Organ transplantation at the Hartford Transplant Center.

Over 1,243 organ transplants have been performed at the Hartford Transplant Center over the past two decades. Survival in kidney, heart, liver, and pancreas patients is at or above the national average. Hartford was one of the first centers to use triple immunosuppression, which significantly improved survival in kidney transplantation. For recipients of kidneys from living related donors and cadaveric kidneys, two-year actuarial graft survival has been 98% and 83%, respectively, over the last five years. For heart and liver transplants, two-year survival has been 79% and 67%, respectively. Despite high success rates at most transplant centers, donor organs remain scarce. This problem needs to be addressed through increased cooperative efforts in the health-care community and the general public.

Albumin improves islet isolation: specific versus nonspecific effects.

1. BSA-containing solutions improve islet yields using standard collagenase digestion techniques. 2. The BSA effect on islet isolation is independent of source and lot of collagenase. 3. The BSA effect on islet isolation is not due solely to its colloid action, as HES failed to achieve the same level of improvement seen with albumin. 4. BSA can protect islets from warm ischemic injury, and the protective action appears to be unique to albumin, as HES was not as effective.

Management of cholelithiasis in heart and kidney transplant patients: with review of laparoscopic cholecystectomy.

The purpose of this study was to determine the incidence of cholelithiasis among heart and kidney transplant recipients. Since recommendations for cholecystectomy in transplant recipients varies widely, we discuss guidelines for surgery including laparoscopic techniques. We reviewed the records of 114 patients who underwent heart transplantation from 1984 to 1993 and 539 kidney transplant patients from 1972 to 1993. Recipients of heart and kidney transplants were found to have an incidence of cholelithiasis of 12% and 3% respectively. Pretransplantation ultrasound surveillance was used in heart transplant recipients and 64% of these with asymptomatic cholelithiasis have not required surgery with close follow-up from six months to six years. Thirty-six percent of the heart patients underwent cholecystectomy. All symptomatic renal transplant patients undergoing ultrasound with the findings of cholelithiasis underwent cholecystectomy. Open cholecystectomies were performed prior to the advent of laparoscopic surgery in six of the first seven attempts. Laparoscopic cholecystectomy on heart and kidney transplant recipients was well tolerated with admission the same day of surgery, a one to two day hospital stay and maintenance of oral immunosuppression. There was a single complication of leg thrombophlebitis, no mortality, and allograft rejection did not occur.

Liver transplantation for acute fulminant hepatic failure.

Orthotopic liver transplantation (OLT) remains the only option for progressive acute fulminant hepatic failure (FHF). The overall one-year survival is approximately 58% versus 75% for all patients undergoing OLT. Nevertheless, this is superior to the results obtained with medical management alone, which carries a mortality of approximately 60-85%. Seven of 32 patients at Hartford Hospital (22%) received liver transplants for acute FHF; the one-year survival was 57%. Four of seven patients are alive with complete neurologic recovery. One case is presented in detail.

Noncompliance in organ transplant recipients.

The frequency of noncompliance with postoperative medical therapy ranges from 2% to 43% in organ transplant recipients and causes more graft loss than uncontrolled rejection in compliant patients. Retrospective and prospective studies undertaken at our center showed no difference in the rate of noncompliance between males and females or between recipients of cadaveric kidneys and those from living, related donors. Patients less than 20 years of age were statistically the most noncompliant (p = 0.0001) compared with those over 40 years. A significant difference in compliance was seen among blacks, Hispanics, and non-Hispanic whites, with the greatest frequency in blacks. This was not due to race, but to socioeconomic status, with those in the low socioeconomic group the most noncompliant. Problems of noncompliance may be reduced if they are identified early in the treatment course.

Renal transplantation at Hartford Hospital: results of combined and flexible immunosuppression.

1. Three groups of first cadaver kidney transplant recipients at Hartford Hospital were analyzed. All received AZA and P, and most received pretransplant blood transfusions. The first group, 41 patients transplanted from 1977-1979, had a 2 year graft survival of 49%; the second group, 72 patients transplanted from 1980 to 1984 had an emphasis on DR typing and 2-year graft survival of 61%. The third group had the addition of CsA (triple immunosuppression) from 1984 to October, 1988. These 200 patients had a 2-year graft survival of 87%. The 2-year patient survival was 82%, 85%, and 94% for the 3 groups, respectively. 2. Triple immunosuppression resulted in less frequent and less severe rejection activity. There was no increase in serious infection and no significant elevation in mean serum creatinine at a 2-year follow-up, when compared to a control group receiving AZA and P. 3. DST was used selectively for one haplotype living-related donor kidney transplants, and in HLA-identical sibling kidney transplantation. Triple immunosuppression was also used in living-related donor kidney transplants, but in a very low-dose range. Only 3 of 58 grafts in living-related donor kidney transplants have been lost in the past 4 years; none due to rejection. 4. OKT3 therapy has been used primarily for steroid-resistant rejection, usually resulting in reversal, but also in a significant increase in CMV infection. When an "OKT3 available" group of cadaver kidney transplant recipients was compared to a previous control group, OKT3 therapy did not appear to improve the overall results. 5. Patients receiving retransplantation experienced a better success rate than reported at many other centers, (72% graft survival at 2 years). The use of OKT3 or ATG and DR matching contributed to the success. 6. The average ATN rate for all perfused kidneys was 36%; 50% for those preserved longer than 28 hours. Imported kidneys preserved with Euro Collins solution had a 63% ATN rate versus 36% for locally procured kidneys. There was no significant difference in graft survival in patients with or without posttransplant ATN.