Follow-up results of synthetic vascular grafts in children undergoing hemodialysis

Polytetrafluoroethylene (PTFE) grafts were inserted in the thigh of 14 children (7 boys and 7 girls, age 12 +/- 1.8 years) who were undergoing chronic hemodialysis for endstage renal disease. Removal of grafts was necessary in three patients within three months of implantation. In a fourth case it was indicated in the fifteenth month. In two cases thrombectomy was necessary. Echocardiography was performed in 10 patients before and three and 12 months after surgery. Cardiac performance followed by echocardiography did not change after one year. After two years the survival of grafts was 71%. It appears that synthetic grafts offer advantages for pediatric hemodialysis patients with arteriovenous fistula failure. On the other hand, this technique entails serious risks.

A multidisciplinary approach to hepatocellular carcinoma in patients with cirrhosis

BACKGROUND

A multidisciplinary approach has been developed to evaluate and treat patients with cirrhosis and hepatocellular carcinoma (HCC).

STUDY DESIGN

We evaluated 153 patients with cirrhosis and HCC. Fourteen patients with Child's A cirrhosis underwent resection. Transplantation was performed in 40 patients with HCC less than 5 cm (32 incidental, eight recognized preoperatively), in six patients with HCC 5 cm or greater not recognized preoperatively, and in 11 patients with recognized HCC 5 cm or greater; the latter 11 underwent transplantation in a multimodality protocol using pretransplant chemoembolization and intraoperative and postoperative chemotherapy.

RESULTS

Among the 14 patients who underwent resection, the three-year survival rate was 39 percent. Among the 40 patients with HCC less than 5 cm who underwent transplantation, no tumor recurrence was observed. Among the six with HCC 5 cm or greater unrecognized preoperatively, three had tumor recurrence. Among the 11 with HCC 5 cm or greater enrolled in the protocol, there were no deaths and one recurrence at a mean of 433 days follow-up. The four-year survival rate for all patients who underwent transplantation with HCC was 56 percent (66 percent excluding the six patients with unrecognized HCC 5 cm or larger).

CONCLUSIONS

Hepatocellular carcinoma less than 5 cm in patients with cirrhosis (Child's B or C) is an indication for hepatic transplantation. Hepatocellular carcinoma less than 5 cm in patients with cirrhosis (Child's A), although resectable, may in some cases be better treated by hepatic transplantation. Transplantation for HCC 5 cm or greater within a multimodality protocol has yielded excellent results at two years.

Loss of speech after orthotopic liver transplantation

Alteration of speech is a rare but distressing complication of orthotopic liver transplantation (OLT). We describe a characteristic speech disorder identified in a large series of consecutive patients undergoing OLT. Between 1988 and 1993, 525 adults underwent OLT. For all recipients with neurologic complications, we reviewed clinical findings, imaging and electrophysiologic test results, and perioperative laboratory data. Five patients (ages 23-52; UNOS status 3-4) exhibited a characteristic pattern of stuttering dysarthria, leading to complete loss of speech production, occasionally with elements of aphasia. In four of the five patients, right-sided focal seizures were subsequently noted. All cases presented within the first 10 postoperative days and improved with 1 month of cessation of cyclosporin (CyA), although halting, monotonous speech was evident to some degree in all five for up to 1 year. There was no correlation between onset of symptoms and CyA levels. None of the patients has clinical or radiologic findings suggestive of central pontine myelinolysis or akinetic mutism. EEGs and Spect scan results were consistent with dysfunction in the left frontotemporoparietal regions of the brain. A characteristic speech disorder, which may be described as cortical dysarthria or speech apraxia, occurs in approximately 1% of adults undergoing OLT. Prompt recognition of this syndrome and temporary cessation of CyA therapy may favorable affect the course.

Successful use of an enhanced immunosuppressive protocol with plasmapheresis for ABO-incompatible mismatched grafts in liver transplant recipients

Graft and patient survival rates after transplantation of ABO-incompatible liver allografts have been poor. We used plasmapheresis and a potent immunosuppressive regimen to control hemagglutinin levels and prevent early rejection. Ten patients who had a United Network for Organ Sharing status of 4 received ABO-incompatible allografts. Quadruple immunosuppression consisted of OKT3, Cytoxan, cyclosporine, and steroid taper; prostaglandin E-1 was administrated intravenously the first week. All patients underwent perioperative plasmapheresis to maintain hemagglutinin levels < 1:16. Patient survival was 80%; graft survival was 60% at 140-505 days. The rejection rate was 90%. Three recipients (A1-->O) lost their grafts to severe rejection at 5, 12, and 30 days after transplantation. All 3 had pretransplantation hemagglutinin levels > or = 1:100. Elevated hemagglutinin levels preceded the diagnosis of severe acute cellular rejection; plasmapheresis failed to lower anti-A titers in these 3 patients. We conclude that in an urgent setting, lowering of preformed hemagglutinins via plasmapheresis in combination with quadruple induction immunosuppression allows liver transplantation across ABO barriers. In patients with high baseline levels of preformed hemagglutinins, the risk of subsequent graft loss may be increased and transplantation with an ABO-incompatible graft may serve as a lifesaving intermediate step.

Pharmacokinetics of amikacin, netilmicin and tobramycin in children with chronic renal failure

The single-dose pharmacokinetics of amikacin, netilmicin and tobramycin administered intramuscularly at doses of 7.5 mg/kg amikacin, 2.5 mg/kg netilmicin or 3 mg/kg tobramycin were studied in 30 children with chronic renal failure. Serum amikacin, netilmicin and tobramycin levels were measured by a radioimmunoassay method. The correlation between serum creatinine levels and the half-life of the antibiotics was found to be statistically significant. There were interpatient differences in serum aminoglycoside levels among those with the same serum creatinine levels. Thus, monitoring of serum creatinine and aminoglycoside levels is recommended, especially for those with renal failure, in order to maintain an optimal dosage between toxic and noneffective serum aminoglycoside levels.

[Disorders of kidney function in asphyxic newborn infants]

In this study it was aimed to investigate the renal function disturbances at an early stage of term newborn babies with perinatal asphyxia. 18 term newborn babies with the diagnosis of perinatal asphyxia were followed in the first 3 days of their lives, and various laboratory tests were applied to evaluate the renal functions. The results were compared with 10 healthy newborn who were chosen as a control group. The renal functions glomerular filtration rate (GFR) and fractional sodium excretion (FENa) were found significantly impaired up to 60% in the asphyctic babies especially those whose clinical presentation was expected to be severe.

High-dose acyclovir and intravenous immune globulin reduce the incidence of CMV disease after liver transplantation

We attempted to prevent cytomegalovirus (CMV) disease in liver transplant (LTx) recipients by means of a combined prophylaxis regimen consisting of high-dose acyclovir (HDA) and immune globulin (IVIG). In 259 consecutive patients, HDA was given for 3 months post-LTx; recipients seronegative for CMV also received IVIG. The previous 94 patients comprised our control group; in this group, low dose acyclovir was given to prevent herpes, and prophylaxis of CMV consisted of IVIG given only to seronegative recipients of seropositive donors. The overall incidence of CMV disease was lower in the HDA group (10.8%) than in the control group (27.6%); (P < 0.001). The CMV disease rate associated with primary exposure was 26.3% in the HDA group and 83.3% in the control group (P < 0.001). The incidence of CMV disease occurring after acute rejection was 9.5% in HDA patients and 24.6% in controls (P < 0.005) The HDA protocol was associated with a trend toward a lower incidence of CMV in patients requiring OKT3 therapy (16.7% vs 29%). High-dose acyclovir/IVIG thus reduces the incidence of CMV disease in seronegative recipients after LTx and lowers the risk of CMV disease associated with therapy for rejection.

CA19-9 does not predict cholangiocarcinoma in patients with primary sclerosing cholangitis undergoing liver transplantation

The results of liver transplantation in patients with cholangiocarcinoma have been poor. It has been suggested that elevated serum CA19-9 levels predict cholangiocarcinoma in patients with primary sclerosing cholangitis. We analyzed the predictive value of CA19-9 antigen as a marker of cholangiocarcinoma in patients with primary sclerosing cholangitis evaluated for liver transplantation. We reviewed the charts of 26 patients with primary sclerosing cholangitis (stage IV) in whom preoperative serum CA19-9 levels were determined; 22 of 26 underwent liver transplant. Explant specimens were serially sectioned and examined for tumor. In 3 of the 26 patients, cholangiocarcinoma was diagnosed during pretransplantation evaluation; exploratory laparotomy on the last patient showed no evidence of cholangiocarcinoma, and this patient is awaiting transplantation. Twelve of the 26 patients had CA19-9 levels more than double the laboratory reference range (0-37 U/mL) (mean 183.1 +/- 103 U/mL, range 77-415 U/mL). Two of the 12 patients with elevated CA19-9 levels had cholangiocarcinoma. Of the 14 patients with normal levels, two had cholangiocarcinoma. No correlation between elevated CA19-9 and bile duct dysplasia was noted. Sensitivity for serum CA19-9 levels more than twice the reference range is 50%, specificity is 54.5%, positive predictive value is 16.6%. An elevated serum CA19-9 level in a patient with stage IV primary sclerosing cholangitis does not reliably predict coexisting cholangiocarcinoma. Persistently high or rising serum CA19-9 levels do not indicate more urgent need for liver transplantation.

A rational approach to the use of hepatic transplantation in the treatment of metastatic neuroendocrine tumors

BACKGROUND

Gastrointestinal neuroendocrine tumors are slow growing, and metastases are often limited to the liver. Whereas in asymptomatic patients, observation alone may be reasonable, in patients with neuroendocrine tumors and unresectable hepatic metastases, transplantation of the liver may be beneficial. We have developed a protocol in which patients with multiple hepatic metastases are initially treated with chemotherapy and embolization to control symptoms and inhibit tumor growth. Hepatic transplantation is reserved for patients in whom tumor progresses or symptoms of hormone production or mass effect persist.

STUDY DESIGN

This is a retrospective review of eight patients with neuroendocrine tumor metastases who were referred to the Mount Sinai Hospital for evaluation for hepatic transplantation.

RESULTS

Of the eight patients, three have undergone transplantation; all are alive, with no evidence of tumor recurrence at 12 to 30 months. In two patients, symptoms have been controlled by embolization of the hepatic artery or chemotherapy, or both; another has had massive hepatomegaly as a result of tumor progression, with wasting and portal hypertension, and currently awaits transplantation. Two patients died as a result of progressive disease, soon after referral.

CONCLUSION

Transplantation of the liver may be an important treatment modality for a selected group of patients with neuroendocrine tumors unresponsive to conventional therapy.

N-acetylcysteine ameliorates reperfusion injury after warm hepatic ischemia

Glutathione is important in cellular defense against oxidative stress. We postulated that administration of N-acetylcysteine (NAC), a glutathione precursor, might help maintain or replenish hepatic glutathione stores, thereby reducing reperfusion injury in liver grafts after warm ischemia. Eighteen pigs were subjected to 2 hr of warm hepatic ischemia and divided into a control group (group A, n = 6), a preischemia treatment group (group B, n = 6: NAC, 150 mg/kg, continuous i.v. infusion 1 hr before ischemia), and a postischemia treatment group (group C, n = 6: NAC, 150 mg/kg continuous i.v., begun 20 min before reperfusion and continued for 1 hr). At initiation of laparotomy, we measured hepatic levels of reduced glutathione (GSH), its oxidized form (GSSG), ATP, aspartate aminotransferase (AST), and lactate dehydrogenase (LDH). Before reperfusion, after 2 hr of warm ischemia, GSH, GSSG, and ATP were measured. One hour after reperfusion, we measured GSH, GSSG, ATP, AST, and LDH. Bile output was recorded every 10 min. Postoperfusion AST and LDH were significantly lower in both treatment groups than in controls. In group B, hepatic glutathione was maintained at significantly higher levels than in controls, even after ischemia (P < 0.05). In group C, although hepatic GSH levels fell until reperfusion, after administration of NAC, hepatic GSH reached the level of the preischemia treatment group. In both treatment groups, GSH 1 hr after reperfusion was significantly higher than in the controls (P < 0.01): regeneration of glutathione was seen in all 6 animals in group C, compared with 2/6 in group B and none in the control group. ATP recovery, bile output, and survival were all better in the treatment groups than in the control group. Pretreatment with NAC helps maintain hepatic glutathione during warm ischemia; given after ischemia, NAC is effective in replenishing depleted glutathione stores. Adjunctive use of NAC was associated with improved glutathione homeostasis, improved bile output and ATP regeneration, and increased survival.

A case of an enterorenal fistula and pyelonephritis with air in the renal pelvis

We report on a 10-year-old boy with recurrent urinary tract infection. Renal ultrasound demonstrated the presence of air in the collecting system of the right kidney. The patient was examined radiologically and an enterorenal fistula was diagnosed. The case serves as a reminder that, although entero-renal fistulas are rare, they should be included in the differential diagnosis of recurrent urinary tract infections, especially if air is observed in the collecting system.

Severe or multiple rejection episodes are associated with early recurrence of hepatitis C after orthotopic liver transplantation

Recurrent hepatitis C causes significant morbidity after liver transplantation. Because immunosuppression is associated with enhanced viral replication, we postulated that clinical recurrence of the disease may be associated with augmented immunosuppression for rejection. In 96 patients with hepatitis C who received liver transplants, we recorded the interval from transplantation to recurrence, the episodes of steroid-resistant rejection (SRR) requiring OKT3, the number of rejection episodes, and the use of OKT3 induction. Recurrence was diagnosed based on elevated transaminases and characteristic histology. Hepatitis C recurred in 43 of 96 patients. Fifteen of 21 patients (71.4%) who previously had SRR had recurrence, versus 28 of 75 patients (37.3%) who either had no SRR (72 patients) or had it after recurrence was diagnosed (3 patients) (P < .01). Mean time to recurrence was 127 +/- 31 days in the 15 patients who had had SRR versus 246 +/- 42 days in the other 28 patients (P = .02). Recurrence and number of rejection episodes were clearly associated: 6 of 33 patients (18.2%) with no rejection had recurrence (P < .05), versus 11 of 26 patients (42.3%) with one rejection episode (P < .05) and 26 of 37 (70.2%) with more than 1 episode (P < .05). OKT3 induction was used in 15 patients; 9 of 15 patients had recurrence (ns) at 337 +/- 95 days. Of 72 patients who initially received triple immunosuppression, 30 patients had recurrence at 186 +/- 25 days (P = .05). Nine patients received primary FK506; 4 had recurrence at 68 +/- 14 days.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of captopril treatment in children with steroid-resistant nephrotic syndrome

We studied the efficacy of captopril, an angiotensin-converting enzyme inhibitor in treating persistent moderate or severe proteinuria in children with various glomerular diseases other than minimal-change nephrotic syndrome. Captopril was administered for 3 months to 15 normotensive and nonazotemic or mildly azotemic patients (12 boys, 3 girls) in whom corticosteroid and cytotoxic treatment had failed to induce remission. Urinary protein excretion decreased from 2873.14 +/- 1937.50 (mean +/- s.e.m.) to 1684.71 +/- 1463.13 mg/day (P < 0.05). The reduction in proteinuria was not related to a significant fall in systemic blood pressure or a change in renal function. Serum albumin did not rise and side effects due to captopril were not observed. We concluded that, in the short term, captopril can be used safely and effectively for decreasing the proteinuria of nephrotic children unresponsive to conventional therapy.

A study on enzyme activities of some sphingolipidoses

Enzyme activities were determined in fibroblast cell cultures of eight patients suspected of having a type of sphingolipidosis. The patients were 0 to 4 years of age; four were female and four were male. Thirteen age-matched controls were also included in the study. In one of the cases, hexosaminidase A activity was found to be 0% (43-82%), while in two other cases beta-galactosidase activity was found to be 5 nmol/h/mg protein (100-1035 nmol/h/mg protein) and arylsulfatase activity was found to be 12 nmol/h/mg protein (106-990 nmol/h/mg protein), respectively. Two more enzymes, alpha-galactosidase (11-39 nmol/h/mg protein) and cerebroside beta-galactosidase (3.7-6.9 nmol/h/mg protein), were also evaluated but were found to be in the normal ranges in these patients. Therefore, these patients were considered to have Tay-Sachs disease, GM1 gangliosidosis and metachromatic leukodystrophy, respectively. The remaining five patients were normal in respect to the five enzyme activities determined. For the prenatal diagnosis of metachromatic leukodystrophy, arylsulfatase A activity was determined in one amniotic cell culture. The activity found in this case was lower than normal (34 nmol/h/mg protein versus 387 nmol/h/mg protein found in three control amniotic cell cultures.