Increased risk of fracture in patients receiving solid organ transplants

The success of organ transplantation is related to advances in immunosuppressive therapy. These medications are associated with medical complications including bone damage. The objective of this study was to estimate and compare age, gender-specific fracture incidence between transplant recipients, and a large sample representative of the civilian noninstitutionalized United States population using the 1994 National Health Interview Survey (NHIS). This was a cohort study set in tertiary care centers. Five hundred and thirty-nine individuals who received abdominal organ and 61 heart transplants surviving at least 30 days at our institution from 1986 to 1996 were included in the study. Incident fractures were ascertained by mail, in-person interview, telephone survey, or medical record review. All fractures were verified. Organ-, age-, and gender-specific fracture numbers and rates and person-years of observation, were calculated for the transplant patients. Weighted age- and gender-specific fracture rates from the 1994 NHIS were applied to the number of person-years of observation for each organ-specific age and gender category of transplant patients to generate an expected number of fractures. The ratio of observed to expected number of fractures was used to compare fracture experience of transplant patients to that of the national sample from the 1994 NHIS. Fifty-six of 600 (9.3%) patients had at least one fracture following 1221 person-years of observation. The sites of initial symptomatic fracture were as follows: foot (n = 22), arm (n = 8), leg (n = 7), ribs (n = 6), hip (n = 4), spine (n = 3), fingers (n = 3), pelvis (n = 2), and wrist (n = 1). Fracture incidence was 13 times higher than expected in male heart recipients age 45-64 years; nearly 5 times higher in male kidney recipients age 25-44 and age 45-64 years; and 18 times and 34 times higher in female kidney recipients age 25-44 years and 45-64 years compared with NHIS data. We have shown an increased incidence of fractures and estimated the magnitude of this problem in patients undergoing solid organ transplantation. Our work defines the need for a long-term prospective study of fracture risk in these patients.

Mycophenolate mofetil and tacrolimus as primary maintenance immunosuppression in simultaneous pancreas-kidney transplantation: initial experience in 50 consecutive cases

BACKGROUND

The current study examines the use of mycophenolate mofetil (MMF) and tacrolimus as primary immunosuppression in simultaneous pancreas-kidney (SPK) transplantation. In addition, analyses of the rates of conversion from one immunosuppressive agent to another, and its subsequent consequences with respect to outcomes were determined. Quality of graft function, infections, and effect on preexisting essential hypertension are also described.

METHODS

Immunosuppression consisted of quadruple therapy with antithymocyte globulin induction, tacrolimus, MMF, and prednisone. Patient and graft survival and rejection rates in 50 consecutive SPK recipients, followed for a minimum of 3 months and a mean of 14 months (range: 3-34 months), are described.

RESULTS

Thirty-nine of 50 (78%) patients tolerated the MMF/tacrolimus combination long-term (mean duration of follow-up: 14+/-7 months). Nine of 50 patients (18%) were converted to Neoral, and 4 patients were converted to azathioprine as a substitute for MMF. The 2-year actuarial patient, kidney, and pancreas survival rates were 97.7%, 93.3%, and 90.0%, respectively. At 6 months after transplant, the overall incidence of acute rejection was 16%. There was a statistically significant (P< or =0.04, Cox-Mantel test) difference in the rate of rejection associated with conversion to Neoral. The incidence of rejection 6 months after transplant in the group maintained on MMF/tacrolimus was 10.2% vs. 44.4% in the group converted to Neoral (P< or =0.04, Cox-Mantel test). Overall, the 1-year actuarial cumulative incidence of tissue-invasive cytomegalovirus disease was 6.6%. There were no cases of fungal infections or post-transplant lymphoproliferative disorders. One patient developed Kaposi's sarcoma 10 months after transplant. With respect to hypertensive disease, 60% (12/20) of the patients who required pharmacologic control of blood pressure before transplant were off all antihypertensive medications at 1 year after transplant. An additional 20% (4/20) of patients had a reduction in the number of medications required to control blood pressure at 1 year after transplant.

CONCLUSIONS

We conclude that the combination of MMF and tacrolimus as primary immunosuppression for SPK transplantation results in excellent patient and graft survival rates, a very low rate of acute rejection, and low rates of infection and malignancy.

Ciliated hepatic foregut cyst mimicking neoplasm

We describe a ciliated hepatic foregut cyst that was clinically considered neoplastic because it was large, bilocular, and associated with a high serological level of carbohydrate antigen 19-9 (CA 19-9). Histologically, the wall of the cyst showed characteristic pseudopapillae lined by ciliated stratified columnar epithelium with interspersed goblet cells and underlying smooth muscle. The epithelium was strongly immunoreactive for CA 19-9. We therefore conclude that large size, multilocularity, and elevated CA 19-9 do not exclude ciliated hepatic foregut cysts from diagnostic consideration.

The role of PCR in the diagnosis and management of CMV in solid organ recipients: what is the predictive value for the development of disease and should PCR be used to guide antiviral therapy?

Cytomegalovirus remains a significant source of morbidity and mortality in immunocompromised hosts. The increased sensitivity of molecular diagnostic techniques (PCR, antigenemia) has resulted in our ability to detect viral replication earlier in the posttransplant period, before the onset of symptoms. With the advent of effective antiviral therapy, "preemptive therapy," guided by sensitive, early and specific predictors of CMV disease, has become a realistic objective. Although multiple studies have analyzed the sensitivity and specificity of these tests, their predictive value for the development of disease has not been defined. The purpose of this study was to evaluate the predictive value of a positive CMV PCR in the setting of solid abdominal organ transplantation. A total of 476 PCR assays were performed on 134 transplant recipients (102 kidney, 19 kidney/pancreas, 11 liver, 2 other) either as protocol serial samples or as dictated by clinical events. All samples were concomitantly analyzed using standard virological assays for CMV including culture, shell vial, and serology. Patients with any CMV seropositive donor/recipient (D/R) combination received ganciclovir prophylaxis in conjunction with antilymphocyte induction for 14 days. No subsequent CMV prophylaxis was used. The positive predictive value was 55% in all seropositive donor/recipient combinations. The highest risk group (seronegative recipient of seropositive donor) showed the highest positive predictive value, whereas seropositive recipients of either seropositive or seronegative donors showed positive predictive values of 45% and 25%, respectively. Negative predictive value was 100% for all groups. Early detection of CMV infection has important implications for patient management, including preemptive therapy, which can be guided by PCR, especially in high risk (D+/R-) patients.

Frequency of hyperkalemia in recipients of simultaneous pancreas and kidney transplants with bladder drainage

Hyperkalemia is the most frequent electrolyte abnormality found in whole organ transplant recipients receiving either cyclosporine (CsA) or tacrolimus (FK506). Recipients of a simultaneous pancreas kidney (SPK) transplant with bladder drainage may be particularly susceptible to hyperkalemia secondary to sodium loss from the bladder-drained pancreas, leading to decreased sodium delivery to potassium secretory sites of the kidney. We looked at the incidence of hyperkalemia in 34 type I diabetic SPK recipients transplanted at our center over the period from 1993 to 1995 and compared this with a cohort of 25 type I diabetic recipients of a kidney alone (K(Tx)) transplant. The incidence of hyperkalemia was 73.5% in recipients of an SPK, while it was 44% in K(Tx) recipients (P<0.05). CsA levels were higher, on average, in the SPK group (339 ng/ml+/-62 versus 272 ng/ml+/-58 in the K(Tx) group, P<0.05). However, CsA levels were not different between groups at the time of hyperkalemia, 320+/-74 versus 298+/-49 for SPK and K(Tx), respectively. CsA levels at the time of hyperkalemia were not different from those at the time of normokalemia. Other medications, serum bicarbonate, and renal function were not different in the groups. SPK recipients appear to have a greater incidence of hyperkalemia than kidney alone transplant recipients. This difference cannot be explained by higher acute CsA levels, other medications, or worse renal function. The increased incidence of hyperkalemia may, in part, be secondary to decreased sodium delivery to the transplanted kidney.

Simultaneous pancreas-kidney versus kidney-alone transplants in diabetics: increased risk of early cardiac death and acute rejection following pancreas transplants

The decision between a simultaneous pancreas-kidney (SPK) or kidney-alone (KA) transplant for the treatment of diabetic end-stage renal disease depends on the risk-versus-benefit of each procedure. In this study we compared the mortality, morbidity, graft function and acute rejection after 88 SPK and 65 KA transplants. All acute rejection episodes were biopsy-proven. Patient survival was higher in the KA group (KA 92%, SPK 83%) at 1 year, but similar in both groups at 5 years (SPK 78%, KA 71%). Whereas myocardial infarction accounted for a similar proportion of deaths in both groups, sepsis and surgical complications were more common causes of death in the SPK group. The majority of cardiovascular deaths occurred early in the SPK group compared to the KA group. Kidney graft survival was similar at 1 year (SPK 79%, KA 81%) and 5 years (SPK 66%, KA 59%). Pancreas graft survival at 1 and 5 years was 75% and 60% respectively. Biopsy-proven acute rejection occurred more frequently in the SPK group (SPK 63%, KA 46%). Morbidity was greater in the SPK group and included vascular (SPK 19%, KA 3%), non-infectious urologic (SPK 23%, KA 3%) and infectious complications (SPK 86%, KA 33%). The majority of complications in the SPK group were related to the pancreas allograft. In summary, SPK transplants were associated with an increased risk of early cardiovascular death, greater morbidity and more frequent biopsy-proven acute rejection episodes. However, kidney graft survival was not affected by the addition of the pancreas allograft.

Markers for pancreatic allograft rejection: comparison of serum anodal trypsinogen, serum amylase, serum creatinine and urinary amylase

Currently, the markers of acute rejection in pancreas allografts are not consistently reliable. The purpose of this study was to evaluate the ability of sAT to predict acute rejection as compared to serum creatinine (sCr), urinary amylase (uAmy) and serum amylase (sAmy). Eleven first-time acute rejection episodes in bladder-drained SPK recipients were studied. All rejection episodes were biopsy-proven (core kidney 9, fine needle kidney 2, fine needle pancreas 5). Sera obtained from days -7 to -1 (pre-treatment), day 0 (start of anti-rejection treatment), and +1 to +7 (post-treatment) periods were analyzed. Peak median sAT and sAmy levels occurred at day 0 compared to day 1 for sCr. uAmy trough levels occurred on days -4, -5 and +2. The difference between pre-treatment levels and those on day 0 were significant for sAT, sAmy and sCr but not for uAmy. Only in the case of sAT was the difference between day 0 levels and post-treatment levels significant. Both sAmy (0.87) and sCr (0.85) demonstrated positive correlation when compared to sAT whereas uAmy demonstrated a weak negative correlation (-0.24). This study confirms that sAT accurately predicts rejection after SPK transplantation.

Sphincter of Oddi dysfunction following liver transplantation. Screening by bedside manometry and definitive manometric evaluation

Although sphincter of Oddi dysfunction (SOD) has been extensively studied in the nontransplant setting, the diagnostic criteria after liver transplantation are not well defined and have been based on clinical features without manometric documentation. The purpose of this study was twofold: (1) to determine the manometric patterns associated with SOD following orthotopic liver transplantation (OLT) and (2) to define the usefulness of bedside T-tube manometry as a screening tool for SOD. ERCP with simultaneous manometry of the sphincter of Oddi (SO) was performed in five patients following OLT with choledochocholedochostomy (CDCD) between 1990 and 1992. The diagnosis of SOD was suspected based on persistently elevated liver function tests, distal common bile duct dilatation in the absence of strictures, and an elevated resting bile duct pressure as measured by bedside T-tube manometry. Two different manometric patterns of SOD were observed. The first pattern (N = 4) consisted of elevated SO basal pressures, infrequent simultaneous phasic activity, and an abnormal response to cholecystokinin-octapeptide (CCK-OP). The second pattern (N = 1) consisted of low basal pressures and absent phasic activity. Four patients were successfully treated with papillotomy and stenting, while the fifth patient required conversion to a choledochojejunostomy because of a concomitant anastomotic stricture. The abnormal SO manometric profiles in patients suspected of having SOD after OLT were different from those observed in the nontransplant setting. Bedside T-tube manometry allowed measurement of the resting bile duct pressure and may be a useful screening tool for SOD.

Back-table renal allograft angioscopy and thrombolysis

Poor back-table perfusion of a renal allograft may occur as a result of intravascular thrombosis of the renal artery branches. We herein report such a case where back-table angioscopy was performed to confirm the diagnosis, followed by successful thrombolysis using urokinase under hypothermic conditions.

Incidence, management and significance of surgical complications after pancreatic transplantation

Despite recent advances, pancreatic transplantation is still in evolution and is associated with considerable surgical morbidity. We reviewed the surgical complications of 127 consecutive whole pancreatic transplants performed at the University of Iowa between March 1984 and January 1992, to evaluate the impact of these complications on graft and patient outcome. Of these transplantations, 89 were simultaneous pancreatic and renal transplants, 32 pancreas after kidney and six pancreas alone. Of all complications requiring hospital admission, 29 percent were surgical in nature. Graft thrombosis (19 percent), deep wound infection (18 percent), duodenal leak (7 percent) and iliac artery disruption (3 percent) were all associated with significant graft (n = 28) and patient (n = 6) loss. In contrast, recurrent urinary tract infections (20 percent), recurrent pancreatitis (17 percent), superficial wound infections (13 percent) and recurrent hematuria (12 percent) did not affect patient or graft outcome. Surgical complications after technically successful transplants were associated with a 4.9 percent mortality rate and a 4.9 percent graft loss. The overall one year actuarial patient and pancreas graft survival rate was 86 and 75 percent, respectively. Despite ongoing refinements in surgical technique, pancreatic transplantation is still associated with considerable surgical morbidity. However, the outcome is favorable if these complications are managed aggressively.

A new technique of prosthetic arteriovenous fistula construction that eliminates the need for temporary access

The use of polytetrafluoroethylene (PTFE) for hemodialysis requires a maturation period to allow for tissue ingrowth around the graft. If hemodialysis is necessary during this waiting period, then temporary access is used. Unfortunately, temporary access is difficult, if not impossible, to establish in many patients undergoing chronic hemodialysis. We describe a technique for the construction of a prosthetic arteriovenous fistula that eliminates the waiting period and the need for temporary access in selected patients who require PTFE fistulas for hemodialysis.

Detection of murine cytomegalovirus (MCMV) DNA in skin using the polymerase chain reaction (PCR)

We used the polymerase chain reaction (PCR) and primers for the immediate early gene of murine cytomegalovirus (MCMV) to detect MCMV DNA in skin harvested from mice during acute infection. MCMV DNA was also detected in DNA extracted from spleen and salivary gland of MCMV-infected mice, but not in the skin, salivary gland, or spleen of uninfected, seronegative mice. Detection of MCMV DNA in skin provides direct evidence that skin can serve as a vehicle for transmission of MCMV. This observation is relevant to humans, such as burn patients, who receive skin allografts that may be infected with cytomegalovirus.

[Unusual complications of bone marrow transplantation. Experience at the BMT Unit of the Francisco Gentil Portuguese Institute of Oncology, Lisbon Center]

Over the past 20 years allogeneic bone marrow transplantation has been increasingly utilized in the treatment of acute and chronic leukemias, aplastic anemia, severe forms of thalassemia, immunodeficiency syndromes and metabolic disorders due to a lack of specific enzymes in the monocyte-macrophage system. Despite the overall success of this approach and besides the so-called classic complications arising from the toxicity of the conditioning regimen, occurrence of GVH disease and interstitial pneumonitis, there are other less common complications which have been reported mainly by teams transplanting on a large number of patients. With only a limited experience, concerning 60 patients with transplants between May 1987 and May 1991, we have seen some unusual complications such as toxoplasma encephalitis, myasthenia gravis and aseptic bone necrosis, which may give rise to difficult diagnostic and therapeutic decisions.