Role of cytokine gene polymorphisms in acute rejection and renal impairment after liver transplantation

Although immunosuppressive regimens are effective, rejection occurs in up to 50% of patients after orthotopic liver transplantation (OLT), and there is concern about side effects from long-term therapy. Knowledge of clinical and immunogenetic variables may allow tailoring of immunosuppressive therapy to patients according to their potential risks. We studied the association between transforming growth factor-beta, interleukin-10, and tumor necrosis factor alpha (TNF-alpha) gene polymorphisms and graft rejection and renal impairment in 121 white liver transplant recipients. Clinical variables were collected retrospectively, and creatinine clearance was estimated using the formula of Cockcroft and Gault. Biallelic polymorphisms were detected using polymerase chain reaction-based methods. Thirty-seven of 121 patients (30.6%) developed at least 1 episode of rejection. Multivariate analysis showed that Child-Pugh score (P =.001), immune-mediated liver disease (P =.018), normal pre-OLT creatinine clearance (P =.037), and fewer HLA class 1 mismatches (P =.038) were independently associated with rejection. Renal impairment occurred in 80% of patients and was moderate or severe in 39%. Clinical variables independently associated with renal impairment were female sex (P =.001), pre-OLT renal dysfunction (P =.0001), and a diagnosis of viral hepatitis (P =.0008). There was a significant difference in the frequency of TNF-alpha-308 alleles among the primary liver diseases. After adjustment for potential confounders and a Bonferroni correction, the association between the TNF-alpha-308 polymorphism and graft rejection approached significance (P =.06). Recipient cytokine genotypes do not have a major independent role in graft rejection or renal impairment after OLT. Additional studies of immunogenetic factors require analysis of large numbers of patients with appropriate phenotypic information to avoid population stratification, which may lead to inappropriate conclusions.

Confirmation of the role of the Mayo Risk Score as a predictor of resource utilization after orthotopic liver transplantation for primary biliary cirrhosis

Resource utilization is an important consideration when patients are selected for orthotopic liver transplantation (OLT). The Mayo Risk Score has been proposed to help predict optimum time for OLT. We assessed the relation between Mayo risk score, Child-Pugh score, and resource utilization and outcome after OLT for primary biliary cirrhosis. The mean Mayo risk score was greater in patients who died than in the survivors (8.6 +/- 1.4 v 7.1 +/- 1.8; P <.05). There was a positive correlation between Mayo risk score and the 4 resource variables studied (intraoperative blood requirements, time ventilated, and duration of intensive care unit and hospital stays). Patients with a Mayo risk score greater than 7.8 used almost twice the resources of patients with a risk score less than 7.8. A positive correlation also existed between Child-Pugh score and duration of hospital stay. The mean Child-Pugh score in patients who died was greater than that in survivors (10.7 +/- 2.0 v 8.5 +/- 2.8, P =.03). This study confirms that Mayo Risk score is an important predictor of resource utilization and outcome after OLT.

Detection of male DNA in the liver of female patients with primary biliary cirrhosis

BACKGROUND/AIMS

Primary biliary cirrhosis is a chronic cholestatic liver disease characterized by progressive inflammatory destruction of bile ducts, with eventual hepatic fibrosis and cirrhosis. Since primary biliary cirrhosis affects predominantly middle-aged women and has pathological similarities to hepatic graft-versus-host-disease, we investigated whether fetal cell microchimerism might be involved in the development of this disease.

METHODS

The presence of Y-chromosome-specific sequences was analyzed by polymerase chain reaction using peripheral blood mononuclear cells from women with primary biliary cirrhosis (n=18) and healthy (control) women (n=18), and by in situ hybridization of liver biopsy sections from women with primary biliary cirrhosis (n=19) and women with chronic hepatitis C or alcoholic liver disease (n=20).

RESULTS

Male cells were detected in liver biopsy specimens of 8 of 19 patients (42%) with primary biliary cirrhosis. Y-chromosome-containing cells were not seen in any of the liver biopsy specimens from women with chronic hepatitis C or alcoholic liver disease. Male cells were detected in peripheral blood mononuclear cells from one healthy control at a level of 1 male cell per 10(6) female cells, but were not detected in peripheral blood mononuclear cells of women with primary biliary cirrhosis.

CONCLUSIONS

The presence of male cells in the liver of women with primary biliary cirrhosis raises the possibility that fetal cell microchimerism may be involved in the pathogenesis of this chronic liver disease.

Liver transplantation for familial amyloidotic polyneuropathy in Australia

Familial amyloidotic polyneuropathy type 1 (FAP-1) is a type of systemic amyloidosis caused by mutant transthyretin (mTTR) that is mainly produced in the liver. Most patients have progressive peripheral and autonomic neuropathy. Ten patients with FAP underwent orthotopic liver transplantation (OLT) at the Queensland Liver Transplant Service (Princess Alexandra Hospital, Brisbane, Australia). Nine patients are still alive, and one patient died of cardiac failure 10 days after OLT. Some symptoms of FAP were alleviated in some of the patients. OLT seems to be a worthwhile treatment for FAP, because it halts the progression of symptoms and achieves improvement in some patients.

Surgical complications and long-term outcome in pediatric liver transplantation

BACKGROUND/AIMS

Liver transplantation has been widely accepted for the treatment of children with end-stage liver disease over the last 10 years particularly with the advent of reduced-size liver transplant technique. This study reviewed the perioperative and long-term results in the pediatric program of the Queensland Liver Transplant Service, Brisbane, Australia.

METHODOLOGY

Retrospective analysis was performed in 153 children who received 176 liver grafts between 1985 and 1995, including 109 (62%) reduced-size and 67 (38%) whole liver grafts. Median follow-up period was 5.3 years.

RESULTS

One-, 5-, and 10-year patient and graft survival rates were 82% and 74%, 75% and 63%, and 70% and 60%, respectively. Normal physical and intellectual development was observed in 98% of survivors. There were no significant differences in patient or graft survival rates between transplants using reduced-size and whole liver grafts. Portal vein thrombosis was the most common vascular complication, occurring in 8%. Hepatic artery thrombosis occurred in 7%, including 11% of children less than 1 year old and 8% of those under 10 kg. Biliary complication was found in 16% and posttransplant gastrointestinal perforation in 19%.

CONCLUSIONS

Liver transplantation has the potential to cure and allow development in children with end-stage liver disease.

Clinicopathologic findings of recurrent primary sclerosing cholangitis after orthotopic liver transplantation

Whether primary sclerosing cholangitis (PSC) occurs after orthotopic liver transplantation is controversial, largely because the pre-transplant diagnosis of PSC is based on nonspecific radiological and histological findings. We reviewed clinical, radiological, and histological records of 53 patients who underwent liver transplantation for PSC between 1985 and 1998. Three patients with patent hepatic arteries and no evidence of chronic rejection had radiological and histological findings that may have been due to recurrent PSC. Bile duct stricturing in these patients proved permanent and progressive and affected both the quality of life and graft survival. The first patient, who is 110 months after transplantation, has had repeated episodes of cholangitis for the last year. The second patient underwent excision of a strictured hepatic duct 45 months after transplantation and was ultimately retransplanted 95 months after initial transplantation. The third patient underwent left hemihepatectomy of an atrophied lobe 50 months after transplantation. Although the patient population assessed in this study is limited, putative recurrent PSC in the allografts has led either to graft loss or to clinically significant hepatobiliary complications of the graft.

Role of donor leukocyte chimerism in establishing the etiology of neutropenia after liver transplantation

BACKGROUND

The quantitation of donor leukocyte chimerism may aid in establishing the etiology of neutropenia after liver transplantation.

METHODS

The incidence and clinical and laboratory characteristics of severe neutropenia were studied in adults who have undergone liver transplantation at our institution over the last 4 years.

RESULTS

Severe neutropenia developed in 5 of 156 patients (3%). The clinical and pathological features were nonspecific. In two patients with a delayed diagnosis of graft-versus-host disease (GVHD), donor leukocytes comprised > or = 50% of the circulating peripheral blood mononuclear cells. In a third patient, an earlier diagnosis of GVHD was suspected on the basis of a donor leukocyte count of 3-10% in the peripheral blood. In contrast, donor leukocyte chimerism was < or = 0.01% in two patients with probable drug-induced neutropenia

CONCLUSIONS

The determination of donor leukocyte chimerism has an important role in the investigation of neutropenia after liver transplantation, allowing early diagnosis and treatment of GVHD.

Liver transplantation in Japanese and Australian/New Zealand children with biliary atresia: a 10-year comparative study

OBJECTIVE

To compare Japanese with Australian/New Zealand (ANZ) children with biliary atresia who were treated by liver transplantation, and evaluate the indications for and timing of transplantation.

DESIGN

Retrospective study.

SETTING

Queensland Liver Transplant Service (QLTS), Australia.

SUBJECTS

43 Japanese and 30 ANZ children with biliary atresia who required transplantation between 1985 and 1992.

INTERVENTIONS

The 43 Japanese children had 52 transplants, and the 30 ANZ children had 33.

MAIN OUTCOME MEASURES

Morbidity, mortality, and long term survival.

RESULTS

The Japanese children had significantly lower serum albumin concentrations than the ANZ children preoperatively (mean (SD) 32 (7) g/L compared with 37 (5), p<0.05). The actuarial survival at 7 years of the ANZ children was significantly higher than that of the Japanese children (79% compared with 49%, p<0.05). There were 24 deaths (17 Japanese, 40%, and 7 ANZ, 23%); 2 of the ANZ and 7 of the Japanese children died more than a year after transplantation. All 26 children who were well-nourished at the time of transplantation defined as a Z-score (weight or height minus mean weight or height for age, sex, and race, divided by the SD) of -1 or more were alive at 1 month compared with 11 of the 47 poorly-nourished children (Z-score <-1). Survival among the Japanese declined after 1 year, and there was no association with Z-scores. Overall, Z-scores for weight improved significantly after transplantation, whereas those for height improved a little, but not significantly so. Japanese children were significantly shorter than ANZ children, and their Z-scores for height did not improve after transplantation.

CONCLUSION

liver transplantation should be done as soon as possible for children with biliary atresia to maximise survival and growth.

High-performance liquid chromatography-tandem mass spectrometry as a reference for analysis of tacrolimus to assess two immunoassays in patients with liver and renal transplants

The accuracy and imprecision of three assays used for therapeutic monitoring of tacrolimus were tested using blood-containing weighed-in amounts of the drug, an enzyme-linked immunosorbent assay (ELISA), a microparticle enzyme immunoassay (MEIA I), and a high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS2) assay. Accuracy was acceptable for the HPLC-MS2 assay at all concentrations tested (< 10% deviation) and for the ELISA at 1.0 and 4.0 microg/l. Accuracy was not acceptable for the ELISA at 15.0 and 50.0 microg/l or for the MEIA I at all concentrations tested. Imprecision was acceptable for the HPLC-MS2 assay at all concentrations tested (coefficient of variation < 10%), for the ELISA at 15.0 and 50.0 microg/l, and for the MEIA I at 15.0 and 50.0 microg/l. Imprecision was not acceptable for the ELISA at 1.0 and 4.0 microg/l or for the MEIA I at 1.0 and 4.0 microg/l. This assessment with weighed-in amounts of tacrolimus verified the HPLC-MS2 assay as a reference method. The performance of the two immunoassays with HPLC-MS2 was then compared in the clinical setting using blood from patients with liver (n = 30) and renal (n = 37) transplants. In the liver transplant group (127 samples), the range of tacrolimus concentrations measured by HPLC-MS2, ELISA, and MEIA I was 1.9 to 31.8, 2.1 to 35.0, and less than 0.1 to 36.5 mg/l, respectively. In the renal transplant group (129 samples), the ranges were 1.7 to 26.1, 1.9 to 24.4, and 0.9 to 28.5 microg/l, respectively. Compared with the HPLC-MS2, the ELISA had minimal bias (0.1 to 0.2 microg/l) but unacceptable variability in values (SD > 13%). The MEIA I had unacceptable bias (1.7-1.8 microg/l) and variability (SD > 23%). These data indicated that neither the ELISA nor MEIA I is interchangeable with HPLC-MS2. Moreover, in view of the current trend to reduce the therapeutic dose of tacrolimus, quantitative results using the MEIA I would not be obtainable during therapeutic drug monitoring in some patients in whom effective therapeutic concentrations can be less than 5.0 microg/l.

Human liver transplant perfusate: an abundant source of donor liver-associated leukocytes

In vitro studies designed to examine the mechanisms of immune tolerance after liver transplantation in humans have been hampered by the difficulty in obtaining sufficient numbers of donor liver-associated leukocytes (LALs). We have investigated whether the ex vivo perfusion of donor livers releases a population of LALs that can be readily retrieved from the waste fluid. The mean number of cells recovered after Ficoll-Hypaque density-gradient separation was 2.6 +/- 0.5 x 10(8) cells, with a viability of 94% +/- 2%. The perfusate lymphocytes comprised mainly T cells (39% +/- 2%) with a very low CD4/CD8 ratio and natural killer (NK) cells (56% +/- 6%) with an increase in the proportion of the CD3-CD56+CD16- subset. The activation marker CD69 was present on the majority of the perfusate lymphocytes. These are the phenotypic characteristics that have been previously reported for lymphocytes isolated from hepatic sinusoids. In mixed lymphocyte reactions, the perfusate cells showed a marked increase in the ability to stimulate allogeneic responder cells, resulting in 353% +/- 78% (P = .003) greater incorporation of [3H]thymidine in responder cells when compared with stimulation by donor peripheral blood mononuclear cells. The results show that large numbers of viable donor lymphocytes can be readily isolated from the liver perfusate solution. These cells have the characteristics of liver-associated lymphocytes with a predominance of activated NK and CD8+ T cells. This population can now be used in in vitro assays to elucidate the influence of donor leukocytes on the development of graft acceptance.

Peripheral blood chimerism following human liver transplantation

The aim of this study was to prospectively investigate the peak levels and kinetics of donor leucocyte chimerism in human recipients following liver transplantation. The peak levels of chimerism were observed within the first 48 hours following transplantation and ranged from 0.15% to 20% of total peripheral blood mononuclear cells. In all but one patient, who developed graft versus host disease, there was an early peak level of chimerism that declined over time such that donor leukocytes were only intermittently detectable after 3 to 4 weeks. In 8 patients who had no episodes of graft rejection, the peak level of donor leukocyte chimerism ranged from 1.3% to 20% (mean +/- SEM; 5.5% +/- 2.1%). In 3 patients who were treated for episodes of acute graft rejection during the first four postoperative weeks, the peak level of donor leukocyte chimerism ranged from 0.15% to 0.2% (0.18 +/- 0.02, P = .012). The results demonstrate a marked variation in the total number of donor leukocytes detectable in the peripheral blood early after liver transplantation and also, that lower levels of chimerism may be associated with lower rates of initial graft acceptance and a higher incidence of acute rejection.

The use of the lidocaine-monoethylglycinexylidide test in the liver transplant recipient

The lidocaine-monoethylglycinexylidide (MEGX) test is used to monitor liver function in liver transplant recipients. Serial studies have been undertaken after 155 allografts. The initial MEGX concentration is significantly correlated with the donor MEGX concentration. It is also influenced by the recipient's pretransplant bilirubin concentration, being lowest among patients with very high bilirubin levels. Use of segmental grafts is also accompanied by low MEGX concentrations. The flow-dependent clearance of lidocaine makes it a sensitive indicator of disturbed liver blood flow, with decreased MEGX concentrations occurring in hepatic artery thrombosis and rejection and as a result of cardiac failure and pulmonary effusions. Significant hepatic ischemia resulting in delayed initial function or cholestasis also is associated with low MEGX concentrations. The initial median MEGX concentrations were lowest among patients who required retransplantation or who died within 2 months of allografting.

Sensitive, specific quantitative analysis of tacrolimus (FK506) in blood by liquid chromatography-electrospray tandem mass spectrometry

The capacity of liquid chromatography-tandem mass spectrometry (LC-MS2) to detect and define individual components in a complex mixture has been utilized to develop a quantitative assay of the potent immunosuppressant drug, tacrolimus. Trough blood concentrations were measured in 175 samples obtained over several weeks after liver transplantation from seven patients. The assay was linear over the range of 0.2 to 100 micrograms/L. Imprecision was <8%, and accuracy was 99-101%. The turnaround time for a batch of 20 samples was 2.5 h. No interference from any of the other drugs being administered to the patients was evident. An ELISA also performed on the same samples overestimated the concentrations substantially, as indicated by a plot of the difference between the results for the two methods vs their mean. The favorable characteristics of the LC-MS2 assay, especially its sensitivity and specificity, will facilitate detailed pharmacokinetic studies of tacrolimus, particularly under circumstances in which metabolism is perturbed by either hepatic dysfunction or drug interactions.

Sensitive, specific quantitative analysis of tacrolimus (FK506) in blood by liquid chromatography-electrospray tandem mass spectrometry

The capacity of liquid chromatography-tandem mass spectrometry (LC-MS2) to detect and define individual components in a complex mixture has been utilized to develop a quantitative assay of the potent immunosuppressant drug, tacrolimus. Trough blood concentrations were measured in 175 samples obtained over several weeks after liver transplantation from seven patients. The assay was linear over the range of 0.2 to 100 micrograms/L. Imprecision was &lt;8%, and accuracy was 99-101%. The turnaround time for a batch of 20 samples was 2.5 h. No interference from any of the other drugs being administered to the patients was evident. An ELISA also performed on the same samples overestimated the concentrations substantially, as indicated by a plot of the difference between the results for the two methods vs their mean. The favorable characteristics of the LC-MS2 assay, especially its sensitivity and specificity, will facilitate detailed pharmacokinetic studies of tacrolimus, particularly under circumstances in which metabolism is perturbed by either hepatic dysfunction or drug interactions.

Renal glomerular lesions in unselected patients with cirrhosis undergoing orthotopic liver transplantation

Renal biopsies were obtained from 23 patients at the time of orthotopic liver transplantation. Twelve biopsies showed minor glomerular abnormalities, 2 exhibited IgA nephropathy and one showed mesangiocapillary glomerulonephritis type I. The remaining 8 patients had glomerular lesions diagnosed as hepatic glomerulosclerosis (HGS). Immunofluorescence, available in 6 of the 8 biopsies with HGS, revealed granular deposits of immunoglobulins and complement in glomerular capillary walls and/or the mesangium. IgA was seen in 5 biopsies with HGS, but the staining for this protein was no more intense than that for the other immunoglobulins in 4 of these. Electron microscopy in HGS revealed partial mesangial interposition, hypertophy of mesangial and endothelial cells, granular material in a widened subendothelial space, slender projections of endothelial cytoplasm extending into the subendothelial space, and clusters of vesicles in the mesangium and glomerular capillary walls. These ultrastructural abnormalities have not hitherto been reported as a group of associated pathological changes. The renal biopsies were obtained from patients with advanced hepatic disease not selected because of urinary abnormalities or renal dysfunction. The frequency of lesions in this group of patients therefore probably reflects the true incidence of glomerular lesions in cirrhosis and related conditions. Progressive decline in renal function was not observed in any patient during follow up which ranged from 11 days to 55 mths.

Hyperthermic isolated limb perfusion for malignant melanoma: response and survival

Response to and survival after hyperthermic isolated limb perfusion (HILP) with melphalan in patients with malignant melanoma at the Royal Brisbane Hospital were reviewed in order to assess the major determinants of response to treatment. Data were collected by clinical chart review and direct patient contact. Response was assessed by clinical observation and measurement of nodules. Survival was calculated from the date of perfusion to the date of patient death. Since 1965 there have been 85 patients (38 men, 47 women) who have undergone 109 limb (102 leg, 7 arm) perfusions. The mean age was 58 years (range 32-82 years). The number of patients per disease stage (M.D. Anderson classification) was as follows: stage I, 5 patients; stage II, 8 patients; stage IIIa, 41 patients; stage IIIab, 25 patients; and stage IIIb, 8 patients. The mean duration of perfusion was 81 minutes. Melphalan was given in divided doses, with a mean total dose 1.39 mg/kg. The mean maximal limb temperature was 41.5 degrees C. Major complications occurred during 20 perfusions (18%). There was one postoperative death from myocardial infarction, and one patient required amputation. Median patient follow-up was 2.65 years (range 1-27 years). A complete response was noted in 34 patients (40%), a partial response in 36 patients (42%), and no response in 11 patients (13%). Response could not be assessed in four patients. The actuarial 5-year survival for the whole group was 45%: stage I, 80%; stage II, 75%; stage IIIa, 44%; stage IIIab, 23%; stage IIIb, 56%. The two significant determinants of response to perfusion were disease stage (p = 0.00005) and nodal status (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Liver transplantation in the presence of situs inversus totalis: application of reduced-size graft

Because of the anatomical features associated with situs inversus, technical difficulties will be encountered during orthotopic liver transplantation. This report describes the case of a patient with situs inversus totalis and end-stage liver disease from biliary atresia who was treated by segmental orthotopic liver transplantation. The segmental graft was safely placed in the left subphrenic space, and a suitable orientation was obtained for anastomoses of the hilar vessels. Chronic rejection necessitated retransplantation, by the same method, 19 months later. This technique has potential advantages in coping with anatomical obstacles encountered in patients with situs inversus.

Hemodynamic changes in blood flow through the denervated liver in pigs

We investigated the effects of liver denervation on hemodynamic circulation in seven anesthetized pigs. Simultaneous measurements of the hepatic artery and portal vein were performed with an ultrasound Doppler flow meter before and after liver denervation. Neither resting systemic nor hepatic hemodynamics changed following liver denervation. However, temporary occlusion of the portal vein resulted in a significant increase in hepatic artery flow in the innervated liver (from 123 +/- 15 ml/min to 177 +/- 17 ml/min, p < .01), whereas, in the denervated liver, a significant decrease was observed (from 128 +/- 11 ml/min to 106 +/- 19 ml/min, p < .05). Thus, the reciprocity between the hepatic artery and portal vein in the hepatic artery flow during portal vein occlusion might intensify symptoms of portal vein thrombosis in liver transplantation. In the denervated liver, a significant decrease also occurred in systolic blood pressure and central venous pressure from 1 to 3 min after portal vein occlusion. Since the liver plays a crucial role in the maintenance of cardiovascular homeostasis during blood loss, it is likely that denervation at the porta hepatis induced a lack of vasoconstriction in the portal territory. Liver denervation might further exacerbate this response to hypotension. The current study confirms that the hepatic nerves play an important role in hepatic arterial and portal venous interactions aimed at maintaining a constant blood flow through the liver. We also suggest that the hepatic nerves are important for cardiovascular homeostasis.

Endotoxin levels in adult liver donors

This study was undertaken to determine the levels of endotoxin in a group of adult donors whose livers were procured for transplantation. In the group of 25 adults, endotoxin levels were found to be significantly elevated in the systemic venous blood when compared to control levels. Portal venous endotoxin levels were also elevated following hepatic hilar dissection and after cannulation of the portal vein prior to removing the donor liver.

Posttransplant gastrointestinal perforation in pediatric liver transplantation

The results of 119 consecutive orthotopic liver transplants in 105 pediatric recipients were reviewed to determine the incidence and management of posttransplant gastrointestinal perforation (PTGIP). Transplantation of 22 children (21%) having had no previous surgery resulted in no PTGIP. However, 15 patients (14%) had PTGIP, and this group had had a greater number of previous laparotomies than did 68 children without PTGIP (2.3 +/- 0.9 v 1.5 +/- 0.8; P < .01). Up to 31% of children with two or more previous operations developed PTGIP. The incidence of PTGIP in patients with a preexisting stoma (26%, n = 23) was not significantly different from that in children whose previous portoenterostomy consisted of a simple Roux loop (15%, n = 60). A total of 32 laparotomies were performed for 35 PTGIP. The operative procedures included an oversewing of the perforated site (n = 22), segmental bowel resection/primary anastomosis (n = 5), creation of enterostomy (n = 7), and drainage (n = 1). After these laparotomies, reperforation occurred in 31% of patients, varying from none after defunctioning enterostomy for colonic perforations to 63% after simple oversew of perforated small bowel. Bolus methylprednisolone therapy or cytomegalovirus infection did not show any link with PTGIP. Children having undergone multiple laparotomies before liver transplantation are more susceptible to PTGIP. There was no death directly caused by PTGIP, but morbidity was considerable.

The management and long-term results of Japanese pediatric liver transplant recipients

We investigated the long-term results and ongoing management issues of 39 Japanese children who underwent liver transplantation in Brisbane, Australia. Whole liver grafts were used in 15 patients (Wh group) and reduced-size grafts were used in 24 patients (Re group). The 1-year and 3-year survival rates were 74% and 60%, respectively, and all cases of late mortality which occurred after 6 months were due to infection. Statistical analysis showed no differences between the Wh and Re groups with regard to late mortality or liver function tests, although 4 of 24 (16.7%) patients from the Re group developed a recurrence of esophageal varices. Three patients treated with cyclosporine developed lymphoproliferative disorders following transplantation, but none of the patients developed severe nephrotoxicity or hypertension. Although a "catch-up" gain in weight was observed, poor growth in height was displayed, and there were no differences between the Wh and Re groups in this regard. Thus, we conclude that late complications of liver transplantation in children are common and further studies are necessary to evaluate the ongoing growth problems.

Malignant ascites. A comparison of peritoneovenous shunting and nonoperative management

BACKGROUND

Effective palliation of malignant ascites remains a difficult management problem.

METHODS

Eighty-five patients with malignant ascites were studied. Forty-two patients had peritoneovenous shunts (PVS) inserted (16 LeVeen, 17 single-valve Denver, 9 double-valve Denver).

RESULTS

Shunt patency was not related to the type of shunt, type of cancer, or any characteristic of the ascitic fluid. Ascites was controlled in 64% of patients with shunts and serum albumin levels were preserved. Survival and quality of life were not significantly different in comparison with those of patients treated by abdominal paracentesis.

CONCLUSIONS

PVS allowed many patients to be treated successfully outside the hospital and are indicated in carefully selected cases.

Malignant ascites. A comparison of peritoneovenous shunting and nonoperative management

BACKGROUND

Effective palliation of malignant ascites remains a difficult management problem.

METHODS

Eighty-five patients with malignant ascites were studied. Forty-two patients had peritoneovenous shunts (PVS) inserted (16 LeVeen, 17 single-valve Denver, 9 double-valve Denver).

RESULTS

Shunt patency was not related to the type of shunt, type of cancer, or any characteristic of the ascitic fluid. Ascites was controlled in 64% of patients with shunts and serum albumin levels were preserved. Survival and quality of life were not significantly different in comparison with those of patients treated by abdominal paracentesis.

CONCLUSIONS

PVS allowed many patients to be treated successfully outside the hospital and are indicated in carefully selected cases.

Glomerular abnormalities in children undergoing orthotopic liver transplantation

A prospective study of renal function was undertaken on an unselected group of 8 children with chronic progressive liver disease on whom a renal biopsy was performed subsequently at the time of orthotopic liver transplantation. Two patients had abnormal urinalyses and 2 elevated urinary albumin/creatinine ratios. The remainder had no clinical evidence of renal dysfunction. All had normal serum creatinine concentrations. Glomerular abnormalities were present in all renal biopsies and were of two types: hepatic glomerulosclerosis (n = 5) and minor glomerular abnormalities (n = 3). IgM immunofluorescence was present in all biopsies and IgA in 6. Elevated serum immunoglobulin levels were observed in all patients, with IgM elevation in 6, IgA in 4 and IgG in 6. C3 and/or C4 were reduced in 5 patients and increased circulating immune complexes containing IgM were noted in 4. The clinical significance of these cirrhosis-associated glomerular abnormalities can only be established by long-term follow-up studies after orthotopic liver transplantation.

Universal occurrence of glomerular abnormalities in patients receiving liver transplants

We conducted a prospective study of renal histology and function in 18 consecutive nonalcoholic patients who underwent orthotopic liver transplantation (OLT). Despite well-preserved renal function, all patients had abnormal renal biopsies. Four patterns of glomerular injury were identified: minor glomerular abnormalities (eight patients), hepatic glomerulosclerosis (seven), membranoproliferative glomerulonephritis (one), and IgA nephropathy (one). In one patient there was insufficient tissue to allow classification. There was a trend toward lower plasma bilirubin and higher plasma albumin in patients with minor glomerular abnormalities than in the group of patients with more severe forms of glomerular injury (29 v 82 mumol/L, 35.5 v 30 g/L; P = 0.1, 0.1 greater than P greater than 0.05, respectively). Glomerular changes persisted in the three patients who died within 7 weeks post-OLT. IgM immunofluorescence was present in all biopsies and IgA in 11. IgM-containing circulating immune complexes occurred in five patients, suggesting a pathogenic role for IgM immune complex deposition. The significance of cirrhosis-associated glomerular abnormalities is not yet known. They may contribute to the hepatorenal syndrome and the renal dysfunction that occurs in up to 94% of patients post-OLT.

Changing patterns in the presentation of breast cancer over 25 years

The clinical stage at presentation of 280 women with histologically proven breast cancer is reviewed over a 25 year time span from 1962 to 1987. The data from 240 unscreened patients, including 87 women from the period 1962 to 1963, 103 women from 1981 to 1982, and 50 women from 1986 to 1987 demonstrate a chronologically based improvement in the stage of disease at presentation over the 25 years. Specifically, over that period, there was a fall in the mean tumour diameter, a reduction in the proportion of patients with involved axillary nodes, and a greater percentage of patients with Stages I and II disease. A reduction in the symptomatic period was also noted over this time, and a direct relationship was found between the duration of symptoms and tumour size, nodal status and overall stage of disease. A subsequent comparison with the staging data from 40 women with breast cancer detected at a breast screening clinic (1985-87) shows that significant further advances in the earlier diagnosis of breast cancer can be achieved. Mammographic breast screening centres represent the best-known means of early breast cancer detection, and thus may hold the key to reducing breast cancer mortality.

Surgical research in Australasia

An analysis has been made of the 642 papers presented to the Surgical Research Society of Australasia between 1962 and 1978. Most areas of research have maintained a relatively stable level of productivity over the period examined. However, while tumour immunology, education, and microsurgery have attracted increasing interest, that of transplantation immunology and cardiovascular research appeared to be decreasing in recent years. The most commonly investigated body systems were gastrointesinal (27%), cardiovascular (21%), and genitourinary (17%). The most commonly studied scientific disciplines were metabolism/biochemistry (22%), physiological measurement (17%), immunology (10%), oncology (9%), and transplantation (8%). Less than 3% of papers related to controlled clinical trials.

A simplified kidney preservation system: the use of hyperosmolar perfusates for continuous perfusion preservation of canine kidneys

Since the quality of renal preservation following simple ice storage is improved by the use of hyperosmolar washout solutions, hyperosmolar perfusates were evaluated for continuous perfusion preservation. Canine kidneys were preserved for 48 hours by continuous perfusion at 5 degrees C, using hyperosmolar cryoprecipitated plasma and 5% albumin perfusates of osmolalities 397 to 430 mOsm/kg H2O. Hyperosmolar plasma gave significantly better preservation than isosmolar plasma, but the results were only marginally superior to those already obtainable with isosmolar albumin solution. No further improvement in preservation by albumin perfusion was obtained with the hyperosmolar formulations. Because isosmolar albumin solution is easier to prepare than hyperosmolar cryoprecipitated plasma and gives comparable results, it remains our perfusate of choice for continuous perfusion preservation.