Em TenVergert

Selective decontamination of the digestive tract to prevent postoperative infection: a randomized placebo-controlled trial in liver transplant patients.

ObjectiveTo determine the efficacy of selective decontamination of the digestive tract (SDD) in patients undergoing elective transplantation of the liver. DesignRandomized, double-blind, placebo-controlled study. SettingTwo academic teaching hospitals. PatientsAdult patients undergoing elective liver transplantation: 26 patients receiving SDD and 29 patients receiving a placebo. InterventionsPatients undergoing SDD were administered 400 mg of norfloxacin once daily as soon as they were accepted for transplantation. Postoperative treatment for this group consisted of 2 mg of colistin, 1.8 mg of tobramycin, and 10 mg of amphotericin B, four times daily, combined with an oral paste containing a 2% solution of the same drugs until postoperative day 30. Prophylactic intravenous administration of antibiotics was not part of the SDD regimen in this study. Control patients were given a similar regimen with placebo drugs. MeasurementsThe mean number of postoperative bacterial and fungal infections in the first 30 days after transplantation was the primary efficacy end point. Days on a ventilator, days spent in the intensive care unit, and medical costs were registered as secondary outcome variables. Main ResultsOf the 26 patients undergoing SDD, 22 (84.5%) developed an infection in the postoperative study period; in the placebo group (n = 29), these numbers were not significantly different (25 patients, 86%). The mean number of postoperative infectious episodes per patient was also not significantly different: 1.77 (SDD) vs. 1.93 (placebo). Infections involving Gram-negative aerobic bacteria and Candida species were significantly less frequent in patients receiving SDD (p < .001 and p < .05). Total costs were higher in the group receiving SDD. ConclusionsSelective decontamination of the digestive tract does not prevent infection in patients undergoing elective liver transplantation and increases the cost of their care. It does, however, affect the type of infection. Infections with Gram-negative bacilli and with Candida species are replaced by infections with Gram-positive cocci.

Cost-effectiveness of lung transplantation in relation to type of end-stage pulmonary disease

The purpose of this study was to explore the relationship between diagnosis and the cost‐effectiveness and cost‐utility of lung transplantation.

Quality of life before and after lung transplantation in patients with emphysema versus other indications.

Whether lung transplantation improves Health-related Quality of Life in patients with emphysema and other end-stage lung diseases before and after lung transplantation was examined. Berween 1992 and 1999, 23 patients with emphysema and 19 patients with other indications completed self-administered questionnaires before lung transplantation, and at 4, 7, 13, and 25 mo. after transplantation. The questionnaire included the Nottingham Health Profile, the State-Trait Anxiety Inventory, the Self-rating Depression Scale, the Index of Well-being, the self-report Karnofsky Index, and four respiratory-specific questions. Neither before nor after transplantation were significant differences found on most dimensions of Health-related Quality of Life between patients with emphysema and other indications. Before transplantation, both groups report major restrictions on the dimensions Energy and Mobility of the Nottingham Health Profile, low experienced well-being, depressive symptoms, and high dyspnea. About 4 mo. after transplantation, most Health-related Quality of Life measures improved significantly in both groups. These improvements were maintained in the following 21 mo.

PROGNOSTIC FACTORS FOR LONG-TERM ACTUAL PATIENT SURVIVAL AFTER ORTHOTOPIC LIVER TRANSPLANTATION IN CHILDREN

Background. Orthotopic liver transplantation has become the treatment of choice for children with end-stage liver disease. Although results have improved the last decades, still a considerable number of children die after transplantation. The aim of this study was to analyze long-term actual survival and to identify prognostic factors for such survival rates. Methods. A consecutive series of 66 children receiving transplants who had or could have had a follow-up of at least 5 years was retrospectively analyzed. Actual survival and prognostic factors in relation to patient, donor, and operation related variables were assessed after multivariate analysis. Results. Actual 1-, 3-, and 5-year patient survival was 86%, 79%, and 73%, respectively. A high Child-Pugh (C-P) score or C-P class C, high donor age, high blood loss index, and retransplantation were predictive factors for actual patient survival. A high blood loss index was correlated with biliary atresia, low recipient age and weight, and with previous upper abdominal operations. The duration of stay of the donor at the intensive care unit (ICU) was a predictive factor for retransplantation. Conclusions. Children with diseases eligible for liver transplantation should be seen early in the course of their disease in a transplantation center. All possible measures should be taken during the transplantation procedure to keep the blood loss at a minimum. Children with biliary atresia deserve special attention in this respect. The choice of donors has implications for survival.

Simulated waiting list prioritization for equitable allocation of donor lungs.

BACKGROUND In lung transplantation (LTx), allocation of donor lungs is usually based on blood group, height and waiting time. Long waiting times favor patients with a slowly progressive end-stage lung disease and make the current allocation system the subject of discussion. In an attempt to equalize the chances for transplantation for every patient, irrespective of diagnosis, we investigated the effect of diagnosis-dependent prioritization on the waiting list, using a simulation model. METHODS For the main disease categories on the waiting list, the relative risks of dying while on the waiting list were calculated using empirical data from the Dutch LTx program gathered over a period of 10 years. In a microsimulation model of the Dutch LTx program based on data from the actual situation, patients with diagnoses associated with a statistically significant increased risk of death while on the waiting list were prioritized by multiplying the time on the waiting list by the relative risk. RESULTS Relative risks of death on the waiting list were increased significantly in patients with cystic fibrosis, primary pulmonary hypertension and pulmonary fibrosis. Prioritization resulted in an increased chance of transplantation for the prioritized diagnoses and a decreased chance for the non-prioritized diagnoses. The distribution of diagnoses after LTx was almost equal to the distribution of diagnoses on the waiting list. CONCLUSION The simulated method of prioritization on the waiting list is a step forward to a more equitable allocation of donor lungs. Moreover, this method is clinically feasible, as long as the waiting list is updated frequently.

Selective treatment of early acute rejection after liver transplantation: Effects on liver, infection rate, and outcome

Abstract To evaluate the results of selective treatment of biopsy‐proven mild acute rejection episodes, we retrospectively studied 1‐week liver biopsies of 103 patients with a primary liver graft in relation to liver function tests. The overall incidence of rejection was 35 %. In four patients the biopsy showed histological features consistent with rejection; in 27 patients it showed mild acute rejection (grade 1), and in 5 patients it showed moderate acute rejection (grade 2). Study group 1 consisted of 19 untreated patients with grade 1 rejection and group 2 of 8 treated patients with grade 1 rejection. At 30 and 90 days, no differences in liver function tests were found. The infection rate, histology after 1 year, and survival in the two groups did not differ. It may, therefore, be concluded that withholding treatment in histologically proven mild acute rejection is possible in selected patients based on histological, biochemical, and clinical criteria. This may reflect the functional diversity of morphologically similar lymphocytic infiltrates observed in graft biopsies showing features of mild acute rejection.

CELLULAR-DAMAGE AND EARLY METABOLIC FUNCTION OF TRANSPLANTED LIVERS STORED IN EUROCOLLINS OR UNIVERSITY-OF-WISCONSIN SOLUTION

In a clinical setting, the effect of Eurocollins (EC) and University of Wisconsin solution (UW) on liver grafts were studied in the early reperfusion phase of liver transplantation. Blood samples were drawn before and after declamping of the portal vein in a group of 11 transplants with EC-perfused livers, and a group of 12 transplants with UW-perfused livers. Parenchymal damage was assessed by the LDH, AST, and ALT, and purine degradation by measuring the uric acid levels. Metabolic function was determined by the serum bile acids and the plasma amino acids, i.e. (valine + leucine + isoleucine)/(phenylalanine + tyrosine) ratio. Donor and pretransplant recipient parameters were almost identical. The cold ischemia time of both groups differed significantly. The results show the following: a significant difference between both the LDH and the uric acid levels in the two groups was revealed, with a smaller increase of the LDH levels and no increase of the uric acid levels in the UW group. Metabolic activity, as measured from the bile acids and the amino acid profile in the peripheral blood, was identical in both groups. We conclude that both EC-stored and UW-stored liver grafts show immediate metabolic function after reperfusion. The amount of metabolic function was equal in both groups, notwithstanding longer cold ischemia time in the UW group. In addition, more parenchymal damage occurred in the EC group.

THE INFLUENCE OF AN IMPROVED PRESERVATION SOLUTION ON PROGNOSTIC FACTORS FOR GRAFT-SURVIVAL IN PEDIATRIC LIVER-TRANSPLANTATION

We investigated the influence of Eurocollins (EC) and University of Wisconson solution (UW) on prognostic factors for graft survival after pediatric liver transplantation. The 1‐year graft survival was studied for 30 patients in which 38 transplantations were performed between 1982 and 1988. We preserved 19 grafts in EC and the other 19 grafts in UW solution. For grafts preserved in EC, the median preservation time was 5 h compared to 10.8 h for grafts preserved in UW solution (P < 0.01). Graft survival at 1 year was equivalent in both groups (63%). No significant differences were observed between the two groups for the following variables: patient diagnosis, child‐pugh score, age, operative time, anhepatic phase, blood loss, morbidity, ICU stay, donor age and graft survival. Multivariate analysis indicated that in the EC group anhepatic phase, blood loss and preservation time were significant predictors of graft survival whereas in the UW group, none of these factors appeared to be significant. We concluded that UW was superior to EC solution in pediatric liver transplantations because it allowed longer preservation times, the length of the anhepatic phase was less important and the tolerance for blood loss seemed to be extended.