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Biomedical subjects

R M Goldstein

Publications and source records attributed to R M Goldstein.

At least 73 records · Page 4Linked to original sources
PubMed1992

Portosystemic shunt versus orthotopic liver transplantation for the Budd-Chiari syndrome.

We have analyzed the indications and results of shunt operation versus orthotopic liver transplantation (OLT) in 22 patients with Budd-Chiari syndrome (BCS). The underlying cause of the syndrome was similar between the two groups and was related to myeloproliferative disorders or the use of birth control pills in 18 of 22 patients. The results of biopsies of the liver showed centrilobular congestion and necrosis in all candidates who underwent shunting and the presence of fibrosis and cirrhosis in the OLT candidates. The indications for shunts included symptoms related to portal hypertension only and well-preserved synthetic hepatic function. Ten patients were treated with 12 shunt procedures, including mesoatrial (eight patients) and side to side portacaval shunt (four patients). Significant complications after shunt procedure included fulminant (one of ten patients) and progressive (one of ten patients) hepatic failure requiring urgent OLT; one death occurred because of pulmonary sepsis. Indications for OLT were signs of end stage liver expressed by severe portal hypertension and variceal bleeding (four of 14 patients), progressive encephalopathy (seven of 14 patients) and poor synthetic function (bilirubin greater than 3 milligrams per deciliter in eight of 14 patients and albumin less than 3.0 grams per liter, or both, in ten of 14 patients). Fourteen patients were treated with 16 OLT, three patients had retransplantation for primary nonfunction graft (two of 14 patients) or chronic rejection (one of 14 patients). There were two early deaths in the group. With a follow-up period between two months to five years, 12 of 14 patients undergoing OLT are alive, fully functional and have normal liver function tests. Seven of ten patients who had shunts are alive, six are able to maintain normal activity and one has progressive end stage hepatic disease and is not a candidate for OLT. However, the hepatic function continues progressively to be abnormal. Various options are available for the treatment of the syndrome. Portosystemic decompression is effective and should be considered at the early stage of the disease, prior to the development of significant hepatic failure. However, few of the patients will continue to have slow, but progressive hepatic failure and may require OLT. The only effective treatment for end stage hepatic disease secondary to the BCS is OLT.

Actuarial Analysis↗
PubMed1991

Race and liver transplantation.

Little is known about the effect of race on the outcome of liver transplantation. We retrospectively reviewed a series of 358 recipients of orthotopic liver transplants to address this issue. Black recipients were underrepresented compared with the general population (6% of transplant recipients vs 12% of the population). Black recipients appeared sicker when presenting for transplantation, as evidenced by a higher priority score and a significantly greater incidence of acute and fulminant presentation. Despite this, black recipients had survival rates following transplantation that were not significantly different from those of white recipients; the 1-, 2-, and 3-year actuarial survival rates of blacks were 89.6%, 68.3%, and 68.3%, respectively, while the actuarial survival rates of whites at the same periods were 86%, 82.4%, and 78.6%, respectively. We conclude that blacks can have an outcome equal to whites following liver transplantation but they are underrepresented compared with the general population.

Adolescent↗
PubMed1991

Results after liver retransplantation in a group of 50 regrafted patients: two different concepts of elective versus emergency retransplantation.

Liver retransplantation remains the only alternative therapy for irreversible graft failure. Previous studies have demonstrated lower survival rates for liver retransplantation than for primary grafts. After reviewing our clinical experience with 55 retransplantations out of 365 liver transplants, we found that the risk and results depend on the surrounding circumstances. Elective retransplantation was shown to be as safe as the first liver transplantation, while emergency retransplantation yielded significantly higher morbidity and mortality rates.

Adolescent↗
PubMed1991

Long-term survival and renal function following liver transplantation in patients with and without hepatorenal syndrome--experience in 300 patients.

We have retrospectively reviewed the first 308 patients undergoing orthotopic liver transplantation (OLTX) at our institution to determine the following: 1) To what extent does renal function deteriorate postoperatively? 2) To what extent does renal function recover after OLTX for hepatorenal syndrome (HRS)? 3) What is the survival rate of patients with HRS compared with those without HRS? In non-HRS patients, GFR declined from 97.1 +/- 2.9 cc/min to 56.6 +/- 2.4 cc/min at 6 weeks postoperative, 62.6 +/- 2.6 cc/min at 1 year, and 58.3 +/- 3.5 cc/min at 2 years. In HRS patients, GFR increased from 19.9 +/- 3.6 cc/min to 32.5 +/- 3.1 cc/min at 6 weeks, 45.9 +/- 5.5 cc/min at 1 year, and 37.9 +/- 5.9 cc/min at 2 years. Dosages of cyclosporine were comparable in both groups. There was no difference in perioperative (90-day) mortality. One- and 2-year actuarial survival rates in the non-HRS patients were 87.2% and 82.1%, respectively. The actuarial 1- and 2-year survival rate for the HRS patients was 76.6% (P = NS). Ten percent of HRS patients developed ESRD posttransplant compared with 0.8% of non-HRS patients (P less than 0.005). We conclude that patients with HRS can safely undergo OLTX with acceptable perioperative mortality and good long-term survival. Most HRS patients have return of acceptable renal function. Patients without HRS have a severe decline in GFR posttransplant, which is stable up to 3 years posttransplant.

Creatinine↗
PubMed1990

The influence of preservation injury on rejection in the hepatic transplant recipient.

The records of 215 liver transplant recipients were reviewed and the degree of preservation injury was estimated by the initial aminotransferase levels. This was compared with the incidence of rejection found in the subsequent 30 days. Those with aspartate aminotransferase greater than 2000 U/L were classified as having severe preservation injury while those with ASAT less than 600 U/L were considered to have had minimal preservation injury. There were no significant differences between these groups in recipient age, sex, cold ischemia time, preoperative physical status, panel-reactive antibodies, or cytotoxic crossmatch. The solution used for organ preservation and the donor age were the only factors that were found to be significantly different between the groups. Older donors were more common in the severe preservation injury group. Severe preservation injury was found more frequently in grafts preserved in Eurocollins solution and the group with minimal preservation injury more frequently used Wisconsin solution. There was significantly more rejection seen in the severe preservation injury group (71%) than in the group without preservation injury (33%). Although there was more rejection in the severe preservation injury group, the rejections were not more severe as judged by the need for multiple courses of therapy or the need for OKT3. Recurrent rejection was also not more frequent in either group. Graft survival was worse in the severe preservation injury group, with a significant increase in early graft loss, but no difference in the frequency of chronic rejection. Recovery of graft function was also delayed in the preservation injury group.

Adenosine↗
PubMed1990

A comparison of UW with Eurocollins preservation solution in liver transplantation.

Fifty consecutive liver transplants were performed using livers perfused with and stored in University of Wisconsin preservation solution. These grafts were compared with the preceding 55 consecutive transplants performed using livers perfused and preserved with Eurocollins solution. The purpose of the study was to determine if organs preserved with UW solution functioned better after transplantation than organs preserved with Eurocollins. Extensive retrospective analysis of prospectively accumulated data included enzyme levels through 30 days, cost and length of hospital stay, blood product usage, and ischemia time. Average age of patients in the UW group was 47.1 years compared with 39.6 years in the EC group (P less than 0.05); cold ischemia time was 7.21 hr in the UW group compared with 5.21 in EC (P = 0.0001). Total bilirubin values were significantly lower on days 0-6 and day 14, but not day 30, in the UW group. Aspartate aminotransferase was significantly lower in the UW group on days 0-1, 3-6, and 14, but not on day 3 or day 30. Prothrombin times were significantly lower in the UW group across all times (days 0-6, 14, and 30). Intraoperative and postoperative use of packed red blood cells and fresh frozen plasma was lower in the UW group (P less than or equal to .05). Also, total hospital days, intensive care unit days, and hospital cost to the patient were lower in the UW group (P less than or equal to .05). A second analysis was done comparing only nonemergent transplants from both groups. These results confirmed the initial analysis of a longer cold ischemia time in the UW group (P less than 0.001), and improved enzyme values in the TBR, AST, and PT in the UW group (P less than 0.05). Also, hospital cost in the UW group was again lower (P less than 0.05). In this nonrandomized study, the cold ischemia time was increased but kept close to that of the control group. We conclude that UW solution is an improved donor liver preservation solution on the basis of improved enzyme values, decreased blood usage, shorter hospital stay, and lower hospital charges.

Adenosine↗
PubMed1990

Liver transplantation, 1990: a Dallas perspective.

A retrospective analysis was undertaken on patients undergoing liver transplantation between April 1985 and May 1980 at Baylor University Medical Center, Dallas, Texas. A total of 358 patients were evaluated, 416 of whom received liver transplants, including 15 simultaneous liver/kidney transplants. The overall patient survival in this group was 82% at 1 year and 75% at 3 years, using Kaplan-Meier life tables.

Adult↗
PubMed1990

Problematic vascular reconstruction in liver transplantation. Part I. Arterial.

Arterial inflow is essential for graft function after liver transplantation. Sometimes the recipient celiac axis is not suitable for anastomosis, and in these cases a conduit from either the aorta or iliac artery is an alternative. We retrospectively reviewed 32 patients who required arterial conduits and compared them with a matched control group who underwent standard arterial reconstruction (donor celiac artery to recipient celiac artery). The indications and surgical technique for arterial conduits are presented. There were no differences in intraoperative vascular flow studies, postoperative liver function, or incidence of rejection in the two groups. There were, however, more deaths in the conduit group, two of which are related to the retropancreatic conduit technique, with the others caused by the patients' underlying condition at transplantation. There was no morbidity or death associated with the antepancreatic conduit techniques. We therefore believe the use of arterial conduits from the aorta or iliac artery, when placed antepancreatically, are safe and should be used without reservation when indicated.

Arteries↗
PubMed1990

Problematic vascular reconstruction in liver transplantation. Part II. Portovenous conduits.

Eight of 265 orthotopic liver transplant procedures performed at this institution since December 1984 have used venous conduits to reconstruct an occluded portal system and supply portal blood to the allograft. The factors mandating the use of these conduits were variable, and several reconstructive techniques were used. We present a series of patients with various conditions in which portal conduits were indicated and describe and illustrate the inherent technical considerations.

Anastomosis, Surgical↗