Unilateral auto-PEEP in the recipient of a single lung transplant

We report a patient who received a right single lung transplant (SLT) for progressive lymphangioleiomyomatosis and required reintubation for postoperative respiratory distress. She developed hemodynamic instability due to mediastinal shift from unilateral auto-PEEP with hyperinflation of the native lung. Placement of a double lumen endotracheal tube (DLET) and institution of differential lung ventilation restored equal lung inflation and hemodynamic stability.     

Reversible acute renal failure induced by losartan in a renal transplant recipient

A 56-year-old man who received a live-related renal transplant in 1988 was started in 1995 on the selective angiotensin II antagonist losartan (Dupont-Merke) to treat worsening hypertension. Two months later because of pulmonary oedema, loop diuretics were started. Within two weeks, serum creatinine had increased from 245 to 571 mumol/l, and the patient became oliguric. A systolic bruit was noted over the graft. Renal angiography showed a 90% stenosis of the transplant renal artery. Losartan was withdrawn, with prompt improvement in renal function. A successful percutaneous transluminal angioplasty performed a few days later resulted in further improvement in renal function accompanied by a significant diuresis.     

Infectivity of hepatic allografts with antibodies to hepatitis B virus

BACKGROUND: Since suitable recipients for hepatic allografts from donors with antibodies to hepatitis B virus (HBV) have not been determined, a review of our 7-year experience with donors positive for hepatitis B surface antibody (anti-HBs), hepatitis B core antibody (anti-HBc), or both was undertaken. METHODS: Recipients of hepatic allografts from donors with antibodies to HBV were identified by a retrospective review of procurement records and screened for HBV infection. RESULTS: From January 1, 1990, to January 1, 1997, 2578 liver transplants were performed and 140 (5.4%) recipients received an allograft from a donor with antibodies to HBV. Twenty-five of 48 recipients of a hepatic allograft from a donor positive only for anti-HBs were screened and none developed HBV infection. Twenty-five of 41 naive recipients of a hepatic allograft from an anti-HBc positive donor were screened and 18/25 (72%) developed HBV infection. Four of these 18 naive recipients with HBV infection received an allograft from a donor positive for both anti-HBc and anti-HBs. Seven of 13 anti-HBs-positive recipients of an allograft from an anti-HBc-positive donor were screened and none developed HBV infection. Fifteen of 16 recipients positive only for anti-HBc who received a hepatic allograft from an anti-HBc-positive donor were screened and 2/15 (13%) developed HBV infection. CONCLUSIONS: Hepatic allografts from donors positive only for anti-HBs do not transmit HBV infection. Hepatic allografts from anti-HBc-positive donors frequently transmit HBV infection to naive recipients regardless of the donor anti-HBs status, and antiviral prophylaxis may be indicated. Anti-HBs-positive recipients appear resistant to HBV infection after orthotopic liver transplantation with an allograft from an anti-HBc-positive donor. Recipients positive only for anti-HBc infrequently develop HBV infection when transplanted with an allograft from an anti-HBc-positive donor; however, HBV prophylaxis may be justified.     

Management of fulminant hepatic failure

There has been considerable public concern that emissions from intensive livestock farming may have hazardous effects on human health, particularly on the respiratory system. From October 1991 to September 1992, data on consultations of asthmatic children (up to 8 years) were obtained by a network of 25 GP and paediatric practices in South Oldenburg, a region with one of the highest livestock densities in Germany. Comparable data from a similar network of 75 practices in 3 adjacent regions (Brunswick, Hanover, Verden) with average livestock density served as a reference. In South Oldenberg, 2084 consultations of 542 asthmatic children were observed, with asthma being the reason for visit in 734 of the contacts (36%). The boy-girl ratio was 2.1:1 among index patients and 1.9:1 among consultations. Consultation rate was 25.2 contacts by asthmatic children per 1,000 total consultations of children up to 8 years in South Oldenburg, compared to 17.8 per 1,000 in Hanover, 15.7 per 1,000 in Brunswick and 13.6 per 1,000 in Verden. Consultations due to asthma scored 11.2/1,000 in South Oldenburg, 10.8/1,000 in Hanover, 7.2/1,000 in Brunswick and 6.5/1,000 in Verden. Asthmatic patients in South Oldenburg were younger (mean age 38 vs. 42 months) than those observed in the reference regions. There were no regional patterns in sex ratio, severity of asthma, respiratory allergies or atopic dermatitis. As this is an ecological study design, inferences concerning the cause of the observed regional differences can only be weak. We therefore propose a case-control study in order to obtain exposure and health data on an individual level.     

Probable acanthamoeba meningoencephalitis in a Korean child

A 5-year-old Korean boy developed multiple subcutaneous, nontuberculous granulomas and died with meningoencephalitis. Autopsy disclosed amebic granulomas in subcutaneous tissue, the left adrenal gland, and the pancreas, with more acute inflammatory lesions in the liver, kidney, and brain. The causative organism is believed to be an Acanthamoeba sp.     

Detection of donor-specific hyporesponsiveness following late failure of human renal allografts

Limiting dilution assays to measure the frequency of interleukin-2-secreting peripheral blood T cells were carried out in patients, whose renal allografts had failed due to acute rejection (9 patients) and in patients whose grafts failed more than two years after transplantation without any recent evidence of acute rejection. Using a modified form of the assay we demonstrate that nearly half of 18 patients whose renal transplants had failed after more than two years have low or undetectable HTLp frequencies against donor, but not third-party DR antigens. No such difference was observed in any of the nine patients studied whose transplants were lost from early acute rejection. These results provide the first indication that, as in rodent models of transplantation, T cell unresponsiveness towards donor MHC antigens can occur following prolonged residence of an allograft in humans. Furthermore, the results suggest that chronic rejection may be driven by mechanisms other than direct allorecognition. The assay may be a valuable tool to study the evolution of donor-specific direct T cell alloresponsiveness in patients with well-functioning grafts.     

Transplantation for acute hepatic failure in children

BACKGROUND/PURPOSE: Acute liver failure in the pediatric population is a rare but highly lethal health problem. Sometimes it is difficult to predict who will benefit from liver transplantation. The authors report on their experience in the past 8 years at a pediatric transplant center. METHODS: A retrospective chart review was performed on all children referred to the liver transplant (TX) service with the diagnosis of acute hepatocellular dysfunction (AHD) from 1988 to 1996. Presentation, chemistries, and clinical course were evaluated. Statistical analysis was performed using analysis of variance. RESULTS: Twenty-six children underwent evaluation. Seventeen patients fulfilled the criteria for fulminant hepatic failure (FHF). Eleven patients recovered without TX, 14 received a TX, and one died awaiting TX. Of those that received a TX, four died in the early postoperative period and 10 survived (mean follow-up of 4.2 years). There was a wide range in most laboratory values. Serum bilirubin levels, ammonia levels, and coagulation parameters, however, reached statistical significance in patients requiring transplant. The most consistent discriminators of need for transplantation and outcome were neurological findings and multisystem organ failure. Children who recovered without TX had no seizures and minimal encephalopathy. Of the 15 children who were recommended for TX, six had seizures and all had encephalopathy, 12 having grade III or IV. All five nonsurvivors had respiratory failure early in their clinical course, and four of five nonsurvivors also had renal failure. CONCLUSIONS: There is significant overlap in the presentation and laboratory findings of children who present with AHD or FHF. Neurological status was an important discriminator of need for transplantation. Patients who presented with multisystem organ failure, including renal failure and respiratory failure, had 100% mortality rate despite liver transplantation.     

Posttransplantation chronic hepatitis in fulminant hepatic failure

Non-A, non-B or seronegative hepatitis is the leading indication for liver transplantation in patients with fulminant hepatic failure (FHF). We examined protocol annual review liver allograft biopsy specimens in consecutive adult patients transplanted for FHF in an attempt to determine the extent of the histological changes. One hundred eleven biopsy specimens from 41 patients transplanted for fulminant seronegative hepatitis and 34 from a comparison group of 16 patients transplanted for other causes of FHF (11 paracetamol overdose, 2 idiosyncratic drug reaction, 3 Wilson's disease) were available. Specimens were analyzed using standard proforma without knowledge of the original diagnosis. Chronic hepatitis was present in 29 patients (71%) transplanted for fulminant seronegative hepatitis (23 mild, 3 moderate, and 3 severe) compared with 5 patients (31%, all mild) transplanted for other causes of FHF. Twenty-five patients (61%) grafted for seronegative FHF had fibrosis (13 mild, 9 moderate, and 3 severe) in contrast to 4 fibrosis (25%) (all mild) in the comparison group. Excluding early allograft failure because of primary graft nonfunction or vascular complications, six patients with seronegative FHF required retransplantation (2 = chronic rejection; 1 = severe hepatitis with panacinar necrosis, resembling original liver; and 3 = chronic hepatitis with precirrhotic fibrosis and prominent cholestasis of unknown cause). One patient in the comparison group had a second graft (chronic rejection). Posttransplantation chronic hepatitis is more frequent and severe in patients transplanted for seronegative hepatitis. Graft survival may be adversely influenced by the development of chronic hepatitis, which may represent persistent or recurrent disease.     

Clinicopathological profile of subacute hepatic failure

Sigmoid volvulus is an unusual cause of intestinal obstruction in children. We report two cases of sigmoid volvulus as a complication of segmental dilatation of the colon occurring in two girls (5 years old and 9 years old) previously treated for chronic constipation. In both cases the constipation had been recognised since the neonatal period mimicking a Hirschsprung's disease, a diagnosis which has been excluded after rectal biopsy. The delayed diagnosis of segmental dilatation of the sigmoid colon followed the volvulus. Segmental colonic resection resulted in both cases in the cure of the constipation.     

Impairment of citrate metabolism in acute hepatic failure

The use of yoga for rehabilitation has diverse applications. Yoga practice benefited mentally handicapped subjects by improving their mental ability, also the motor co-ordination and social skills. Physically handicapped subjects had a restoration of some degree of functional ability after practicing yoga. Visually impaired children children showed a significant decrease in their abnormal anxiety levels when they practiced yoga for three weeks, while a program of physical activity had no such effect. Socially disadvantaged adults (prisoners in a jail) and children in a remand home showed significant improvement in sleep, appetite and general well being, as well as a decrease in physiological arousal. The practice of meditation was reported to decrease the degree of substance (marijuana) abuse, by strengthening the mental resolve and decreasing the anxiety. Another important area is the application of yoga (and indeed, lifestyle change), in the rehabilitation of patients with coronary artery disease. Finally, the possible role of yoga in improving the mental state and general well being of HIV positive persons and patients with AIDS, is being explored.     

Factor VII levels as a guide to prognosis in fulminant hepatic failure

Levels of clotting factors II, V, and VII were measured on admission and then daily in 12 patients with grade IV hepatic coma due to fulminant hepatic failure. Factor VII levels obtained within 36 hours of the development of grade IV coma were not of value in predicting which patients would subsequently recover consciousness. Four of the latter group had levels below 9% at this time while the levels in three of the seven fatal cases were higher. Serial determinations were of more value and levels rose rapidly in those patients who ultimately made a complete recovery.     

The beneficial effects of ciprofloxacin on survival and hepatic regenerative activity in a rat model of fulminant hepatic failure

Recently, we reported that ciprofloxacin, an antimicrobial agent with gamma-aminobutyric acid (GABA(A)) receptor antagonist properties, significantly increases hepatic regenerative activity in animal models of alcohol-induced liver disease and cirrhosis. In the present study, we documented the effects of ciprofloxacin on survival and hepatic regeneration in a D-galactosamine (D-gal)-induced model of acute hepatic injury in rats. One hundred nineteen adult, male Sprague-Dawley rats (n = 19-20/group) were treated with intraperitoneal D-gal (total dose: 2.5 g/kg), followed by gastric gavage with either saline, ciprofloxacin (10, 50, or 100 mg/kg), norfloxacin (250 mg/kg), or intraperitoneal putrescine (300 micromol/kg), a potent hepatic growth promoter. Mortality rates were then documented over a 4-day period. An additional 45 rats (n = 15/group) received a sublethal dose of D-gal (1.0 g/kg), followed by gastric gavage with either saline or ciprofloxacin (100 mg/kg), or intraperitoneal putrescine (300 micromol/kg). In these rats, hepatic regenerative activity was documented at 12, 24, and 60 hours post-D-gal by 3H-thymidine incorporation into hepatic DNA and proliferating cell nuclear antigen (PCNA) staining. In the survival study, a dose-response effect of ciprofloxacin on survival was observed (ciprofloxacin: 10 mg/kg, 10%; 50 mg/kg, 26%; and 100 mg/kg, 35%) with the results in the 100-mg/kg-treated group being significant when compared with the 5% survival rate in saline-treated controls (P < .05). Survival figures in the norfloxacin- and putrescine-treated groups were not significantly improved (15% and 25%, respectively). In the regeneration study, compared with the D-gal + saline-treated control group, DNA synthesis rates at 60 hours were increased in the D-gal + ciprofloxacin and D-gal + putrescine groups (10.2 +/- 3.3 vs. 18.2 +/- 5.1 and 18.8 +/- 6.8 x 10(3) dpm/mg DNA respectively; P < .05). The results of PCNA staining also supported enhanced hepatic regeneration in the ciprofloxacin-treated group at 60 hours (saline, 13.4 +/- 3.7; ciprofloxacin, 47.4 +/- 7.3; and putrescine, 8.4% +/- 2.8% hepatocytes staining positive). Ciprofloxacin at a dose of 100 mg/kg significantly improves survival and hepatic regenerative activity in this animal model of acute hepatic injury.