Mycophenolate mofetil (MMF) and sirolimus impair wound healing. We compared sirolimus vs. MMF to determine the relative impact on surgical complications and wound healing in adult kidney transplant recipients. This retrospective, single center study of 235 adult kidney transplants performed between 1 January 2000 and 31 January 2002 identified 158 adult, kidney‐only recipients treated with tacrolimus and prednisone, from which two groups were defined: group 1 (n = 84) received MMF, group 2 (n = 74) received sirolimus. The incidence of fluid collections, wound problems, dehiscence, and urine leak were compared. A multivariate stepwise logistical regression analysis was performed to identify risk factors. The overall incidence of complications was 21.5%, with rates significantly lower in group 1 (2.4%) vs. group 2 (43.2%, p < 0.0001). Regression analysis showed only sirolimus (p < 0.001) and hypo‐albuminemia (p = 0.006) to independently correlate with complication occurrence. In subanalyses, lymphoceles correlated only with sirolimus (p = 0.003), while other wound problems also correlated with higher body mass index (p = 0.067). The use of sirolimus, tacrolimus and prednisone was associated with a greater incidence of lymphoceles, non‐lymphocele perinephric fluid collections and other consequences of poor wound healing, as compared to contemporary patients treated with MMF, tacrolimus and prednisone.
ABO-incompatible liver transplants (LTX) have been associated with a high risk of antibody-mediated rejection, poor patient and graft survival, and a high risk of vascular thrombosis and ischemic bile duct complications. We used pretransplantation and posttransplantation double-volume total plasma exchange (TPE), splenectomy, and quadruple immunosuppression (cyclophosphamide or mycophenolate mofetil, prednisone, (P = .03 compared with pretransplantation pre-TPE 1 6 ) . ABO-incompatible liver transplantations can be performed with acceptable patient and graft survival rates with a low risk of antibody-mediated rejection with a combination of TPE, splenectomy, and quadruple immunosuppression. Recovery of isohemagglutinin antibody levels without humoral rejection suggests that accommodation may be the protective mechanism preventing late antibody-mediated rejection. The risk of antibody-mediated rejection in ABO-incompatible kidney transplant recipients can be reduced by the pretransplantation removal of anti-A or anti-B isohemagglutinins using total plasma exchange (TPE) or immunoadsorbent columns, splenectomy, and quadruple l Although the liver seems to be more resistant to hyperacute rejection than the kidney and the heart, hyperacute rejection of the liver has been shown in presensitized recipientsI2-l4 and in recipients of ABO-incompatible liver allografts.15-'7 Antibody-mediated rejection also leads to an increased risk of vascular and biliary tract complications, leading to a markedly increased failure rate of ABO-incompatible liver allografts.18-20 Improvements in patient and graft survival rates have been achieved with perioperative TPE and quadruple immunosuppression, but antibody-mediated rejection and graft loss has not been eliminated.21Since 1992, we have used a protocol in ABO-incompatible liver transplant recipients based on the data from ABO-incompatible kidney transplantation.6-10 This includes pretransplantation TPE to remove anti-A and anti-B isohemagglutinins; posttransplantation TPE to maintain low titers for 2 weeks posttransplanl (Jdnuay,), 2003: pp [22][23][24][25][26][27][28][29][30]
Five children with cystic fibrosis complicated by hepatic cirrhosis received liver grafts. They all had portal hypertension with varices and three had variceal bleeding; respiratory function was only moderately impaired, but four were colonised with pseudomonas and one with aspergillus. Liver transplantation was well tolerated and there was no increase in respiratory or other early postoperative complications. Four of the children were fully well from 14 to 35 months after transplantation; the most recently transplanted had problems from a biliary stricture. In spite of the need for immunosuppression there was no increase in infection and respiratory fimction improved or remained stable. Once the children were stabilised after transplantation their nutrition and general health were greatly improved.
To determine the effects of tracheostomy on respiratory mechanics and work of breathing (WOB).Design: A before-and-after trial of 20 patients undergoing tracheostomy for repeated extubation failure.Setting: Surgical intensive care unit at a university teaching hospital and a level I trauma center.Patients: A consecutive sample of 20 patients who met extubation criteria (PaO 2 , Ͼ55 mm Hg; pH Ͼ7.30; and respiratory rate, Ͻ30/min on room air continuous positive airway pressure after 20 minutes) but failed extubation on 2 occasions were eligible for the study.Interventions: Respiratory mechanics, lung volumes, and WOB were measured before and after tracheostomy.Main Outcome Measures: Patients in whom extubation fails often progress to unassisted ventilation after tracheostomy. The study hypothesis was that tracheostomy would result in improved pulmonary function through changes in respiratory mechanics.Results: Data are given as means ± SDs. After tracheostomy, WOB per liter of ventilation (0.97 ± 0.32 vs 0.81 ± 0.46 J/L; PϽ.09), WOB per minute (8.9 ± 2.9 vs 6.6 ± 1.4 J/min; PϽ.04), and airway resistance (9.4 ± 4.1 vs 6.3 ± 4.5 cm H 2 O/L per second; PϽ.07) were reduced compared with breathing via an endotracheal tube. These findings, however, do not fully explain the ability of patients to be liberated from mechanical ventilation after tracheostomy. In 4 patients who were extubated before tracheostomy, WOB was significantly greater during extubation than when breathing through an endotracheal or tracheostomy tube (1.2 ± 0.19 vs 0.81 ± 0.24 vs 0.77 ± 0.22 J/L). Conclusions:We believe that the rigid nature of the tra-cheostomytuberepresentsreducedimposedWOBcompared with the longer, thermoliable endotracheal tube. The clinical significance of this effect is small, although as respiratory rate increases, the effects are magnified. In patients in whom extubation failed, WOB may be elevated because of incompletecontroloftheupperairway.Futurestudiesshould evaluate the cause of increased WOB after extubation.
Hepatic artery thrombosis (HAT) after liver transplantation is a potentially life-threatening complication that occurs in 2-25% of patients, depending on several risk factors and the patient population studied. Arterial thrombosis occurring early after liver transplantation is associated with acute fulminant hepatic failure, biliary tract necrosis and leaks, or relapsing bacteremia and is associated with a high rate of graft loss and patient mortality. The onset of late posttransplant HAT (after 6 months) has been thought to have a more benign and often asymptomatic course. The reasons for the differences between the manifestations of early and late HAT are not well understood. We reviewed the adult liver transplant experience at the University of Cincinnati and found four patients with late HAT, three of whom developed severe intrahepatic biliary necrosis. Two patients were successfully retransplanted and 1 patient who refused retransplantation died. One patient had mild, transient graft damage due to gradual arterial stenosis and the development of arterial collaterals prior to thrombosis. Late HAT has a significant potential for irreversible graft damage requiring retransplantation. Screening for the development of hepatic artery stenosis prior to late thrombosis may be worthwhile.
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