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Elisofon SA, Magee JC, Ng VL, Horslen SP, Fioravanti V, Economides J, Erinjeri J, Anand R, Mazariegos GV, Martin A, Mannino D, Flynn L, Mohammad S, Alonso E, Superina R, Brandt K, Riordan M, Lokar J, Ito J, Elisofon S, Zapata L, Jain A, Foristal E, Gupta N, Whitlow C, Naik K, Espinosa H, Miethke A, Hawkins A, Hardy J, Engels E, Schreibeis A, Ovchinsky N, Kogan‐Liberman D, Cunningham R, Malik P, Sundaram S, Feldman A, Garcia B, Yanni G, Kohli R, Emamaullee J, Secules C, Magee J, Lopez J, Bilhartz J, Hollenbeck J, Shaw B, Bartow C, Forest S, Rand E, Byrne A, Linguiti I, Wann L, Seidman C, Mazariegos G, Soltys K, Squires J, Kepler A, Vitola B, Telega G, Lerret S, Desai D, Moghe J, Cutright L, Daniel J, Andrews W, Fioravanti V, Slowik V, Cisneros R, Faseler M, Hufferd M, Kelly B, Sudan D, Mavis A, Moats L, Swan‐Nesbit S, Yazigi N, Buranych A, Hobby A, Rao G, Maccaby B, Gopalareddy V, Boulware M, Ibrahim S, El Youssef M, Furuya K, Schatz A, Weckwerth J, Lovejoy C, Kasi N, Nadig S, Law M, Arnon R, Chu J, Bucuvalas J, Czurda M, Secheli B, Almy C, Haydel B, Lobritto S, Emand J, Biney‐Amissah E, Gamino D, Gomez A, Himes R, Seal J, Stewart S, Bergeron J, Truxillo A, Lebel S, Davidson H, Book L, Ramstack D, Riley A, Jennings C, Horslen S, Hsu E, Wallace K, Turmelle Y, Nadler M, Postma S, Miloh T, Economides J, Timmons K, Ng V, Subramonian A, Dharmaraj B, McDiarmid S, Feist S, Rhee S, Perito E, Gallagher L, Smith K, Ebel N, Zerofsky M, Nogueira J, Greer R, Gilmour S, Robert C, Cars C, Azzam R, Boone P, Garbarino N, Lalonde M, Kerkar N, Dokus K, Helbig K, Grizzanti M, Tomiyama K, Cocking J, Alexopoulos S, Bhave C, Schillo R, Bailey A, Dulek D, Ramsey L, Ekong U, Valentino P, Hettiarachchi D, Tomlin R. Society of pediatric liver transplantation: Current registry status 2011-2018. Pediatr Transplant 2020; 24:e13605. [PMID: 31680409 DOI: 10.1111/petr.13605] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/08/2019] [Accepted: 09/27/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND SPLIT was founded in 1995 in order to collect comprehensive prospective data on pediatric liver transplantation, including waiting list data, transplant, and early and late outcomes. Since 2011, data collection of the current registry has been refined to focus on prospective data and outcomes only after transplant to serve as a foundation for the future development of targeted clinical studies. OBJECTIVE To report the outcomes of the SPLIT registry from 2011 to 2018. METHODS This is a multicenter, cross-sectional analysis characterizing patients transplanted and enrolled in the SPLIT registry between 2011 and 2018. All patients, <18 years of age, received a first liver-only, a combined liver-kidney, or a combined liver-pancreas transplant during this study period. RESULTS A total of 1911 recipients from 39 participating centers in North America were registered. Indications included biliary atresia (38.5%), metabolic disease (19.1%), tumors (11.7%), and fulminant liver failure (11.5%). Greater than 50% of recipients were transplanted as either Status 1A/1B or with a MELD/PELD exception score. Incompatible transplants were performed in 4.1%. Kaplan-Meier estimates of 1-year patient and graft survival were 97.3% and 96.6%. First 30 days of surgical complications included reoperation (31.7%), hepatic artery thrombosis (6.3%), and portal vein thrombosis (3.2%). In the first 90 days, biliary tract complications were reported in 13.6%. Acute cellular rejection during first year was 34.7%. At 1 and 2 years of follow-up, 39.2% and 50.6% had normal liver tests on monotherapy (tacrolimus or sirolimus). Further surgical, survival, allograft function, and complications are detailed.
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Affiliation(s)
- Scott A Elisofon
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - John C Magee
- Division of Surgery, University of Michigan Transplant Center, Ann Arbor, Michigan
| | - Vicky L Ng
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Transplant and Regenerative Medicine Center, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Simon P Horslen
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Vicki Fioravanti
- Section of Hepatology and Liver Transplantation, Children's Mercy Hospital, Kansas City, Missouri
| | | | | | | | - George V Mazariegos
- Division of Pediatric Transplant Surgery, Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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Demetris AJ, Bellamy C, Hübscher SG, O'Leary J, Randhawa PS, Feng S, Neil D, Colvin RB, McCaughan G, Fung JJ, Del Bello A, Reinholt FP, Haga H, Adeyi O, Czaja AJ, Schiano T, Fiel MI, Smith ML, Sebagh M, Tanigawa RY, Yilmaz F, Alexander G, Baiocchi L, Balasubramanian M, Batal I, Bhan AK, Bucuvalas J, Cerski CTS, Charlotte F, de Vera ME, ElMonayeri M, Fontes P, Furth EE, Gouw ASH, Hafezi-Bakhtiari S, Hart J, Honsova E, Ismail W, Itoh T, Jhala NC, Khettry U, Klintmalm GB, Knechtle S, Koshiba T, Kozlowski T, Lassman CR, Lerut J, Levitsky J, Licini L, Liotta R, Mazariegos G, Minervini MI, Misdraji J, Mohanakumar T, Mölne J, Nasser I, Neuberger J, O'Neil M, Pappo O, Petrovic L, Ruiz P, Sağol Ö, Sanchez Fueyo A, Sasatomi E, Shaked A, Shiller M, Shimizu T, Sis B, Sonzogni A, Stevenson HL, Thung SN, Tisone G, Tsamandas AC, Wernerson A, Wu T, Zeevi A, Zen Y. 2016 Comprehensive Update of the Banff Working Group on Liver Allograft Pathology: Introduction of Antibody-Mediated Rejection. Am J Transplant 2016; 16:2816-2835. [PMID: 27273869 DOI: 10.1111/ajt.13909] [Citation(s) in RCA: 361] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 06/01/2016] [Accepted: 05/25/2016] [Indexed: 02/06/2023]
Abstract
The Banff Working Group on Liver Allograft Pathology reviewed and discussed literature evidence regarding antibody-mediated liver allograft rejection at the 11th (Paris, France, June 5-10, 2011), 12th (Comandatuba, Brazil, August 19-23, 2013), and 13th (Vancouver, British Columbia, Canada, October 5-10, 2015) meetings of the Banff Conference on Allograft Pathology. Discussion continued online. The primary goal was to introduce guidelines and consensus criteria for the diagnosis of liver allograft antibody-mediated rejection and provide a comprehensive update of all Banff Schema recommendations. Included are new recommendations for complement component 4d tissue staining and interpretation, staging liver allograft fibrosis, and findings related to immunosuppression minimization. In an effort to create a single reference document, previous unchanged criteria are also included.
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Affiliation(s)
- A J Demetris
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - C Bellamy
- The University of Edinburgh, Edinburgh, Scotland
| | | | - J O'Leary
- Baylor University Medical Center, Dallas, TX
| | - P S Randhawa
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - S Feng
- University of California San Francisco Medical Center, San Francisco, CA
| | - D Neil
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - R B Colvin
- Massachusetts General Hospital, Boston, MA
| | - G McCaughan
- Royal Prince Alfred Hospital, Sydney, Australia
| | | | | | - F P Reinholt
- Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - H Haga
- Kyoto University Hospital, Kyoto, Japan
| | - O Adeyi
- University Health Network and University of Toronto, Toronto, Canada
| | - A J Czaja
- Mayo Clinic College of Medicine, Rochester, MN
| | - T Schiano
- Mount Sinai Medical Center, New York, NY
| | - M I Fiel
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - M L Smith
- Mayo Clinic Health System, Scottsdale, AZ
| | - M Sebagh
- AP-HP Hôpital Paul-Brousse, Paris, France
| | - R Y Tanigawa
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - F Yilmaz
- University of Ege, Faculty of Medicine, Izmir, Turkey
| | | | - L Baiocchi
- Policlinico Universitario Tor Vergata, Rome, Italy
| | | | - I Batal
- Columbia University College of Physicians and Surgeons, New York, NY
| | - A K Bhan
- Massachusetts General Hospital, Boston, MA
| | - J Bucuvalas
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - C T S Cerski
- Universidade Federal do Rio Grande do Sul, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | | | | | - M ElMonayeri
- Ain Shams University, Wady El-Neel Hospital, Cairo, Egypt
| | - P Fontes
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - E E Furth
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | - A S H Gouw
- University Medical Center Groningen, Groningen, the Netherlands
| | | | - J Hart
- University of Chicago Hospitals, Chicago, IL
| | - E Honsova
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - W Ismail
- Beni-Suef University, Beni-Suef, Egypt
| | - T Itoh
- Kobe University Hospital, Kobe, Japan
| | | | - U Khettry
- Lahey Hospital and Medical Center, Burlington, MA
| | | | - S Knechtle
- Duke University Health System, Durham, NC
| | - T Koshiba
- Soma Central Hospital, Soma, Fukushima, Japan
| | - T Kozlowski
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - C R Lassman
- David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - J Lerut
- Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - J Levitsky
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - L Licini
- Pope John XXIII Hospital, Bergamo, Italy
| | - R Liotta
- Istituto di Ricovero e Cura a Carattere Scientifico, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center, Palermo, Italy
| | - G Mazariegos
- Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - M I Minervini
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | - J Misdraji
- Massachusetts General Hospital, Boston, MA
| | - T Mohanakumar
- St. Joseph's Hospital and Medical Center, Norton Thoracic Institute, Phoenix, AZ
| | - J Mölne
- University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - I Nasser
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - J Neuberger
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - M O'Neil
- University of Kansas Medical Center, Kansas City, KS
| | - O Pappo
- Hadassah Medical Center, Jerusalem, Israel
| | - L Petrovic
- University of Southern California, Los Angeles, CA
| | - P Ruiz
- University of Miami, Miami, FL
| | - Ö Sağol
- School of Medicine, Dokuz Eylul University, Izmir, Turkey
| | | | - E Sasatomi
- University of North Carolina School of Medicine, Chapel Hill, NC
| | - A Shaked
- University of Pennsylvania Health System, Philadelphia, PA
| | - M Shiller
- Baylor University Medical Center, Dallas, TX
| | - T Shimizu
- Toda Chuo General Hospital, Saitama, Japan
| | - B Sis
- University of Alberta Hospital, Edmonton, Canada
| | - A Sonzogni
- Pope John XXIII Hospital, Bergamo, Italy
| | | | - S N Thung
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - G Tisone
- University of Rome-Tor Vergata, Rome, Italy
| | | | - A Wernerson
- Karolinska University Hospital, Stockholm, Sweden
| | - T Wu
- Tulane University School of Medicine, New Orleans, LA
| | - A Zeevi
- University of Pittsburgh, Pittsburgh, PA
| | - Y Zen
- Kobe University Hospital, Kobe, Japan
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Gondolesi GE, Mazariegos G, Starzl TE. Thomas Starzl, Video Interview for His Living Legend Award at the ISBTS 2015. Transplant Proc 2016; 48:444-9. [PMID: 27109975 DOI: 10.1016/j.transproceed.2016.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 02/02/2016] [Accepted: 02/03/2016] [Indexed: 10/21/2022]
Abstract
At the 14th International Small Bowel Transplant Symposium, (ISBTS2015) held in Buenos Aires, a session to recognize the pioneers that have dedicated their lives to make our current field possible was organized. Dr Thomas Starzl received the first Living Legend Award. A video interview was obtained at his office, edited, and later presented during the scientific meeting. More than 600 people saw Dr Starzl's interview, which captivated the audience for 40 minutes, before smiles, tears and the final applause erupted at the conclusion. We would like to share this video with all of you to inspire the current generations and the generations to come. The manuscript has the main parts of the interview, which can also be accessed at http://isbts2015.tts.org/starzl.mp4.
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Affiliation(s)
- G E Gondolesi
- ISBTS 2015, Chairman, Instituto de Trasplante Multiorgánico, Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal, Hospital Universitario-Fundación Favaloro, Buenos Aires, Argentina.
| | - G Mazariegos
- Member of the ISBTS 2015, Scientific Planning Committee, Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Thomas E Starzl Transplantation Institute, Pittsburgh, Pennsylvania, United States
| | - T E Starzl
- Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, Unites States
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Ningappa M, Ashokkumar C, Higgs BW, Sun Q, Jaffe R, Mazariegos G, Li D, Weeks DE, Subramaniam S, Ferrell R, Hakonarson H, Sindhi R. Enhanced B Cell Alloantigen Presentation and Its Epigenetic Dysregulation in Liver Transplant Rejection. Am J Transplant 2016; 16:497-508. [PMID: 26663361 PMCID: PMC5082419 DOI: 10.1111/ajt.13509] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 07/30/2015] [Accepted: 08/20/2015] [Indexed: 01/25/2023]
Abstract
T cell suppression prevents acute cellular rejection but causes life-threatening infections and malignancies. Previously, liver transplant (LTx) rejection in children was associated with the single-nucleotide polymorphism (SNP) rs9296068 upstream of the HLA-DOA gene. HLA-DOA inhibits B cell presentation of antigen, a potentially novel antirejection drug target. Using archived samples from 122 white pediatric LTx patients (including 77 described previously), we confirmed the association between rs9296068 and LTx rejection (p = 0.001, odds ratio [OR] 2.55). Next-generation sequencing revealed that the putative transcription factor (CCCTC binding factor [CTCF]) binding SNP locus rs2395304, in linkage disequilibrium with rs9296068 (D' 0.578, r(2) = 0.4), is also associated with LTx rejection (p = 0.008, OR 2.34). Furthermore, LTx rejection is associated with enhanced B cell presentation of donor antigen relative to HLA-nonidentical antigen in a novel cell-based assay and with a downregulated HLA-DOA gene in a subset of these children. In lymphoblastoid B (Raji) cells, rs2395304 coimmunoprecipitates with CTCF, and CTCF knockdown with morpholino antisense oligonucleotides enhances alloantigen presentation and downregulates the HLA-DOA gene, reproducing observations made with HLA-DOA knockdown and clinical rejection. Alloantigen presentation is suppressed by inhibitors of methylation and histone deacetylation, reproducing observations made during resolution of rejection. Enhanced donor antigen presentation by B cells and its epigenetic dysregulation via the HLA-DOA gene represent novel opportunities for surveillance and treatment of transplant rejection.
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Affiliation(s)
- M Ningappa
- Hillman Center for Pediatric Transplantation, Thomas E Starzl Transplantation Institute, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC), 4401 Penn Avenue, FP-6, Transplant, Room 6140, Mail Stop: CHL 03-06-02, Pittsburgh, PA 15224, USA
| | - C Ashokkumar
- Hillman Center for Pediatric Transplantation, Thomas E Starzl Transplantation Institute, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC), 4401 Penn Avenue, FP-6, Transplant, Room 6140, Mail Stop: CHL 03-06-02, Pittsburgh, PA 15224, USA
| | - BW Higgs
- Hillman Center for Pediatric Transplantation, Thomas E Starzl Transplantation Institute, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC), 4401 Penn Avenue, FP-6, Transplant, Room 6140, Mail Stop: CHL 03-06-02, Pittsburgh, PA 15224, USA
| | - Q Sun
- Hillman Center for Pediatric Transplantation, Thomas E Starzl Transplantation Institute, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC), 4401 Penn Avenue, FP-6, Transplant, Room 6140, Mail Stop: CHL 03-06-02, Pittsburgh, PA 15224, USA
| | - R Jaffe
- Department of Pathology, University of Pittsburgh, Division of Pediatric Pathology, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC), 4401 Penn Avenue, B255, Pittsburgh, PA 15224, USA
| | - G Mazariegos
- Hillman Center for Pediatric Transplantation, Thomas E Starzl Transplantation Institute, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC), 4401 Penn Avenue, FP-6, Transplant, Room 6140, Mail Stop: CHL 03-06-02, Pittsburgh, PA 15224, USA
| | - D Li
- Department of Bioengineering, University of California, San Diego, Powell-Focht Bioengineering Hall, Room 431, 9500 Gilman Drive MC 0412, La Jolla, CA 92093-0412 USA
| | - DE Weeks
- Department of Human Genetics, University of Pittsburgh, 130 DeSoto Street, Pittsburgh, PA 15261 USA
| | - S Subramaniam
- Department of Bioengineering, University of California, San Diego, Powell-Focht Bioengineering Hall, Room 431, 9500 Gilman Drive MC 0412, La Jolla, CA 92093-0412 USA
| | - R Ferrell
- Department of Human Genetics, University of Pittsburgh, 130 DeSoto Street, Pittsburgh, PA 15261 USA
| | - H Hakonarson
- Center for Applied Genomics, 1216 E. Abramson’s Research Center, ARC 1216E, Children’s Hospital of Philadelphia, 34 and Civic Center Blvd., Philadelphia, PA 19104 USA
| | - R Sindhi
- Hillman Center for Pediatric Transplantation, Thomas E Starzl Transplantation Institute, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center (UPMC), 4401 Penn Avenue, FP-6, Transplant, Room 6140, Mail Stop: CHL 03-06-02, Pittsburgh, PA 15224, USA
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Grant D, Abu-Elmagd K, Mazariegos G, Vianna R, Langnas A, Mangus R, Farmer DG, Lacaille F, Iyer K, Fishbein T. Intestinal transplant registry report: global activity and trends. Am J Transplant 2015; 15:210-9. [PMID: 25438622 DOI: 10.1111/ajt.12979] [Citation(s) in RCA: 270] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 07/16/2014] [Accepted: 08/12/2014] [Indexed: 01/25/2023]
Abstract
The Registry has gathered information on intestine transplantation (IT) since 1985. During this time, individual centers have reported progress but small case volumes potentially limit the generalizability of this information. The present study was undertaken to examine recent global IT activity. Activity was assessed with descriptive statistics, Kaplan-Meier survival curves and a multiple variable analysis. Eighty-two programs reported 2887 transplants in 2699 patients. Regional practices and outcomes are now similar worldwide. Current actuarial patient survival rates are 76%, 56% and 43% at 1, 5 and 10 years, respectively. Rates of graft loss beyond 1 year have not improved. Grafts that included a colon segment had better function. Waiting at home for IT, the use of induction immune-suppression therapy, inclusion of a liver component and maintenance therapy with rapamycin were associated with better graft survival. Outcomes of IT have modestly improved over the past decade. Case volumes have recently declined. Identifying the root reasons for late graft loss is difficult due to the low case volumes at most centers. The high participation rate in the Registry provides unique opportunities to study these issues.
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Affiliation(s)
- D Grant
- Department of Surgery, University Health Network, Toronto, Canada
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Shellmer D, DeVito Dabbs A, Dew M, Mazariegos G. Teen Pocket PATH: A Randomized Pilot of a Mobile Health Application To Improve Adherence Among Adolescent Solid Organ Transplant Recipients. J Heart Lung Transplant 2014. [DOI: 10.1016/j.healun.2014.01.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Englesbe MJ, Kelly B, Goss J, Fecteau A, Mitchell J, Andrews W, Krapohl G, Magee JC, Mazariegos G, Horslen S, Bucuvalas J. Reducing pediatric liver transplant complications: a potential roadmap for transplant quality improvement initiatives within North America. Am J Transplant 2012; 12:2301-6. [PMID: 22883313 PMCID: PMC3429726 DOI: 10.1111/j.1600-6143.2012.04204.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Though robust clinical data are available within transplantation, these data are not used for broad-based, multicentered quality improvement initiates. This article describes a targeted quality improvement initiative within the Studies of Pediatric Liver Transplantation (SPLIT) Registry. Using standard statistical techniques and clinical expertise to adjust for data and statistical reliability, we identified the pediatric liver transplant centers in North America with the lowest hepatic artery thrombosis rate and biliary complication rates. A survey was completed to establish current practices within the entire SPLIT group. Surgeons from the highest performing centers presented a detailed, technically oriented overview of their current practices. The presentations and discussion that followed were recorded and form the basis of the best practices described herein. We frame this work as a unique six-step approach roadmap that may serve as an efficient and cost effective model for novel broad-based quality improvement initiatives within transplantation.
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Affiliation(s)
- MJ Englesbe
- Department of Surgery – University of Michigan
| | - B Kelly
- Department of Surgery – Vanderbilt University, the Michael E. DeBakey
| | - J Goss
- Department of Surgery – Baylor College of Medicine
| | - A Fecteau
- Department of Surgery – University of Toronto
| | | | - W Andrews
- Department of Surgery - University of Missouri-Kansas City School of Medicine
| | - G Krapohl
- Department of Surgery – University of Michigan
| | - JC Magee
- Department of Surgery – University of Michigan
| | - G Mazariegos
- Department of Surgery – University of Pittsburgh
| | - S Horslen
- Department of Pediatrics-University of Washington
| | - J. Bucuvalas
- Department of Pediatrics -University of Cincinnati
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Abrams P, Soltys K, Sindhi R, Bond G, Abu-Elmagd KM, Mazariegos G. LONG-TERM OUTCOMES IN PEDIATRIC INTESTINAL RETRANSPLANTATION. Transplantation 2010. [DOI: 10.1097/00007890-201007272-00797] [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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Gopasetty M, Mazariegos G, Abu-Elmagd K, R. SI. Small Bowel Transplantation without Simultaneous Liver Graft Shows Increased Susceptibility to Chronic Rejection in Children. J Surg Res 2010. [DOI: 10.1016/j.jss.2009.11.654] [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: 11/30/2022]
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Ashokkumar C, Talukdar A, Sun Q, Higgs BW, Janosky J, Wilson P, Mazariegos G, Jaffe R, Demetris A, Dobberstein J, Soltys K, Bond G, Thomson AW, Zeevi A, Sindhi R. Allospecific CD154+ T cells associate with rejection risk after pediatric liver transplantation. Am J Transplant 2009; 9:179-91. [PMID: 18976293 PMCID: PMC2997472 DOI: 10.1111/j.1600-6143.2008.02459.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [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: 01/25/2023]
Abstract
Antigen-specific T cells, which express CD154 rapidly, but remain untested in alloimmunity, were measured with flow cytometry in 16-h MLR of 58 identically-immunosuppressed children with liver transplantation (LTx), to identify Rejectors (who had experienced biopsy-proven rejection within 60 days posttransplantation). Thirty-one children were sampled once, cross-sectionally. Twenty-seven children were sampled longitudinally, pre-LTx, and at 1-60 and 61-200 days after LTx. Results were correlated with proliferative alloresponses measured by CFSE-dye dilution (n = 23), and CTLA4, a negative T-cell costimulator, which antagonizes CD154-mediated effects (n = 31). In cross-sectional observations, logistic regression and leave-one-out cross-validation identified donor-specific, CD154 + T-cytotoxic (Tc)-memory cells as best associated with rejection outcomes. In the longitudinal cohort, (1) the association between CD154 + Tc-memory cells and rejection outcomes was replicated with sensitivity/specificity 92.3%/84.6% for observations at 1-60 days, and (2) elevated pre-LTx CD154 + Tc-memory cell responses were associated with significantly increased incidence (p = 0.02) and hazard (HR = 7.355) of rejection in survival/proportional hazard analysis. CD154 expression correlated with proliferative alloresponses (r = 0.835, p = 7.1e-07), and inversely with CTLA4 expression of allospecific CD154 + Tc-memory cells (r =-0.706, p = 3.0e-05). Allospecific CD154 + T-helper-memory cells, not CD154 + Tc-memory, were inhibited by increasing Tacrolimus concentrations (p = 0.026). Collectively, allospecific CD154 + T cells provide an estimate of rejection risk in children with LTx.
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Affiliation(s)
- C Ashokkumar
- University of Pittsburgh and Children's Hospital of Pittsburgh, Department of Transplant Surgery, Pittsburgh, PA, USA
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11
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Strauss K, Hartman T, Mazariegos G. Reply to: "Elective Liver Transplantation for the Treatment of Classical Maple Syrup Urine Disease". Am J Transplant 2006. [DOI: 10.1111/j.1600-6143.2006.01467.x] [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: 11/27/2022]
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12
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Abu-Elmagd K, Bond G, Mazariegos G, Murase N, Martin D, Koritsky D, Sindhi R, Laughlin K, Wu T, Demetris A, Marcos A, Fung J, Starzl TE, Reyes J. A NEW TOLERGENIC IMMUNOSUPPRESSIVE STRATEGY FOR HUMAN INTESTINAL TRANSPLANTATION. Transplantation 2004. [DOI: 10.1097/00007890-200407271-00071] [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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13
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Jain AB, Reyes J, Marcos A, Mazariegos G, Eghtesad B, Fontes PA, Cacciarelli TV, Marsh JW, de Vera ME, Rafail A, Starzl TE, Fung JJ. Pregnancy after liver transplantation with tacrolimus immunosuppression: a single center's experience update at 13 years. Transplantation 2003; 76:827-32. [PMID: 14501862 PMCID: PMC2975613 DOI: 10.1097/01.tp.0000084823.89528.89] [Citation(s) in RCA: 166] [Impact Index Per Article: 7.9] [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: 01/01/2023]
Abstract
BACKGROUND Chronic liver disease often leads to amenorrhea in women of childbearing age. There are several reports of successful pregnancy after liver transplantation (LTx) with cyclosporine A immunosuppression. Tacrolimus has been increasingly used in solid-organ transplantation, and the effect of the drug on pregnancy is still of interest to clinicians. This study updates our single-center experience. METHODS All pregnancies after LTx with tacrolimus immunosuppression were followed prospectively. Patients' clinical courses during pregnancy and labor along with gestational period and birth weight were catalogued. Changes in liver function, renal function, and immunosuppression also were recorded. The birth weight percentile was calculated on the basis of the gestational period using a standard chart. RESULTS Thirty-seven mothers delivered 49 babies. Three mothers delivered three times, and six mothers delivered two times. Thirty-six mothers (97%) survived the pregnancy, and 36 allografts (97%) survived. The one death and graft loss was in a patient who demonstrated infra-aortic arterial graft, which clotted by the gravid uterus during labor. The patient developed a gangrenous liver and died before she could undergo retransplantation. The mean gestational period was 36.4+/-3.2 weeks, excluding two premature deliveries at 23 and 24 weeks gestation. Twenty-two babies (46.9%) were delivered by cesarean section, and the other babies were delivered vaginally. In addition to the two premature babies, one baby, who was born to a mother with Alagille syndrome, died from congenital birth defects. The rest of the newborns survived. The mean birth weight was 2,797+/-775 g, with 38 babies (78%) weighing more than 2,000 g. The mean birth weight percentile to gestational period was 54+/-23. Four babies (8.5%) had a birth weight percentile of less than 25, and 28 babies (59.6%) had a birth weight percentile greater than 50. Twelve patients demonstrated an increase in hepatic enzymes without jaundice during the pregnancy. All of them responded to augmentation of immunosuppression. CONCLUSION The present report reconfirms the safety of tacrolimus during pregnancy after LTx. Preterm delivery and low birth weight seem to be a persistent problem in all solid-organ transplantation under any form of immunosuppression. However, toxemia of pregnancy and new onset of hypertension seem to be have a low occurrence with the use of tacrolimus.
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Affiliation(s)
- Ashokkumar B Jain
- Thomas E. Starzl Transplantation Institute, Division of Transplantation, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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14
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Martin D, Ezzelarab M, Bond G, Reyes J, Mazariegos G, Abu-Elmagd K. Patient profile and candidacy for intestinal transplantation at the University of Pittsburgh. Transplant Proc 2002; 34:1897-8. [PMID: 12176619 DOI: 10.1016/s0041-1345(02)03114-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- D Martin
- Thomas Starzl Transplantation Institute, University of Pittsburgh Medical Center, Intestinal Rehabilitation and Transplant Center, Pittsburgh, PA 15213, USA
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Sindhi R, Ganjoo J, McGhee W, Mazariegos G, Reyes J. Preliminary immunosuppression withdrawal strategies with sirolimus in children with liver transplants. Transplant Proc 2002; 34:1972-3. [PMID: 12176651 DOI: 10.1016/s0041-1345(02)03145-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Rakesh Sindhi
- Pediatric Transplantation, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15217, USA.
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Jain A, Mazariegos G, Pokharna R, Parizhskaya M, Smith A, Kashyap R, Fung JJ, Reyes J. Almost total absence of chronic rejection in primary pediatric liver transplantation under tacrolimus. Transplant Proc 2002; 34:1968-9. [PMID: 12176649 DOI: 10.1016/s0041-1345(02)03143-3] [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: 11/30/2022]
Affiliation(s)
- A Jain
- Children's Hospital of Pittsburgh and the Thomas E. Starzl Transplantation Institute, Department of Surgery, School of Pharmaceutical Sciences, University of Pittsburgh Medical Center, 3601 Fifth Avenue, Pittsburgh, PA 15213, USA
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17
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Jain A, Mazariegos G, Kashyap R, Kosmach-Park B, Starzl TE, Fung JJ, Reyes J. Pediatric liver transplantation in 808 consecutive children: 20-years experience from a single center. Transplant Proc 2002; 34:1955-7. [PMID: 12176642 PMCID: PMC2975381 DOI: 10.1016/s0041-1345(02)03136-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [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: 01/10/2023]
Affiliation(s)
- A Jain
- Children's Hospital of Pittsburgh and the Thomas E. Starzl Transplantation Institute, Dept. of Surgery, School of Pharmaceutical Sciences, University of Pittsburgh Medical Center, 3705 Fifth Avenue, Pittsburgh, PA 15213, USA
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18
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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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19
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Sindhi R, Webber S, Venkataramanan R, McGhee W, Phillips S, Smith A, Baird C, Iurlano K, Mazariegos G, Cooperstone B, Holt DW, Zeevi A, Fung JJ, Reyes J. Sirolimus for rescue and primary immunosuppression in transplanted children receiving tacrolimus. Transplantation 2001; 72:851-5. [PMID: 11571449 DOI: 10.1097/00007890-200109150-00019] [Citation(s) in RCA: 73] [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: 11/25/2022]
Abstract
AIMS The role of sirolimus (SRL) as a rescue agent (n=42) and as a component of primary immunosuppression (n=8) was evaluated in a mixed population of 50 transplanted children receiving tacrolimus (liver: 26, heart: 5, intestinal: 5, liver-intestine: 9, lung: 1, bone marrow: 1, liver-kidney: 1, multivisceral: 1). Rescue indications for tacrolimus (TAC) failure were recurrent acute rejection and acute rejection complicating withdrawal of immunosuppression in posttransplant lymphoproliferative disorder (PTLD). Rescue indications for TAC toxicity were nephrotoxicity, pancreatitis, seizures, hypertrophic cardiomyopathy, and graft-versus-host disease. RESULTS Mean age at rescue was 11.5 years and mean follow-up was 204 (range 18-800) days. As primary immunosuppression, SRL+TAC prevented early acute rejection in 7/8 children. The indication for rescue resolved in 33/42 children. In children with TAC toxicity, this was associated with decrease in TAC doses by 50%, significant improvements in renal function, and continuing decline in Epstein-Barr virus (EBV) viral load in PTLD patients. Serious adverse events led to discontinuation of SRL in 9/42 rescue patients, 3 of them also experienced acute rejection. Three additional children also experienced acute rejection on SRL therapy (overall incidence 6/50, 12%). Pharmacokinetic analysis in the first week of SRL administration suggested a short half-life (11.8+/-5.5 hr, n=21). CONCLUSIONS SRL and reduced-dose TAC may achieve adequate immunosuppression without compromising renal function or enhancing EBV viremia significantly.
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Affiliation(s)
- R Sindhi
- Thomas E. Starzl Transplantation Institute, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, Pennsylvania 15213, USA.
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20
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Abu-Elmagd K, Reyes J, Bond G, Mazariegos G, Wu T, Murase N, Sindhi R, Martin D, Colangelo J, Zak M, Janson D, Ezzelarab M, Dvorchik I, Parizhskaya M, Deutsch M, Demetris A, Fung J, Starzl TE. Clinical intestinal transplantation: a decade of experience at a single center. Ann Surg 2001; 234:404-16; discussion 416-7. [PMID: 11524593 PMCID: PMC1422031 DOI: 10.1097/00000658-200109000-00014] [Citation(s) in RCA: 262] [Impact Index Per Article: 11.4] [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: 12/12/2022]
Abstract
OBJECTIVE To assess the long-term efficacy of intestinal transplantation under tacrolimus-based immunosuppression and the therapeutic benefit of newly developed adjunct immunosuppressants and management strategies. SUMMARY BACKGROUND DATA With the advent of tacrolimus in 1990, transplantation of the intestine began to emerge as therapy for intestinal failure. However, a high risk of rejection, with the consequent need for acute and chronic high-dose immunosuppression, has inhibited its widespread application. METHODS During an 11-year period, divided into two segments by a 1-year moratorium in 1994, 155 patients received 165 intestinal allografts under immunosuppression based on tacrolimus and prednisone: 65 intestine alone, 75 liver and intestine, and 25 multivisceral. For the transplantations since the moratorium (n = 99), an adjunct immunosuppressant (cyclophosphamide or daclizumab) was used for 74 transplantations, adjunct donor bone marrow was given in 39, and the intestine of 11 allografts was irradiated with a single dose of 750 cGy. RESULTS The actuarial survival rate for the total population was 75% at 1 year, 54% at 5 years, and 42% at 10 years. Recipients of liver plus intestine had the best long-term prognosis and the lowest risk of graft loss from rejection (P =.001). Since 1994, survival rates have improved. Techniques for early detection of Epstein-Barr and cytomegaloviral infections, bone marrow augmentation, the adjunct use of the interleukin-2 antagonist daclizumab, and most recently allograft irradiation may have contributed to the better results. CONCLUSION The survival rates after intestinal transplantation have cumulatively improved during the past decade. With the management strategies currently under evaluation, intestinal transplant procedures have the potential to become the standard of care for patients with end-stage intestinal failure.
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Affiliation(s)
- K Abu-Elmagd
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
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21
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Awad MR, Webber S, Boyle G, Sturchioĉ C, Ahmed M, Martell J, Law Y, Miller SA, Bowman P, Gribar S, Pigula F, Mazariegos G, Griffith BP, Zeevi A. The effect of cytokine gene polymorphisms on pediatric heart allograft outcome. J Heart Lung Transplant 2001; 20:625-30. [PMID: 11404167 DOI: 10.1016/s1053-2498(01)00246-7] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [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: 11/30/2022] Open
Abstract
BACKGROUND Cytokines play a major role in the inflammatory and immune responses that mediate allograft outcome. Several studies have shown that the production of cytokines varies among individuals and these variations are determined by genetic polymorphisms, most commonly within the regulatory region of the cytokine gene. The aim of this study was to assess the effect of these allelic variations on acute rejection after pediatric heart transplantation. METHODS We performed cytokine genotyping using polymerase chain reaction-sequence specific primers in 93 pediatric heart transplant recipients and 29 heart donors for the following functional polymorphisms: tumor necrosis factor-alpha (TNF-alpha) (-308), interleukin (IL)-10 (-1082, -819, and -592), TGF-beta1 (codon 10 and 25), IL-6 (-174), and interferon-gamma (INF-gamma) (+874). The distribution of polymorphisms in this population did not differ from published controls. The patients were classified as either non-rejecters (0 or 1 episode) or rejecters (> 1 episode) based on the number of biopsy proven rejection episodes in the first year after transplantation. RESULTS Forty-two of the 69 TNF-alpha patients (61%) in the low producer group were non-rejecters, while 9 of the 24 (37.5%) with high TNF-alpha were non-rejecters (p = 0.047). In contrast, IL-10 genotype showed the opposite finding. Forty-two of the 66 patients (64%) in the high and intermediate IL-10 group were non-rejecters, while 9 of the 26 (35%) in the low IL-10 group were non-rejecters (p = 0.011). The combination of low TNF-alpha with a high or intermediate IL-10 genotype was associated with the lowest risk of rejection (34/49 or 69% non-rejecters). Neither the distribution of the IL-6, INF-gamma, and TGF-beta1 genotype in recipients nor the donor genotype showed any association with acute rejection. CONCLUSION Genetic polymorphisms that have been associated with low TNF-alpha and high IL-10 production are associated with a lower number of acute rejection episodes after pediatric heart transplantation.
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Affiliation(s)
- M R Awad
- Department of Pathology, University of Pittsburgh School of Medicine, Thomas E. Starzl Transplant Institute and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA. mrawad+@pitt.edu
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22
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Jain A, Mazariegos G, Kashyap R, Marsh W, Khanna A, Iurlano K, Fung J, Reyes J. Reasons why some children receiving tacrolimus therapy require steroids more than 5 years post liver transplantation. Pediatr Transplant 2001; 5:93-8. [PMID: 11328546 DOI: 10.1034/j.1399-3046.2001.005002093.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [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: 11/23/2022]
Abstract
Tacrolimus is a potent immunosuppressive agent and has been used in liver transplantation (LTx) for nearly a decade. More than 70% of children can be maintained on tacrolimus monotherapy, without steroids, by the end of 1 yr post-Tx. This freedom from steroids does not appear to change significantly in subsequent years. The use of steroids has obvious metabolic and cosmetic disadvantages, besides affecting linear growth in children. The present study identifies why some children still require steroid therapy after successful LTx. One hundred and sixty-six consecutive pediatric patients who had undergone primary LTx between October 1989 and December 1992, were included in this study. Follow-up ranged from 6 to 9 yr (mean 7.5 +/- 0.8 yr). One hundred and forty-one children were alive in November 1998 and these patients constituted the study group. Their current rate of prednisone use, reason for prednisone use, and prednisone dose were examined retrospectively. Of the 141 patients, 139 (98.5%) had stopped taking steroids at some time-point after LTx. Thirteen patients (9%) were off immunosuppression altogether (group I), 97 were undergoing tacrolimus monotherapy (group II), and the remaining 31 were receiving therapy with steroids and tacrolimus (group III). The mean prednisone dose at the last follow-up was 6.5 +/- 4.9 mg/day (median 5.0 mg/day). In group III, two children were never weaned off steroids because of inadequate follow-up (both lived outside the country), and the remaining 29 children completely stopped steroid therapy at some time-point after LTx; however, prednisone was re-introduced for clinically suspected or biopsy-proven rejection in 24. Seven children in group III had completely stopped immunosuppressive therapy either as part of an immunosuppression reduction protocol (n = 3) or for suspected or proven post-transplant lymphoproliferative disorder (PTLD) (n = 4). In eleven of the 18 children in group III, requirement of steroid for rejection was thought to be related, in part, to non-compliance. In three children in group III, steroids were re-introduced for renal dysfunction, and two of these patients subsequently received a kidney Tx. In one child with cerebral ischemia, steroids were used to reduce brain edema, and another child had features of auto-immune hepatitis. Hence, almost all children can be weaned off steroids when tacrolimus is used as primary immunosuppression after primary LTx. However, approximately 22% of children may need re-institution of steroids because of late acute rejection or renal dysfunction. The concomitant use of other non-steroidal immunosuppressive agents with tacrolimus may further reduce the dose and rate of steroid use.
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Affiliation(s)
- A Jain
- Thomas E. Starzl Transplantation Institute, Department of Surgery and Department of Pharmaceutical Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Abstract
Three of 70 small bowel transplant recipients were diagnosed with adenovirus enteritis. The biopsies were performed for surveillance in one patient at 2.7 years after transplantation and in two symptomatic children 1.5 years and 4.5 months after transplantation. In all three patients the characteristic epithelial changes were not noted by the primary observers. Two biopsies had been called "suggestive of acute rejection" and both patients had been so treated. One biopsy had been diagnosed as "regenerative". Once the epithelial changes were recognized as being viral, confirmation was possible by stool culture in one patient, immunohistochemistry in two patients, or by lift technique of the H&E sections for electron microscopy. The immune suppression was reduced and none of the patients developed disseminated infection. As in other transplanted organs, such as lung and liver, adenovirus infection may be limited largely to the allograft but can be destructive. Early recognition of the characteristic changes that are illustrated can lead to confirmation of the virus and appropriate reduction of immune suppression. A mistaken diagnosis of rejection and augmentation of immune suppression can lead to viral dissemination and potential fatality.
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Affiliation(s)
- M Parizhskaya
- Department of Pathology, Children's Hospital of Pittsburgh and the University of Pittsburgh School of Medicine, PA 15213, USA
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Garrido V, Bond GJ, Mazariegos G, Wu T, Martin D, Colangelo J, Ezzelarab M, Fung J, Reyes J, Abu-Elmagd K. Late severe rejection of intestinal allografts: risks and survival outcome. Transplant Proc 2001; 33:1556-7. [PMID: 11267419 DOI: 10.1016/s0041-1345(00)02592-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- V Garrido
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Kashyap R, Jain A, Reyes J, Demetris AJ, Elmagd KA, Dodson SF, Marsh W, Madariaga V, Mazariegos G, Geller D, Bonham CA, Cacciarelli T, Fontes P, Starzl TE, Fung JJ. Causes of death after liver transplantation in 4000 consecutive patients: 2 to 19 year follow-up. Transplant Proc 2001; 33:1482-3. [PMID: 11267383 PMCID: PMC2953259 DOI: 10.1016/s0041-1345(00)02561-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [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: 12/26/2022]
Affiliation(s)
- R Kashyap
- Thomas E. Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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26
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Kashyap R, Jain A, Reyes J, Demetris AJ, Elmagd KA, Dodson SF, Marsh W, Madariaga V, Mazariegos G, Geller D, Bonham CA, Cacciarelli T, Fontes P, Starzl TE, Fung JJ. Causes of retransplantation after primary liver transplantation in 4000 consecutive patients: 2 to 19 years follow-up. Transplant Proc 2001; 33:1486-7. [PMID: 11267385 PMCID: PMC2987633 DOI: 10.1016/s0041-1345(00)02563-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [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: 01/06/2023]
Affiliation(s)
- R Kashyap
- Thomas E. Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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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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Jain A, Reyes J, Kashyap R, Dodson SF, Demetris AJ, Ruppert K, Abu-Elmagd K, Marsh W, Madariaga J, Mazariegos G, Geller D, Bonham CA, Gayowski T, Cacciarelli T, Fontes P, Starzl TE, Fung JJ. Long-term survival after liver transplantation in 4,000 consecutive patients at a single center. Ann Surg 2000; 232:490-500. [PMID: 10998647 PMCID: PMC1421181 DOI: 10.1097/00000658-200010000-00004] [Citation(s) in RCA: 427] [Impact Index Per Article: 17.8] [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: 02/07/2023]
Abstract
OBJECTIVE To evaluate the long-term survival outcomes of a large cohort of liver transplant recipients and to identify static and changing factors that influenced these outcomes over time. SUMMARY BACKGROUND DATA Liver transplantation has been accepted as a therapeutic option for patients with end-stage liver disease since 1983, with continual improvements in patient survival as a result of advances in immunosuppression and medical management, technical achievements, and improvements in procurement and preservation. Although many reports, including registry data, have delineated short-term factors that influence survival, few reports have examined factors that affect long-term survival after liver transplantation. METHODS Four thousand consecutive patients who underwent liver transplantation between February 1981 and April 1998 were included in this analysis and were followed up to March 2000. The effect of donor and recipient age at the time of transplantation, recipient gender, diagnosis, and year of transplantation were compared. Rates of retransplantation, causes of retransplantation, and cause of death were also examined. RESULTS The overall patient survival for the entire cohort was 59%; the actuarial 18-year survival was 48%. Patient survival was significantly better in children, in female recipients, and in patients who received transplants after 1990. The rates of retransplantation for acute or chronic rejection were significantly lower with tacrolimus-based immunosuppression. The risk of graft failure and death was relatively stable after the first year, with recurrence of disease, malignancies, and age-related complications being the major factors for loss. CONCLUSION Significantly improved patient and graft survival has been observed over time, and graft loss from acute or chronic rejection has emerged as a rarity. Age-related and disease-related causes of graft loss represent the greatest threat to long-term survival.
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Affiliation(s)
- A Jain
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Affiliation(s)
- J R Madariaga
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
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Nalesnik M, Jaffe R, Reyes J, Mazariegos G, Fung JJ, Starzl TE, Abu-Elmagd K. Posttransplant lymphoproliferative disorders in small bowel allograft recipients. Transplant Proc 2000; 32:1213. [PMID: 10995914 PMCID: PMC2975486 DOI: 10.1016/s0041-1345(00)01191-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [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: 11/21/2022]
Affiliation(s)
- M Nalesnik
- Departments of Pathology, Pittsburgh, Pennsylvania, USA.
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Abu-Elmagd K, Fung J, McGhee W, Martin D, Mazariegos G, Schaefer N, Demetris J, Starzl TE, Reyes J. The efficacy of daclizumab for intestinal transplantation: preliminary report. Transplant Proc 2000; 32:1195-6. [PMID: 10995903 PMCID: PMC2994253 DOI: 10.1016/s0041-1345(00)01180-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [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: 02/06/2023]
Affiliation(s)
- K Abu-Elmagd
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
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32
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de Vera ME, Reyes J, Demetris J, Mazariegos G, Schaefer N, Vargas H, Bond G, Wu T, Fung J, Starzl TE, Abu-Elmagd K. Isolated intestinal versus composite visceral allografts: causes of graft failure. Transplant Proc 2000; 32:1221-2. [PMID: 10995919 PMCID: PMC2957096 DOI: 10.1016/s0041-1345(00)01196-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [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: 01/01/2023]
Affiliation(s)
- M E de Vera
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
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Bond G, Reyes J, Mazariegos G, Wu T, Schaefer N, Demetris J, Fung JJ, Starzl TE, Abu-Elmagd K. The impact of positive T-cell lymphocytotoxic crossmatch on intestinal allograft rejection and survival. Transplant Proc 2000; 32:1197-8. [PMID: 10995904 PMCID: PMC3005342 DOI: 10.1016/s0041-1345(00)01181-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [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: 12/16/2022]
Affiliation(s)
- G Bond
- 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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Sigurdsson L, Reyes J, Kocoshis SA, Mazariegos G, Abu-Elmagd K, Green M. Bacteremia after intestinal transplantation in children correlates temporally with rejection or gastrointestinal lymphoproliferative disease. Transplantation 2000; 70:302-5. [PMID: 10933153 DOI: 10.1097/00007890-200007270-00011] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.1] [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: 11/25/2022]
Abstract
BACKGROUND Bacteremia occurs frequently after intestinal transplantation (ITx) in children. During our initial experience with this procedure, we noted that bacteremic episodes tended to occur simultaneously with the presence of rejection and/or gastrointestinal (GI) posttransplant lymphoproliferative disease (PTLD). AIM To document the association of bacteremia with rejection and GI PTLD in pediatric ITx recipients. METHODS Retrospective analysis of all medical records from 62 children who underwent ITx between July 1990 and January 1998 at Children's Hospital of Pittsburgh. A bacteremic episode was defined as two positive blood cultures from different sites at the same time or from the same site at different times. Rejection and PTLD were defined using previously published criteria. RESULTS A total of 39/62 ITx recipients had 133 blood stream infections (2.1 episodes/patient) including 121 episodes of bacteremia and 12 of fungemia. Enteric organisms were the most frequently recovered pathogens (Gram negative rods, n=76; enterococci, n=36). Enteric organisms were recovered as a single organism (n=57), with another enteric bacteria (n=23), or with coagulase negative staphylococci (CONS) (n=24). CONS were recovered as a single organism on 21 occasions. An obvious source of bacteremia was not found for 115/121 episodes. Endoscopy was performed for 107 of the 115 bacteremia episodes; an abnormal histology was identified in 74 revealing rejection (n=36), GI PTLD (n=21), or both (n=17). When endoscopy showed GI pathology, enteric organisms alone or in combination with CONS were recovered on 63/107 occasions, although CONS were recovered alone only 11 times. CONCLUSIONS Bacteremia accompanies GI rejection and intestinal PTLD in ITx recipients. Endoscopy should be performed to inspect the allograft when bacteremia occurs without an obvious source in these patients. This is especially true for patients with bacteremia due to enteric organisms.
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Affiliation(s)
- L Sigurdsson
- Department of Pediatrics, Children's Hospital of Pittsburgh, PA 15213-2583, USA
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Reyes J, Jain A, Mazariegos G, Kashyap R, Green M, Iurlano K, Fung J. Long-term results after conversion from cyclosporine to tacrolimus in pediatric liver transplantation for acute and chronic rejection. Transplantation 2000; 69:2573-80. [PMID: 10910279 DOI: 10.1097/00007890-200006270-00017] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Tacrolimus is beneficial in liver transplantation for reversing steroid-resistant acute rejection, and for controlling the process of chronic rejection in allograft recipients receiving Cyclosporine- (CyA) based regimens. Very little is known about the long-term efficacy of tacrolimus in pediatric transplantation after conversion from CyA. Our study examines the long-term outcome after conversion to tacrolimus for acute or chronic rejection in pediatric liver transplant (LTx) recipients. METHOD Seventy-three children (age < 18 years) receiving their primary LTx under CyA between August 1989 and April 1996 were converted to tacrolimus for ongoing acute rejection (n=22, group I) or chronic rejection (n=51, group II). Mean age at the time of conversion was 10.2+/-5.5 years with a mean interval from LTx to conversion of 3.5+/-2.9 (range 0.5-10.1 years). There were 33 boys and 40 girls. All patients were followed until June 1999. Mean follow-up was 97.3+/-17.4 months (range 62.4-118.9 months). RESULTS Overall 5-year actual patient survival was 78.1% and 8-year actuarial survival was 74.6%. Patients converted to tacrolimus therapy to resolve acute rejection (group I) experience significantly better patient and graft survival at 5 and 8 years than those converted to resolve chronic rejection (group II). Eight-year patient survival and graft survival was 95.5 and 90.9% for group I compared to 74.6 and 53.5% for group II, respectively (long rank P=0.035 and 0.01, respectively). Nearly 75% of children were weaned off steroids after conversion. There was a marked improvement in hypertension, gum hyperplasia, hirsutism, and cushingoid appearance. One child in group I (4.5%) and four children in group II (7.8%) developed posttransplant lymphoproliferative disorder after conversion. There was an improvement in growth in children who were less than the age of 12 years at the time of conversion and who were weaned off steroids; more significantly girls responded more favorably than boys. CONCLUSION The benefit of transplantation is maintained long-term after conversion to tacrolimus for acute or chronic rejection. The response rate was significantly better in group I as compared with group 11. Marked improvement in growth, hypertension, and reversal of the brutalizing effects of CyA was noted after conversion to tacrolimus. The results suggest that early conversion of pediatric liver transplant patients is warranted for the treatment of acute and chronic rejection, and for improvements in quality of life.
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Affiliation(s)
- J Reyes
- Thomas E Starzl Transplantation Institute, University of Pittsburgh Medical Center and Children Hospital, PA 15213, USA
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Abstract
BACKGROUND To evaluate the effect of intrahepatic arterial chemotherapy (IAC) on children with primary hepatic malignancies. METHOD A nonrandomized inception cohort of 11 pediatric patients was referred for treatment of advanced primary hepatic malignancies at Children's Hospital of Pittsburgh. None of the patients was a candidate for resection before the initiation of IAC. Tumor response to treatment was observed by determining serum alpha-fetoprotein (AFP) levels and by abdominal computed tomographic scan. The patients received hepatic artery infusions of cisplatin and/or doxorubicin. The last five also received gelfoam embolization. RESULTS Eight of 11 patients had multiple IAC treatments. Eight patients had AFP-producing tumors, and five of the eight had dramatic reductions in serum levels after IAC treatment. Five of the 11 patients underwent successful orthotopic liver transplantation after receiving IAC therapy, and the five explanted specimens showed varying degrees of tumor necrosis. One-year survival in patients in the authors' center is 67% for those with hepatoblastoma and 40% for those with hepatocellular carcinoma. Three-year survival is 60% and 30% for patients with hepatoblastoma and hepatocellular carcinoma, respectively. CONCLUSION Intrahepatic arterial chemotherapy therapy can halt the progression and possibly down-stage advanced pediatric hepatic malignancies. This therapy can also be used as a successful adjunct in altering a patient's chance for successful liver transplantation.
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Affiliation(s)
- D A Gerber
- Department of Surgery, University of North Carolina, Chapel Hill 27599, USA
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Abstract
The diagnosis and treatment of moderate-to-severe diarrhea in solid organ transplant recipients is often a challenge because of the variety of infectious and non-infectious causes. The morbidity associated with this clinical condition is of particular significance in the pediatric population where malnutrition may lead to poor growth and development. Rarely, Cryptosporidium has been identified as the cause of clinically significant diarrhea in pediatric solid organ transplant patients. A retrospective review identified cases of cryptosporidiosis among the 1160 non-renal, abdominal organ transplant recipients cared for at the Children's Hospital of Pittsburgh between 1981 and June 1998. Four cases of clinically significant diarrhea were identified in three liver transplant recipients and one small bowel transplant recipient. Endoscopy and biopsy with histologic confirmation diagnosed three cases; ova and parasitic examination of stool specimens identified the fourth case. Therapy varied among the patients depending on when they had been diagnosed as, over the years, different and newer agents have been indicated for the treatment of cryptosporidiosis. All four patients resolved their infections. Hence, endoscopy and biopsy is recommended for pediatric transplant patients who present with chronic diarrhea of unknown etiology. The patients who may be at a higher risk for cryptosporidial infections include those with an increased immunosuppressive state (i.e. pre-existing immunodeficiency, malignancy, re-transplantation, and those receiving higher doses of immunosuppressive therapy). While cryptosporidiosis is a non-lethal complication, it allows the clinician to gain further insight into the degree of immunosuppression of their patient.
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Affiliation(s)
- D A Gerber
- Department of Transplantation, Children's Hospital of Pittsburgh, Pennsylvania, 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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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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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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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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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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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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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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48
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Casavilla A, Mazariegos G, Fung JJ. Cadaveric liver donors; what are the limits? Transplant Proc 1996; 28:21-3. [PMID: 8644182] [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] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The current crisis in organ availability will only be solved by aggressive and innovative solutions. One approach, outlined here, is to more carefully assess current donors and determine how to safely "push the limits" of acceptable cadaveric liver donors. Our experience, as well as that of others, indicates that donors with these higher risk factors may be used in certain carefully defined situations. The key elements to an appropriate use of these donors are careful donor and recipient assessment, and avoiding the presence of multiple risk-factors. These guidelines form a foundation for continuing assessment of methods to increase, in an incremental fashion, the number of cadaver livers successfully transplanted.
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Affiliation(s)
- A Casavilla
- University of Pittsburgh Medical Center, PA 15213, USA
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49
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Abu-Elmagd K, Fung J, Todo S, Rao A, Reyes J, Demetris J, Mazariegos G, Fontes P, McMichael J, Furukawa H. The current status of hepatic transplantation at the University of Pittsburgh. Clin Transpl 1995:145-70. [PMID: 8794262 PMCID: PMC2987661] [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] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Tacrolimus is a more potent and satisfactory immunosuppressant than CyA for combination therapy with prednisone. In randomized trials comparing the 2 drugs, the ability of tacrolimus to rescue intractably rejecting grafts on the competing CyA arm allowed equalization of patient and graft survival on both arms when the intent-to-treat analytic methodology was applied. The ability of tacrolimus to systematically rescue the treatment failures of CyA suggested, as a matter of common sense, that it is the preferred baseline drug for hepatic transplantation. This conclusion was supported by analysis of secondary end points, including the ability to prevent rejection. Hepatic-intestinal, multivisceral and isolated intestinal transplantation became feasible on a practical basis only after the advent of tacrolimus. Nevertheless, better management strategies must be devised before intestinal transplantation, alone or with other abdominal viscera, will meet its potential. One such strategy is based on the discovery of the presence of previously unsuspected, low-level donor leukocyte chimerism in long-surviving allograft recipients. We believe that this chimerism is the essential explanation for the feasibility of organ transplantation and a link to the acquired neonatal tolerance demonstrated by Billingham, Brent and Medawar (32). The hematolymphopoietic chimerism in organ recipients explains why weaning to a drug-free state in selected long-term survivors is frequently feasible and particularly if the allograft is a liver. Weaning should never be attempted without a stepwise protocol and careful monitoring of graft function. Recognition of the natural chimerism that develops after whole organ transplantation has led to efforts to augment it with perioperative donor BM infusion. This procedure has been shown to be free of significant complications (including GVHD) in all kinds of whole organ recipients, including those given intestine. The prospects of clinical xenotransplantation must be evaluated in the same context of chimerism as that delineated for allotransplantation with the discovery of spontaneous chimerism. Before addressing chimerism-related questions in xenotransplantation, the additional barrier of the complement activation syndromes that cause hyperacute rejection will have to be surmounted. Although measures to effectively transplant xenografts have so far eluded us, the availability of the more potent drug, tacrolimus, and recognition of the seminal basis of allograft (or xenograft) acceptance via chimerism has inserted an element of reality into the largely wishful thinking that has been evident in discussions about the future of xenotransplantation.
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Affiliation(s)
- K Abu-Elmagd
- Pittsburgh Transplant, Departments of Surgery, Medicine, and Pathology, Divisions of Transplantation, University of Pittsburgh, Pennsylvania, USA
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Saidman SL, Duquesnoy RJ, Demetris AJ, McCauley J, Ramos H, Mazariegos G, Shapiro R, Starzl TE, Fung JJ. Combined liver-kidney transplantation and the effect of preformed lymphocytotoxic antibodies. Transpl Immunol 1994; 2:61-7. [PMID: 8081794 PMCID: PMC2956073 DOI: 10.1016/0966-3274(94)90080-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.6] [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: 01/28/2023]
Abstract
Thirty-eight sequentially placed liver and kidney allografts were evaluated with respect to patient and graft survival, and the influence of preformed lymphocytotoxic antibodies was analysed. The results suggest that the survival rate of combined liver and kidney transplantation is similar to the survival rate of liver transplantation alone. Sequentially placed kidney allografts may be protected from hyperacute rejection in the presence of donor specific lymphocytotoxic antibodies, but not in all instances. Both patient and kidney allograft survival was lower in positive crossmatch patients (33% and 17% respectively) than in negative crossmatch patients (78% and 75%). High levels of panel reactive antibodies (> 10%) also appeared to have a deleterious effect on survival, although the majority of the patients who failed also had a positive crossmatch. Although performed lymphocytotoxic antibodies are not an absolute contraindication to combined liver-kidney transplantation, they do appear to have a deleterious effect on long-term graft survival. However, more correlation with clinical parameters is needed.
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Affiliation(s)
- S L Saidman
- Department of Pathology, University of Pittsburgh School of Medicine
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