well as aspartate aminotransferase (921 IU/l) and alanine aminotransferase (1350 IU/l) concentrations. Prothrombin time was less than 10 %. Serological tests could rule out viral hepatitis, metabolic or autoimmune causes of liver failure. On abdominal computed tomography and ultrasonography no pathological changes were detected. Above all portal vein thrombosis, ascites, focal lesions of the liver and extrahepatic cholestasis could be excluded. Liver histology showed extensive hepatocellular necrosis with intrahepatic cholestasis. TREATMENT AND CLINICAL COURSE: The patient's physical condition deteriorated. She had to be intubated because of respiratory insufficiency and encephalopathy stage IV. Because of progressive liver failure under conservative treatment the patient received an orthotopic liver transplant 11 days after admission. CONCLUSIONS: The exclusion of other causes and the histological diagnosis made Kava-Kava as the cause of acute liver failure most likely. This is the 18th case of Kava-Kava induced liver failure reported to the European regulatory authorities.

Alanine Transaminase↗

PubMed2001

Dose optimization of mycophenolate mofetil when administered with a low dose of tacrolimus in cadaveric renal transplant recipients.

BACKGROUND: Supplementation of immunosuppressive therapy with mycophenolate mofetil (MMF) has been found to reduce the rate of acute rejection in renal transplantation. We report a dose-finding study for MMF when administered in combination with low-dose tacrolimus and corticosteroid prophylaxis in cadaveric renal transplant recipients. METHODS: Two hundred thirty-two patients at 16 centers were enrolled in this randomized, parallel-group study. The three treatment groups were tacrolimus and corticosteroids (MMF-0 group, n=82); tacrolimus, corticosteroids, and 1 g of MMF daily (MMF-1 g group, n=79); and tacrolimus, corticosteroids, and 2 g of MMF daily (MMF-2 g group, n=71). Study duration was 6 months, and patients were followed up for patient and graft survival for 12 months. RESULTS: At 6 months posttransplantation, daily doses of 1 g and 2 g of MMF were associated with significantly lower rates of acute rejection compared with tacrolimus alone. The Kaplan-Meier rates were 48.5%, 24.9%, and 22.9%, respectively, for the three treatment groups when acute rejection was determined by clinical criteria (P=0.007). At month 12, patient survival rates were 100%, 97.5%, and 97.2% and graft survival rates were 90.2%, 92.4%, and 93.0% for the MMF-0 group, MMF-1 g group, and the MMF-2 g group, respectively. Gastrointestinal adverse events and leukopenia were higher in the MMF groups, especially in the MMF-2 g group (P<0.05). CONCLUSIONS: Low-dose tacrolimus combined with a MMF dose of 1 g daily and corticosteroids provided an optimized efficacy and safety profile. A higher dose of MMF (2 g) was associated with greater toxicity without a significant improvement in efficacy.

Adrenal Cortex Hormones↗

PubMed2001

[Management of biliary complications after orthotopic liver transplantation].

In this retrospective analysis we report our results after liver transplantation regarding biliary complications (bc) and the effectiveness of endoscopic therapy. In the last 4 1/2 years we found 13 biliary leaks (7 in combination with a stenosis, 3 at the T tube insertion site), 9 biliary stenosis, 3 papillary stenosis, 2 biliary aggregates and one case of ischemic type biliary lesion, resulting in an overall complication rate of 30%. 10 (36%) "bc" could be treated successfully endoscopically, whereas 8 (32%) patients are still under observation with an endoprosthesis in the biliary tract. 10 endoscopic trials were without the desired effect, requiring a surgical reintervention. In 4 cases a thrombosis of the hepatic artery was responsible for the unwanted course.

Adolescent↗

PubMed2001

The anastomosis between renal polar arteries and arteria epigastrica inferior in kidney transplantation: an option to decrease the risk of ureter necrosis?

Ureteral necrosis after renal transplantation is often the result of impaired perfusion due to loss of donor polar arteries. A way of preserving polar arteries is their anastomosis with the A. epigastrica inferior. In three cases (aged 49-, 58-, and 63 years), 9.3 % of 33 living donors, we detected donor polar arteries on both sides, and anastomosed the polar artery to the A. epigastrica inferior with microsurgical methods. Intraoperatively, the flow was measured by flowmeter, in the postoperative course duplexsonography and MR-angiography was performed. In all three cases we noted a bluish, ischemic parenchym mass of 10-25 % of the kidney and ureter. It recovered immediately, however, after the polar artery had been reconstructed. Intraoperative measurement showed a high flow on the polar- and the main renal artery. Duplexsonography and MR-angiography documented a good flow on the A. epigastrica anastomosis. There have been no signs of ureteral problems at all. After a mean follow-up time of 26 months, the mean creatinine level is 1.46 mg/ml. Ureteral necrosis after kidney transplantation is mostly the result of a lack of perfusion of the polar arteries of the lower kidney pole. If arteriosclerotic lesions inhibit an anastomosis with the renal artery, the anastomosis with the A. epigastrica inferior seems to be a useful alternative.

Anastomosis, Surgical↗

PubMed2001

Basiliximab in the therapy of acute rejection after organ transplantation.

Explore the source record for details and available documents.

Acute Disease↗

PubMed2001

[MARS (Molecular Adsorbent Recycling System) as a novel hepatic detoxification procedure until orthotopic liver transplantation].

MARS (Molecular Adsorbent Recycling System) as a novel hepatic detoxification procedure until orthotopic liver transplantation. We report the case of a 30-year-old man who was admitted because of acute liver failure due to longstanding ethanol abuse. On conservative treatment liver function progressively deteriorated and the patient was listed for orthotopic liver transplantation. Because of a rapidly progressive and clinically severe hepatic encephalopathy together with increasing bilirubin levels (maximum 39 mg/dl) we began intermittent extracorporeal detoxification with the Molecular Adsorbent Recycling System (MARS). Under MARS therapy serum bilirubin decreased significantly (to 20 mg/dl after three cycles) and encephalopathy improved rapidly until the patient was completely oriented. No effect of MARS on liver function could be demonstrated. MARS treatment was successfully continued until a cadaver liver became available after 48 days and the patient was transplanted in good clinical and neurological condition and without complications. MARS represents a novel detoxification technique which, in patients with acute liver failure, can successfully replace hepatic detoxification until orthotopic liver transplantation can be performed.

Adult↗

PubMed2001

Noncardiac surgery in patients with left ventricular assist devices.

BACKGROUND: Noncardiac surgery, especially abdominal surgical procedures in patients with long-term mechanical circulatory support and strong anticoagulation, is difficult. METHODS: We report on 14 patients (aged 44 +/- 15 years) with a portable Novacor or HeartMate system, who underwent noncardiac surgical procedures while being supported by the device. RESULTS: The patients underwent 20 procedures for noncardiac reasons; most had an intestinal operation or cholecystectomy. Half of the procedures were performed within 30 days after placement of the device (mean interval, 53 +/- 57 days), only 6 interventions were necessary after 100 days of mechanical support. Complications occurred in 8 patients (57%), 5 of whom had undergone cholecystectomy and had unacceptably high sanguineous drainage losses. CONCLUSIONS: An elective surgical procedure can be performed with an acceptable risk if the operation is carefully managed. Postponing resumption of full anticoagulation is advisable as it may reduce bleeding complications without apparently increasing the risk for thromboembolism. Emergency interventions remain a difficult task.

Adult↗

PubMed2000

Cadaveric "two-in-one" kidney transplantation from marginal donors: experience of 26 cases after 3 years.

BACKGROUND: Because of the problem of organ shortage, the use of renal transplants from marginal donors has been tested by different procedures. METHODS: In our center 26 recipients (59 +/- 7 years) underwent double renal transplantation from July 1996 to August 1999 using marginal donors (71 +/- 6 years). A special scoring was applied that included donor age, serum creatinine, the grade of glomerulosclerosis, and kidney weights leading to the decision whether single or dual or no kidney transplantation was performed. RESULTS: After an average follow-up of 18 +/- 10 months 22 of 26 (85%) double kidney transplant recipients are alive and have functioning grafts. Three patients died with well-functioning grafts. The actuarial 1-year patient and graft survival rate was 94% (n=18), the 2-year rate 92% (n=12). Two patients lost one graft each without becoming dialysis dependent. The average serum creatinine was 1.6 +/- 0.5 mg/dl after 12 months (n=17) and 1.9 +/- 0.6 mg/dl after 24 months (n=11). Primary nonfunction occurred in 31%, acute rejection within the first 6 months in 14%. Ten patients who received single old grafts according to our score had similar transplant survival rates but worse graft function after 1 year. CONCLUSIONS: Transplant function and survival of patients after dual kidney transplantation indicate that this procedure is reasonable to ameliorate the problem of organ shortage. The most crucial point is to establish a widely accepted standardized scoring for the donors leading to single, dual, or refusal of transplantation.

Aged↗

PubMed2000

Long-term investigations after pyloromyotomy for infantile pyloric stenosis.

Between 1919 and 1941, 71 infants suffering from pyloric hypertrophy were operated on by Ramstedt performing an extramucosal pyloromyotomy. Of these patients, we could identify and investigate 41. Four out of 31 long-term surviving patients have been Billroth II-resected (BII). One of these needed re-resection because of an anastomotic ulcer. None of all the long-term survivors developed a carcinoma. Two patients were treated conservatively because of gastritis and one because of esophagitis. All patients, except the one requiring re-resection and one suffering from maldigestion, were absolutely free of complaints. The average time between operation and re-checking was 57 years. The oldest patient was examined 72 years after the operation.

Adolescent↗

PubMed2000

Preoperative diagnosis of bile duct strictures--comparison of intraductal ultrasonography with conventional endosonography.

BACKGROUND: The accuracy of intraductal ultrasonography (IDUS) and endoscopic ultrasonography (EUS) were compared in diagnosing biliary obstruction and in predicting surgical resectability. METHODS: Fifty-six patients with biliary obstruction were investigated preoperatively with both conventional EUS and IDUS. The ultrasonographic miniprobe was inserted into the bile duct system through the working channel of the duodenoscope during endoscopic retrograde cholangiopancreatography (ERCP). Conventional endosonography was performed with echoendoscopes in a standard technique. Images of endoluminal ultrasonography were prospectively reviewed and compared with intraoperative findings and resection specimen analyses. RESULTS: IDUS exceeded EUS in terms of accuracy (IDUS, 89.1%; EUS, 75.6%; P < 0.002), sensitivity (IDUS, 91.1%; EUS, 75.7%; P < 0.002), specificity (IDUS, 80%; EUS, 75%; NS), and T-staging (IDUS, 77.7%; EUS, 54.1%; P < 0.001). In bile duct carcinomas the accuracy rate for lymph node staging using IDUS (60%) is comparable with that using EUS (62.5%). In pancreatic carcinomas, however, lymph node staging using IDUS (13.3%) is significantly (P < 0.002) inferior to EUS (69.2%). Endoluminal ultrasonography may predict the potential resectability of bile duct tumors (IDUS, 81.8%; EUS, 75.6%; P < 0.002). CONCLUSIONS: IDUS proved to be accurate in preoperative diagnosing and T-staging of malignant biliary strictures, whereas it is not suitable for lymph node staging. IDUS using miniprobes during ERCP exceeds conventional EUS in terms of depiction of bile duct obstruction, diagnostic accuracy, and sensitivity and in the prediction of surgical tumor resectability. Additionally, different to EUS, IDUS can conveniently be performed during ERCP in one and the same session.

Adult↗

PubMed2000

Measurement of skeletal status after renal transplantation by quantitative ultrasound.

BACKGROUND: Osteoporosis remains a major problem following kidney transplantation. Radiographic measures of bone mass are of limited predictive value after transplantation and are complicated by preexisting renal osteopathy. Quantitative ultrasound (QUS) is a new and non-invasive method to assess skeletal status, however, no data exist on ultrasonic bone parameter after kidney transplantation. We evaluated the potential use of this novel method in renal allograft recipients and studied the accuracy compared to normal controls. METHOD: Thirty patients (NTP, age 47.5 +/- 13.0 years) were studied 4.8 +/- 3.2 years after transplantation. Twenty-five healthy control persons (CON) were matched for age and sex. The left and right os calcis were studied by QUS and speed of sound (SOS) and broadband ultrasound attenuation (BUA) were measured. Bone stiffness (BS) was calculated from these parameters and corrected for age (CBS). Differences between right and left os calcis were compared to CON to assess the side variability. RESULTS: Mean +/- SD BS was 75 +/- 22% compared to young adults, age-corrected CBS was decreased in NTP with 86 +/- 25% of normal, indicating a two-fold increased risk of fracture. SOS was 1525 +/- 47.7 m/s, BUA 105 +/- 22 dB/MHz. Mean difference between right and left os calcis was significantly higher in NTP than in CON (7.2 +/- 7.1% vs. 2.1 +/- 2.1%, p < 0.01). Limits of agreement of the measurements (MW of differences +/- 2 SD) according to a Bland-Altmann-type statistic were -16.9% and 20.7%. There was no correlation between CBS and age, cumulative steroid dose, parathyroid hormone concentrations or time after transplantation. CONCLUSION: Our data show altered bone structure expressed by low bone stiffness values measured by quantitative ultrasound in kidney transplant patients. However, because of relatively high inter-feet variance of QUS results we suggest measurement of both ossa calcis to minimize measurement error after transplantation.

Biomechanical Phenomena↗

PubMed1999

Prognostic value of lymphocyte apoptosis in acute rejection of renal allografts.

BACKGROUND: Apoptosis is a cellular phenomenon generally found within rejecting transplants. It may play a role in physiological or therapy-associated deletion of infiltrating lymphocytes or in graft cell destruction. Our study focuses on apoptosis of infiltrating lymphocytes during acute kidney rejection after the initial steroid pulse therapy and on possible prognostic implications. METHODS: Renal biopsy specimens of 23 transplant recipients with acute tubulo-interstitial rejection were examined for appearance of apoptosis and compared with 11 transplant biopsies with unspecific organ injury accompanied by lymphocyte infiltration. In all patients, biopsies were performed after steroid pulse therapy, and, after confirmation of rejection, antilymphocytic antibody treatment was carried out. Apoptosis was determined via terminal deoxynucleotidyltransferase-mediated dUTP-digoxigenin nick end labeling analysis and confirmed by electron microscopy. RESULTS: Apoptosis of lymphocytes or of tubular epithelium was detected in 11 cases of acute rejection (48%), respectively. Four biopsies showed lymphocytic as well as tubular apoptosis, whereas five sections showed no signs of programmed cell death. In biopsies revealing unspecific injury, tubular cell apoptosis was more frequently found (73%) compared with lymphocyte apoptosis (27%, P<0.05). Most interestingly, patients with a beneficial recovery from acute rejection had a higher proportion of lymphocyte apoptosis compared with patients with poor rejection outcome. The Bcl-2 oncoprotein was widely found within infiltrating lymphocytes without counter-regulating apoptosis. CONCLUSIONS: Lymphocyte apoptosis is found as frequently as tubular cell apoptosis in rejecting renal grafts after steroid pulse therapy and might have prognostic value for rejection outcome.

Acute Disease↗