Evans syndrome in a pediatric liver transplant recipient with an autoantibody with apparent specificity for the KEL4 (Kpb) antigen.

Although most warm red blood cell (RBC) autoantibodies react broadly with panel cells in addition to the patient's own RBCs, occasionally an autoantibody with specificity for a specific blood group antigen is encountered. Rare cases of warm autoantibodies with specificity for the Kpb antigen of the Kell blood group system have been described. We report a pediatric transplant recipient with anemia, immune-mediated hemolysis, thrombocytopenia, and a warm autoantibody with apparent anti-Kpb specificity. The patient's autoimmune anemia and thrombocytopenia responded well to discontinuing the immunosuppressant tacrolimus, trans- fusions with Kp(b-) RBCs, and intravenous immunoglobulin therapy, with disappearance of the pathologic antibody. During the autoimmune hemolysis, the patient's RBCs did not react with antisera specific for Kpb. However, repeat testing of the patient's RBCs with Kpb-specific antisera 15 months after the resolution of hemolysis showed reactivity, indicating that the RBC autoantibody was associated with a transient disappearance of the Kpb antigen.

Favorable results of coronary artery bypass and/or valve replacement in octogenarians.

Between October 1987 and July 1990, of 763 patients undergoing open heart surgery, 43 (5.6%) were 80 (mean and median 82) years of age or older. There were 20 men and 23 women. Eighteen patients (42%) were initially assessed using the angina score of the New York Heart Association or Canadian Cardiovascular Association as class IV. Nine procedures (21%) were performed electively and 34 (79%) urgently. A total of 26 patients (60%) underwent coronary bypass surgery, while 11 (26%) had valve replacements and six (14%) had both coronary bypass surgery and valve replacement; 74% of the patients received two or more grafts. The hospital mortality rate of the octogenarian patients was 9% (four of 43), significantly higher (P < 0.05) than the overall hospital mortality rate of 3.6% for patients < or = 79 years of age. A history of myocardial infarction within 2 weeks before the procedure was obtained in nine of 43 patients (21%); 22 (51%) had experienced at least one myocardial infarction before surgery. Ejection fractions were 'normal' in 28 patients (65%), 'fair' in nine (21%) and 'poor' in six (14%). The mean length of hospital stay for the octogenarian patients was 19 (range 8-64) days. Thirty-five of the 39 operative survivors were followed for a mean of 14 (range 3-35) months. The actuarial probability of survival was 86% at the end of this time. A total of 31 patients (79%) assessed using the angina score of the New York Heart Association or Canadian Cardiovascular Association were class I or II. During the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)

Vasodilator correction of hypotension in the postoperative period.

This case is unusual in that hypotension, as opposed to hypertension, was a consequence of increased sympathetic tone in the postoperative period, but it illustrates the well known fact that patients in compensated congestive heart failure do poorly when faced with an elevated myocardial oxygen need from either increased rate or afterload. Vasodilator therapy was effective in immediately reducing afterload and systolic regurgitant fraction, thereby increasing oxygen supply and lowering myocardial oxygen consumption.