Acute Esophageal Necrosis in an Immunosuppressed Kidney Transplant Recipient: A Case Report.

Acute esophageal necrosis (AEN) is rare and characterized endoscopically by distal esophageal ulceration, blackening, and necrosis. It typically arises in patients with multiple comorbidities who have significant systemic disease and frailty. Specific precipitating events are variable. Evidence suggests a multifactorial etiology likely involving esophageal ischemia in the setting of corrosive injury from gastric contents and impaired tissue repair mechanisms. In the transplant setting, immunosuppression likely plays a substantial role. We report a case of AEN in a 70-year-old man following a renal transplant.

Impact of Ethylene Glycol Toxicity on Donor Organ Viability: A Case Report.

Using kidneys from deceased donors whose demise was secondary to ethylene glycol (EG) toxicity requires considerable thought and planning. The exact impact that kidneys from these donors could have is unclear. The shortage of viable organs and growing wait list mortality should lead us to consider these allografts as potential life-saving transplants. Because it is crucial for the transplant community to use every available allograft, we need to develop processes that optimize each possible scenario. This article is a discussion of the viability of kidneys from a donor with EG-induced brain death and a proposed algorithm for encouraging the use of renal allografts after EG toxicity.

Case Report Demonstrating the Safe and Effective Means of Expanding the Donor Pool With Livers Recovered From Brain-Dead Donors After Ethylene Glycol Toxicity.

The growing disparity between organ supply and demand has become the greatest hurdle facing transplant professionals and life-saving transplants. Because the organ shortage has become the rate-limiting step to effective transplants, it is critical for the transplant community to identify viable mechanisms to expand the donor pool and use every available allograft. Although using kidneys from deceased donors whose demise was secondary to ethylene glycol (EG) toxicity requires great deliberation and precise timing as described by Barbas et al [5], using hepatic allografts in this setting involves far less risk. The following is a discussion of a 61-year-old male who was diagnosed with end-stage liver disease secondary to non-alcoholic steatohepatitis and ultimately underwent a life-saving transplant with a liver recovered from a donor with EG-induced brain death and allocated nationally due to trepidation by local and regional centers to use the liver from a donor after EG toxicity.

Fatal Apophysomyces elegans infection transmitted by deceased donor renal allografts.

Two patients developed renal mucormycosis following transplantation of kidneys from the same donor, a near-drowning victim in a motor vehicle crash. Genotypically, indistinguishable strains of Apophysomyces elegans were recovered from both recipients. We investigated the source of the infection including review of medical records, environmental sampling at possible locations of contamination and query for additional cases at other centers. Histopathology of the explanted kidneys revealed extensive vascular invasion by aseptate, fungal hyphae with relative sparing of the renal capsules suggesting a vascular route of contamination. Disseminated infection in the donor could not be definitively established. A. elegans was not recovered from the same lots of reagents used for organ recovery or environmental samples and no other organ transplant-related cases were identified. This investigation suggests either isolated contamination of the organs during recovery or undiagnosed disseminated donor infection following a near-drowning event. Although no changes to current organ recovery or transplant procedures are recommended, public health officials and transplant physicians should consider the possibility of mucormycosis transmitted via organs in the future, particularly for near-drowning events. Attention to aseptic technique during organ recovery and processing is re-emphasized.

Supply and demand for liver transplant surgery: are we training enough surgeons?

The purpose of our study is to determine whether the current level of transplant fellow training is sufficient to meet the future demand for liver transplantation in the United States. Historical data from the Nationwide Inpatient Samples (NIS) for the years 1998 through 2003 were used to construct an estimate of the annual number of liver transplant procedures currently being performed in the United States, and the number projected for each year through 2020. Estimates for the current and future number of surgeons performing liver transplant procedures were also constructed using the same database. The NIS database was used because current national transplant registries do not include information on the number of surgeons performing liver transplant procedures. Using historical data derived from the NIS database, we project that the estimated number of liver transplant procedures per surgeon will remain relatively stable through 2020, with each surgeon performing an average of 12.9 procedures in 2020 compared to 12.9 currently. We conclude that the relationship between demand for liver transplantation in the United States and the supply of liver transplant surgeons will remain stable over the next 15 years.

Familial hypocalciuric hypercalcemia in the donor and recipient of a living related donor kidney transplant.

Familial hypocalciuric hypercalcemia (FHH) is caused by heterozygous inactivation of the calcium-sensing receptor, which is notably expressed in parathyroid and kidney. FHH is characterized by asymptomatic hypercalcemia and hypophosphatemia and confers minimal, if any, morbidity. Renal transplantation in patients with FHH has not been described previously. This report describes a patient with FHH who developed end-stage renal disease from another cause and subsequently received a living related donor kidney transplant from her FHH-affected daughter. The excellent posttransplant clinical course of both recipient and donor is emphasized.

Obesity predicts increased overall complications following pancreas transplantation.

PURPOSE: We sought to evaluate the role of recipient body mass index (BMI) on postoperative complications in patients receiving pancreas transplants. METHODS: A single-institution retrospective study of 145 consecutive patients undergoing either simultaneous kidney pancreas (SPK) or pancreas after kidney (PAK) transplantation from January 1997 through December 2003. Variables analyzed included: age, sex, BMI, number of prior transplants, cytomegalovirus status of donor and recipient, postoperative insulin resistance, complications, and overall patient and graft survival. Differences in continuous variables and dichotomous variables were evaluated using two-tailed t test and Fisher exact test, respectively. Univariate and multivariate logistic regression analyses were employed to identify predictors of overall complications following surgery. RESULTS: Obesity was defined by a BMI > or = 30. Of the 145 patients, 33 (23%) had a BMI > or = 30 and 112 (77%) had a BMI < 30. There was no significant difference in age or sex between obese and nonobese patients (P = .98 and P = .56, respectively). The type of transplantation, SPK or PAK, did not affect the complication rate (P = .36). Overall complications (infection, dehiscence, evisceration, ventral hernia, allograft failure, gangrene, necrotizing fasciitis, postoperative bleeding, or death) were significantly higher in the obese group (81% vs 40%, P < .001). Obesity was specifically associated with increased frequency of dehiscence, ventral hernia, intra-abdominal infection, gangrene, necrotizing fasciitis, and repeat laparotomy. Obese patients also had a threefold higher rate of graft pancreatitis/enteric leak. Multivariate logistic regression analysis identified age > or = 50 and BMI > or = 30 as independent predictors of overall complications following surgery (odds ratio 4.0, P = .014 and OR 6.8, P < .001, respectively). There was no difference identified between groups with regards to allograft failure, posttransplant insulin resistance, and death. CONCLUSION: Obese patients are at increased risk of overall complications following pancreas transplantation. Specifically, obese patients experience higher frequency of dehiscence, ventral hernia, intra-abdominal infection, gangrene, and necrotizing fasciitis. This study demonstrates the need for careful postoperative monitoring in the obese patient.

Transplantation of hepatitis C-positive livers in hepatitis C-positive patients is equivalent to transplanting hepatitis C-negative livers.

A significant number of patients with end-stage liver disease secondary to hepatitis C die of disease-related complications. Liver transplantation offers the only effective alternative. Unfortunately, organ demand exceeds supply. Consequently, some transplant centers have used hepatitis C virus-positive (HCV(+)) donor livers for HCV(+) recipients. This study reviews the clinical outcome of a large series of HCV(+) recipients of HCV(+) liver allografts and compares their course with that of HCV(+) recipients of HCV-negative (HCV(-)) allografts. The United Network for Organ Sharing Scientific Registry was reviewed for the period from April 1, 1994, to June 30, 1997. All HCV(+) transplant recipients were analyzed. Two groups were identified: a group of HCV(+) recipients of HCV(+) donor livers (n = 96), and a group of HCV(+) recipients of HCV(-) donor livers (n = 2,827). A multivariate logistic regression model was used to determine the odds of graft failure and patient mortality, and unadjusted graft and patient survival were determined using the Kaplan-Meier method. There were no differences in demographic criteria between the groups. A greater percentage of patients with hepatocellular carcinoma received an HCV(+) allograft (8.3% v 3.1%; P =.01). Patient survival showed a significant difference for the HCV(+) group compared with the HCV(-) group (90% v 77%; P =.01). Blood type group A, group B, group O incompatibility was significant, with 4.2% incompatibility in the HCV(+) group and only 1.3% in the HCV(-) group (P =.04). Donor hepatitis C status does not impact on graft or patient survival after liver transplantation for HCV(+) recipients. Their survival was equivalent, if not better, compared with the control group. Using HCV(+) donor livers for transplantation in HCV(+) recipients safely and effectively expands the organ donor pool.

Decreased tolerance to interleukin-2 with repeated courses of therapy in patients with metastatic melanoma or renal cell cancer.

High-dose interleukin-2 (IL-2) therapy has a response rate of approximately 20% in patients with metastatic melanoma and renal cell cancer. Animal models have shown that the anti-tumor effects of IL-2 are dose and schedule dependent, and one report has shown that patients with melanoma who responded to IL-2 therapy received more doses of IL-2 than did those who did not respond. The current study evaluated patients' tolerance to IL-2 over multiple courses of therapy and the factors that affected the number of doses delivered. Patients with metastatic melanoma or renal cell cancer who received at least two consecutive courses of high-dose intravenous IL-2 alone from October 1, 1985 through December 31, 1996 were evaluated. Patients served as their own controls in paired analyses. The number of doses tolerated from one course to the next and the reasons for stopping therapy were analyzed. One hundred fifty-nine patients received two or more courses of therapy during the study. The median number of doses of high-dose IL-2 decreased from course 1 (15 doses) to course 2 (12 doses) (p2 = 0.0001). Pretreatment factors were not found to significantly influence the decrease in the number of doses delivered. Only 2 of 33 separate toxic effects resulting in discontinuation of IL-2 dosing were found to be significantly different between courses. After adjusting for multiple tests of statistical significance, serum aspartate aminotransferase elevations were more likely to stop course 1 (p2 = 0.0033) and creatinine elevations were more likely to stop course 2 (p2 = 0.00007). The influence of renal toxicity was further assessed by comparing the median creatinine value at the time IL-2 dosing was discontinued. This difference was found to be significant when cycle 1 of course 1 (1.5 mg/dL) was compared with cycle 1 of course 2 (1.8 mg/dL; p2 = 0.0001). When pretreatment factors were analyzed, male sex (p2 = 0.006), a diagnosis of renal cell cancer (p2 = 0.008), previous nephrectomy (p2 = 0.001), and older age (p2 = 0.0055) were significantly associated with the development of renal toxicity that resulted in discontinuation of IL-2 therapy. Furthermore, the same four patient subsets had higher baseline creatinine values in individual univariate analyses. This study identified subsets of patients who tolerated less IL-2 with repeated courses. The decreasing tolerance to IL-2 was associated primarily with elevations in creatinine. Finding ways to ameliorate the renal toxicity seen during IL-2 therapy in this patient population may allow an increase in the number of IL-2 doses administered and potentially an increase in clinical response.

Primary pineal melanoma: case report.

Primary melanomas of the central nervous system are unusual, and those in the pineal region are exceedingly rare. We present a case of primary pineal melanoma in a 60-year-old man. The lesion was subtotally resected through an infratentorial, supracerebellar approach. The clinical features and the histological findings are discussed. Eight previous case reports are reviewed.

The pathology of arteriovenous malformations of the brain treated by embolotherapy. II. Results of embolization with multiple agents.

Light microscopic and immunohistochemical examination was undertaken of intracranial arteriovenous malformations (AVMs) surgically resected from 18 patients, each of whom had undergone preoperative angiographic embolization with multiple agents. Distinct patterns of tissue reaction to these agents were noted, even when more than one substance was present in a vascular lumen. Avitene produced the mildest tissue response but resulted in relatively early endothelialization and recanalization. Cyanoacrylates were longer-lasting but associated with more acute and chronic (including granulomatous) inflammation and vessel wall changes. Polyvinyl alcohol foam/ethanol mixture had intermediate properties. Endothelial proliferation over embolization material was confirmed using immunohistochemical application of an antibody to cell proliferation-specific proteins. The significance of these findings for combined endovascular and surgical treatment of cerebral vascular malformations is discussed.

Synovial metallosis resulting from intraarticular intramedullary nailing of a distal femoral nonunion.

An 80-year-old man sustained a T-shaped supracondylar fracture of the femur associated with distal one-third shaft comminution. Initial failure of a 95 degrees angle blade plate was followed by insertion of an intraarticular intramedullary nail stabilized with static locking-screw fixation. A second failure of the implant was treated by extraarticular tension band condylar buttress plate osteosynthesis. Severe knee synovial metallosis was found at the time of removal of the intraarticular nail device.