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1.
Clin Transplant ; 37(9): e15036, 2023 09.
Artículo en Inglés | MEDLINE | ID: mdl-37218656

RESUMEN

INTRODUCTION: Detection of alcohol (ETOH) use with biomarkers provides an opportunity to intervene and treat patients with alcohol use disorder before and after liver transplant (LT). We describe our center's experience using urine ethyl glucuronide (EtG) and serum phosphatidylethanol (PEth) in alcohol screening protocols. METHODS: Single-center, retrospective review of patients presenting for LT evaluation, patients waitlisted for LT for alcohol-associated liver disease (ALD), and patients who received a LT for ALD over a 12-month period, from October 1, 2019 through September 30, 2020. Patients were followed from waitlisting to LT, or for up to 12 months post-LT. We monitored protocol adherence to screening for ETOH use- defined as completion of all possible tests over the follow-up period- at the initial LT visit, while on the LT waitlist and after LT. RESULTS: During the study period, 227 patients were evaluated for LT (median age 57 years, 58% male, 78% white, 54.2% ALD). Thirty-one patients with ALD were placed on the waitlist, and 38 patients underwent LT for ALD during this time period. Protocolized adherence to screening for alcohol use was higher for PEth for all LT evaluation patients (191 [84.1%] vs. 146 [67%] eligible patients, p < .001), in patients with ALD waitlisted for LT (22 [71%] vs. 14 (48%] eligible patients, p = .04) and after LT for ALD, 20 (33 [86.8%] vs. 20 [52.6%] eligible patients, p < .01). Few patients with a positive test in any group completed chemical dependency treatment. CONCLUSIONS: When screening for ETOH use in pre- and post-LT patients, protocol adherence is higher using PEth compared to EtG. While protocolized biomarker screening can detect recurrent ETOH use in this population, engagement of patients into chemical dependency treatment remains challenging.


Asunto(s)
Alcoholismo , Hepatopatías Alcohólicas , Trasplante de Hígado , Humanos , Masculino , Persona de Mediana Edad , Femenino , Mejoramiento de la Calidad , Consumo de Bebidas Alcohólicas , Alcoholismo/diagnóstico , Etanol , Biomarcadores
2.
Diabetes Metab ; 45(3): 301-305, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-29395812

RESUMEN

AIM: Islet autotransplantation (IAT) is considered a 'non-immune' model of islet transplant, with no risk for autoimmune-mediated beta cell loss, but we have previously observed de novo type 1 diabetes in one total pancreatectomy with islet autotransplantation (TPIAT) recipient. We aimed to investigate the clinical significance of glutamic acid decarboxylase antibodies (GADA), as a sensitive marker for autoimmune diabetes mellitus (DM), in patients with chronic pancreatitis undergoing TPIAT. METHODS: We identified 9 patients undergoing TPIAT with elevated GADA pre-TPIAT (8 non-diabetic and 1 with C-peptide positive DM), otherwise demographically similar to GADA negative TPIAT recipients (n=341). Metabolic and clinical measures related to islet cell function were recorded both before and after TPIAT. RESULTS: None of the 9 TPIAT patients achieved insulin independence after surgery, vs. 33% of GADA negative patients (n=318 with 1-yr follow-up). The two patients with the highest titters of GADA (>250 IU/mL) both experienced islet graft failure, despite normoglycaemia pre-TPIAT and high islet mass transplanted (5276 and 9378 IEQ per kg), with elevated HbA1c levels post-TPIAT (8.3%, 9.6%). The remaining 7 seven were insulin dependent with partial graft function and HbA1c levels <7%. CONCLUSION: Insulin dependence was more frequent in 9 patients with elevated GADA prior to TPIAT than in GADA negative TPIAT recipients, with graft failure in 2 cases. We speculate that beta-cell autoimmunity may occur in a small subset of TPIAT recipients and that beta cell antibody testing prior to TPIAT may be warranted to identify individuals at higher risk for insulin dependence.


Asunto(s)
Autoanticuerpos , Diabetes Mellitus Tipo 1/cirugía , Glutamato Descarboxilasa/inmunología , Trasplante de Islotes Pancreáticos/métodos , Pancreatectomía/métodos , Pancreatitis Crónica/cirugía , Adulto , Diabetes Mellitus Tipo 1/inmunología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pancreatitis Crónica/inmunología , Pronóstico , Trasplante Autólogo , Adulto Joven
3.
Transplant Proc ; 50(10): 3937-3939, 2018 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-30577290

RESUMEN

Genitourinary (GU) tract infection with Mycobacterium avium intracellulare complex (MAI) is very rare and, to our knowledge, has never been reported in the solid organ transplant literature. CASE DESCRIPTION: A 61-year-old Somali-born woman had a history of liver cirrhosis due to chronic hepatitis C infection. She was diagnosed as having and treated for latent tuberculosis infection and GU tract infection due to MAI. She received a total of 17 months antimycobacterial therapy consisting of azithromycin, ethambutol, and moxifloxacin. Within 5 months of the initiation of antimicrobial therapy, there was documented sterilization of urine mycobacterial cultures. Liver and kidney transplant was performed 3 months after finishing the treatment course. One year following transplant, GU tract infection due to MAI recurred. She declined further diagnostic testing as well as mycobacterial therapy. She died 15 months following transplant for reasons not related to infections. CONCLUSION: The treatment of MAI infection in solid organ transplant candidates and recipients is challenging, and the duration of therapy in this population is not known. The recurrence of infection following transplant in this case may argue in favor of a duration that extends beyond the date of transplant. The combination of a fluoroquinolone and ethambutol may successfully prevent reactivation of tuberculosis in patients with history of latent tuberculosis infection and deserves further evaluation.


Asunto(s)
Antibacterianos/uso terapéutico , Trasplante de Riñón , Trasplante de Hígado , Infección por Mycobacterium avium-intracellulare/inmunología , Etambutol/uso terapéutico , Femenino , Fluoroquinolonas/uso terapéutico , Humanos , Huésped Inmunocomprometido , Tuberculosis Latente/complicaciones , Persona de Mediana Edad , Complejo Mycobacterium avium , Infección por Mycobacterium avium-intracellulare/complicaciones , Infección por Mycobacterium avium-intracellulare/tratamiento farmacológico , Recurrencia , Infecciones Urinarias/complicaciones , Infecciones Urinarias/tratamiento farmacológico , Infecciones Urinarias/inmunología
4.
Pediatr Transplant ; 22(3): e13154, 2018 05.
Artículo en Inglés | MEDLINE | ID: mdl-29388290

RESUMEN

Many pediatric centers utilize a variety of protocols including preemptive plasmapheresis to prevent the recurrence of FSGS post-transplant. But the effectiveness of this expensive, time-consuming process of plasmapheresis in the prevention of FSGS recurrence is still unclear. We retrospectively reviewed all pediatric cases of FSGS in our center that received a kidney transplant and compared the transplant and patient outcomes of those transplanted after 2006 who received pretransplant plasmapheresis to those prior to 2006 who did not. Of the 57 children with FSGS, 31 and 26 were transplanted before and after 2006, respectively. The cohorts differed significantly in keeping with the center immunosuppression protocol changes, and prior to 2006, the recipients were significantly younger. All children with FSGS transplanted after 2006 underwent three and one sessions of 1.0 plasma volume/exchange plasmapheresis with fresh frozen plasma replacement prior to the transplant in living and deceased donors, respectively, in addition to five sessions of every other day post-transplant pheresis. The incidence (27% vs 26%, P = 1.0) and time to recurrence of FSGS in the kidney allograft (P = .22) were not significantly different in patients that did and did not undergo prophylactic plasmapheresis. We need to re-evaluate the role of preemptive plasmapheresis in the prevention of FSGS recurrence in a prospective multicenter study.


Asunto(s)
Glomeruloesclerosis Focal y Segmentaria/terapia , Trasplante de Riñón , Atención Perioperativa/métodos , Plasmaféresis/métodos , Adolescente , Niño , Preescolar , Femenino , Humanos , Masculino , Recurrencia , Estudios Retrospectivos , Resultado del Tratamiento
5.
Transplant Proc ; 49(2): 309-315, 2017 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-28219590

RESUMEN

We analyzed the effectiveness of paravertebral-block for immediate postoperative pain control in living liver donors. Specifically, we sought to determine whether or not the addition of paravertebral catheters with continuous ropivacaine infusion would decrease postoperative opioid use and reduce the incidence of adverse effects and complications. We reviewed the records of 26 patients who underwent right-lobe living donor hepatectomy (RLDH): 16 with and 10 without such catheters. The primary outcome was opioid use on postoperative day (POD) 1 through 3. For each of those 3 days, we calculated each patient's opioid use in morphine equivalents (mg). We also noted pain scores, adverse effects, and complications. The rate of decrease in morphine equivalents was higher in the catheter group (rate of change = -22.72; P = .038) for POD 1 (0-24 hours) and POD 2 (25-48 hours) than in the noncatheter group. For POD 2 alone, the catheter group used, on average, 20.98 mg fewer morphine equivalents than the noncatheter group (P = .023). The catheter group had a markedly reduced pain trajectory postoperatively (P = .014) than the noncatheter group. The catheter placement procedure itself was safe.


Asunto(s)
Amidas/administración & dosificación , Anestésicos Locales/administración & dosificación , Trasplante de Hígado/métodos , Donadores Vivos , Dolor Postoperatorio/prevención & control , Adulto , Anciano , Analgésicos Opioides/administración & dosificación , Cateterismo Periférico , Femenino , Hepatectomía/métodos , Humanos , Infusión Espinal , Hígado/cirugía , Trasplante de Hígado/efectos adversos , Masculino , Morfina/administración & dosificación , Bloqueo Nervioso/métodos , Dimensión del Dolor , Dolor Postoperatorio/etiología , Estudios Retrospectivos , Ropivacaína , Sitio Donante de Trasplante/cirugía , Resultado del Tratamiento
6.
Am J Transplant ; 17(6): 1670-1673, 2017 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-28133953

RESUMEN

In small children with end-stage renal disease, an adult-sized kidney transplant is the best option. However, in the face of a completely thrombosed inferior vena cava (IVC), such transplants can be challenging, given the difficulty of achieving adequate renal venous outflow and the risk of graft thrombosis. Using a new technique to anastomose the renal vein to the right hepatic vein/IVC junction, we successfully implanted an adult-sized graft in two small children (9.8 and 14 kg) who had end-stage renal disease and a completely thrombosed IVC. After mobilizing the right lobe of the liver and obtaining total vascular occlusion of the liver, we used a Fogarty catheter to dilate the retrohepatic IVC. In the right hepatic vein, we made a venotomy and extended it inferiorly onto the retrohepatic IVC. To that venotomy, we anastomosed the donor left renal vein, using continuous 7-0 Prolene sutures. Both patients attained excellent renal allograft function: One had a serum creatinine level of 0.30 mg/dL at 6 mo after transplant, and the other had a level of 0.29 mg/dL at 1 year. In these two small children with completely thrombosed IVC, our technique for transplanting an adult-sized kidney provided adequate venous outflow.


Asunto(s)
Trasplante de Riñón , Vena Cava Inferior/cirugía , Trombosis de la Vena/cirugía , Adulto , Preescolar , Femenino , Humanos , Recién Nacido , Donadores Vivos , Masculino , Pronóstico
7.
Am J Transplant ; 17(4): 1112-1118, 2017 04.
Artículo en Inglés | MEDLINE | ID: mdl-27643615

RESUMEN

Beta cell death may occur both after islet isolation and during infusion back into recipients undergoing total pancreatectomy with islet autotransplantation (TPIAT) for chronic pancreatitis. We measured the novel beta cell death marker unmethylated insulin (INS) DNA in TPIAT recipients before and immediately after islet infusion (n = 21) and again 90 days after TPIAT, concurrent with metabolic functional assessments (n = 25). As expected, INS DNA decreased after pancreatectomy (p = 0.0002). All TPIAT recipients had an elevated unmethylated INS DNA ratio in the first hours following islet infusion. In four samples (three patients), INS DNA was also assessed immediately after islet isolation and again before islet infusion to assess the impact of the isolation process: Unmethylated and methylated INS DNA fractions both increased over this interval, suggesting death of beta cells and exocrine tissue before islet infusion. Higher glucose excursion with mixed-meal tolerance testing was associated with persistently elevated INS DNA at day 90. In conclusion, we observed universal early elevations in the beta cell death marker INS DNA after TPIAT, with pronounced elevations in the islet supernatant before infusion, likely reflecting beta cell death induced by islet isolation. Persistent posttransplant elevation of INS DNA predicted greater hyperglycemia at 90 days.


Asunto(s)
Metilación de ADN , ADN/química , Diabetes Mellitus Tipo 1/cirugía , Células Secretoras de Insulina/patología , Insulina/genética , Trasplante de Islotes Pancreáticos , Pancreatectomía/efectos adversos , Pancreatitis Crónica/cirugía , Adolescente , Adulto , Biomarcadores/metabolismo , Niño , ADN/genética , Femenino , Rechazo de Injerto , Supervivencia de Injerto , Humanos , Células Secretoras de Insulina/metabolismo , Masculino , Complicaciones Posoperatorias , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Trasplante Autólogo , Adulto Joven
8.
Am J Transplant ; 17(2): 443-450, 2017 02.
Artículo en Inglés | MEDLINE | ID: mdl-27459721

RESUMEN

Insulin independence after total pancreatectomy and islet autotransplant (TPIAT) for chronic pancreatitis is limited by a high rate of postprocedure beta cell apoptosis. Endogenous glucagon-like peptide-1 and glucose-dependent insulinotropic peptide, which are increased by dipeptidyl peptidase 4 inhibitor therapy (sitagliptin) may protect against beta cell apoptosis. To determine the effect of sitagliptin after TPIAT, 83 adult TPIAT recipients were randomized to receive sitagliptin (n = 54) or placebo (n = 29) for 12 months after TPIAT. At 12 and 18 months after TPIAT, participants were assessed for insulin independence; metabolic testing was performed with mixed meal tolerance testing and frequent sample intravenous glucose tolerance testing. Insulin independence did not differ between the sitagliptin and placebo groups at 12 months (42% vs. 45%, p = 0.82) or 18 months (36% vs. 44%, p = 0.48). At 12 months, insulin dose was 9.0 (standard error 1.7) units/day and 7.9 (2.2) units/day in the sitagliptin and placebo groups, respectively (p = 0.67) and at 18 months 10.3 (1.9) and 7.1 (2.6) units/day, respectively (p = 0.32). Hemoglobin A1c levels and insulin secretory measures were similar in the two groups, as were adverse events. In conclusion, sitagliptin could be safely administered but did not improve metabolic outcomes after TPIAT.


Asunto(s)
Diabetes Mellitus/terapia , Rechazo de Injerto/tratamiento farmacológico , Supervivencia de Injerto/efectos de los fármacos , Células Secretoras de Insulina/patología , Trasplante de Islotes Pancreáticos/efectos adversos , Pancreatectomía/efectos adversos , Fosfato de Sitagliptina/uso terapéutico , Adulto , Glucemia , Femenino , Hemoglobina Glucada , Rechazo de Injerto/etiología , Humanos , Hipoglucemiantes/uso terapéutico , Masculino , Trasplante Autólogo
9.
Minerva Chir ; 70(1): 57-62, 2015 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-25584826

RESUMEN

Pancreas transplants are now highly effective for patients with diabetes mellitus. Improvements in outcomes have primarily been due to significant reductions in technical failures and immunological graft loss. In this short review we discuss three areas of controversy in the field of pancreas transplantation. Notwithstanding the controversies we have highlighted, in line with the American Diabetic Association position statement, simultaneous pancreas-kidney transplants and pancreas after kidney transplants should be routine for diabetic kidney recipients, and a pancreas transplant alone is appropriate for non-uremic labile diabetic patients.


Asunto(s)
Diabetes Mellitus/cirugía , Trasplante de Riñón , Trasplante de Páncreas , Guías como Asunto , Humanos , Trasplante de Riñón/tendencias , Trasplante de Páncreas/tendencias , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento
10.
Am J Transplant ; 14(5): 1120-8, 2014 May.
Artículo en Inglés | MEDLINE | ID: mdl-24731165

RESUMEN

Use of grafts from donation after circulatory death (DCD) as a strategy to increase the pool of transplantable livers has been limited due to poorer recipient outcomes compared with donation after brain death (DBD). We examined outcomes of recipients of failed DCD grafts who were selected for relisting with regard to waitlist mortality and patient and graft survival after retransplant. From the Scientific Registry of Transplant Recipients database, we identified 1820 adults who underwent first deceased donor liver transplant January 1, 2004 to June 30, 2011, and were relisted due to graft failure; 12.7% were DCD recipients. Compared with DBD recipients, DCD recipients had better waitlist survival (90-day mortality: 8%, DCD recipients; 14-21%, DBD recipients). Of 950 retransplant patients, 14.5% were prior DCD recipients. Graft survival after second liver transplant was similar for prior DCD (28% graft failure within 1 year) and DBD recipients (30%). Patient survival was slightly better for prior DCD (25% death within 1 year) than DBD recipients (28%). Despite higher overall graft failure and morbidity rates, survival of prior DCD recipients who were selected for relisting and retransplant was not worse than survival of DBD recipients.


Asunto(s)
Rechazo de Injerto/mortalidad , Hepatopatías/cirugía , Trasplante de Hígado/mortalidad , Complicaciones Posoperatorias , Donantes de Tejidos , Obtención de Tejidos y Órganos/estadística & datos numéricos , Adulto , Muerte , Femenino , Estudios de Seguimiento , Rechazo de Injerto/etiología , Rechazo de Injerto/cirugía , Supervivencia de Injerto , Humanos , Hepatopatías/complicaciones , Trasplante de Hígado/efectos adversos , Masculino , Persona de Mediana Edad , Pronóstico , Reoperación , Factores de Riesgo , Tasa de Supervivencia , Listas de Espera
11.
Am J Transplant ; 13(12): 3183-91, 2013 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-24148548

RESUMEN

The simple question of how much tissue volume (TV) is really safe to infuse in total pancreatectomy-islet autotransplantation (TP-IAT) for chronic pancreatitis (CP) precipitated this analysis. We examined a large cohort of CP patients (n = 233) to determine major risk factors for elevated portal pressure (PP) during islet infusion, using bivariate and multivariate regression modeling. Rates of bleeding requiring operative intervention and portal venous thrombosis (PVT) were evaluated. The total TV per kilogram body weight infused intraportally was the best independent predictor of change in PP (ΔPP) (p < 0.0001; R(2) = 0.566). Rates of bleeding and PVT were 7.73% and 3.43%, respectively. Both TV/kg and ΔPP are associated with increased complication rates, although ΔPP appears to be more directly relevant. Receiver operating characteristic analysis identified an increased risk of PVT above a suggested cut-point of 26 cmH2O (area under the curve = 0.759), which was also dependent on age. This ΔPP threshold was more likely to be exceeded in cases where the total TV was >0.25 cm(3)/kg. Based on this analysis, we have recommended targeting a TV of <0.25 cm(3)/kg during islet manufacturing and to halt intraportal infusion, at least temporarily, if the ΔPP exceeds 25 cmH2O. These models can be used to guide islet manufacturing and clinical decision making to minimize risks in TP-IAT recipients.


Asunto(s)
Trasplante de Islotes Pancreáticos/métodos , Islotes Pancreáticos/citología , Páncreas/cirugía , Pancreatectomía/métodos , Pancreatitis Crónica/terapia , Adolescente , Adulto , Anciano , Peso Corporal , Niño , Preescolar , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Pancreatitis , Vena Porta/patología , Curva ROC , Factores de Riesgo , Trombosis , Resultado del Tratamiento , Adulto Joven
12.
Am J Transplant ; 13(10): 2664-71, 2013 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-23924045

RESUMEN

Islet autotransplant (IAT) may ameliorate postsurgical diabetes following total pancreatectomy (TP), but outcomes are dependent upon islet mass, which is unknown prior to pancreatectomy. We evaluated whether preoperative metabolic testing could predict islet isolation outcomes and thus improve assessment of TPIAT candidates. We examined the relationship between measures from frequent sample IV glucose tolerance tests (FSIVGTT) and mixed meal tolerance tests (MMTT) and islet mass in 60 adult patients, with multivariate logistic regression modeling to identify predictors of islet mass ≥2500 IEQ/kg. The acute C-peptide response to glucose (ACRglu) and disposition index from FSIVGTT correlated modestly with the islet equivalents per kilogram body weight (IEQ/kg). Fasting and MMTT glucose levels and HbA1c correlated inversely with IEQ/kg (r values -0.33 to -0.40, p ≤ 0.05). In multivariate logistic regression modeling, normal fasting glucose (<100 mg/dL) and stimulated C-peptide on MMTT ≥4 ng/mL were associated with greater odds of receiving an islet mass ≥2500 IEQ/kg (OR 0.93 for fasting glucose, CI 0.87-1.0; OR 7.9 for C-peptide, CI 1.75-35.6). In conclusion, parameters obtained from FSIVGTT correlate modestly with islet isolation outcomes. Stimulated C-peptide ≥4 ng/mL on MMTT conveyed eight times the odds of receiving ≥2500 IEQ/kg, a threshold associated with reasonable metabolic control postoperatively.


Asunto(s)
Glucemia/metabolismo , Diabetes Mellitus Tipo 1/prevención & control , Trasplante de Islotes Pancreáticos , Islotes Pancreáticos/metabolismo , Pancreatectomía , Pancreatitis Crónica/cirugía , Complicaciones Posoperatorias/prevención & control , Adulto , Péptido C/análisis , Femenino , Estudios de Seguimiento , Prueba de Tolerancia a la Glucosa , Humanos , Masculino , Cuidados Preoperatorios , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Trasplante Autólogo
13.
Am J Transplant ; 13(7): 1840-9, 2013 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-23711225

RESUMEN

Technical failure (TF) continues to have a significant impact on the success of pancreas transplantation. We assessed risk factors for TF in 1115 pancreas transplants performed at a single center between 1998 and 2011. The overall TF rate was 10.2%. In a multivariable model, donor BMI ≥ 30 (HR 1.87, p = 0.005), donor Cr ≥ 2.5 (HR 3.16, p = 0.007), donor age >50 (HR 1.73, p = 0.082) and preservation time >20 h (HR 2.17, p < 0.001) were associated with TF. Bladder drainage of exocrine secretions was protective (HR 0.54, p = 0.002). We incorporated these factors in a Composite Risk Model. In this model the presence of one risk factor did not significantly increase risk of TF (HR 1.35, p = 0.346). Two risk factors in combination increased risk greater than threefold (HR 3.65, p < 0.001) and three risk factors increased risk greater than sevenfold (HR 7.66, p = <0.001). The analysis also identified many factors that were not predictive of TF, including previous transplants, immunosuppressive agent selection, and almost all recipient demographic parameters. While the model suggests that two or more risk factors predict TF, strategies to reduce preservation time may mitigate some of this risk.


Asunto(s)
Rechazo de Injerto/epidemiología , Trasplante de Páncreas , Sistema de Registros , Medición de Riesgo/métodos , Femenino , Estudios de Seguimiento , Rechazo de Injerto/etiología , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Obtención de Tejidos y Órganos/normas , Insuficiencia del Tratamiento , Estados Unidos/epidemiología
14.
Am J Transplant ; 13(4): 961-970, 2013 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-23432755

RESUMEN

Rapid discontinuation of prednisone (RDP) has minimized steroid-related complications following kidney transplant (KT). This trial compares long-term (10-year) outcomes with three different maintenance immunosuppressive protocols following RDP in adult KT. Recipients (n=440; 73% living donor) from March 2001 to April 2006 were randomized into one of three arms: cyclosporine (CSA) and mycophenolate mofetil (MMF) (CSA/MMF, n=151); high-level tacrolimus (TAC, 8-12 µg/L) and low-level sirolimus (SIR, 3-7 µg/L) (TACH/SIRL, n=149) or low-level TAC (3-7 µg/L) and high-level SIR (8-12 µg/L) (TACL/SIR(H) , n=140). Median follow-up was ∼7 years. There were no differences between arms in 10-year actuarial patient, graft and death-censored graft survival or in allograft function. There were no differences in the 10-year actuarial rates of biopsy-proven acute rejection (30%, 26% and 20% in CSA/MMF, TACH/SIRL and TACL/SIRH) and chronic rejection (38%, 35% and 31% in CSA/MMF, TACH/SIRL and TACL/SIRH). Rates of new-onset diabetes mellitus were higher with TACH/SIRL (p=0.04), and rates of anemia were higher with TACH/SIRL and TACL/SIRH (p=0.04). No differences were found in the overall rates of 16 other post-KT complications. These data indicate that RDP-based protocol yield acceptable 10-year outcomes, but side effects differ based on the maintenance regimen used and should be considered when optimizing immunosuppression following RDP.


Asunto(s)
Terapia de Inmunosupresión/métodos , Inmunosupresores/uso terapéutico , Trasplante de Riñón/métodos , Prednisona/uso terapéutico , Adulto , Ciclosporina/uso terapéutico , Diabetes Mellitus Tipo 1/diagnóstico , Femenino , Humanos , Donadores Vivos , Masculino , Persona de Mediana Edad , Ácido Micofenólico/análogos & derivados , Ácido Micofenólico/uso terapéutico , Complicaciones Posoperatorias , Estudios Prospectivos , Sirolimus/uso terapéutico , Esteroides/uso terapéutico , Tacrolimus/uso terapéutico , Factores de Tiempo , Trasplante Homólogo , Resultado del Tratamiento
15.
Am J Transplant ; 12(2): 447-57, 2012 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-22070451

RESUMEN

The shortage of deceased donor organs for solid organ transplantation continues to be an ongoing dilemma. One approach to increase the number of pancreas transplants is to share organs between procurement regions. To assess for the effects of organ importation, we reviewed the outcomes of 1014 patients undergoing deceased donor pancreas transplant at a single center. We performed univariate and multivariate analyses of the association of donor, recipient and surgical characteristics with patient outcomes. Organ importation had no effect on graft or recipient survival for recipients of solitary pancreas transplants. Similarly, there was no effect on technical failure rate, graft survival or long-term patient survival for simultaneous kidney-pancreas (SPK) recipients. In contrast, there was a significant and independent increased risk of death in the first year in SPK recipients of imported organs. SPK recipients had longer hospitalizations and increased hospital costs. This increased medical complexity may make these patients more susceptible to short-term complications resulting from the longer preservation times of import transplants. These findings support the continued use of organ sharing to reduce transplant wait times but highlight the importance of strategies to reduce organ preservation times.


Asunto(s)
Agencias Internacionales , Trasplante de Páncreas , Sistema de Registros , Donantes de Tejidos/provisión & distribución , Obtención de Tejidos y Órganos/estadística & datos numéricos , Adulto , Femenino , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Estados Unidos
16.
Aliment Pharmacol Ther ; 26(9): 1187-94, 2007 Nov 01.
Artículo en Inglés | MEDLINE | ID: mdl-17944733

RESUMEN

BACKGROUND: Serum alpha fetoprotein (AFP), ultrasound, computerized tomography scanning, and magnetic resonance imaging are commonly used to screen for hepatocellular carcinoma (HCC) in patients with cirrhosis. AIM: To assess the accuracy of screening in advanced cirrhosis. METHODS: The study group consisted of 239 patients with proven HCC in the explanted liver at the time of liver transplant. AFP and imaging were done at referral and serially until transplant. RESULTS: Hepatocellular carcinoma was detected before liver transplant in 78% and discovered incidentally in 22%. The cause of cirrhosis was hepatitis C (HCV) (55%), hepatitis B (HBV) (17%), alcohol (9%), and other/unknown (19%). Although AFP was elevated 62%, the median level was 15 ng/mL. Only 26%, 15% and 13% were more than 100, 400 and 1000 ng/mL, respectively. By comparison, AFP was elevated in 20% without HCC, but exceeded 100 ng/mL in only 3%. The overall accuracy of AFP was poor regardless of the cutoff. Magnetic resonance imaging was more accurate than computerized tomography or ultrasound in detecting tumour, particularly when performed within 3 months of transplant. CONCLUSIONS: Magnetic resonance imaging is most sensitive for imaging HCC and best reflects actual tumour size. AFP is insensitive and adds little to screening strategies, but has prognostic value when extremely elevated.


Asunto(s)
Carcinoma Hepatocelular/diagnóstico , Cirrosis Hepática/diagnóstico , Neoplasias Hepáticas/diagnóstico , alfa-Fetoproteínas/metabolismo , Adolescente , Adulto , Anciano , Carcinoma Hepatocelular/diagnóstico por imagen , Femenino , Humanos , Cirrosis Hepática/diagnóstico por imagen , Neoplasias Hepáticas/diagnóstico por imagen , Trasplante de Hígado , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X , Ultrasonografía
17.
Am J Transplant ; 7(5): 1258-64, 2007 May.
Artículo en Inglés | MEDLINE | ID: mdl-17286619

RESUMEN

Pulmonary hypertension in the setting of cirrhosis and portal hypertension is known as portopulmonary hypertension (PPHTN). Moderate or severe PPHTN is uncommon, but has a poor prognosis and is considered to be a contraindication to liver transplantation. We assessed the impact of vasodilation therapy on pulmonary hemodynamics and outcome after liver transplant in these patients. Eighty-six patients evaluated for liver transplant between 1997 and 2005 had an estimated right ventricular systolic pressure >40 mm Hg or a clinical suspicion of PPHTN. Right heart catheterization confirmed PPHTN in 30 patients (ten mild, eight moderate, and 12 severe). Sixteen of the 20 with moderate-to-severe pulmonary hypertension (mPAP >or= 35) were otherwise considered suitable liver transplant candidates and were treated with vasodilation therapy. mPAP fell to less than 35 mm Hg in 12 patients (75%) and 11 of them then underwent orthotopic liver transplantation. One- and five-year survivals in the transplanted patients were 91% and 67%, respectively. Nine of 11 were off vasodilator therapy after a median of 9.2 months following transplantation. None of the patients who failed vasodilator therapy survived (median survival, 8 months). Effective pharmacologic control of PPHTN before liver transplant is associated with excellent posttransplant survival that is similar to patients transplanted for other indications.


Asunto(s)
Antihipertensivos/uso terapéutico , Hipertensión Portal/tratamiento farmacológico , Hipertensión Pulmonar/tratamiento farmacológico , Cirrosis Hepática/cirugía , Trasplante de Hígado/mortalidad , Vasodilatadores/uso terapéutico , Adulto , Presión Sanguínea/efectos de los fármacos , Presión Sanguínea/fisiología , Bosentán , Diltiazem/uso terapéutico , Epoprostenol/uso terapéutico , Femenino , Humanos , Hipertensión Portal/complicaciones , Hipertensión Portal/fisiopatología , Hipertensión Pulmonar/complicaciones , Hipertensión Pulmonar/fisiopatología , Cirrosis Hepática/complicaciones , Cirrosis Hepática/fisiopatología , Trasplante de Hígado/fisiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Sulfonamidas/uso terapéutico , Tasa de Supervivencia , Resultado del Tratamiento
18.
Am J Transplant ; 5(12): 2968-73, 2005 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-16303012

RESUMEN

The diagnosis of acute graft versus host disease (aGVHD) following liver transplantation can be difficult, since many of the clinical signs can be caused by drug reactions or viral infections. To establish criteria for the persistence of donor T-cells versus engraftment, we measured donor T-cells by short tandem repeat (STR) assays in 49 liver transplant patients for 8 or more weeks post-transplant. Donor CD3+ T-cells were detected in 38 of 49 patients, on POD 2 with a mean level of 5%. The top of the 99% confidence interval for weeks 1, 2, 3, 4 and 8 were 11, 6, 3, 2 and 3%. Donor CD8+ T-cells were measured in eight patients. The level of CD8+ T-cells was much less than that for CD3+ T-cells, except in two cases of apparent aGVHD. One patient developed severe aGVHD with donor T-cells as high as 84%. The other had 10% donor T-cells for more than 16 weeks associated with fever and neutropenia. We tested the sensitivity of PCR-ssp typing of HLA DR/DQ for donor T-cells. At least one donor type was detected in all samples with 1% or more donor DNA. Thus, higher levels of donor T-cell chimerism, particularly with a high proportion of CD8+ T-cells, strongly supports a diagnosis of aGVHD.


Asunto(s)
Linfocitos T CD8-positivos/fisiología , Pruebas Genéticas/métodos , Enfermedad Injerto contra Huésped/diagnóstico , Trasplante de Hígado , Quimera por Trasplante/genética , Enfermedad Aguda , Adulto , Anciano , Alelos , Complejo CD3/metabolismo , Femenino , Enfermedad Injerto contra Huésped/inmunología , Prueba de Histocompatibilidad , Humanos , Masculino , Persona de Mediana Edad , Reacción en Cadena de la Polimerasa , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/inmunología , Estudios Prospectivos , Sensibilidad y Especificidad , Secuencias Repetidas en Tándem , Quimera por Trasplante/inmunología
19.
Transplant Proc ; 37(5): 2174-8, 2005 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-15964371

RESUMEN

The goals of this study were to assess waitlist morbidity in terms of the frequency of health care services utilized by patients while on the liver transplant (LTX) waiting list and to determine whether that utilization can be predicted by the Model for End-Stage Liver Disease (MELD). Sixty-three noncomatose subjects were followed from waitlist placement until death, change in status, LTX, or study discontinuance. Health care events included doctor/clinic visits, labs, outpatient/inpatient tests and procedures, and hospital/intensive care unit days. Listing MELD scores and LTX MELD scores were examined against the number of health care event occurrences within 60 days of listing and 60 days of LTX, respectively, as were changes in MELD scores between listing and LTX and differences in the number of occurrences between the two time points. The only significant correlations noted were between LTX MELD scores and number of hospital days near LTX (r = .360, P = .046) and between LTX MELD scores and the sum total number of occurrences near LTX (r = .370, P = .044). These results suggest that MELD scores do not appear to predict morbidity in terms of health care utilization in patients awaiting LTX. Developing a system capable of predicting waitlist morbidity may lead to the implementation of medical interventions aimed at circumventing foreseeable complications and/or crises in patients awaiting LTX.


Asunto(s)
Trasplante de Hígado/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Listas de Espera , Humanos , Pacientes Internos , Hepatopatías/clasificación , Hepatopatías/cirugía , Morbilidad , Pacientes Ambulatorios , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos
20.
Transplant Proc ; 37(10): 4416-23, 2005 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-16387135

RESUMEN

METHODS: We reviewed our prospectively maintained database of 2005 liver transplantations. Therapy was either started de novo or converted from calcineurin inhibitors (CNIs) to sirolimus as the main immunosuppressive agent for nephrotoxicity or rejection. Glomerular filtration rate (GFR) was determined with iodine 125-labeled sodium isthalamate (Glofil-125), and serum creatinine concentration was obtained before and 3 months after transplantation, and yearly in both groups. Sirolimus levels were 10 to 15 ng/mL in patients at less than 3 months after transplantations and 5 to 10 ng/mL in the remaining patients. All patients received mycophenolate mofetil as maintenance therapy. RESULTS: Data for 29 patients in the de novo group and 35 in the conversion group were reviewed. Patients in the de novo group demonstrated an acute cellular rejection rate of 17.2%, 40% of which were steroid resistant. In this group, 48.2% discontinuation of sirolimus was necessary because of adverse effects. Patients in the conversion group demonstrated an acute cellular rejection rate of 2.8% and a 34.3% rate of sirolimus discontinuation. Seventeen (56.7%) patients at 1 year and 8 (44.4%) patients at 2 years demonstrated continued improvement in GFR. In the conversion group, case-control analysis did not demonstrate a significant difference in GFR and serum creatinine concentration (P > .05) at 1 and 2 years after conversion. At the time of review, no patients in the conversion group required hemodialysis. CONCLUSIONS: Conversion to sirolimus therapy is an effective strategy in improving renal function in patients with CNI-induced nephrotoxicity and can be done without increased rejection. Most of our patients (65.7%) tolerated sirolimus conversion. Of these, 56.7% and 44.4% demonstrated continued increase in GFR with the CNI-free regimen at 1 and 2 years, respectively. Long-term, large-population, prospective, randomized, controlled studies should further validate these results.


Asunto(s)
Tasa de Filtración Glomerular/efectos de los fármacos , Trasplante de Hígado/fisiología , Sirolimus/uso terapéutico , Creatinina/sangre , Quimioterapia Combinada , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Inmunosupresores/uso terapéutico , Pruebas de Función Renal , Hepatopatías/clasificación , Hepatopatías/cirugía , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/inmunología , Estudios Retrospectivos , Factores de Tiempo
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