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Biomedical subjects

L R Kaiser

Publications and source records attributed to L R Kaiser.

At least 127 records · Page 7Linked to original sources
PubMed1993

The donor lung: infectious and pathologic factors affecting outcome in lung transplantation.

The prevalence of posttransplantation pulmonary infection and the importance of this complication with respect to morbidity in patients undergoing lung transplantation is significant. Over a 1-year period, case histories of all patients undergoing lung transplantation at Barnes Hospital, Washington University, were reviewed to examine the importance of organisms isolated in the donor lung in the development of subsequent invasive infection in transplant recipients. Twenty-eight of 29 bronchial washings (97%) taken from donors before retrieval grew at least one organism. The most common organisms identified were Staphylococcus and Enterobacter. In 12 of these cases (43%), similar organisms were isolated from the tracheobronchial tree of the recipients, and 6 of these recipients (21%) subsequently had invasive pulmonary infections as a result of the organism originally isolated in the donor. We recommend that antibiotic coverage in transplant recipients should be initiated on the basis of Gram stain results and modified on the basis of cultures obtained from the donor lungs. Pathologic analysis of donor lung tissue taken before transplantation was available in 12 cases. Four donors had histologic evidence of established pneumonia in the donor lung, and infections then developed in the recipients. One other patient who received a lung that had widespread bone marrow emboli and subsequent infarction later had a complete anastomotic dehiscence. An additional patient had profound early donor lung dysfunction without any evidence of rejection or infection. Pathologic findings from the donor in this case demonstrated preexistent acute vasculitis with emboli. We suggest that as preservation techniques improve, the opportunities for closer scrutiny of donor lung tissue before implantation will become increasing desirable and feasible.

Hospitals, University↗
PubMed1992

Pulmonary "twinning" procedure: use of lungs from one donor for single-lung transplantation in two recipients.

Since the introduction of lung transplantation as an option for patients with end-stage respiratory disease in the early 1980s, there have been substantial advances made in the technical aspects of transplantation as well as the early clinical results. With an ever-increasing number of patients being designated suitable candidates for transplantation, the volume of transplants in the foreseeable future will be limited more on the basis of donor lung supply than any other single factor. Pulmonary "twinning" provides an important step in ensuring that all suitable and available donor lungs are utilized whenever feasible. This report reviews the results of 20 single-lung transplantations carried out in five separate transplantation centers using organs retrieved from ten donors. The overall mortality rate in this group of patients was 5%, which compares very favorably with historical controls. No serious problem was noted with respect to increased perioperative morbidity or increased ischemic times in this group of patients. We suggest that this process should be considered and, wherever possible, adopted by all major lung transplant centers.

Adult↗
PubMed1992

Management of dysfunction in the transplanted lung: experience with 7 clinical cases. Washington University Lung Transplant Group.

In a series of 34 lung transplant patients, donor lung dysfunction occurred on 7 occasions. One patient underwent retransplantation and the remaining 6 were treated conservatively. Survival was 100% in the donor lung dysfunction group. Percent predicted forced expiratory volume in 1 second, carbon monoxide diffusion, room air oxygen tension, and distance walked in 6 minutes were all lower (p less than 0.05) at 1 month after transplantation in those patients with donor lung dysfunction as compared with those without. These differences were not significant at 3 months after transplantation. We conclude that donor lung dysfunction can usually be managed conservatively with satisfactory results. Longer follow-up of this group of patients will be necessary to determine the long-term consequences of early graft injury.

Adult↗
PubMed1992

Pediatric lung transplantation for pulmonary hypertension and congenital heart disease.

Five children underwent lung transplantation for end-stage pulmonary hypertension and respiratory insufficiency associated with congenital heart disease. One (17 mo) had pulmonary hypertension with a patent ductus arteriosus and required two periods of preoperative extracorporeal membrane oxygenation before successful bilateral sequential lung transplantation. One (21 mo) required bilateral lung transplantation for pulmonary hypertension and bronchopulmonary dysplasia associated with iatrogenic injury to the left pulmonary artery. This child also had patent ductus arteriosus ligation and preoperative catheter closure of an atrial septal defect. Extracorporeal membrane oxygenation was required for early postoperative pulmonary support. One child underwent right single-lung transplantation and closure of an atrial septal defect for pulmonary hypertension. Two patients had single-lung transplantation for Eisenmenger's syndrome: 1 with muscular inlet ventricular septal defect closure, atrial septal defect closure, and right single-lung transplantation; 1 with ventricular septal defect closure, patent ductus arteriosus ligation, right ventricular outflow tract patch repair, and single-lung transplantation. All patients survived operation, with one late death (lymphoproliferative disease). The 4 survivors are all ambulatory without oxygen and have evidence of normal pulmonary artery pressure 9 to 12 months after transplantation.

Adolescent↗
PubMed1992

Lung transplantation of ventilator-dependent patients. The Washington University Lung Transplantation Group.

During the last few years, lung transplantation has been extended to patients with a variety of end-stage lung diseases, but recipient selection guidelines have remained relatively strict. Ventilator-dependent patients have traditionally been considered poor candidates for transplantation. However, patients who have been thoroughly evaluated and accepted for transplantation and subsequently develop respiratory failure caused by progression and/or exacerbation of their underlying disease and recipients who experience respiratory failure caused by graft failure may be suitable candidates while ventilator-dependent if no other major complications or contraindications arise before a donor organ becomes available.

Adult↗
PubMed1992

The role of transbronchial lung biopsy in the treatment of lung transplant recipients. An analysis of 200 consecutive procedures.

STUDY OBJECTIVE: The purposes of this study were as follows: (1) to establish the positivity rate and complication rate of transbronchial lung biopsies in the treatment of lung transplant recipients; (2) to determine the sensitivity of transbronchial lung biopsy specimens for the diagnosis of clinically suspected acute rejection and cytomegalovirus pneumonia; and (3) to examine the results of surveillance transbronchial lung biopsies in clinically and physiologically stable recipients. DESIGN: Retrospective review and analysis of 203 consecutive procedures. SETTING: Washington University Lung Transplantation Program, Washington University School of Medicine and Barnes Hospital, St. Louis, Mo. PATIENTS: Fifty-five lung transplant recipients. INTERVENTIONS: Biopsies were done with 2-mm fenestrated forceps using fluoroscopic guidance. Two hundred three bronchoscopies with transbronchial lung biopsy were performed for clinical indications (n = 88), routine surveillance (n = 90), or follow-up of a previous biopsy (n = 25). Biopsy specimens showing acute allograft rejection were classified according to the scheme recommended by the Lung Rejection Study Group. MEASUREMENTS AND RESULTS: The positivity rate and complication rate were determined for the procedures. In procedures performed for clinical indications, the sensitivity for the diagnosis of acute rejection and cytomegalovirus pneumonia was calculated by a decision-to-treat analysis. A specific histologic diagnosis was detected in 69 percent of the clinical procedures, 57 percent of the surveillance procedures, and 64 percent of the follow-up procedures. For clinical indications, the sensitivity of transbronchial lung biopsy was 72 percent for the diagnosis of acute rejection and 91 percent for the diagnosis of cytomegalovirus pneumonia. Surveillance biopsy specimens often showed clinically inapparent rejection or cytomegalovirus pneumonia. The overall complication rate was 8.9 percent; none of the complications were life threatening. CONCLUSIONS: Transbronchial lung biopsy is a useful and safe procedure in the treatment of lung transplant recipients. When performed for clinical indications, the procedure proved to be sensitive for the diagnosis of acute rejection and cytomegalovirus pneumonia. When performed for surveillance in clinically and physiologically stable recipients, the incidence of rejection and cytomegalovirus pneumonia was unexpectedly high; the potential clinical implications of these findings will require further study.

Biopsy, Needle↗
PubMed1992

Hospitals without walls: trustees reach out to the community. Interview by Karen Gardner.

"A futurist is someone who either predicts or invents the future, and I really try to do both," says Leland R. Kaiser, Ph.D., president of Kaiser & Associates, Brighton, CO, and associate professor, University of Colorado at Denver School of Business. Kaiser--a former hospital trustee--says, "When you're inventing the future, you're using a vision of how you would like to see the organization be in the future, and then you help the organization achieve that." Kaiser concentrates on helping institutions achieve a vision that has been formed by his many years of health care and management experience as well as an extraordinary sensitivity to the needs of communities and the potential that the United States health care system has to address those needs. Futurist Kaiser recently spoke with Trustee editor Karen Gardner about his vision of health care delivery, the central role that trustees must play in order to realize that vision, and the promise of a truly community-based health care system.

Chief Executive Officers, Hospital↗
PubMed1992

Single lung transplantation for pulmonary hypertension. Technical aspects and immediate hemodynamic results.

Donor availability has limited the clinical applicability of heart-lung transplantation in patients with end-stage pulmonary hypertension. Satisfaction with single lung transplantation in other patient groups prompted its extension to patients with pulmonary hypertension. Nine patients with end-stage pulmonary hypertension underwent single lung transplantation. Important technical considerations included routine use of cardiopulmonary bypass, simultaneous closure of significant associated cardiac defects (n = 4), and use of remaining thoracic donor organs in multiple recipients (total thoracic transplants from eight donors = 21). Analysis of immediate postoperative hemodynamics suggests that early relief of pulmonary hypertension and improvement in right ventricular function can be expected. There was one postoperative death. Eight patients have been discharged and are alive and well at a mean follow-up period of 1 year. All eight survivors have returned to New York Heart Association functional class I from their preoperative levels of III or IV. These results support the use of single lung transplantation as a transplant option in patients with end-stage pulmonary hypertension. The question of long-term durability remains unanswered.

Adult↗
PubMed1992

The current status of lung transplantation.

The supply of donor organs remains extremely limited and improved methods to maintain the lungs of potential donors to allow for transplantation must be developed. Improved methods for preservation will increase the supply of suitable lungs and considerably simplify the logistics of transplantation, just as has occurred with liver transplantation. In the meantime, we continue to strive to utilize donor organs in the most efficient manner. On four occasions within the past 5 months, we have performed two simultaneous single lung operations and are prepared either to do this as a routine, or to offer the other lung to another center. Sufficient progress has been achieved to date to warrant the continued application of lung transplantation for end-stage pulmonary disease. With increasing experience, one can anticipate refinement of techniques and broader application of these procedures. Single lung transplantation, initially restricted to patients with end-stage pulmonary fibrosis, now has been applied successfully to patients with emphysema, pulmonary hypertension, and other conditions. We anticipate offering lung transplantation in the pediatric and even neonatal population in the very near future. This may prove to be particularly important in the group of children with so-called bronchopulmonary dysplasia, an end-stage interstitial fibrosis occurring in a small percentage of children born with what initially appears to be hyaline membrane disease and who require prolonged mechanical ventilation. Though currently transplantation can offer real benefit only to a limited number of individuals, it serves to create hope for many others. An additional benefit may prove to be the interest and attention that transplantation focuses on patients with end-stage lung disease and on the pathophysiology of chronic respiratory failure. Knowledge gained ultimately may result in the prevention of many of the disorders for which lung transplantation currently offers the only hope.

History, 20th Century↗
PubMed1992

Morbidity, mortality, and early results of single versus bilateral lung transplantation for emphysema.

Both single lung transplantation and bilateral lung transplantation have been successful in patients with chronic obstructive pulmonary disease. Limited availability of donor lungs dictates wider use of single lung transplantation as long as this procedure provides a comparable functional result at less risk. Early morbidity, mortality rates, and functional results were compared in 32 consecutive patients undergoing either single or bilateral lung transplantation for end-stage chronic obstructive pulmonary disease. When pretransplantation and posttransplantation values of forced expiratory volume in 1 second, single breath diffusing capacity, total lung capacity, arterial oxygen tension, and 6-minute walking distance were compared, statistically significant improvement (p less than 0.01) was seen in both groups. However, significantly higher values (p less than 0.01) were attained for forced expiratory volume in 1 second, single breath diffusing capacity, and arterial oxygen tension in the bilateral transplantation group than in the single lung transplantation group. Patients receiving bilateral lung transplants were at greater risk for postoperative complications, especially cardiac arrhythmias and bronchial anastomotic defects. Actuarial survival for the single lung transplantation group was 93% at 1 year, versus 87% at 6 months and 71% at 1 year for the bilateral lung transplantation group. The optimal transplantation procedure for patients with chronic obstructive pulmonary disease has not been determined. Longer follow-up periods are needed to define better the roles of bilateral and single lung transplantation in this group of patients.

Age Factors↗
PubMed1992

Lung transplantation. Analysis of thirty-six consecutive procedures performed over a twelve-month period. The Washington University Lung Transplant Group.

A consecutive series of 36 lung transplant procedures in 35 patients, performed over a 12-month period, has been reviewed. There were 14 men and 21 women undergoing 23 single, 12 bilateral, and one en bloc double lung transplant. There were one hospital death and three late deaths in the series, giving a hospital survival rate of 97.2% and a 1-year actuarial survival figure of 91.7%. Airway complications occurred in six patients (17.2%), one of whom died. Cytomegalovirus infection was demonstrated in 18 patients (51%), but no deaths have resulted. The most common cardiac complication was an atrial tachyarrhythmia (nine patients, 25.7%) and three patients had a cardiac arrest, but all were successfully resuscitated. Twelve patients required a further 25 surgical procedures after transplantation; however, renal and hematologic complications were uncommon. The prevalence and management of the other associated complications is discussed.

Adult↗
PubMed1992

Extracellular matrix protein gene expression in atherosclerotic hypertensive pulmonary arteries.

Lobar pulmonary arteries from patients with unexplained pulmonary hypertension were obtained at the time of single-lung transplantation to determine the response of large elastic vessels to increased intraluminal pressure. Specifically, human pulmonary arteries were examined to determine if remodeling remained active at the time of surgery and whether remodeling was similar to previously reported remodeling observed in several animal models. Grossly, the hypertensive vessels appeared atherosclerotic. Histochemical stains revealed a thick, diffuse neointima in hypertensive vessels compared with normal vessels. Immunohistochemistry demonstrated elastin protein in the neointima and in situ hybridization studies demonstrated tropoelastin mRNA largely in the neointima. Similarly, immunohistochemistry and in situ hybridization detected cellular fibronectin, thrombospondin and type I collagen protein and mRNA within the thickened intima from hypertensive vessels. These studies provide evidence that hypertensive vessels in patients with severe chronic pulmonary hypertension are actively remodeling but that the pattern of remodeling is different from previously described animal models.

Adult↗
PubMed1991

The Washington University-Barnes Hospital experience with lung transplantation. Washington University Lung Transplantation Group.

OBJECTIVE: --To review our experience with lung transplantation, emphasizing recipient selection, choice of procedure, functional results, and outcome. DESIGN: --Retrospective review of patients who received lung transplants at Barnes Hospital, St Louis, Mo, between July 1, 1988, and January 31, 1991. SETTING: --Washington University School of Medicine, St Louis, Mo, and Barnes Hospital, a medical school and its affiliated referral hospital, respectively. PATIENTS: --Sixty-nine lung transplant procedures were performed in 66 recipients. Patients with clinically and physiologically severe lung disease were selected according to predetermined guidelines. Underlying diseases in the recipients included chronic obstructive pulmonary disease, alpha 1-antitrypsin deficiency emphysema, cystic fibrosis, pulmonary fibrosis, primary pulmonary hypertension, Eisenmenger's syndrome associated with an atrial septal defect, bronchiectasis, eosinophilic granuloma, and lymphangiomyomatosis. INTERVENTION: --Double-lung, bilateral sequential, and single-lung transplantations were performed. Eight patients underwent en bloc double-lung transplantations or a modification of this procedure with separate bronchial anastomoses. Thereafter, the bilateral sequential approach to replacement of both lungs was performed in 26 patients. Thirty-two patients underwent single-lung transplantations. MAIN OUTCOME MEASURES: --Pulmonary function tests, arterial blood gas levels, pulmonary artery pressure, pulmonary vascular resistance, and actuarial survival. RESULTS: --Actuarial survival at 1 year for the 66 lung transplant recipients was 79%. Actuarial survival at 1 year was 82% for the bilateral lung transplant recipients and was 90% for the single-lung transplant recipients. In patients with either restrictive or obstructive lung disease, pulmonary function tests and arterial blood gas levels improved markedly after lung transplantation. In patients with primary pulmonary hypertension or Eisenmenger's syndrome, the pulmonary artery pressure decreased and the cardiac index increased into the normal range after single-lung transplantation. CONCLUSIONS: --In carefully selected patients with end-stage lung disease, single-lung and bilateral lung transplantations can significantly improve functional capacity, with promising early actuarial survival statistics after 1 year.

Actuarial Analysis↗
PubMed1991

Bilateral sequential lung transplantation: the procedure of choice for double-lung replacement.

We recently described a technique for bilateral sequential lung transplantation that replaces the en bloc double-lung operation, a procedure that was accompanied by frequent problems with airway healing. Twenty-seven patients have undergone 28 bilateral sequential lung transplantations over the past 14 months. Eighteen patients had transplantation because of end-stage emphysema; 6, cystic fibrosis; and 1 each, obliterative bronchiolitis, usual interstitial pneumonitis with pulmonary fibrosis, and bronchiectasis. Cardiopulmonary bypass was used electively in the first 5 patients until it was recognized that the procedure could be done safely without it, and in only 3 additional recipients has it been employed. Mean ischemic time for the first lung was 276 +/- 43 minutes and for the second lung, 410 +/- 64 minutes. There have been five deaths, three in the postoperative period (11% operative mortality) and two late. The other patients are alive and well and do not require oxygen 2 to 15 months after transplantation. Mean forced expiratory volume in 1 second rose from 16% +/- 8% of predicted to 84% +/- 17% at 12 weeks. Six-minute walk values increased from a mean of 251 +/- 91 m to 666 +/- 42 m at 24 weeks. The excellent exposure afforded to both hemithoraces by the thoracosternotomy incision and the rare need of cardiopulmonary bypass have allowed us to offer the option of transplantation to patients who formerly would have been turned down because of previous pulmonary resection or pleurectomy. On four occasions, ventilator-dependent patients underwent successful transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗