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Arranz R, Conde E, Rodriguez-Salvanés F, Pajuelo FJ, Cabrera R, Sanz MA, Petit J, Bueno J, Maldonado J, Odriozola J, Conde JG, Brunet S, Carreras E, Iriondo A, Fernández-Rañada JM, Marín P. CsA-based post-graft immunosuppression: the main factor for improving outcome of allografted patients with acquired aplastic anemia. A retrospective survey by the Spanish Group of Hematopoietic Transplantation. Bone Marrow Transplant 2002; 29:205-11. [PMID: 11859392 DOI: 10.1038/sj.bmt.1703349] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2001] [Accepted: 10/04/2001] [Indexed: 11/08/2022]
Abstract
A retrospective multicenter study was performed to assess the clinical results in patients with acquired aplastic anemia (AA) allografted over a 19 year period and to identify prognostic factors influencing survival. From April 1978 to December 1997, 176 patients were transplanted. Records from 160 receiving related matched bone marrow transplantation (BMT) were reviewed. Fifty-two percent of the patients were older than 20 years, 5% older than 40; 6.3% were untransfused at BMT and 56.2% had received prior treatments. Conditioning regimens were with chemotherapy in 43.7% of the procedures and with additional irradiation in 56.3%. Graft-versus-host disease (GVHD) prophylaxis was based on cyclosporin A (CsA) in 58.1% of the patients while methotrexate (MTX) was administered to 41.9%. Transplantation earlier on, a longer interval from diagnosis to BMT, GVHD prophylaxis with MTX, graft failure/rejection and acute severe GVHD were adverse factors for survival. The use of CsA emerged as the main factor for the improvement, inducing a significant decrease in graft failure/rejection rate and severe acute GVHD when compared with MTX alone. Radiation-containing regimens decreased the graft failure/rejection rate without improving survival due to the increased risk of acute GVHD. Age and number of transfusions pretransplant did not influence outcome. Survival achieved since 1991 is 79.79%, and graft failure and acute severe GVHD rates are 6.0% and 11.8%, respectively. In conclusion, CsA-based post-graft immunosuppression has been crucial in achieving improved survival in patients with acquired AA up to 40 years of age. Regardless of CsA use, further improvement in survival was apparent with time, probably due to better skills in patient care.
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Affiliation(s)
- R Arranz
- Hematology Department, Hospital Universitario de la Princesa, Madrid, Spain
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Aguirrezabalaga J, Gómez M, Novás S, Fernández C, Corbal G, Fraguela J, Bueno J, Suarez F, Otero A. Combined liver-pancreas transplantation: contribution of five cases. Transplant Proc 2002; 34:211-2. [PMID: 11959251 DOI: 10.1016/s0041-1345(01)02729-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- J Aguirrezabalaga
- Liver Transplantation Unit, Juan Canalejo Medical Centre, La Coruña, Spain
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Rogers J, Bueno J, Shapiro R, Scantlebury V, Mazariegos G, Fung J, Reyes J. Results of simultaneous and sequential pediatric liver and kidney transplantation. Transplantation 2001; 72:1666-70. [PMID: 11726829 DOI: 10.1097/00007890-200111270-00016] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The indications for simultaneous and sequential pediatric liver (LTx) and kidney (KTx) transplantation have not been well defined. We herein report the results of our experience with these procedures in children with end-stage liver disease and/or subsequent end-stage renal disease. PATIENTS AND METHODS Between 1984 and 1995, 12 LTx recipients received 15 kidney allografts. Eight simultaneous and seven sequential LTx/KTx were performed. There were six males and six females, with a mean age of 10.9 years (1.5-23.7). One of the eight simultaneous LTx/KTx was part of a multivisceral allograft. Five KTx were performed at varied intervals after successful LTx, one KTx was performed after a previous simultaneous LTx/KTx, and one KTx was performed after previous sequential LTx/KTx. Immunosuppression was with tacrolimus or cyclosporine and steroids. Indications for LTx were oxalosis (four), congenital hepatic fibrosis (two), cystinosis (one), polycystic liver disease (one), A-1-A deficiency (one), Total Parenteral Nutrition (TPN)-related (one), cryptogenic cirrhosis (one), and hepatoblastoma (one). Indications for KTx were oxalosis (four), drug-induced (four), polycystic kidney disease (three), cystinosis (one), and glomerulonephritis (1). RESULTS With a mean follow-up of 58 months (0.9-130), the overall patient survival rate was 58% (7/12). One-year and 5-year actuarial patient survival rates were 66% and 58%, respectively. Patient survival rates at 1 year after KTx according to United Network of Organ Sharing (liver) status were 100% for status 3, 50% for status 2, and 0% for status 1. The overall renal allograft survival rate was 47%. Actuarial renal allograft survival rates were 53% at 1 and 5 years. The overall hepatic allograft survival rate was equivalent to the overall patient survival rate (58%). Six of seven surviving patients have normal renal allograft function, and one patient has moderate chronic allograft nephropathy. All surviving patients have normal hepatic allograft function. Six (86%) of seven sequentially transplanted kidneys developed acute cellular rejection compared with only two (25%) of eight simultaneously transplanted kidneys (P<0.04). CONCLUSIONS Simultaneously transplanted kidneys were less likely to develop rejection than sequentially transplanted kidneys in this series. This did not have any bearing on patient or graft survival rates. Mortality correlated directly with the severity of United Network of Organ Sharing status at the time of kidney transplantation. Candidates for simultaneous or sequential LTx/KTx should be prioritized based on medical stability to optimize distribution of scarce renal allografts.
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Affiliation(s)
- J Rogers
- Section of Transplant Surgery, Department of Surgery, Medical University of South Carolina, Charlston, SC, USA
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Bueno J, Amiguet JA, Carasusan J, Cebollada J, Carretero J. Bisoprolol vs. chlorthalidone: a randomized, double-blind, comparative study in arterial hypertension. J Cardiovasc Pharmacol 2001; 16 Suppl 5:S189-92. [PMID: 11527126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The antihypertensive effect and tolerance of bisoprolol and chlorthalidone were evaluated in a randomized, double-blind, controlled trial during 4 weeks of treatment. A total of46 patients, aged 18-65 years, were initially included; 41 patients presenting with a diastolic blood pressure between 95 and 120 mm Hg at the end of a previous placebo period completed the trial. They were randomly allocated to two groups: 22 patients were treated with bisoprolol 10 mg o.d., and 19 patients with chlorthalidone 50 mg o.d. Both treatments induced a significant reduction in systolic and diastolic blood pressure (p < 0.001). No difference in antihypertensive efficacy was found between the two treatments after 4 weeks. However, with chlorthalidone, significant changes were found with regard to serum potassium (decrease; p < 0.001) and uric acid (increase: p < 0.05) and the incidence of clinical side effects was higher in the chlorthalidone group (37%) in comparison to the patients treated with bisoprolol (13%).
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Affiliation(s)
- J Bueno
- Internal Medicine Service, Hospital Clinico, Zaragoza, Spain
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Trujillo MJ, Martinez-Gimeno M, Giménez A, Lorda I, Bueno J, García-Sandoval B, Ramos C, Carballo M, Ayuso C. Two novel mutations (Y141H; C214Y) and previously published mutation (R142W) in the RDS-peripherin gene in autosomal dominant macular dystrophies in Spanish families. Hum Mutat 2001; 17:80. [PMID: 11139263 DOI: 10.1002/1098-1004(2001)17:1<80::aid-humu27>3.0.co;2-g] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- M J Trujillo
- Department of Genetics, Fundación Jiménez Díaz, Av. Reyes Católicos No. 2, 28040 Madrid, Spain
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Bueno J, Zuazu J, Villalba T, Julià A. Acute leukaemia in Jehovah's witnesses. Haematologica 2001; 86:E02. [PMID: 11224505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Affiliation(s)
- J Bueno
- Servicio de Hematología Clínica. Hospital Vall d'Hebron. Barcelona. Spain.
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Bueno J, Guiterrez J, Mazariegos GV, Abu-Elmagd K, Madariaga J, Ohwada S, Kocoshis S, Reyes J. Analysis of patients with longitudinal intestinal lengthening procedure referred for intestinal transplantation. J Pediatr Surg 2001; 36:178-83. [PMID: 11150461 DOI: 10.1053/jpsu.2001.20047] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND/PURPOSE Longitudinal intestinal lengthening procedures (LILP) in patients with short gut syndrome (SGS) enhances small intestinal peristalsis and decreases bacterial overgrowth without reducing absorptive surface. Therefore, patients theoretically may be easily weaned off TPN. The aim of this study was to evaluate the impact of failed LILP in SGS patients referred for intestinal transplantation. METHODS Twenty-seven (11%) of 230 children with SGS and total parenteral nutrition (TPN) dependency evaluated for intestinal transplantation at our institution had undergone LILP. This was performed at a mean age of 1.7 years (range, 1 day to 14.7 years); the mean age at the time of evaluation was 3.3 years (range, 0.4 to 17 years). Two patients underwent LILP immediately after birth. The principle diagnoses producing SGS were gastroschisis (n = 8), intestinal atresia (n = 11), neonatal volvulus (n = 7) and necrotizing enterocolitis (n = 1). Before LILP, the mean length of intestine was 32 cm (range, 8 to 70 cm). Fifteen (56%) patients had jaundice at the time of evaluation. RESULTS All but one child were considered candidates for intestinal transplantation. The mean intestinal length achieved after LILP was 48 cm (range, 16 to 100). The mean follow-up from the date of LILP was 876 days (range, 109 to 4,109 days). After LILP, only 9 (33%) patients increased their caloric intake through the enteral route by > or =50%, and only 1 patient could be weaned off TPN. In the patients with liver dysfunction at the time of LILP, none recovered. Most of the patients had multiple episodes of sepsis after LILP. Fourteen (52%) of 27 patients underwent intestinal transplantation, 7 combined with a liver allograft because of TPN-induced end-stage liver disease. Six of the transplanted patients are alive and TPN free. Of the remaining 13 (48%) nontransplanted patients, 9 patients died. The main cause of death was TPN-induced liver failure. Three patients are on partial TPN, and only 1 patient was weaned off TPN. The presence of an ileocecal valve did not impact on outcome. Surprisingly, patients with > or =50% of colon at the time of LILP had poorer survival than those with less. Twelve (44%) of 27 patients had surgical complications, and in both patients with LILP performed in the neonatal period it failed immediately with acute complications. There were no differences in patient survival rate for patients with SGS without LILP (n = 203) and those with LILP (n = 27). CONCLUSION Based on patients with unsuccessful LILP referred for intestinal transplantation, we believe this procedure should be avoided in the neonatal period, in those patients with liver dysfunction, and when intestinal length is <50 cm.
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Affiliation(s)
- J Bueno
- Children's Hospital of Pittsburgh, Thomas E. Starzl Transplantation Institute, University of Pittsburgh and Gastroenterology and Complejo Hospitalario Juna Canalejo
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58
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Bueno J, Serralta A, Planells M, Pous S, Ballester C, Ibáñez F, Rodero D. Colecistectomía laparoscópica y sus complicaciones: nuestra experiencia en nueve años. Cir Esp 2001. [DOI: 10.1016/s0009-739x(01)71784-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Serralta A, Planells M, Bueno J, Rodero D. A simple scoring system to reduce intraabdominal septic complications after laparoscopic appendectomy. Surg Endosc 2000; 14:1028-30. [PMID: 11116411 DOI: 10.1007/s004640000281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND The development of intraabdominal abscess (IAA) following laparoscopic appendectomy (LA) is associated with significant morbidity. The aim of the present study was to validate an IAA risk score constructed from a previous review of 156 consecutive LA. METHODS The score was tested in 250 subsequent consecutive LA and in patients with a positive risk score. Broad-spectrum antibiotics were administered in order to avoid IAA. RESULTS Factors related to IAA included clinically complicated appendicitis, leucocytosis >15,000/microl, a difference of >1 degrees C between axillary and rectal temperature, intraoperative findings such as (gangrenes and perforation), and intraoperative perforation of the appendix. In this series, broad-spectrum antibiotic therapy in patients with a positive IAA risk score reduced the incidence of IAA from 7.05% to 1.60%. CONCLUSION This policy of identifying high-risk patient via the scoring system and instituting subsequent antibiotic therapy in patients at risk reduces the incidence of IAA following LA.
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Affiliation(s)
- A Serralta
- Servicio de Cirugía General y del Aparato Digestivo II, Hospital Universitario "La Fe", Avda Campanar 21, 46009 Valencia, Spain
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Abu-Elmagd K, Fung J, Bueno J, Martin D, Madariaga JR, Mazariegos G, Bond G, Molmenti E, Corry RJ, Starzl TE, Reyes J. Logistics and technique for procurement of intestinal, pancreatic, and hepatic grafts from the same donor. Ann Surg 2000; 232:680-7. [PMID: 11066140 PMCID: PMC1421222 DOI: 10.1097/00000658-200011000-00010] [Citation(s) in RCA: 158] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess a technique for simultaneous recovery of the intestine, pancreas, and liver from the same donor. SUMMARY BACKGROUND DATA With the more frequent use of pancreatic and intestinal transplantation, a procurement procedure is needed that permits retrieval of both organs as well as the liver from the same cadaveric donor for transplantation to different recipients. It is believed by many procurement officers and surgeons, however, that this objective is not technically feasible. METHODS A technique for simultaneous recovery of the intestine, pancreas, and liver was used in 13 multiorgan cadaver donors during a 26-month period, with transplantation of the organs to 33 recipients. The intestine was removed from 11 donors separately and in continuity with the pancreas in the other 2. Six additional pancreases were excised and transplanted separately. Thirteen livers were retrieved, one of which was discarded because of steatorrhea. Ten of the remaining 12 livers were transplanted intact; the other 2 were split in situ and used as reduced-size hepatic allografts in four recipients. RESULTS None of the 11 intestinal, 6 pancreatic, 2 intestinal-pancreatic, or 14 whole or partial liver allografts sustained serious ischemic injury or were lost as a result of technical complications. One liver recipient died 25 months after surgery of recurrent C virus hepatitis. The other 32 recipients had adequate allograft function with a mean follow-up of 8 months. CONCLUSION It was possible using the described technique to retrieve intestine, pancreas, and liver allografts safely from the same donor and to transplant these organs to different recipients.
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Affiliation(s)
- K Abu-Elmagd
- Thomas E. Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
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Pérez-Calvo J, Civeira F, Ferrando J, Martínez-Rodés P, Torralba MA, Banzo J, Prats E, Bueno J. [The effects of enalapril on exercise capacity and right ventricular function in patients with chronic cor pulmonale]. An Med Interna 2000; 17:527-32. [PMID: 11109647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
BACKGROUND Chronic cor pulmonale (CPC) in patients with chronic obstructive pulmonary disease (COPD) is a predictor of mortality. ACE inhibitors (ACEIs) improve the symptoms and reduce mortality of left ventricular or congestive failure, however their long term use in patients with CPC has not been tested. The aim of this study is to assess the effect on exercise tolerance and cardiorespiratory function of long term administration of enalapril in patients with CPC. METHODS Placebo-controlled, double blind, randomized study. 28 patients (24 men and 4 women, mean age of 68.11 +/- 7.78, range 51-79) with CPC and without exacerbation of their respiratory symptoms at baseline were double blind randomised to receive enalapril or placebo for 6 months, added to their previous therapy. Respiratory function test, exercise tolerance ("six minutes walking test") and isotopic ventriculography were performed at baseline and at the end of the study. RESULTS At baseline there were no differences in FEV1, FVC, FEV1/FVC and exercise tolerance. Both placebo and enalapril were well tolerated. At the end of the study, patients taking enalapril increased their exercise tolerance an 8.9% (19 m) vs 4.7% (33 m) in the placebo group (p 0.44; 95 percent confidence interval, -41.10 to 91.99). RVEF improved a 6.4% with enalapril but worsened a 7.09% in placebo group (p 0.15; 95 percent confidence interval, -12.87 to 2.10). CONCLUSIONS Long term administration of enalapril do not improve neither exercise tolerance, nor right ventricular (RV) function, although given in increasingly doses is well tolerated and might prevent further worsening in RV systolic function.
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Affiliation(s)
- J Pérez-Calvo
- Servicio de Medicina Interna B, Hospital Clínico Universitario, Zaragoza.
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Abstract
BACKGROUND This study was designed to review our experience with combined partial hepatectomy and vena caval replacement for primary and metastatic liver tumors. STUDY DESIGN The medical records of all the patients who underwent liver resection and excision of the vena cava over a period of 13 years and 4 months at a single institution were analyzed. The types of tumors fell into four categories: 1) metastatic, 2) primary leiomyosarcoma of the inferior vena cava, 3) tumors with direct extension to the liver, and 4) cholangiocarcinoma. RESULTS The perioperative mortality was 11% related to technical complications and hepatic insufficiency. Other important complications included biliary fistula and liver abscess; patients recovered from these complications without sequelae. Six of nine patients are alive with a followup from 6 months to 156 months (median 66.5 months), and three of them are free of disease. The most common sites of recurrence were lung, liver, and brain. The patients with leiomyosarcoma of the cava and pheochromocytoma who underwent these combined procedures had the longest survival. CONCLUSIONS This small series confirms the feasibility of obtaining longterm survival after excision of tumors that have involved portions of the liver and the vena cava. Innovative variations on the method of vena caval replacement and increased awareness of these complex surgical techniques will expand the indications of hepatic resection.
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Affiliation(s)
- J R Madariaga
- Department of Surgery, Thomas E Starzl Transplantation Institute, University of Pittsburgh, PA 15213, USA
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63
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Giraldo M, Martin D, Colangelo J, Bueno J, Reyes J, Fung JJ, Starzl TE, Abu-Elmagd K. Intestinal transplantation for patients with short gut syndrome and hypercoagulable states. Transplant Proc 2000; 32:1223-4. [PMID: 10995920 PMCID: PMC2958563 DOI: 10.1016/s0041-1345(00)01197-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- M Giraldo
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
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Green M, Bueno J, Rowe D, Mazariegos G, Qu L, Abu-Almagd K, Reyes J. Predictive negative value of persistent low Epstein-Barr virus viral load after intestinal transplantation in children. Transplantation 2000; 70:593-6. [PMID: 10972215 DOI: 10.1097/00007890-200008270-00010] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The correlation between an elevated Epstein-Barr virus (EBV) viral load in the peripheral blood and the subsequent development of EBV-associated posttransplant lymphoproliferative disease (PTLD) is the basis for strategies using serial measurements of the EBV viral load to guide preemptive therapy (PT). Neither the frequency, duration of monitoring, nor the predictive negative value of viral load monitoring for asymptomatic patients with persistent low or nondetectable viral loads against the development of PTLD has been established. METHODS Since April 1994, children undergoing intestinal transplantation (ITx) underwent serial monitoring of the EBV viral load in their peripheral blood using a quantitative competitive EBV polymerase chain reaction assay (PCR). Samples were obtained every 2 weeks for the first 3 months and then every 1-3 months depending on the patients clinical condition. EBV viral loads > or =40 (for patients who were EBV seronegative pre-ITx) and > or =200 (for those who were seropositive) genome copies/10(5) peripheral blood lymphocytes were felt to identify patients at increased risk for PTLD and generally prompted PT. RESULTS A total of 30 ITx recipients were compliant with our monitoring protocol; 23/30 are alive 6-59 months post-ITx. A total of 12/30 never had a viral load >40 and did not receive PT. In contrast, 18/30 had > or =1 high viral load (> or =200); the first high viral load was measured a median of 59 days post-ITx (range 1-440). A late rise (>6 months post-ITx) was seen in only 2/18 children. A total of 0/12 patients with persistently low viral loads received PT and none developed PTLD. In contrast, 5/18 with > or =1 one high viral load (including 2/14 who received and 3/4 who did not receive PT) developed PTLD. All five children with PTLD were EBV seropositive pre-ITx and experienced their first high EBV PCR within the first 3 months after ITx. CONCLUSIONS The predictive negative value of persistently low or nondetectable EBV viral loads was 100% in this study. Patients with nondetectable or low viral loads for the first 6 months after ITx did not develop PTLD regardless of their pretransplant EBV serological status. The frequency of viral load monitoring can be safely decreased for patients whose viral loads remain low for the first 6 months ITx.
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Affiliation(s)
- M Green
- Department of Pediatrics, Children's Hospital of Pittsburgh, The Thomas Starzl Transplantation Institute, University of Pittsburgh School of Medicine, PA 15213, USA
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Iglesia MA, Puig J, Arellano A, Bueno J. Oral manifestations associated with elastic pseudoxanthoma. Med Oral 2000; 5:261-265. [PMID: 11507563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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66
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Reyes JD, Carr B, Dvorchik I, Kocoshis S, Jaffe R, Gerber D, Mazariegos GV, Bueno J, Selby R. Liver transplantation and chemotherapy for hepatoblastoma and hepatocellular cancer in childhood and adolescence. J Pediatr 2000; 136:795-804. [PMID: 10839879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVE To describe our experience with total hepatectomy and liver transplantation as treatment for primary hepatoblastoma (HBL) and hepatocellular carcinoma (HCC) in children. STUDY DESIGN A retrospective analysis of the perioperative course of 31 children with unresectable primary HBL (n = 12) and HCC (n = 19) who underwent transplantation between May 1989 and December 1998. Systemic (n = 18) and intraarterial (n = 7) neoadjuvant chemotherapy were administered; follow-up ranged from 1 to 185 months. RESULTS For HBL, 1-year, 3-year, and 5-year posttransplantation survival rates were 92%, 92%, and 83%, respectively. Intravenous invasion, positive hilar lymph nodes, and contiguous spread did not have a significant adverse effect on outcome; distant metastasis was responsible for 2 deaths. Intraarterial chemotherapy was effective in all patients treated. For HCC, the overall 1-year, 3-year, and 5-year disease-free survival rates were 79%, 68%, and 63%, respectively. Vascular invasion, distant metastases, lymph node involvement, tumor size, and gender were significant risk factors for recurrence. Intraarterial chemotherapy was effective in 1 of 3 patients. Six patients died of recurrent HCC, and 3 deaths were unrelated to recurrent tumor. CONCLUSION Liver transplantation for unresectable HBL and HCC can be curative. Risk factors for recurrence were significant only for HCC, with more advanced stages amenable to cure in the HBL group.
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Affiliation(s)
- J D Reyes
- University of Pittsburgh, Thomas E. Starzl Transplantation Institute, PA, USA
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67
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Calvo C, Gude F, Abell??n J, Oliv??n J, Olmos M, Pita L, S??nz D, Sarasa J, Bueno J, Herrera J, Mac??as J, Sagastagoitia T, Ferro B, Vega A, Mart??nez J. A Comparative Evaluation of Amlodipine and Hydrochlorothiazide as Monotherapy in the Treatment of Isolated Systolic Hypertension in the Elderly. Clin Drug Investig 2000. [DOI: 10.2165/00044011-200019050-00001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Parra JA, Acinas O, Bueno J, Güezmes A, Fernández MA, Fariñas MC. Xanthogranulomatous cholecystitis: clinical, sonographic, and CT findings in 26 patients. AJR Am J Roentgenol 2000; 174:979-83. [PMID: 10749233 DOI: 10.2214/ajr.174.4.1740979] [Citation(s) in RCA: 106] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The purpose of our study was to evaluate the sonographic and CT features of xanthogranulomatous cholecystitis, correlating the pathologic and surgical findings. MATERIALS AND METHODS Xanthogranulomatous cholecystitis was pathologically diagnosed in 26 patients from January 1996 to August 1998. The patients were 15 women and 11 men with a mean age of 63 years. All patients had preoperative sonography and nine also underwent CT In five patients, sonography was performed on the surgical specimen. Clinical indications for imaging included cholecystitis (14 patients), biliary colic (six patients), stone-induced pancreatitis (three patients), tumor (two patients), and gallstone ileus (one patient). RESULTS The most characteristic sonographic finding, confirmed by sonographic study of the surgical specimens, was the presence of hypoechoic nodules or bands in the gallbladder wall, which were seen in 35% of the patients. Cholelithiasis and a thickened gallbladder wall were frequent findings. The most characteristic (specific) CT finding was a hypodense band in the gallbladder wall, seen in 33% of the patients. Two of twelve patients who underwent laparoscopic cholecystectomy required conversion to open surgery. CONCLUSION Although the preoperative imaging diagnosis of xanthoganulomatous cholecystitis is difficult, the presence of hypoechoic nodules or bands in the gallbladder wall on sonography or of a hypodense band around the gallbladder on CT, is highly suggestive of this disease.
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Affiliation(s)
- J A Parra
- Department of Radiology (Servicio de Radiodiagnóstico), Hospital Sierrallana, Torrelavega, Cantabria, España
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Reyes J, Gerber D, Mazariegos GV, Casavilla A, Sindhi R, Bueno J, Madariaga J, Fung JJ. Split-liver transplantation: a comparison of ex vivo and in situ techniques. J Pediatr Surg 2000; 35:283-9; discussion 289-90. [PMID: 10693682 DOI: 10.1016/s0022-3468(00)90026-5] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND/PURPOSE The expanding applicability of liver transplantation as treatment for end-stage liver disease has fostered a disproportionate increase in liver transplant candidates in the face of an unchanging pool of donor organs. This has resulted in disparities in pretransplant waiting times and deaths. The splitting of a liver allograft allows for the transplantation of 2 recipients, usually an adult and a child, thus providing a means to expand the cadaveric donor pool. METHODS The authors present their results on the performance of an ex vivo (back table) split and in situ (in a hemodynamically stable cadaveric donor) split to evaluate safety, applicability, and effectiveness. Between November 1989 through April 1998, 54 split-liver transplant recipient operations were performed (24 pediatric and 30 adult). Thirty donors were procured: the ex vivo splitting yielded 25 grafts from 13 donors (donor age, 24.6+/-11 years), and the in-situ technique yielded 29 grafts from 17 donors (mean donor age of 25.5+/-10.4 years). Five donors involved interinstitutional sharing for which the left side of the graft was kept at the host hospital and the right side grafts were utilized at our center. RESULTS Overall 1-year patient survival was 85%, with a graft survival of 72%. Patient survival was similar with ex vivo (74%) as compared with the in situ splitting group (96%; P = .06), as was graft survival in ex vivo (61 %) versus in situ (81%) splitting (P = .15). The pediatric population benefited most from the in situ technique, with a 1-year patient survival rate of 100% with the in situ technique versus the ex vivo technique survival rate of 64% at 1 year (P = .02). The 1-year graft survival comparing these 2 techniques was 83% for the in situ group versus 45% for the ex vivo group. Analysis of the program evolution of split-liver transplantation suggested a time-dependent learning curve, which was applicable to surgical splitting technique, implantation, and recipient selection. CONCLUSIONS The principle of splitting livers from cadaveric donors is fundamentally sound and technically feasible. The authors' outcomes analysis using 2 different procurement techniques suggests that the in situ technique is clinically efficacious, can be used alternatively with the ex vivo technique, and is comparable to whole-liver allograft transplantation.
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Affiliation(s)
- J Reyes
- Children's Hospital of Pittsburgh, Thomas E Starzl Transplantation Institute, University of Pittsburgh School of Medicine, PA 15213, USA
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Bueno J, Abu-Elmagd K, Mazariegos G, Madariaga J, Fung J, Reyes J. Composite liver--small bowel allografts with preservation of donor duodenum and hepatic biliary system in children. J Pediatr Surg 2000; 35:291-5; discussion 295-6. [PMID: 10693683 DOI: 10.1016/s0022-3468(00)90027-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND/PURPOSE Liver and intestinal transplantation is commonly required for children with intestinal failure who suffer concomitant total parenteral nutrition (TPN)-induced liver failure. Retrieval of such composite allografts using previously described "standard techniques" mandates reconstruction of the biliary system with a defunctionalization loop of the proximal allograft jejunum. The occasional posttransplant biliary complications have been associated with significant morbidity and mortality. Also, size matching has limited the pool of donor organs for this patient population. To improve outcome and increase the donor pool the authors have utilized a duodenal-sparing composite liver small bowel allograft technique (DLSBTx) by preserving the head of the pancreas and the pancreatic-duodenal arteries. This precludes a biliary drainage procedure. METHODS Nine children (5 girls, 4 boys), with a mean age of 1.4 years (range, 1 to 17.4 years) received a DLSBTx. In 2 patients the liver was reduced; 1 patient received the whole pancreas. The mean recipient weight at the time of transplantation was 17.4 kg (range, 6.6 to 49.8 kg). The mean age and mean weight for donors was 7.9 years (range, 3 days to 22 years) and 25 kg (range, 4 to 70 kg), respectively. All transplants were performed under tacrolimus and steroid immunosuppression. RESULTS With a mean follow-up of 419 days (range, 5 to 795 days), patient and graft survival rates are 78% and 67%, respectively. One patient underwent a combined retransplantation with the standard technique 31 days after the primary allograft was destroyed by a native pancreatic fistula. Currently, all surviving recipients are at home and off TPN. DLSBTx allowed the expansion of the donor pool by transplanting 6 patients with donor to recipient weight ratio > or =1 and utilizing 2 less than 5-kg donors, including a neonatal donor. In 55% of the patients, chemical pancreatitis was observed during the early postoperative period. None of the duodenal allografts experienced signs of ischemia or leak. CONCLUSIONS The technical advantages of this procedure include avoidance of a biliary reconstruction and simplification of the operative procedure. This, together with the feasibility of split or reduced liver grafting promises to increase the donor pool from neonates to adults.
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Affiliation(s)
- J Bueno
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh and Children's Hospital of Pittsburgh, PA 15213, USA
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71
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Serralta Serra A, Planells Roig M, López Martínez C, Moya Sanz A, Montes Benito H, Esteban E, García Espinosa R, Bueno J, Ballester C, Rodero Rodero D. [An aneurysm of the gastroduodenal artery: its treatment via selective embolization]. Rev Esp Enferm Dig 2000; 92:46-7. [PMID: 10749598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Abstract
BACKGROUND Children with chronic intestinal pseudo-obstruction (CIPO) often require total parenteral nutrition (TPN) which puts them at risk of liver failure and recurrent line infections. Intestinal transplantation has become a therapeutic option for TPN dependent children with intestinal failure who are failing management with TPN. AIMS To investigate the outcome of children with CIPO referred for intestinal transplantation. METHODS A retrospective review was carried out of records and diagnostic studies from 27 patients with CIPO referred for intestinal transplantation. RESULTS Five children were not listed for transplantation: two because of parental decision, two because of suspicion of Munchausen syndrome by proxy, and one because he tolerated enteral nutrition. Six are still TPN dependent and awaiting transplantation. Eight children died awaiting transplantation. Eight children underwent transplantation. Three died (two months, seven months, and four years after transplant). Five children are alive with a median follow up of 2.6 years (range two months to six years). All transplanted children were able to tolerate full enteral feedings. The postoperative course was complicated by dumping syndrome, Munchausen syndrome by proxy, narcotic withdrawal, and uncovering of achalasia. Conclusion-Intestinal transplantation may be a life saving procedure in children with CIPO. Early referral and thorough pretransplant evaluation are keys to successful transplantation.
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Affiliation(s)
- L Sigurdsson
- Department of Paediatric Gastroenterology, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213-2583, USA
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Bueno J, Zuazu J, Villalba T, Julià A. [Acute leukemia in Jehovah's Witnesses]. Sangre (Barc) 1999; 44:381-2. [PMID: 10618916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Two cases of young patients, Jehova Witnesses (JW), diagnosed as having acute lymphoblastic leukaemia are presented. In one case a complete remission (CR) was obtained, lasting until now, 20 months after diagnosis; the other one died 11 months after diagnosis without achieving a CR. Three important questions can be raised in JW: 1) the absolute respect to patients' wishes; 2) to treat or not to treat; and 3) the pertinent therapy. The answer is yes to 1) and 2), and a slight myelotoxic therapy for the last one.
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Affiliation(s)
- J Bueno
- Servicio de Hematología Clínica, Hospital General Vall d'Hebron, Barcelona.
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Abstract
The aim of this study was to elucidate the neuropathological substrate of intestinal failure before and after small bowel transplantation (SBT). Retrospective analysis of complete autopsy or brain biopsy specimens of 17 patients with intestinal failure (12 children and 5 adults) were studied. Patients were divided into two groups. Group I (transplanted group; n = 13) included those patients who underwent intestinal transplantation under tacrolimus and steroids immunosuppressive therapy. Group II (control group) included 4 children with intestinal failure who were candidates for SBT and died while awaiting an intestinal allograft. Central nervous system (CNS) abnormalities were seen in 92% of the SBT recipients and in 100% of SBT candidates. The neuropathological lesions of SBT recipients included: (a) vascular lesions: global brain ischemia, infarcts, intracranial hemorrhage and edema (7 children/2 adults; 69%); (b) cerebral atrophy (6 children; 46%); (c) Alzheimer type II gliosis (5 children/4 adults; 69%); (d) infection (3 patients; 23%) due to cytomegalovirus (1 child), Aspergillus fumigatus (1 adult) and progressive multifocal leukoencephalopathy (PML)-like (1 adult); (e) Epstein-Barr virus-related cerebral post-transplant lymphoproliferative disorder (2 children; 15%); and (f) central pontine and extrapontine myelinolysis (1 child; 7.5%). The neuropathological lesions of SBT candidates were Alzheimer type II astrocytosis (4 patients), vascular changes (4 patients), brain atrophy (4 patients) and cerebral candidiasis (1 patient). CNS vascular, metabolic and infectious pathology are significant causes of morbidity and mortality in patients suffering intestinal failure, both before and after SBT. Brain atrophy was a frequent finding and may be related to nutritional and developmental inadequacy of long-term total parenteral nutrition.
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Affiliation(s)
- M A Idoate
- Department of Neuropathology, University of Pittsburg Medical Center, PA 15123, USA
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Mazariegos G, Abu-Elmagd K, Bueno J, Kocoshis S, Reyes J. EXPANDING INDICATIONS FOR INTESTINAL TRANSPLANTATION. Transplantation 1999. [DOI: 10.1097/00007890-199904150-00780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abu-Elmagd KM, Reyes J, Fung JJ, Mazariegos G, Bueno J, Martin D, Colangelo J, Rao A, Demetris A, Starzl TE. Clinical intestinal transplantation in 1998: Pittsburgh experience. Acta Gastroenterol Belg 1999; 62:244-7. [PMID: 10427791 PMCID: PMC2965419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- K M Abu-Elmagd
- University of Pittsburgh, Thomas E. Starzl Transplantation Institute, Falk Clinic, PA 15213, USA
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Molmenti E, Mazariegos G, Bueno J, Cacciarelli T, Alasio T, Khanna A, Kosmach B, Jain A, Fung J, Reyes J. Noncompliance after pediatric liver transplantation. Transplant Proc 1999; 31:408. [PMID: 10083164 DOI: 10.1016/s0041-1345(98)01682-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- E Molmenti
- Thomas E. Starzl Transplantation Institute, Pittsburgh, Pennsylvania 15213, USA
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78
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Abu-Elmagd KM, Reyes J, Fung JJ, Mazariegos G, Bueno J, Janov C, Colangelo J, Rao A, Demetris A, Starzl TE. Evolution of clinical intestinal transplantation: improved outcome and cost effectiveness. Transplant Proc 1999; 31:582-4. [PMID: 10083246 PMCID: PMC2963188 DOI: 10.1016/s0041-1345(98)01565-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- K M Abu-Elmagd
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, PA 15213, USA
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Bueno J, Ohwada S, Kocoshis S, Mazariegos GV, Dvorchik I, Sigurdsson L, Di Lorenzo C, Abu-Elmagd K, Reyes J. Factors impacting the survival of children with intestinal failure referred for intestinal transplantation. J Pediatr Surg 1999; 34:27-32; discussion 32-3. [PMID: 10022138 DOI: 10.1016/s0022-3468(99)90223-3] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of this study was to analyze factors impacting on the survival of pediatric patients with intestinal failure referred for intestinal transplantation (ITx). METHODS Two hundred fifty-seven children (mean age, 3.4+/-0.26 years) with intestinal failure were evaluated for ITx between 1990 and 1998. All patients were dependent on total parenteral nutrition (TPN) for a mean of 31+/-2.7 months. The mean follow-up time from the date of evaluation was 9.2+/-0.9 months. RESULTS Eighty-two (32%) children underwent ITx with a mean waiting time of 10.1+/-1.3 months (simultaneous liver-intestinal allograft in 68% instances). Of the 175 patients who did not undergo transplantation, 120 died, 23 were lost to follow-up, and 32 are alive. Younger patients (< or =1 year) had poorer survival rates than patients older than 1 year (P<.0001). The patients with the worse prognosis were those with necrotizing enterocolitis, and those with the best prognosis were those with Hirschsprung's disease. Patients with "surgical" causes had poorer survival rates than those with "nonsurgical" causes (P<.04). Patients with bridging fibrosis or established cirrhosis had an earlier mortality than patients with portal fibrosis (P<.003). The worst survival rate was found for patients with bilirubin levels of greater than 3 mg/dL (P<.0001), plateletcounts less than 100.000/mL (P<.0001), prothrombin time greater than 15 seconds (P = .03) or partial thromboplastin time greater than 40 seconds (P<.04). Children who at the time of evaluation needed only an isolated intestinal allograft had a better prognosis than those who required a combined liver-intestine allograft (P<.00001). With multivariate analysis independent prognosis risk factors of poor outcome were hyperbilirubinemia and severity of histopathologic damage. CONCLUSIONS Early referral for ITx should occur before the development of liver dysfunction, taking into consideration the aforementioned risk factors that would facilitate the development and ominous evolution to liver failure.
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Affiliation(s)
- J Bueno
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh and Children's Hospital of Pittsburgh Transplantation Surgery, PA 15213, USA
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Abstract
PURPOSE Variceal bleeding in children generally presents in the setting of cirrhosis but may also occur in the absence of liver disease and after successful liver transplantation. The authors reviewed their experience with portosystemic shunting in children to better define its efficacy in sclerotherapy failures, as primary therapy, and its role before and after liver transplantation. METHODS Between 1983 and 1997, 21 children with recurrent variceal bleeding underwent portosystemic shunting at the authors' institution. Patients were divided into two groups: 13 patients in group I presented with intrinsic liver disease (cirrhosis) as a cause for portal hypertension; eight patients in group II with no liver disease had extrahepatic portal venous thrombosis, five of which occured after successful liver transplantation. The mean age was 8.6 years (range, 3 to 18). Shunt procedures were semielective, and were performed successfully in all children without any operative morbidity or mortality. Follow-up ranged from 6 months to 15 years. RESULTS Shunt procedures included splenorenal (n = 15), splenocaval (n = 1), side-to-side splenorenal (n = 1), inferior mesenteric vein to renal vein (n = 1), mesocaval (n = 1), and transcutaneous intrahepatic portosystemic shunt (TIPS; n = 2). All patients in group II are alive and well with no further bleeding or occlusions. Of the 13 patients in group I, three had bleeding postshunt, and three patients went on to require liver transplantation because of worsening liver disease. One child died of liver failure with encephalopathy 4 years after shunting. There were two shunt occlusions. CONCLUSIONS Portosystemic shunting is effective therapy in patients with intrinsic liver disease, with salvage amenable by liver transplantation in the treatment failures. It is definitive therapy in patients with extrahepatic venous thrombosis.
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Affiliation(s)
- J Reyes
- Children's Hospital of Pittsburgh, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, PA 15213, USA
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Daller JA, Bueno J, Gutierrez J, Dvorchik I, Towbin RB, Dickman PS, Mazariegos G, Reyes J. Hepatic hemangioendothelioma: clinical experience and management strategy. J Pediatr Surg 1999; 34:98-105; discussion 105-6. [PMID: 10022152 DOI: 10.1016/s0022-3468(99)90237-3] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE This study sought to define management strategies based on clinical experience in treating infantile hepatic hemangioendothelioma. METHODS A retrospective analysis of patients with hemangioendothelioma presenting to a tertiary liver transplantation center between 1989 and 1997 was performed. RESULTS Thirteen patients (median age, 14 days) with hemangioendothelioma were identified. Congestive heart failure (P<.03) and abdominal mass (P<.081) were predictive of 5-month mortality rates. Ultrasonography and computerized axial tomography were the diagnostic modalities most commonly used. Treatment strategies consisted of medical management (steroids and alpha-interferon) and interventional modalities (hepatic artery ligation or embolization, resectional surgery, or orthotopic liver transplantation). Patients who underwent resectional surgery, with or without orthotopic liver transplantation, had a lower 5-month mortality rate (P<.02) and a greater 2-year survival rate (P<.003) than did those who underwent hepatic artery ligation or embolization. Early morbidity and mortality tended to be a consequence of the primary lesion, whereas late morbidity and mortality were reflective of the treatment modality used. CONCLUSIONS In cases of failed medical management, resectional therapy should be used when possible. If partial hepatectomy is not technically achievable, hepatic artery embolization should be used either as definitive therapy or as a temporizing measure until orthotopic liver transplantation is possible.
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Affiliation(s)
- J A Daller
- Thomas E. Starzl Transplant Institute, University of Pittsburgh and Children's Hospital of Pittsburgh Transplantation Surgery, PA 15213, USA
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Escartín A, Bueno J, Lampreave F, González-Ramón N, Piñeiro A, Cruz I, García-Gil FA. Analysis of pig-MAP after small bowel transplantation in pigs. Transplant Proc 1998; 30:4334-6. [PMID: 9865377 DOI: 10.1016/s0041-1345(98)01430-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- A Escartín
- Unidad Mixta de Investigación (Hospital Clinico-Facultad de Medicina, University of Zaragoza, Spain.
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Rovera GM, Strohm S, Bueno J, Kocoshis SA, Abu-Elmagd K, Todu S, Reyes J. Nutritional monitoring of pediatric intestinal transplant recipients. Transplant Proc 1998; 30:2519-20. [PMID: 9745467 DOI: 10.1016/s0041-1345(98)00707-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- G M Rovera
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, PA, USA
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Affiliation(s)
- H Mousa
- Department of Pediatric Gastroenterology and Transplantation Surgery, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, PA 15213-2583, USA
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Affiliation(s)
- L Cicalese
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, PA 15213, USA
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Abstract
A composite graft consisting of a reduced left lateral hepatic segment in continuity with the small intestine was procured from an adult cadaveric donor using a modified in situ split technique. The primary recipient was a 3-year-old boy with hepatointestinal failure. The right side of the liver was transplanted into a 63-year-old man with a central hepatoma and hepatitis C cirrhosis. This was accomplished with center-to-center sharing of the liver portion of the allograft. The in situ split technique was feasible, with good initial allograft function. However, both grafts failed subsequently because of peri-operative recipient-related complications. The adult patient died of an infected pseudoaneurysm of the arterial graft, and the pediatric patient required repeat transplantation as a result of the late diagnosis of a native pancreatic fistula with cholestatic damage to the reduced liver allograft. The child is currently alive 8 months after repeat transplantation.
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Affiliation(s)
- J Reyes
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh Intestinal Care Center, Pennsylvania 15213, USA
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Mazariegos GV, Bueno J, Flynn B, Gronsky C, Iurlano K, Reyes J. CLINICAL IMPACT OF TITRATED WITHDRAWAL OF IMMUNOSUPPRESSION IN PEDIATRIC LIVER TRANSPLANT RECIPIENTS. Transplantation 1998. [DOI: 10.1097/00007890-199806270-00356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abu-Elmagd K, Reyes J, Todo S, Rao A, Lee R, Irish W, Furukawa H, Bueno J, McMichael J, Fawzy AT, Murase N, Demetris J, Rakela J, Fung JJ, Starzl TE. Clinical intestinal transplantation: new perspectives and immunologic considerations. J Am Coll Surg 1998; 186:512-25; discussion 525-7. [PMID: 9583691 PMCID: PMC2955329 DOI: 10.1016/s1072-7515(98)00083-0] [Citation(s) in RCA: 215] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although tacrolimus-based immunosuppression has made intestinal transplantation feasible, the risk of the requisite chronic high-dose treatment has inhibited the widespread use of these procedures. We have examined our 1990-1997 experience to determine whether immunomodulatory strategies to improve outlook could be added to drug treatment. STUDY DESIGN Ninety-eight consecutive patients (59 children, 39 adults) with a panoply of indications received 104 allografts under tacrolimus-based immunosuppression: intestine only (n = 37); liver and intestine (n = 50); or multivisceral (n = 17). Of the last 42 patients, 20 received unmodified adjunct donor bone marrow cells; the other 22 were contemporaneous control patients. RESULTS With a mean followup of 32 +/- 26 months (range, 1-86 months), 12 recipients (3 intestine only, 9 composite grafts) are alive with good nutrition beyond the 5-year milestone. Forty-seven (48%) of the total group survive bearing grafts that provide full (91%) or partial (9%) nutrition. Actuarial patient survival at 1 and 5 years (72% and 48%, respectively) was similar with isolated intestinal and composite graft recipients, but the loss rate of grafts from rejection was highest with intestine alone. The best results were in patients between 2 and 18 years of age (68% at 5 years). Adjunct bone marrow did not significantly affect the incidence of graft rejection, B-cell lymphoma, or the rate or severity of graft-versus-host disease. CONCLUSIONS These results demonstrate that longterm rehabilitation similar to that with the other kinds of organ allografts is achievable with all three kinds of intestinal transplant procedures, that the morbidity and mortality is still too high for their widespread application, and that the liver is significantly but marginally protective of concomitantly engrafted intestine. Although none of the endpoints were markedly altered by donor leukocyte augmentation (and chimerism) with bone marrow, establishment of the safety of this adjunct procedure opens the way to further immune modulation strategies that can be added to the augmentation protocol.
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Affiliation(s)
- K Abu-Elmagd
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, PA 15213, USA
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Martín-Crespo R, Bueno J, Alvarez I, De Miguel E, Vázquez J. Histomorphometric changes after small bowel transplantation. Rev Esp Enferm Dig 1998; 90:345-51. [PMID: 9656754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Rejection results in destruction of the intestinal mucosa. This is the major cause of morbidity and morbility in human allografts. The aim of this study was to investigate histomorphometric changes in both the graft and recipient intestinal mucosa after experimental orthotopic small bowel transplantation. EXPERIMENTAL DESIGN Using the pig model, 21 large-white pigs underwent: laparotomy (n = 7) (control group); orthotopic small bowel transplantation without immunosuppression (n = 7); and orthotopic small bowel transplantation with cyclosporine A (n = 7). RESULTS 1) Significant reduction of total mucosal thickness (villi plus crypt) (p < 0.05) in both the graft and recipient mucosa; 2) Attenuation of this effect by administration of cyclosporine A, which reduced the loss of mucosal thickness mainly at the expense of crypt hipertrophy. CONCLUSIONS These findings suggest that villi and crypt length measurements may be a reliable method for monitoring rejection after small bowel transplantation.
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Affiliation(s)
- R Martín-Crespo
- Pediatric Surgery Service, Hospital Infantil Universitario Gregorio Marañón, Madrid, Spain
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91
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Abstract
Epstein-Barr virus (EBV) infection in association with immunosuppressive drugs used for solid organ transplantation can produce a spectrum of illnesses. Forty-one children who ranged in age from 6 months to 18.5 years received small intestinal transplants alone or in combination with other organs while undergoing primary tacrolimus (FK506) immunosuppression between July 1990 and June 1995. We reviewed hematoxylin and eosin-stained sections from all biopsy, surgical, and autopsy material from these children to determine the incidence and morphology of EBV-associated disease. Nuclear staining with in situ hybridization for EBV early RNA transcript (EBER) using the EBER-1 probe confirmed the presence of EBV. The EBV lymphoproliferations were graded as 1 to 4 according to histopathology and EBV quantitation determined in the area of greatest positivity. Twenty-one patients (51%) had EBV documented histologically on one or more occasions; only 8 (38%) are alive; 5 of these had the highest grade of 2. Posttransplant lymphoproliferative disease (PTLD) developed in 13 patients. Three of 10 patients (30%) with grade 3 lesions (polymorphous PTLD) are alive with intermittent evidence of EBV infection; 6 died with PTLD. Monomorphic PTLD (grade 4) was the cause of death in the three additional patients. Thirteen of 20 patients (65%) with no histologic evidence of EBV are alive. The incidence of EBV infection in pediatric small intestinal transplant recipients is higher than reported for any other solid organ cohort. With the aid of frequent EBER staining we were able to diagnose EBV infections in 51% of 41 patients; PTLD (grade 3 or 4) developed in 32% of these children. Low-grade EBV infections often preceded the development of PTLD and were identified in gastrointestinal biopsy samples from patients with concurrent PTLD; however, results of gastrointestinal biopsy samples may be negative for EBV in some patients with PTLD and, thus, underestimate systemic EBV-associated lymphoproliferations. Rejection and EBV infection can occur simultaneously, therefore, attention to low-grade infection may be useful to patient management.
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Affiliation(s)
- L Finn
- Department of Pathology, Children's Hospital of Pittsburgh, Pennsylvania, USA
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92
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Abstract
A rare case of pneumatosis intestinalis is described in a patient with appendicitis. Gas in the colonic wall, epiploic appendices and mesentery caused a new appearance not previously reported on plain radiography or CT. The relevance of an associated redundant right colon is also discussed.
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Affiliation(s)
- J A Parra
- Department of Radiology, Hospital Sierrallana, Cantabria, Spain
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93
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94
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Reyes J, Bueno J, Kocoshis S, Green M, Abu-Elmagd K, Furukawa H, Barksdale EM, Strom S, Fung JJ, Todo S, Irish W, Starzl TE. Current status of intestinal transplantation in children. J Pediatr Surg 1998; 33:243-54. [PMID: 9498395 PMCID: PMC2966145 DOI: 10.1016/s0022-3468(98)90440-7] [Citation(s) in RCA: 175] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE A clinical trial of intestinal transplantation (Itx) under tacrolimus and prednisone immunosuppression was initiated in June 1990 in children with irreversible intestinal failure and who were dependent on total parenteral nutrition (TPN). METHODS Fifty-five patients (28 girls, 27 boys) with a median age of 3.2 years (range, 0.5 to 18 years) received 58 intestinal transplants that included isolated small bowel (SB) (n = 17), liver SB (LSB) (n=33), and multivisceral (MV) (n=8) allografts. Nine patients also received bone marrow infusion, and there were 20 colonic allografts. Azathioprine, cyclophosphamide, or mycophenolate mofetil were used in different phases of the series. Indications for Itx included: gastroschisis (n=14), volvulus (n=13), necrotizing enterocolitis (n=6), intestinal atresia (n=8), chronic intestinal pseudoobstruction (n=5), Hirschsprung's disease (n=4), microvillus inclusion disease (n=3), multiple polyposis (n=1), and trauma [n=1). RESULTS Currently, 30 patients are alive (patient survival, 55%; graft survival, 52%). Twenty-nine children with functioning grafts are living at home and off TPN, with a mean follow-up of 962 (range, 75 to 2,424) days. Immunologic complications have included liver allograft rejection (n=18), intestinal allograft rejection (n=52), posttransplant lymphoproliferative disease (n=16), cytomegalovirus (n=16) and graft-versus-host disease (n=4). A combination of associated complications included intestinal perforation (n=4), biliary leak (n=3), bile duct stenosis (n=1), intestinal leak (n=6), dehiscence with evisceration (n=4), hepatic artery thrombosis (n=3), bleeding (n=9), portal vein stenosis (n=1), intraabdominal abscess (n=11), and chylous ascites (n=4). Graft loss occurred as a result of rejection (n=8), infection (n=12), technical complications (n=8), and complications of TPN after graft removal (n=3). There were four retransplants (SB, n=1; LSB n=3). CONCLUSIONS Intestinal transplantation is a valid therapeutic option for patients with intestinal failure suffering complications of TPN. The complex clinical and immunologic course of these patients is reflected in a higher complication rate as well as patient and graft loss than seen after heart, liver, and kidney transplantation, although better than after lung transplantation.
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Affiliation(s)
- J Reyes
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, PA 15213, USA
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95
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Trujillo MJ, Bueno J, Osorio A, Sanz R, Garcia-Sandoval B, Ramos C, Ayuso C. Three novel RDS-peripherin mutations (689delT, 857del17, G208D) in Spanish familes affected with autosomal dominant retinal degenerations. Hum Mutat 1998. [DOI: 10.1002/(sici)1098-1004(1998)12:1<70::aid-humu11>3.0.co;2-m] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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96
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Abu-Elmagd K, Fung J, Reyes J, Rao A, Jain A, Mazariegos G, Marsh W, Madariaga J, Dvorchik I, Bueno J, Rogers J, McMichael J, Dodson F, Vargus H, Martin J, Slivka A, Balan V, Corry R, Rakela J, Murase N, Demetris J, Iwatsuki S, Starzl T. Hepatic and intestinal transplantation at the University of Pittsburgh. Clin Transpl 1998:263-86. [PMID: 10503105 PMCID: PMC2956306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Affiliation(s)
- K Abu-Elmagd
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pennsylvania, USA
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97
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Bueno J, Green M, Kocoshis S, Furukawa H, Abu-Elmagd K, Yunis E, Irish W, Todo S, Reyes J, Starzl TE. Cytomegalovirus infection after intestinal transplantation in children. Clin Infect Dis 1997; 25:1078-83. [PMID: 9402361 PMCID: PMC2962562 DOI: 10.1086/516113] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Sixteen episodes of cytomegalovirus (CMV) disease occurred in 10 of 41 children undergoing intestinal transplantation from 1990 to 1995. Stratification of CMV disease by donor (D)/recipient (R) serological status was as follows: 3 of 8, D+/R-; 3 of 9, D+/R+; 4 of 9, D-/R+; and 0 of 15, D-/R-. Treatment resulted in resolution of CMV disease in 93.3% of episodes. No deaths attributable to CMV disease occurred in this series. CMV in D+/R- children resulted in more extensive and persistent disease. However, patient and graft survival rates were similar in the different D/R subgroups and between children with and without CMV disease. Cumulative dose of steroid boluses (relative risk [RR], 1.59; 95% confidence interval [CI], 1.14-2.21) and history of steroid recycles (RR, 2.72; 95% CI, 1.21-6.13) were associated with CMV disease. These results suggest that although CMV-associated morbidity in pediatric intestinal transplant recipients was substantial, it was not associated with an increased rate of mortality or graft loss, even among high-risk D+/R- patients.
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Affiliation(s)
- J Bueno
- University of Pittsburgh, Department of Surgery, Children's Hospital of Pittsburgh, Pennsylvania, USA
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98
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Reyes J, Todo S, Green M, Yunis E, Schoner D, Kocoshis S, Furukawa H, Abu-Elmagd K, Tzakis A, Bueno J, Starzl TE. Graft-versus-host disease after liver and small bowel transplantation in a child. Clin Transplant 1997; 11:345-8. [PMID: 9361921 PMCID: PMC2967285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
An 8-month-old child with an immunodeficiency disorder characterized by abnormal lymphocyte function and by low IgG and IgA levels had combined liver and small bowel transplantation under tacrolimus and steroid immunosuppression for the treatment of short gut syndrome and hepatic cirrhosis. The patient developed an early postoperative episode of Pneumocystis carinii pneumonia, and a subsequent surgical complication, prompting discontinuance of tacrolimus. A skin rash eventually shown to be graft-versus-host disease (GVHD) developed in the flank on the 12th post-transplant day and gradually became generalized. Peritonitis, sepsis, multisystem organ failure including the liver allograft led to death on the 23rd post-operative day. The mechanisms leading to post-transplant GVHD under the specific circumstances in this case are discussed.
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Affiliation(s)
- J Reyes
- University of Pittsburgh Medical Center, Department of Surgery, PA, USA
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99
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López Santamaria M, Gamez M, Murcia J, Paz Cruz JA, Bueno J, Canser E, Qi B, Lobato R, Martinez L, Jara P, Tovar JA. The effect of hepatic vascular exclusion on hepatic blood flow and oxygen supply--uptake ratio in the pig. Eur J Pediatr Surg 1997; 7:270-4. [PMID: 9402483 DOI: 10.1055/s-2008-1071169] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The hemodynamic disturbances produced by total hepatic vascular exclusion (THVE) for 40 minutes were studied in 7 pigs (19-22 kg). THVE was produced by clamping the hepatic pedicle and inferior vena cava, above and below the liver, for a 40-minutes period, followed by unclamping. Compared to baseline values, 30 minutes after onset of THVE, there was a decrease in cardiac output (3.86 +/- 0.55 vs 1.23 +/- 0.23 L x min-1), systemic arterial pressure (97.54 +/- 13.58 vs 43.43 +/- 11.38 mm Hg), and pulmonary artery pressure (16.57 +/- 6.38 vs 12.57 +/- 3.58) and an increase in systemic and pulmonary vascular resistance (1772 +/- 198 vs 2351 +/- 462, and 182 +/- 66 vs 361 +/- 124 dyn x s x cm-5 respectively). As a result of diminished cardiac output, the systemic oxygen supply decreased (461 +/- 131 vs 101 +/- 46 ml x min-1), but the systemic oxygen extraction rate rose from 17.3% t0 31.2%. Thirty minutes after unclamping, the changes had reversed and all the parameters tended to normalize. Total hepatic blood flow 30 minutes after unclamping was higher than at baseline (5.08 +/- 1.2 vs 6.66 +/- 0.67 ml x min-1 x 100 g-1), because of the increase in portal blood flow (4.52 +/- 1.21 vs 6.07 +/- 0.70 ml x min-1 x 100 g-1). There were no significant differences in hepatic oxygen supply and uptake at baseline and after unclamping (152.6 +/- 23.0 vs 187.0 +/- 34.7 and 22.7 +/- 4.9 vs 28.7 +/- 8.4 ml O2 respectively). AST rose (29 +/- 7 vs 136 +/- 91 U/l), but there was no change in the remaining liver enzymes, glucose, creatinine and serum electrolytes, so we conclude that the hemodynamic disturbances produced by 40 minutes of THVE are manageable and spontaneously reversible. Liver metabolism was not greatly disturbed, so THVE was judged to be a viable technique to be added to the surgeon's range of options.
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Affiliation(s)
- M López Santamaria
- Department of Pediatric Surgery, Hospital Infantil La Paz, Madrid, Spain
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100
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Pulyaeva H, Bueno J, Polette M, Birembaut P, Sato H, Seiki M, Thompson EW. MT1-MMP correlates with MMP-2 activation potential seen after epithelial to mesenchymal transition in human breast carcinoma cells. Clin Exp Metastasis 1997; 15:111-20. [PMID: 9062387 DOI: 10.1023/a:1018444609098] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We have previously reported that human breast carcinoma (HBC) cell lines expressing the mesenchymal intermediate filament protein vimentin (VIM+) are highly invasive in vitro, and highly metastatic in nude mice when compared to their VIM- counterparts. Since only VIM+ cell lines can be induced to activate matrix metalloproteinase-2 (MMP-2) upon stimulation with Concanavalin A (Con A), we have examined here membrane type 1 MMP (MT1-MMP), a cell surface activator of MMP-2. Northern analysis reveals baseline expression of MT1-MMP in five of the six VIM+ cell lines studied (MDA-MB-231, MDA-MB-435, BT-549, Hs578T, MCF-7(ADR)), each of which showed variable activation of exogenous MMP-2 after treatment with Con A. In contrast, the four VIM-, poorly invasive HBC cell lines studied (MCF-7, T47D, MDA-MB 468, ZR-75-1) lacked baseline MT1-MMP mRNA expression, and showed no induction of either MT1-MMP expression or MMP-2-activation with Con A. Such differential MT1-MMP expression was confirmed in vivo using in situ hybridization analysis of nude mouse tumor xenografts of representative cell lines. Western analysis of the MDA-MB-231 cells revealed baseline membrane expression of a 60 kDa species, which was strongly induced by Con A treatment along with a weaker band co-migrating with that from MT1-MMP-transfected COS-1 cells (63 kDa), presumably representing latent MT1-MMP. MT1-MMP immunofluorescence strongly decorated Con A-stimulated MDA-MB-231 cells in a manner consistent with membranous staining, but did not decorate the unstimulated MDA-MB-231 cells or MCF-7 cells under either condition. Collectively, the results suggest the constitutive production of active MT1-MMP which is unavailable for either MMP-2 activation or immuno-decoration until Con A treatment. Since VIM expression arises by virtue of the so-called epithelial to mesenchymal transition (EMT) in invasive embryonic epithelia, we propose that this represents a major metastasis mechanism in breast carcinomas. MT1-MMP on the surface of such 'fibroblastoid' carcinoma cells may mediate a paracrine loop for the utilization of stromally produced MMP-2, and contribute to the poorer survival associated with VIM+ breast carcinomas.
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Affiliation(s)
- H Pulyaeva
- Lombardi Cancer Center, Georgetown University Medical Center, Washington, DC 20007, USA
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