Yeast contamination of kidney, liver and cardiac preservation solutions before graft: need for standardisation of microbial evaluation.

Contamination of preservation solution (PS) with yeasts during solid organ recovery can lead to life-threatening complications in the recipients. The prevalence of such a contamination needs to be established. From January 2004 to December 2008, we prospectively investigated the potential fungal contamination of all the PSs collected in our institution using a standardised procedure consisting in centrifugation of 10 mL PS and incubation of the pellet seeded on fungal-specific medium for 15 days at 30 degrees C. During the study period, 728 transplantations (397 kidneys, 262 livers and 69 hearts) were performed for which 659 PSs (90.5%) were available. The yeast contamination rate was 0% (0/62), 3.1% (11/356) and 4.1% (10/241) for heart, kidney and liver transplants, respectively. We identified 10 Candida albicans, five C. glabrata, two C. krusei, one C. tropicalis, one C. valida, one Pichia etchelsii and one Rhodorula sp. Routine bacterial analysis identified only five of these 21 fungal contaminations. Twenty recipients were alive after at least one year of follow-up and one died from meningeal carcinomatosis at seven months. Three patients were found to have the same species of Candida from their surgical drains but did not develop any infection or abnormalities upon ultrasound investigation. Fourteen patients received antifungal drugs. Yeast contamination occurred in 3.4% of all kidney and liver PSs tested. Its clinical consequences and therapeutic management remain to be defined. Our study also suggests that optimisation/standardisation of microbiological procedures is warranted, including analysis of large PS volume, seeding of fungal-specific medium and prolonged incubation.

Nicardipine as antihypertensive therapy in liver transplant recipients: results of long-term use.

Arterial hypertension is frequent in liver transplant recipients on cyclosporine A (CsA). Nicardipine is a calcium channel blocker (CCB) that has been shown to be efficient in controlling postoperative hypertension. However, its use has been limited in organ recipients because of its reported interaction with CsA metabolism. In this report, we studied the results of the long-term use of nicardipine after liver transplantation. Forty-nine consecutive liver transplant recipients with a follow-up longer than 2 years were studied. Immunosuppressive regimen was based on CsA and prednisone. Patients with immediate postoperative hypertension received intravenous nicardipine, secondarily switched to oral nicardipine (group 1, n = 27). Patients with delayed hypertension (i.e., >2 weeks posttransplant) received other antihypertensive drugs which did not interact with CsA metabolism. These patients and those without hypertension formed group 2 (n = 22). The two groups were similar for age, sex, body weight, and transplantation indications. Interaction of nicardipine with CsA metabolism was confirmed. Whereas cyclosporine blood levels were similar in both groups at any time during the study, the mean cyclosporine daily dose required to achieve such levels was 30% lower in group 1 compared with group 2 (P < .01). This resulted in a significant cost-containment. The use of nicardipine was not associated with an increased incidence of graft rejection or CsA toxicity episodes. The results in liver transplant recipients showed that nicardipine interacts with CsA metabolism, leading to a 30% reduction in CsA dose and does not increase the risk of CsA toxicity or graft rejection. Nicardipine can be used safely for the treatment of arterial hypertension after liver transplantation with a potential cost-containment.

[Limitation of blood transfusions during hepatectomies. Study of 150 consecutive hepatic resections on healthy and pathological livers]. / Limitation des transfusions sanguines au cours des hépatectomies. Etude de 150 résections hépatiques consécutives sur foie sain et pathologique.

OBJECTIVE: Over the last 5 years, a policy to limit blood transfusions has been adopted in patients undergoing liver resection. The aim of this retrospective study was to report the results of 150 liver resections performed during this period. METHODS: There were 63 major (42%) and 87 minor hepatectomies (58%). Resection was performed for malignant lesions in 64% of the patients. Vascular exclusion of the liver was used in large (> or = 10 cm) tumors and those located at the cavohepatic junction. Clamping of the portal triad or selective clamping of the pedicle of the portal lobe was used in peripheral lesions < 10 cm in diameter. Anesthesia was adapted to the type of vascular clamping and blood transfusions were deliberately limited. Red blood cells were transfused to maintain the hematocrit level above 25% in healthy patients and above 30% in patients with risk of coronary artery disease. RESULTS: Ninety three patients (62%) did not receive blood transfusions. Three patients received more than 10 units of packed red blood cells (2%). 48% of patients with major hepatectomies and 72% with minor hepatectomies were not transfused. The rate of non transfused patients was 93% for benign lesions and 44% for malignant lesions. The presence of pathologic changes in non-tumor liver parenchyma did not influence the need for transfusions. Hospital mortality was 3% (5/150). There was no mortality in patients with normal non-tumorous livers, 14% in the presence of cirrhosis, and 12% in the presence of obstructive jaundice or steatosis > 50%. The specific morbidity rate was 7% in patients with normal livers and 54% in patients with abnormal livers. CONCLUSION: This series shows that more than 60% of liver resections can be performed without blood transfusions. These results require an appropriate surgical technique and collaboration between anesthesiologist and surgeon. Thus hepatectomies in normal non-tumorous livers can be performed without mortality. In contrast, the presence of abnormalities of the non-tumorous liver parenchyma remains a major risk factor.

Orthotopic liver transplantation with preservation of the caval and portal flows. Technique and results in 62 cases.

Sixty-two OLTs in 61 patients were performed using a technical modification reported recently, including total hepatectomy with preservation of the inferior vena cava, partial clamping of the native vena cava, and side-to-side cavacaval anastomosis. We further modified the technique by adding the early construction of a temporary end-to-side portacaval shunt, and, more recently, by using an end-to-side caval reconstruction. With this technique, the caval and portal flows were maintained throughout the procedure. Hemodynamic parameters were analyzed prospectively during the operative period and remained stable at all stages of the procedure. Venous bypass was avoided in all cases without need for increased fluid infusion. Operative time and transfusion requirements were 6.8 +/- 1.6 hr and 9.8 +/- 4.3 U of packed RBC, respectively. There were no specific complications or deaths due to the technique used and hospital mortality was 10% (6/61). The technique used in this study is a safe adjunct to the technical armamentarium of clinical liver transplantation. Its main advantage seems to be hemodynamic stability throughout the procedure, obviating the need for venous bypass or fluid overload.

[Value of a powerful initial immunosuppression after liver transplantation. Prospective study of 60 cases]. / Intérêt d'une forte immunosuppression initiale après transplantation hépatique. Etude prospective de 60 cas.

With usual immunosuppression, the incidence of acute rejection after liver transplantation is higher than 60% in most series. The aim of this prospective study was to assess the value of a powerful initial immunosuppression on acute rejection, mortality and morbidity. REGIMEN. Group 1: patients with normal postoperative renal function (serum creatinaemia < 150 mumol/L) received cyclosporine from day 1 to day 15 by continuous i.v. infusion to reach a whole blood level of 400 to 500 ng/mL; after day 15, cyclosporine was reduced. Group 2: in cases of postoperative renal failure (serum creatinine > or = 150 mumol/L), anti-thymocyte globulins were used for 10 days; cyclosporine was introduced after recovery of renal failure at usual doses. In addition, all patients received steroids and azathioprine according to usual regimens. RESULTS. From January 1989 to June 1992, 60 cases were studied in 59 patients: 45 (75%) entered group 1 and 15 (25%) entered group 2. In group 1, there were 11 acute rejection episodes (24%) and one postoperative death at three months (2.3%). In group 2, two early deaths (within 5 days) were excluded from the study of rejection. Among the 13 remaining cases, there were three episodes of acute rejection (23%) and one hospital death at three months. Overall, there were 14 episodes of acute rejection (24%), 12 of which were steroid-responsive (86%), no chronic rejection, a usual rate of infections (57%), one retransplantation (1.7%) and a hospital mortality of 6.8% (4 of 59 cases). One year survival was 78%, with 5 of 7 late deaths due to recurrent cancer. CONCLUSIONS. Our results suggest that, after liver transplantation, a) high initial cyclosporine dose in patients with normal postoperative renal function is associated with reduced incidence and severity of acute rejection without increased mortality and morbidity, b) antithymocyte globulins are an efficient alternative to cyclosporine in patients with postoperative acute renal failure and saves OKT3 for the treatment of steroid-resistant rejection.

[Double liver-kidney transplantation in the presence of a positive T cross-match]. / Double transplantation hépatique et rénale en présence d'un cross-match T positif.

Kidney transplantation, when performed across a positive T lymphocyte cross-match, is always followed by the occurrence of a hyperacute rejection. On the other hand, successful hepatic allografts have been reported under these same conditions. Furthermore, clinically and experimentally hepatic allograft has been reported to induce tolerance of other organs from the same donor. Thus, combined liver-kidney transplantation constitutes an ideal application of these immunological events. We report here the case of a sequential liver-kidney transplantation in which liver transplantation performed prior to kidney transplantation with an organ from the same donor induced kidney tolerance despite an initial positive T lymphocyte cross-match.

[Liver transplantation associated with combined adjuvant treatment in hepatocellular carcinoma. Feasibility and preliminary results]. / Transplantation hépatique associée à un traitement adjuvant combiné dans le carcinome hépatocellulaire. Faisabilité et résultats préliminaires.

Combined adjuvant therapy was prospectively assessed in 7 patients receiving orthotopic liver transplantation for hepatocellular carcinoma complicating cirrhosis. The protocol included hepatic arterial chemotherapy while waiting for transplant, immediate preoperative liver irradiation, and early postoperative chemotherapy. There were no postoperative deaths, and morbidity included mainly hematologic toxicity of chemotherapy. Two patients died of tumor recurrence 6 and 14 months after transplant. The remaining 5 patients are alive and free of disease with a follow-up of 7 to 26 months. These results show the feasibility of aggressive adjuvant therapy in patients transplanted for hepatocellular carcinoma and suggest a possible effect of such a protocol on the prevention of tumor recurrence.